The NHS is in serious trouble. This is the considered diagnosis of Lord Darzi’s report on the NHS.
Undertaken over just nine weeks, it is an astonishing piece of work and its commissioning underscores the new government’s commitment to action on the NHS right from the beginning. It sets out in detail the steady decline in the health service over the past 15 years and thoroughly rejects the idea that this is purely a pandemic hangover.
But, my goodness, it’s a bleak read. Demand for the NHS has never been higher and yet performance across the board is shockingly poor. Just a few highlights: 2 million people are waiting for community or mental health services, many of them children and almost 400,000 for more than a year; more than 300,000 people are waiting over a year for outpatient treatment – 15 times as many as in 2010; and nearly 10% of patients have to wait more than 12 hours to be seen in A&E, which causes an estimated 14,000 unnecessary deaths a year.
State healthcare is like a staircase with emergency care at the bottom. For a patient with the frailty of chronic ill-health or old age to end up in A&E they must fall past numerous safety steps along the way. The first, and perhaps most important, is good social welfare to improve overall health and reduce poverty. Next come public health measures for the primary prevention of illness, then reliable access to GPs and community care with rapid response services to treat illness before it progresses to hospital care.
Then, when specialist treatment or an operation are needed, it has to be provided quickly enough to prevent further deterioration. Advanced care conversations should occur early, before hospitalisation, to identify those approaching the end of life for whom care at home may be more appropriate.
All of these steps are failing. Patients are tumbling into A&E, where they will wait longer for their care and be more likely to die as a result. Even once they are admitted to a hospital bed, patients are often stuck for prolonged periods owing to inadequate social care services meaning that they cannot be easily discharged.
There are 28 hospitals’ worth of patients in England just waiting for a safe place to be sent to. This intolerable pressure on acute hospitals is the most visible and dramatic aspect of struggling NHS care but Darzi’s report correctly identifies that this has driven investment in hospitals at the expense of more important community care to prevent the need for hospitalisation in the first place. This balance needs redressing urgently.
And yet it is also clear that even while investment in hospitals has been relatively protected, productivity here is also falling. Blocked beds are one reason but there are many others, including the shambolic condition of our estates and our poor use of technology.
The NHS is indeed “broken”, and in response the prime minister this week set out his vision to fix it. There are three “big shifts”: improved digitisation of our outdated paper and analogue systems; moving care from the hospital setting into the community; and moving from treating established sickness to ensuring the primary prevention of disease.
There will be a 10-year plan published to set out exactly how this will be done, due next year. Impressive proposals include NHS health checks at work and advanced diagnostic tests to be offered on the local high street. Even at this stage, however, it is clear that it is unlikely to involve additional money and will be based largely around reform.
So far, so good. But the problem is that I have heard much of this before, and many times. Even during the shameful degradation of the health service over the past 15 years, there have been many similarly noble visions proposed for the NHS.
It has long been standard advice for aspiring consultants preparing for their job interview: just make sure you’ve read Five Year Forward View, Long Term Plan and NHS: from good to great.
Many of the themes contained in these old documents are the same as those Kier Starmer set out.
Previous attempts to digitise the NHS have been little short of catastrophic, and I have witnessed many of the chaotic reorganisations since 2012 that have made things worse.
Darzi’s report is categorical that failures in NHS management are not responsible for the current problems.
And, unfortunately, although of course reform must accompany any investment, I cannot see how it can be achieved without more money. Despite being a huge and disparate organisation, the NHS is managerially lean and we achieve a lot with a little compared to other healthcare systems who pay much more per population than we do.
It is surely impossible to start all these new initiatives – and improve our digital and physical infrastructure – without either paying for them or pulling resources from current services that are already far beyond capacity.
Darzi’s report clearly identifies the desperate shortage of capital over many years that prevents our hospitals functioning effectively, although it feels like Starmer forgot to read that part.
Furthermore, without improving overall population health, demand on the care sector will continue to rise.
In my patients I see daily the effects of poverty, for example unemployment, poor housing, obesity due to poor diet, inability to afford prescription charges to take their medication. I am sure that the mental health of my patients has never been poorer as a result. These issues are not within the power of the NHS to solve – how much use is an inhaler to someone whose mouldy house and chronic stress is causing their asthma?
We cannot expect the NHS to improve population health on its own. But this is not even what worries me most. All organisations live or die by their workforce and since the trauma of the pandemic our staff have remained tired, disengaged and fed up.
The reduction in productivity is not due to staff working less hard, rather our time is increasingly spent trying to mitigate failings elsewhere. Working in the NHS is a miserable experience at the moment and it is heartbreaking. I became a doctor expecting to work hard, and I certainly do, but the chronic inability to do my job properly and the futility of being unable to help so many of my patients destroys the satisfaction that used to make my hard work so rewarding.
I see the same in my colleagues every day. Worryingly our junior doctors seem particularly affected. Without a motivated and productive workforce, how can we hope to reform?
I do not wish to sound too cynical here. Of course there are reasons to hope – the NHS and its staff are resilient and given the tools and means we will be able to deliver the excellent care I know we can. And I do believe that we now have a government that has committed to the NHS on its founding principles, recognises the daunting scale of the issues facing it, and is at least realistic about the effort and time it will take to repair.
But words have been said before. Truly the scale of the task is immense, perhaps more so now than ever.
Will this time be different? God, I hope so.
