What the NHS Needs

Ara Darzi released his report on the English National Health Service last month. To no one’s surprise, he finds that the service is ‘in serious trouble’, with crumbling buildings, demoralised staff and slipping standards in key areas such as maternity care. More than 7.6 million people are on waiting lists. The number waiting longer than a year for mental health services is more than the population of Leicester. Among them are 109,000 children and young people. Only a third of dentists are accepting new NHS patients, and DIY dentistry kits are for sale in pound shops. Yet Darzi also insists that the ‘vital signs’ of the NHS ‘remain strong’ and his report outlines strategies for the new Labour government to adopt.

How did we get here? As with so much in British public life, the years either side of 2010 are something of a fissure. New Labour’s stewardship of the health service after 1997 was marred by the cost-inefficient Private Finance Initiative and the heavy use of performance targets, which staff found exhausting. But the service reached 2010 with the highest patient satisfaction levels on record and waiting times for in-patient hospital care down to four weeks – unimaginable now. In the run-up to the general election in July, a clip from Question Time in 2005 circulated on social media. It showed members of the public complaining to Tony Blair that their GPs were offering them appointments too quickly.

In his account of the subsequent downturn, Darzi highlights funding shortfalls under Conservative governments. Day-to-day health spending in the UK between 2010 and 2019 ‘virtually flatlined’. Capital investment was £27 billion lower than the Western European average (the maintenance backlog in 2022 was £11.6 billion). Darzi identifies other factors that have contributed to the NHS’s malaise, including the confusion created by the 2012 Health and Social Care Act, failures to listen to patients and the Covid pandemic. But by drawing attention to the damage wrought by financial shortfalls, he provides a welcome antidote to claims in the media that the NHS is actually well-funded (plausible only if you just look at spending increases during and after the pandemic, rather than taking the average across the years of austerity).

Yet in his response to the Darzi Report, the new health secretary, Wes Streeting, told the BBC that if healthcare spending kept increasing then Britain was in danger of becoming ‘an NHS with a country attached’. Given that the UK allocated only 10.9 per cent of GDP to healthcare in 2023 (a whole percentage point lower than France or Germany), there is a fair way to go before that happens. His comments will please the Institute of Economic Affairs, which has been publishing pamphlets with titles such as After the NHS (1968) for decades. Nigel Farage and Reform campaigned on a commitment to replacing the NHS with a system of tax relief for private medical insurance and publicly funded vouchers (strikingly similar to the proposals outlined by the IEA in After the NHS). Streeting’s claims that the service is ‘broken’ carry risk. There is some merit in his insistence that the word accurately conveys the plight of patients waiting for treatment. But few public services or industries have been salvaged after the boss agreed with their ideological opponents that they were unfit for purpose.

Darzi and Streeting converge in their plans to fix the NHS. One of the solutions centres on the expanded use of digital technology and AI. During the pandemic an incredible 80 per cent of people registered on the NHS app, but fewer than 20 per cent now use it monthly. One of the strengths of the NHS is its capacity to maximise economies of scale: it can use its buying power to negotiate better prices for medicines, for example. A revamped NHS app might be able to draw on the health service’s size and the trust that the public still has in it. The potential benefits of AI remain up for debate. A number of research papers and case studies have suggested how machine learning might usefully process large amounts of patient data or help practitioners with diagnostics (if regulated properly and applied ethically). But are we ‘on the precipice of an artificial intelligence revolution’, as Darzi insists? The report offers no details of the form such a revolution might take, and no substantial comment on the risks.

The report’s emphasis on prevention builds on much firmer ground. In the dying days of New Labour, Gordon Brown appointed Darzi to the House of Lords and made him parliamentary under-secretary of state for health. He published a ten-year strategic plan for developing the health service, High Quality Care for All (2008), which recommended softening the Blairite use of targets and expanding public health policies to help prevent illness. The financial crisis curtailed the chance to fully realise the report’s suggestions, and David Cameron’s election victory drove many of Darzi’s goals further out of reach. In 2020, the public health expert Michael Marmot – another Brown recruit – found life expectancy falling in the areas hardest hit by benefit reforms, homelessness and cuts to local public health budgets. The average male life expectancy in Blackpool is now more than a decade lower than in Hart, Hampshire.

In his new report, Darzi once again urges a focus on prevention, calling for ‘bold action … on obesity and regulation of the food industry’. He also wants more NHS health checks to prevent chronic conditions such as heart disease. These are not novel ideas. The 1946 NHS Act included provision for a national network of health centres – familiar to us now, but radical in the mid-20th century – to bring together GPs, nurses, dentists and public health experts to treat patients in a holistic way and identify ill-health in advance.

Health centres started expanding at scale during the 1960s and 1970s, but – as in other health systems – hospitals have long taken the lion’s share of budgets and prestige. And, as Darzi observes, intercepting ill health at its source requires moving beyond the NHS. As decades of research has shown, health outcomes are shaped by your employment and income, the house you live in, the air you breathe, the mental stress you face and so on. When it comes to these ‘social determinants of health’, to borrow Marmot’s phrase, the wider welfare state enters the equation – including the provision of benefits, income support, childcare and housing.

The regeneration, or even maintenance, of this social fabric will be challenging for Labour. Parts were lost during the 1980s and 1990s, and others abandoned more recently, including Sure Start Centres, which had helped drive down hospital admissions for children. The work of prevention is tough and requires thinking both expansively and over the longer-term (a challenge for governments seeking short-term gain during an election cycle). It also costs money.

So far, Labour has refused to end the two-child limit on benefit payments (introduced in 2017), citing constraints on public finances. New modelling in the Journal of Epidemiology and Community Health suggests that doing so would ‘substantially improve child health and reduce health inequalities in England’. The preventative aspirations of the Darzi Report are inescapably tied to public investment both in and beyond the NHS. More generous benefits and improved social services may be less flashy than new AI infrastructure, but they offer the best chance of turning the nation’s health around, and meeting the expectations of the millions who cited the NHS as a main concern when they voted in July.