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Alderwick160924
10.1136/bmj.q2032
Editorials
Darzi’s NHS review shows depth of problems for Labour
Alderwick Hugh director of policy
Dunn Phoebe senior policy fellow
Health Foundation, London, UK
Hugh.Alderwick@health.org.uk
2024
18 9 2024
386 q2032© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
2024
BMJ
https://creativecommons.org/licenses/by-nc/4.0/ This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

Findings may buy time but highlight government policy tensions
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pmcAra Darzi’s independent review into the performance of the NHS in England, commissioned soon after Labour’s election victory in July 2024, was published on 12 September.1 The idea was to provide a rapid assessment of the state of the health system—focusing on problems, not solutions. Darzi’s findings are intended to inform the government’s 10 year plan for reforming the English NHS—expected in spring next year.2 The report comes around 16 years after Darzi’s last review into the English NHS.3

Darzi paints a bleak picture of a health system in crisis.1 People are waiting too long for care in hospitals, primary care, mental health services—everywhere. Long waits in major hospital emergency departments are pulling at the social contract underpinning the NHS and likely to be contributing to thousands of additional deaths. Quality of care is mixed. And care in some areas, such as for people with cardiovascular disease, seems to be going in the wrong direction. The share of NHS resources going to hospitals is increasing, despite repeated political promises to do the opposite, and NHS productivity has stalled. The NHS’s problems pre-date the covid-19 pandemic.

The review points to a combination of factors behind the decline. Austerity in the 2010s left the NHS constrained by sustained low funding growth. Weak capital investment—in buildings, equipment, and information technology—has held back staff and their ability to work productively. The 2012 reforms introduced by then health secretary, Andrew Lansley, to the structure of the NHS caused ongoing harm and disruption—described by Darzi as “a calamity without international precedent.”1 Covid-19 came amid the mess and made it much worse.

None of this is new. Analysis of these and other problems in the NHS is well known.4 5 The decline in NHS performance over 14 years of Conservative governments is plain to see.6 So what do we learn from the review? Darzi’s report illustrates four broader tensions in Labour’s policy approach.

Rhetoric meets reality

First is when to shift from problems to solutions. As with the economy,7 Labour’s political narrative on the NHS so far has emphasised the depth of the crisis inherited from the Conservatives. The health secretary, Wes Streeting, declared the NHS “broken” on his first day in the job.8 Darzi’s review adds heft to this narrative and helps Labour extend the story further. In his response to the review, the prime minister, Keir Starmer, said that “until this morning, we didn’t know the full scale of the damage.”9 This line may buy time. But the responsibility for fixing these problems now belongs to Labour. The government has pointed to broad changes it wants to make to help address these challenges, such as shifting care from hospitals to the community.10 But detail on how is lacking. And the rhetoric of “reform or die”9 may alienate some professional groups needed to deliver the changes.

Second is which problems Labour should prioritise. Darzi was asked to focus on the NHS, and his diagnosis runs to more than 150 pages and several hundred more of technical annexes. Yet the task of improving the nation’s health is about more than the health service—as Darzi acknowledges.

Health and health inequalities are shaped by social, economic, and environmental factors, such as income, jobs, and housing.11 Take this broader lens and the list of problems grows longer. Since 2010, life expectancy in England has stalled, and health inequalities between richer and poorer areas have widened.12 Public health budgets have been cut,13 and investment in wider services that shape health has been weak.14 Labour knows this and has set ambitious goals to reduce health inequalities through a “health in all policies” approach.10 But the risk is Labour’s health mission gets skewed towards the NHS—and skewed even further towards meeting high profile targets to reduce hospital waiting lists.

Third is how quickly Labour can address these problems. Labour has promised to meet key NHS performance standards, such as at least 92% of patients starting consultant led treatment within 18 weeks of a general practitioner referral, within five years.15 16 17 Yet these targets have been routinely missed for nearly a decade.18 Returning them in half that time is unlikely without substantial increases in NHS funding and capacity.19 Darzi seems to agree: the review states that “it is unlikely that waiting lists can be cleared and other performance standards restored in one parliamentary term.”1 Might Darzi be used as political cover to plot a more pragmatic path to recovering NHS performance?

And fourth is the mismatch between Labour’s ambitions on funding and reform. Darzi points to underinvestment as a root cause of the NHS crisis. This includes weak capital investment compared with other European countries, such as France and Germany.20 Recent analysis suggests that NHS spending would need to grow by around 3.8% a year in real terms over the next decade—much higher than current projected spending—to achieve the kind of improvements set out by Labour.21 But the health secretary has emphasised reform over investment22 and—in his recent speech on the NHS—Starmer said, “we have to fix the plumbing before turning on the taps.”9 Policy change is no doubt needed to redefine NHS priorities, align public policy levers—such as targets, regulation, and payment systems—behind them, steer new technology towards the NHS’s objectives, and more. But Labour should remember that its last round of reforms responsible for turning around NHS performance in the 2000s did so backed by annual spending growth of close to 7%.23 24

Competing interests: We have read and understood BMJ policy on declaration of interests and declare that HA was part of the expert reference group for the Darzi review.

