Independent Investigation of the National Health Service in England (Lord Darzi, 12 September 2024)

Summary

In July 2024, the Secretary of State for Health and Social Care commissioned Lord Darzi to conduct an immediate and independent investigation of the NHS. Lord Darzi’s report provides an overview of the current performance of the NHS across England and the challenges facing the healthcare system. Lord Darzi has considered the available data and intelligence to assess:

• patient access to healthcare
• the quality of healthcare being provided
• the overall performance of the health system

Content

NHS Performance

Concerning the performance of the NHS, the report states the following key areas of concern:

• How long people wait, and the quality of treatment, are at the heart of the social contract between the NHS and the people. The NHS has not been able to meet the most important promises made to the people since 2015.
• People are struggling to see their GP.
• Waiting lists for community services and mental health have surged.
• A&E is in an awful state.
• Waiting times for hospital procedures have ballooned.
• Cancer care still lags behind other countries.
• Care for cardiovascular conditions is going in the wrong direction.
• The picture on quality of care is mixed.
• The NHS budget is not being spent where it should be—too great a share is being spent in hospitals, too little in the community, and productivity is too low.
• The NHS is not contributing to national prosperity as it could.

Considering the drivers of NHS performance, the report highlights four inter-related factors that have contributed to the current state of the NHS:

• Austerity in funding and capital starvation.
• The impact of the Covid-19 pandemic and its aftermath.
• Lack of patient voice and staff engagement.
• Management structures and systems.

Patient safety

It notes the following points specifically in regards to patient safety:

• There have been improvements in patient safety, with more error-free care in hospitals and a reduction in the number of suicides in inpatient mental health facilities, partly as a result of sustained political attention. The power of prevention is illustrated through the impressive achievements of the Diabetes Prevention Programme, which reduces the risk of type II diabetes by nearly 40 per cent.
• Pressure and stress are at high levels which contributes to poor morale. This leads to burnout, absenteeism, high turnover, and the loss of trained staff. This dynamic impairs patient safety.
• Training in silos impairs teamwork which compromises patient safety. This is partly a result of divergent curricula for different staff groups that damage attitudes and a lack of focus on learning the skills for teamwork.
• Unstable working patterns and the lack of rest space impair teamworking and morale. Having dedicated space and refreshments benefits staff and improves patient safety.
• Transgressive behaviour is more common than admitted, which is very difficult to deal with, and damaging to morale and patient safety.
• Response to safety incidents is dominated by personal reactions; fear of blame by colleagues and others is a significant disincentive to investigation and learning; a culture of openness is essential to patient safety, but often lacking.
• Good progress was made in reducing healthcare acquired infections from 2007-08 to 2011-12, though since then progress has plateaued. Deaths from venous thromboembolism (blood clots in the veins, which can result from hospital stays) spiked during the Covid-19 pandemic and have not yet returned to pre-pandemic levels.

The report also states that:

“There has been good progress in improving patient safety, partly as a result of sustained focus and political attention, notably from the Rt Hon. Jeremy Hunt MP who was the longest serving health secretary and a passionate advocate for improvement. The proportion of care that is error-free has increased, while avoidable harms like pressure ulcers have fallen.”

To support the statement above, it references evidence in its Technical Annex relating to rates of harm-free care recorded under the NHS Safety Thermometer initiative which monitored four conditions (pressure ulcers, falls, UTIs in patients with a catheter, VTEs) between January 2013 and March 2017.

Themes for the 10-year health plan

It concludes by identifying the following major themes for the forthcoming 10-year health plan, which the Government is aiming to complete around spring 2025:

• Re-engage staff and re-empower patients. Despite all the challenges and low morale, NHS staff are profoundly passionate and motivated to raise the quality of care for patients. Their talents must be harnessed to make positive change. The best change empowers patients to take as much control of their care as possible.
• Lock in the shift of care closer to home by hardwiring financial flows. General practice, mental health and community services will need to expand and adapt to the needs of those with long-term conditions whose prevalence is growing rapidly as the population age. Financial flows must lock-in this change irreversibly or it will not happen.
• Simplify and innovate care delivery for a neighbourhood NHS. The best way to work as a team is to work in a team: we need to embrace new multidisciplinary models of care that bring together primary, community and mental health services.
• Drive productivity in hospitals. Acute care providers will need to bring down waiting lists by radically improving their productivity. That means fixing flow through better operational management, capital investment in modern buildings and equipment, and re-engaging and empowering staff.
• Tilt towards technology. There must be a major tilt towards technology to unlock productivity. In particular, the hundreds of thousands of NHS staff working outside hospitals urgently need the benefits of digital systems. There is enormous potential in AI to transform care and for life sciences breakthroughs to create new treatments.
• Contribute to the nation’s prosperity. With the NHS budget at £165 billion this year, the health service’s productivity is vital for national prosperity. Moreover, the NHS must rebuild its capacity to get more people off waiting lists and back into work. At the same time, it should better support British biopharmaceutical companies.
• Reform to make the structure deliver. 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 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. Change will only be successful if the NHS can recover its capacity to deliver plans and strategies as well as to make them.