Sep 12, 2024 11 min read

Cowper’s Cut 340: D-day launches Lord Darzi’s second NHS reform report

Lord Darzi’s ‘Independent Investigation Of The NHS In England’ does two main things: it tells health experts nothing they don’t already know about the dreadful present state of the English NHS, and it is very much about apportioning blame for how it got into that state.

These are both good and needful things.

Over the years since the end of the Covid19 pandemic, the English NHS’s current leadership have shown an unfortunate tendency to downplay and under-state how bad things really are.

They coupled this with attempts to pretend that the NHS had adequate resources, and to encourage financial lying by local NHS systems - which worked about as well as you’d expect. The NHS is currently in deficit of at least £2 billion, and this is expected to worsen as the current financial year continues.

Productivity’s collapse

The statistics are grim, if familiar. Productivity has cratered, as last year’s Institute For Government report ‘The NHS Productivity Puzzle’ showed in detail.

Despite the hospital workforce rising by 17 per cent between 2019 and last year, acute output has not risen at nearly the same rate, leading to a large “productivity gap”: one reason why NHS waiting lists remain high. Failure to modernise and update infrastructure (such as diagnostic or operating theatre capacity) exacerbated this problem.

It finds that “there are 7 per cent fewer daily outpatient appointments for each consultant, 12 per cent less surgical activity for each surgeon, and 18 per cent less activity for each clinician working in emergency medicine”.

The UK has appreciably higher cancer mortality rates than other comparable countries. Ambitions to diagnose more cancers at early stages saw “no progress whatsoever” between 2013 and 2021. Long waits in A&E are likely to be causing 14,000 excess deaths every year.

The review observes that “as of June 2024, more than 1 million people were waiting for community services, including more than 50,000 people who had been waiting for over a year, 80 per cent of whom are children and young people. By April 2024, about 1 million people were waiting for mental health services. Long waits have become normalised”.

Money in the wrong places

The report is clear that the acute sector’s longstanding tendency to be a ‘resource sponge’ has, if anything, intensified. “We have underinvested in the community. We have almost 16 per cent fewer fully qualified GPs than other high income countries (OECD 19) relative to our population.

“After years of cuts, the number of mental health nurses has just returned to its 2010 level. Between 2009 and 2023 the number of nurses working in the community actually fell by 5 per cent, while the number of health visitors, who can be crucial to development in the first five years of life, dropped by nearly 20 per cent between 2019 and 2023.

“Since at least 2006, and arguably for much longer, successive governments have promised to shift care away from hospitals and into the community. In practice, the reverse has happened.

“Both hospital expenditure and hospital staffing numbers have grown faster than the other parts of the NHS, while numbers in some of the key out-of-hospital components have declined. Between 2006 and 2022, the share of the NHS budget spent on hospitals increased from 47 per cent to 58 per cent”.

Four drivers of failure

Darzi’s report ascribes the blame for the current state of the English NHS to four main drivers. The first is the austerity decade from 2010-19, when the NHS had real-terms funding increases averaging about 1% over inflation, in contrast to the long run average of nearly 3.4%.

This particularly includes capital spending, of which the report shows a cumulative underspend of £37 billion: “the NHS has been starved of capital and the capital budget was repeatedly raided to plug holes in day-to-day spending.

“The result has been crumbling buildings that hit productivity – services were disrupted at 13 hospitals a day in 2022-23. The backlog maintenance bill now stands at more than £11.6 billion”.

Blame Lansley

“The Health and Social Care Act of 2012 was a calamity without international precedent. It proved disastrous. By dissolving the NHS management line, it took a “scorched earth” approach to health reform, the effects of which are still felt to this day. It has taken more than 10 years to get back to a sensible structure. And management capability is still behind where it was in 2011.”

The second area of blame is the 2012 Health And Social Care Act: the Lansley NHS reforms introduced by the Coalition Government.

Darzi calls it a “scorched-earth approach to health reform … uniquely complicated piece of legislation”. He correctly relates to this issues around management structures and systems.

Lord Darzi is not wrong. Lord Lansley has not had anything like the blame that he deserves for this disastrous set of NHS reforms, which aimed to turn competition, clinical commissioning and choice by patients into the new operating system of the NHS.

This failed absolutely: the ‘three Cs’ have driven precisely nothing in NHS reform post-2012, and the Lansley reforms were quietly undone by Simon Stevens during his tenure as NHS England chief executive.

One must have a heart of stone not to laugh at the memory of Lord Lansley telling the 2011 Royal College of Nursing conference “I’m sorry if what I’m setting out to do hasn’t communicated itself”.

Management issues

A key aspect of the Lansley reforms was cutting NHS management by 45% of its level in 2008-9. Darzi’s report notes that the fall of local operational management numbers since that time has been in contrast to the rise in national regulation, which has overseen the performance collapse.

The number of people employed by NHS England and the Department of Health But Social Care rose from 53.2 per provider trust to a peak of 109.2 in 2022-23, before falling back to 89.8 last year.

Since 2008, “the number of people in regulatory roles for each provider trust has gone from 5 per provider to more than 35 … (leading to) a burden on boards and management teams of care-providing organisations”.

Darzi eschews NHS manager-bashing, writing that “good management has a vital role in healthcare … the NHS is not employing enough people whose primary responsibility is that its resources are used well, and the talents of its clinicians are focused on delivering high-quality care.

