The Darzi review: the NHS “is in serious trouble” but what comes next?

Lyn Whitfield, content director at Highland Marketing, takes a look at Lord Darzi’s review of the NHS, immediate reaction, and next steps. The review calls for a “tilt towards technology” to improve productivity. But, for the moment, the funding and policy required to invest in serious change are not on the table.

Every politician needs a story to tell about the state of the country and how it got to be the way it is, so they can spin a narrative about their actions. On Thursday, Lord Darzi delivered a novella length account of the state of the NHS and how it ended up in “serious trouble.”

The NHS “is in serious trouble”

Lord Darzi’s headline conclusions are set out in a summary letter to health and social care secretary Wes Streeting, who commissioned his review days after the general election.

The surgeon and former minister in Gordon Brown’s government says he was “shocked” by some of the things he saw during his short inquiry, even though he has worked in the service for 30-years. “People are struggling to see their GP” and waiting lists “have ballooned.” A&E “is in an awful state.”

Cancer care and cardiovascular care are “lagging behind other countries” or going backwards. And the NHS “is not contributing to national prosperity as it could”, with 2.8 million people inactive due to long-term sickness, up nearly a million on the pre-Covid era.

Why?

The report notes that some of the reasons for the NHS’ plight are beyond its direct control. The health of the nation has “deteriorated” as poor-quality housing, low-incomes, and insecure employment have escalated, driving demand “from a society in distress.” Social care faces a crisis of its own.

However, it lists some historical causes, starting with the austerity of the Cameron/Osborne era and moving on to the Lansley reforms of 2012, which it describes as “a calamity without international precedent” that dissolved lines of management and accountability.

By the time Covid-19 arrived, the NHS was in a poor state, had to cancel far more elective procedures than comparable systems, and has struggled to recover. Playing into these problems, Lord Darzi argues that successive administrations have put resources in the wrong place.

Hospitals continue to get more funding and staff than other parts of the system, even though policy makers have talked about a ‘left shift’ into community and primary care and prevention “since at least 2006, and arguably much longer.” And there has been a serious shortfall in capital spending for facilities and technology.

Darzi estimates that if the NHS had invested at the rate of comparable countries, it would have spent an additional £37 billion; enough to eliminate backlog maintenance three times over, build Boris Johnson’s 40 new hospitals, or modernise every surgery in the country.

Technology: in the digital foothills

Or fund two more rounds of the National Programme for IT. As things stand, Lord Darzi says health services are stuck “in the foothills of digital transformation” and this is one reason for poor and falling productivity.

Hospitals do have more staff than before the pandemic, but they are unable to work effectively in aging and collapsing buildings with poor IT systems. They just end up “wasting time solving problems, such as ringing around wards desperately trying to find beds” which “crushes their enjoyment of work.”

The report argues for “a major tilt towards technology” and duly ticks off the “enormous potential of AI.” But it’s more interested in community and primary care.

It notes that community services have been slow to adopt the kind of automated route planning and activity tracking that has transformed logistics and delivery services, and that while some GPs “have made significant shifts towards a digital model for patients,” others haven’t.

Even biggish, national programmes haven’t made the impact they should. Virtual wards and remote consultations “have not radically reshaped services.” The NHS App “is not currently living up to its potential impact, given the vast scale of its registered user base.” Just a handful of areas are effectively using data to inform services.

Critical, but not dead

Lord Darzi concludes that the NHS is in a “critical condition.” But he doesn’t think it is dead. Towards the end of his summary letter, he specifically addresses the right-wing commentator trope that its universal, taxpayer-funded model should be abandoned.

Every country “with the prominent exception of the United States” is striking for universal healthcare, he says. And private or social insurance are just more expensive ways of achieving that. So, the question is “not whether we can afford the NHS” but how to turn it around.

He also rejects the idea that there are too many managers or that the service has been badly managed. Certainly, he says, people have been focused on “keeping the show on the road” but in a “broken system” different decisions “would have made only a marginal difference.”

Instead, and even though Streeting didn’t ask for policy proposals, the report identifies some themes for the new ten-year plan for the NHS that is being drawn up in Whitehall. These include re-engaging staff and empowering patients, taking steps to “lock in the shift to care close to home” by “hardwiring” the financial flows that will be needed to deliver it, and encouraging multi-disciplinary working.

Lord Darzi also calls for better productivity through a “tilt towards technology” and argues this will be a good investment if it succeeds in “getting more people off waiting lists and back to work.” Crucially, he warns that “change will only be successful if the NHS can recover its capacity to deliver plans as well as make them.”

Reaction: ministers face tough choices

The media latched on to the dismal aspects of the report, with the BBC running stories from patients about their experiences and papers appealing for examples of poor care. Staff bodies and think-tanks found its conclusions realistic – but were significantly more interested in what comes next.

Sarah Woolnough, chief executive of the King’s Fund, described the report as “authoritative and sobering” and said ministers now face “tough trade-offs between tackling immediate NHS pressures and prioritising reform of the root causes of the crisis.”

This theme was picked up by Matthew Taylor from the NHS Confederation, who also argued that ministers will need to “work on two fronts”: first, “to help the NHS avoid a winter crisis”, and second, “to prepare for the long-term through the planned ten-year strategy.”

Neither, he argued, could be done without more money and “emergency funding will be needed in the Autumn Budget” to head off a financial crisis that is threatening to reduce services and staff just when they should be ramping up for winter.

The Nuffield Trust also argued that “the health service is staring down the barrel of a significant shortfall in funding in this current year” and that chancellor Rachel Reeves will need “a clear plan to tackle this” – while working out a longer-term funding settlement.

Do politicians want to make them?

It’s not at all clear that the government sees things this way. For the moment, at least, Reeves is holding to the line that there won’t be more money in October. Indeed, the NHS is being asked to make cuts to fill its share of the £22 billon “black hole” that the Treasury has uncovered in this year’s finances.

Meanwhile, Reeves’ boss, prime minister Keir Starmer, is suggesting that there won’t be much coming at the end of the comprehensive spending review, either. In a speech to the King’s Fund, he played up the “unforgivable” state of the NHS outlined in the Darzi review and put the blame firmly on the Conservatives (“as everybody in the country knows, the last government broke the NHS”). 

But when it came to looking forward, he said the government would not “raise taxes on working people” so the NHS will just have to “reform or die.” As if the NHS has been refusing to change, instead of being landed with impossible reforms and no money to fund them. As Lord Darzi had just explained.

Streeting picked a similar approach, attacking the Conservatives in the Commons, and then picking a fight with the British Medical Association, which he accused of “sabre rattling over pay” and being “locked into a way of life and a way of practising medicine [that is] very hard to move to a different place” (The Guardian).

Read into Darzi what you will

The problem with stories is that people can use them in different ways; to inspire action, to defend inaction, to identify new villains. And it’s far from clear that former Labour peer Lord Darzi and today’s Labour politicians are on the same page when it comes to how to read his report.

Lord Darzi clearly believes the NHS has “strong vital signs” and can be restored to health with the right treatment. But in public at least, Sir Keir, Reeves and Streeting are keener on the “it’s broken” and ‘the Tories broke it” bits of his report than on the policy and funding implications, at least as they apply to them.

As a trust chief executive told the Health Service Journal recently: “Mr Streeting made it clear that he will ‘still be blaming the Tories if we have a bad winter’ but ‘thereafter it’s our fault’.