NHS productivity will not improve without capital investment in buildings. Airedale General Hospital, constructed with reinforced autoclaved aerated concrete (RAAC) – light, bubbly and profoundly unsafe – is going to have to be rebuilt. Photo Workers.
The government is keen — alarmingly keen — to say that the NHS is “broken”. You might almost think that ministers would like it to be…
What is the Labour government up to with our NHS? On coming to office, they commissioned the respected surgeon Lord Ara Darzi to conduct a review of the NHS in England. This was published on 12 September.
But before the review was even begun, health secretary Wes Streeting pronounced the NHS to be “broken”, rushing out his diagnosis before the assessment. Then when the review was published, Keir Starmer again called the NHS “broken”. Yet that was not what the report concluded.
In fact, the concluding chapter of the Darzi review has the title “The NHS is in critical condition, but its vital signs are strong.” And crucially he has confidence in NHS staff to fix the problems and explicitly states, “Many of the solutions can be found in parts of the NHS today. The vast array of good practice that already exists in the health service should be the starting point for the plan to reform it.”
That is not a diagnosis of “broken”.
Since the report has been published the government has made little reference to it and the findings have not featured prominently in the BBC and other media discussions of the service. This is a report they wish to bury. The onus is on the working class and its organisations, the trade unions, to make sure that the Darzi review is widely read and shared.
The review does not in any way seek to minimise the current problems in the NHS. It highlights the struggle to see a GP and the long waits in Accident and Emergency as particularly worrying, citing the Royal College of Emergency Medicine data on long waits in A&E causing 14,000 unnecessary deaths each year.
Cancer
Similarly, the report notes that Britain has appreciably higher cancer mortality rates than other countries. It notes that no progress whatsoever was made in diagnosing cancer at stage I and II between 2013 and 2021 and lists a range of issues with cancer treatment.
The report says that cardiovascular care is “going in the wrong direction” with worsening outcomes. A particular concern is the wide regional variations.
One example is that the percentage of suspected stroke patients who receive the necessary brain scan within an hour of arrival at hospital varies from 80 per cent in Kent to only around 40 per cent in Shropshire.
The report does not seek to duplicate the recent detailed Care Quality Commission report into maternity care, rather it concurs with the conclusion that many maternity services require urgent improvements. The Royal College of Midwives agrees, and warns against ignoring them.
‘Darzi’s first recommendation is the antithesis of the Streeting and Starmer narrative of the broken NHS…’
But none of these serious issues led Darzi to declare the NHS to be broken. In fact, he writes that, “Nothing that I have found draws into question the principles of a health service that is taxpayer funded, free at the point of use, and based on need, not ability to pay.”
He points out that with 2.8 million of the population economically inactive due to long term illness, having more people in work is crucial to growing the economy and therefore “It is not a question of whether we can afford the NHS. Rather, we cannot afford not to have the NHS, so it is imperative that we turn the situation around.”
Underfunding
The remit given to him prevented him from making funding recommendations, but he is absolutely clear in his findings on the damage of underfunding since 2010: “The 2010s were the most austere decade since the NHS was founded, with spending growing at around 1 per cent in real terms…The NHS has been starved of capital and the capital budget was repeatedly raided to plug holes in day-to-day spending.”
He blames this austerity – not staff – for much of the NHS’s ills: “Crumbling buildings, services disrupted at 13 hospitals a day in 2022-23, a backlog maintenance bill [of] more than £11.6 billion, and a lack of capital means too many outdated scanners, too little automation, and parts of the NHS yet to enter the digital era.”
Darzi is particularly critical of the Andrew Lansley reforms of the 2010 coalition government. He writes: “Just imagine if all the effort and resource that had been poured into dissolving and reconstituting management structures [post the 2012 Act] had been invested in improving the delivery of services…The result of the disruption was a permanent loss of capability from the NHS. Experienced managers left, meaning the NHS lost their skills, relationships and institutional memory.”
The combined effect of the austerity and the Lansley reforms meant that the NHS was not in a good position when the pandemic hit.
What needs to be done?
The government did ask Darzi to identify major themes for the forthcoming 10-year health plan. His first recommendation is to re-engage staff, as he argues that despite all the challenges and low morale, NHS staff hold the key to making improvements.
This is the antithesis of the Streeting and Starmer narrative of a broken NHS. There is already evidence that the “broken NHS” narrative is adversely affecting recruitment to the NHS. Recruitment to nursing was not hit by the pandemic and rose in 2021. But far fewer people applied to study nursing this September – down by over a fifth according to a report in the Nursing Times.
The report also makes a number of suggestions about how the financial systems in the NHS need to be aligned to delivering care closer to people’s homes, and makes a range of suggestions for reducing the waiting lists. Despite the injunction not to mention funding, he is very clear that NHS productivity will not improve without capital investment in buildings, equipment and technology.
The report is explicit that “a top-down reorganisation of NHS England and Integrated Care Boards is neither necessary nor desirable”, but states that there is more work to be done to clarify roles and accountabilities, ensure the right balance of management resources in different parts of the structure, and strengthen key processes such as capital approvals.
Welcomed
Professional associations broadly welcomed Lord Darzi’s report and the emphasis on the need to value the people who work in the NHS. But several, including the BMA, are too ready to accept the government’s assessment of the service as “broken”. That may prove to be a distraction and an obstacle to implementing Darzi’s proposals.
Unison represents many people working in the NHS. Its general secretary, Christina McAnea, said in response to the report, “Employees need to be convinced the health service can be saved and that it has a future they want to be part of.”
NHS workers, their professional bodies and trade unions can make a start on breaking the cycle of denigration and neglect. They all have know what’s wrong and ideas on how to fix it. Leaving it to a government whose only real aim is to be re-elected will not meet the need.
In the 1980s the Thatcher government commissioned the Black Report on health inequalities. When she did not like its conclusions, she limited the print run. In response trade unions and other organisations arranged their own print run, and it became one of the best-known public health reports of the 20th century.
Workers in the NHS, and the rest of us, should take the same approach to the Darzi review.
Lord Darzi’s own ten-page summary of his findings and recommendations is an accessible introduction to the comprehensive 163 pages full review – share it and talk about what’s to be done.