The NHS is in “serious trouble”, independent report warns

Lord Darzi’s independent report on the state of the NHS in England has just been published.

Entitled ‘Independent Investigation of the National Health Service in England’, the report provides an in-depth understanding of the current performance of the NHS across England and the challenges facing the healthcare system.

The first part of the report delves into the performance of the NHS.

One headline finding is that the NHS is in “serious trouble”, with public satisfaction at its lowest level ever.

Worryingly, while life expectancy has risen post-COVID-19, the proportion of life spent in ill-health has also increased. The report states that many of the social determinants of health – such as poor-quality housing, low income, insecure employment – have moved in the wrong direction over the past 15 years, which has resulted in a rise in demand for NHS services.

Contributing to this picture of increased ill-health are a surge in multiple long-term health conditions and the public health grant being slashed by more than 25 percent in real terms since 2015.

Unsurprisingly, following many headlines over the last few years about the NHS not meeting waiting time targets, Lord Darzi’s investigation highlights that many waiting time targets within the NHS are not being met. This spans across GP services, community services, A&E, routine surgery, hospital procedures, cancer and cardiac services, and more. Due to this, public trust and confidence in the NHS have been damaged.

Coupled with unmet waiting time targets is a trend of worsening NHS services, which exacerbates the problem.

Importantly, the report highlights that the NHS budget is spent too much hospitals and too little in the community. Post-pandemic, the number of appointments, operations, and procedures have not increased in line with the rise in staff numbers, which also results in fallen productivity.

The report continues: “The key reason for this is that patients no longer flow through hospitals as they should. A desperate shortage of capital prevents hospitals being productive. And the dire state of social care means 13 percent of NHS beds are occupied by people waiting for social care support or care in more appropriate settings.”

Lord Darzi adds that too many people end up in hospital because there is not enough investment in the community. Staff levels in the community have decreased over the years, which adds to the issue.

Since 2006, successive governments have failed to deliver on promises to shift care away from hospitals and into the community. The reverse has happened instead, the report rules.

This is reinforced by performance standards being focused on hospitals and not on primary care, community services, or mental health. When reactive short-term funding solutions are injected into the system, again, the money is given to hospitals where the problems are most apparent. Resultantly, the NHS has implemented the inverse of its strategy, and the problems are systemic, according to the report.

In addition, the report outlines that the start of 2024, 2.8 million people were economically inactive due to long-term sickness. It stresses the importance of people being in work to improve their wellbeing and grow the economy, particularly to create more tax receipts to fund public services.

The second part of the report explores what is driving poor NHS performance.

It underlines that four heavily inter-related factors have contributed to the current 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.

Some of the key issues are around austerity and a lack of capital investment.

Lord Darzi found that from 2010 to 2018, spending grew at around one percent a year in real terms, against a long-term average of 3.4 percent. In 2018, a promise was made of a 3.4 percent a year real terms increase for five years in revenue spending. However, this promise was broken, and spending actually increased at just under three percent a year in real terms between 2019 and 2024.

Additionally, the NHS has been “starved” of capital and that the capital budget was repeatedly raided to plug holes in day-to-day spending. There is a shortfall of £37 billion of capital investment in the NHS.

This lack of capital means that the NHS is left with many outdated technologies and is not able to benefit from digital technologies that can help predict and prevent health problems.

This combination of a lack of capital and austerity, Lord Darzi states, meant that the NHS was not resilient during the COVID-19 pandemic.

Furthermore, the report notes that patients’ satisfaction with the NHS has declined, and their concerns are not being acted on. In tandem with an increase in patient complaints, NHS staff are also disengaged, with “distressingly high levels” of sickness absence.

Looking at systems and structures, the report notes that 2022 Act, which put integrated care systems (ICSs) on a statutory basis, has the makings of a sensible management structure. Despite this, Lord Darzi states that the framework of national standards, financial incentives, and earned autonomy as part of a mutually reinforcing approach is no longer as effective as it once was and needs to be reinvigorated.

The current structure of NHS organisations and staff members can also make it difficult to hold people accountable. As the report explains: “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.”

The third and final part of the report draws a conclusion on the findings and makes a series of recommendations to improve the NHS.

In conclusion, the report states that the NHS is in a “critical condition”, but its vital signs are strong.

While the report notes some serious problems, like a loss of trust from frontline staff, a lack of capital investment in the NHS, and increased demand on services, NHS staff have a shared determination to make the NHS better for patients, and clinical staff are widely admired for their skills.

Importantly, Lord Darzi notes: “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.”

The report also affirms that waiting times must improve quickly, but that it will take years to get the NHS back to peak performance.

Off the back of this report, a 10-year health plan is due to be published, which will take into account the following suggestions for improvement.

These are: re-engage staff and re-empower patients; facilitate care closer to home by hardwiring financial flows; embrace new multidisciplinary models of care that bring together primary, community, and mental health services; drive productivity in hospitals; harness the power of technology to unlock productivity; get more people off NHS waiting lists and back into work; and reform the current structure to make it work.