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For many who have recently used the NHS in England, Lord Ara Darzi’s dire conclusions about the state of the health service will come as no surprise. They know the system is in “serious trouble”, emergency departments are in a “parlous state”, waiting times have soared and people are struggling even to see their GP. But the government-commissioned report by the surgeon and former health minister offers a penetrating diagnosis of what ails the NHS and an outline of a cure. Prime Minister Sir Keir Starmer says the service must “reform or die”, and cautiously insists there will be no extra funding. Without reformBut there is no escaping the fact that healing the NHS will also require money.
Without mentioning the Conservative Party even once 163 pagesDarzi leaves no doubt as to who he blames. A reorganization “calamity” in 2012 destabilized the National Health ServiceThe “most austere decade in the history of the NHS” meant that current funding grew, in 2010-2018, to levels far below historic levels, with the capital budget often being used to plug the gap. Darzi estimates that England has spent £37bn less on health since 2010 than if it had matched the levels of its rich-country peers. Its weakened state meant the NHS had to cancel far more routine care than other countries during the Covid-19 pandemic.
These problems have been compounded by a wider deterioration in public health and the parallel crisis in social care, which means that one in seven hospital beds is occupied by someone who shouldn’t be there. The breakdown and lack of capacity help explain why, despite having more staff than in 2019, NHS productivity has fallen, with 12 per cent less surgical activity per surgeon.
The “three shifts” that encapsulate the The government’s response The challenges of the 10-year plan – which still needs to be developed in a ten-year plan – all make sense. The shift of healthcare from hospitals to the community, promised by successive governments but never delivered, must finally happen, along with an associated shift “from disease to prevention”. The vision of community centres managing people’s health and carrying out preventive and diagnostic tests, to reduce the number of people arriving at hospital, is compelling. The shift “from analogue to digital”, in a service that is woefully under-digitalised, is also crucial to taking advantage of new technologies that can speed up the shift to prevention.
But all this will require reforms that go far beyond the national health system, including rebuilding public health services traditionally provided by local authorities and, above all, revamping social care, about which Labour has so far said very little.
More investment will also be needed. Starmer is right to make additional funding conditional on reform, given the precarious state of public finances. Outstanding On Thursday, the spending watchdog announced reform and the need to incentivise a huge and inertia-prone system. But reform and investment must happen in parallel. Reducing future NHS operating costs requires investment in infrastructure and equipment today. And the transition from hospital-based to more outpatient care will require years of “double-duty” while the preventative system develops enough to ease demand on hospitals.
The government has ruled out any change to Britain’s taxpayer-funded healthcare model, although, in the longer term, the UK would do well to look at what it could borrow from continental European systems that use social insurance models. As it has also rejected any increase in basic taxes, Starmer’s government must find other means of increasing healthcare investment, probably through borrowing, within the constraints of its fiscal rules. Other sectors are also clamouring for funds. However, given how central healthcare is to all public services and to driving growth, fixing the NHS is surely this government’s main domestic policy challenge.