Provenance and peer review: Commissioned; not externally peer reviewed.
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1 Department of Health and Social Care. Independent investigation of the NHS in England. 2024. https://www.gov.uk/government/publications/independent-investigation-of-the-nhs-in-england
2 West D . New 10-year health plan due next spring. Health Serv J 2024 Jul 22. https://www.hsj.co.uk/integrated-care/new-10-year-health-plan-due-next-spring/7037515.article
3 Department of Health and Social Care. High quality care for all: NHS next stage review final report. 2008. https://www.gov.uk/government/publications/high-quality-care-for-all-nhs-next-stage-review-final-report
4 Anderson M Pitchforth E Asaria M . LSE-Lancet Commission on the future of the NHS: re-laying the foundations for an equitable and efficient health and care service after COVID-19. Lancet 2021;397 :1915-78. 10.1016/S0140-6736(21)00232-4  33965070
5 Freedman S, Wolf R. The NHS productivity puzzle: Why has hospital activity not increased in line with funding and staffing? Institute for Government, 2023. https://www.instituteforgovernment.org.uk/publication/nhs-productivity
6 Alderwick H . Conservative Party’s legacy on the NHS. BMJ 2024;386 :q1491. 10.1136/bmj.q1491  38969349
7 Eardley N, Reuben A. Are the UK's finances really worse than Labour expected? BBC News 27 Jul 2024. https://www.bbc.co.uk/news/articles/c9r329y9pqxo
8 UK Government. The NHS is broken: Health and Social Care Secretary statement. 5 Jul 2024. https://www.gov.uk/government/speeches/statement-from-the-secretary-of-state-for-health-and-social-care
9 UK Government. PM speech on the NHS: 12 September 2024. https://www.gov.uk/government/speeches/pm-speech-on-the-nhs-12-september-2024
10 Labour Party. Build an NHS fit for the future. 2023. https://labour.org.uk/wp-content/uploads/2023/05/Mission-Public-Services.pdf
11 McGovern L. The relative contribution of multiple determinants to health. Health Affairs 2014. https://www.healthaffairs.org/content/briefs/relative-contribution-multiple-determinants-health
12 Raleigh V. What is happening to life expectancy in England? King’s Fund, 2024. https://www.kingsfund.org.uk/insight-and-analysis/long-reads/whats-happening-life-expectancy-england
13 Finch D, Gazzillo A, Vriend M. Investing in the public health grant: what it is and why greater investment is needed. Health Foundation, 2024. https://www.health.org.uk/news-and-comment/charts-and-infographics/public-health-grant-what-it-is-and-why-greater-investment-is-needed
14 Zaranko B. Spending review 2020: covid-19, Brexit and beyond. Institute for Fiscal Studies, 2020. https://ifs.org.uk/books/spending-review-2020-covid-19-brexit-and-beyond
15 Labour Party. Change: Labour party manifesto 2024. 2024. https://labour.org.uk/change/
16 Illman J . Streeting commits to hit four-hour target in first term. Health Serv J 2024 Jun 19. https://www.hsj.co.uk/policy-and-regulation/streeting-commits-to-hit-four-hour-target-in-first-term/7037339.article#
17 Starmer K. Today. BBC Radio 4, 22 May 2023. https://www.bbc.co.uk/programmes/m001m4f7
18 Nuffield Trust. NHS performance tracker. https://www.nuffieldtrust.org.uk/qualitywatch/nhs-performance-summary
19 Alderwick H . Labour’s health “mission”. BMJ 2023;381 :1232. 10.1136/bmj.p1232  37257901
20 Rebolledo I, Charlesworth A. How does UK health spending compare across Europe over the past decade? Health Foundation, 2022. https://www.health.org.uk/news-and-comment/charts-and-infographics/how-does-uk-health-spending-compare-across-europe-over-the-past-decade
21 Rocks S, Issa Z, Thorlby R, Douglas HR, Charlesworth A. How much funding does the NHS need over the next decade? Health Foundation, 2024. https://www.health.org.uk/publications/long-reads/how-much-funding-does-the-nhs-need-over-the-next-decade
22 Smyth C. Money alone won’t cure the NHS, warns Labour. Times 2023 Apr 21. https://www.thetimes.com/uk/healthcare/article/nhs-crisis-reform-funds-uk-2023-ktvx5s2p5
23 Rocks S, Fozzard K, Issa Z, Boccarini G. Health care funding: three key questions about funding in England. Health Foundation, 2024. https://www.health.org.uk/publications/long-reads/health-care-funding
24 Murray R. Lessons from the 2000s: the ambition to reduce waits must be matched with patience and realism. King’s Fund, 2021. https://www.kingsfund.org.uk/publications/nhs-waiting-times