“Accountability is important. But too many people holding people to account, rather than doing the job, can be counterproductive … NHS organisations should focus on the patients and communities they serve, but the sheer number of national organisations that can ‘instruct’ the NHS encourages too many to look upwards rather than to those they are there to serve.”

Ooops. Does Darzi recommend another top-down NHS redisorganisation?

Thankfully, not: “while a top-down reorganisation of NHS England and integrated care boards is neither necessary nor desirable, there is more work to be done to … ensure the right balance of management resources in different parts of the structure.”

The third and fourth aspects are no less important: the impact of the Covid-19 pandemic and its aftermath; and the lack of patient voice and staff engagement.

Social care is not the focus of this document, but Darzi notes its “dire state”, which is driving people staying in hospitals inappropriately because of the lack or unaffordability of community social care.

Long-term hope

Lord Darzi has not lost hope: indeed, he concludes that “the NHS is in critical condition, but its vital signs are strong”. But his report does not offer any false reassurance.

We go back to his basics - the unambiguous identification of the root causes: “four heavily inter-related factors have contributed to the current dire state of the NHS. They are austerity in funding and capital starvation; the impact of the Covid-19 pandemic and its aftermath; lack of patient voice and staff engagement; and management structures and systems”.

Bar the pandemic, the three issues here relate to how the NHS has been reformed, run and resourced under the 2010-24 Conservative governments.

On waiting times, Lord Darzi’s report concludes, “I have no doubt that significant progress will be possible but it is unlikely that waiting lists can be cleared and other performance standards restored in one parliamentary term. Just as we in the NHS have turned around performance before, we can do so again”.

It will be interesting when we get the details about how, in the Spring 2025 ten-year plan.

Conclusion: it’s the politics, stupid

This is, albeit implicitly, a very political report. The Darzi Review is of a piece with the rest of Labour’s post-election communications about the state of the state and the economy that they have inherited.

This is largely an expanded reflection of the Cameron/Osborne messaging in 2010 that Labour crashed the economy: Labour’s 2024 riposte is that the Conservatives crashed both the economy and the public services. Imitation is the sincerest form of flattery.

The Darzi Review’s main, unstated purpose is about the allocation of political blame. It does that quite effectively.

Labour’s political strategy in office so far has been a tribute act to Cameron and Osborne’s effective if ludicrous assertion that Labour ‘crashed the economy/maxed out the nation’s credit card’.

Except that Labour left behind them generally well-functioning public services in 2010. So their line is ‘the Conservatives crashed the economy AND public services’. Expect to hear it on the hour, every hour for at least the next few years.

Prime Minister Liz Of The 49 Days Truss gave Labour bottomless credibility with their ‘crashed the economy’ line.

And the current state of public services speaks for itself.

It was interesting and unexpected (to me, at least) just how long the New Darzi Review goes on the Lansley NHS reforms.

It’s also politically smart.

Because the Lansley reforms were a total failure. Choice, competition and clinical commissioning drove precisely nothing in the NHS over the past 12 years.

Now Labour just need to work out what works, and how to do it.

Racist misogynist Tory donor and TPP boss Frank Hester gave Tories more money

You could knock me down with a feather.

Racist misogynist and owner of ‘System One’ software manufacturers TPP Frank Hester gave the Conservative And Unionist Party a further £5 million shortly before the General Election was called in May.

Lib Dem MP Layla Moran appointed unopposed as new Commons Health Select Committee chair

Thank you, Wes! Look forward to engaging with you and your ministerial team. https://t.co/16C6Phfxun
— Layla Moran 🔶🕊️ (@LaylaMoran) September 10, 2024

Liberal Democrat MP for Oxford West and Abingdon Layla Moran was this week elected unopposed as the new chair of the House Of Commons Health Select Committee. Her statement read, “with millions stuck on waiting lists, doctors and nurses overstretched, and far too many elderly people trapped in hospitals without a care plan, the role of the Committee as a critical friend of the Government as it tackles these challenges has never been more important.

“From social care to dentistry, and waiting lists to the workforce crisis, it has never been more pressing to find common ground across the political spectrum and I look forward to running a Committee that champions the voice of patients and front line health and social care staff.”

Tom Riordan appointed second DHBSC permanent secretary

Former Leeds City Council chief executive and runner-up candidate in the last NHS England leadership race Tom Riordan was been appointed second permanent secretary at the Department For Health But Social Care.

Local Government Chronicle note that Riordan “spent three months in central government as the national tracing lead for NHS Test & Trace during the first year of the Covid19 pandemic, where he is credited with getting movement on issues such as data sharing in order to allow councils to play a bigger role in tackling local outbreaks.

Delighted to be welcoming Tom Riordan as Second Permanent Secretary at @DHSCgovuk.

An outstanding local government leader and a proven public service reformer with extensive experience in health and social care system transformation and preventative healthcare.
— Wes Streeting MP (@wesstreeting) September 10, 2024

“Health and social care secretary Wes Streeting highlighted Riordan’s experience as a “proven public service reformer with extensive experience in health and social care system transformation and preventative healthcare. His experience will be invaluable as we deliver the mission of this government to build an NHS and social care system fit for the future”.

Riordan replaces Shona Dunn who left DHBSC to become chief executive of St John’s Ambulance.