Darzi’s NHS diagnosis is largely right – now the government needs to act

Ari Darzi does not soften his words when allocating blame for the state of the NHS. The surgeon, and former health minister, argues that austerity, underinvestment in capital throughout the 2010s, and the Lansley reforms (which he calls a “calamity without international precedence”) are all to blame for the poor performance of the NHS. There is no doubt as to the identity of the architects of those decisions: the governments between 2010 and 2024. He is right in his assessment. 

Capital underinvestment, poor management, and over-centralisation have hurt the NHS

Capital underinvestment is a major reason why the large increase of staff in hospitals since 2019 – roughly 20% across England – has not led to a commensurate increase in activity, with decrepit buildings, out of date IT systems and hardware, and a lack of appropriate equipment all hindering the efforts of NHS staff.

Darzi identifies NHS management as an issue – a point that the IfG has repeatedly made. Management in the NHS is far too centralised, with large numbers of people in the Department for Health and Social Care (DHSC) and NHS England tasked with afflicting trusts with heavy reporting burdens and a dizzying array of targets. At the same time, there is a lack of management and administration capacity in trusts and integrated care boards (ICBs). That makes it difficult for hospitals to plan care effectively and leads to frontline staff spending more time on admin.

He also points out that NHS funding and care is far too centralised in hospitals, despite repeated commitments to move care into the community and better integrate primary, community, mental health and adult social care services. That has contributed to the steady erosion of GPs from general practice, making it more difficult for patients to access the service and increasing the likelihood they will require more intensive and expensive hospital care.

While Darzi makes it clear that general practice has not been sufficiently supported or funded, it is arguable that he underplays the crisis. There are half as many GP partners under the age of 40 in 2024 compared to 2016. That poses a severe risk to a service that relies on GPs taking on partnership to deliver care. GPs are also leaving more deprived areas more quickly than the better off parts of the country. That will likely worsen health inequalities. The general practice estate is suited to a model of care that was designed in the 1940s and is woefully inadequate for the enormous recent shift in workforce.

Adult social care was outside Darzi’s remit, though he acknowledges its importance. That will be a relief for the government. Labour recently scrapped long-planned funding reforms and have subsequently been extremely quiet about its plan for the sector. That is an unsustainable approach. The sector is in dire need of support and reform. Ministers will not fix the NHS without fixing adult social care.  

The government must now rise to the challenge set by Darzi

Every issue that Darzi raised has been discussed at length in health policy circles. The Institute for Government has been pointing out the service’s woes since 2017, with multiple reports since the pandemic digging into more depth on the same causes that Darzi identifies. We are far from alone; think tanks such as the King’s Fund, the Health Foundation, Nuffield Trust, the Institute for Fiscal Studies, and the Institute for Public Policy Research have also made broadly similar arguments.

Labour too was well aware of these problems before commissioning Darzi’s report, but did so hoping it would provide political cover. Today’s coverage will help them apportion blame for poor NHS performance to previous governments. But this exercise will only be of value in the long-term if it is a spur to action. It is helpful for there to be more widespread understanding of the problems facing the NHS, but it is now the government’s responsibility to do something about it.

Darzi’s report now becomes the watermark against which Labour’s record on the NHS will be judged. That is both an opportunity and a risk for Labour; if the NHS improves then Labour can rightly claim credit. But there will be nowhere to hide if performance flatlines or worsens. 

The question now is what the government actually plans to do. The autumn budget will be the first time that the government has to choose how to allocate scarce funding between services and will provide an early indication of its priorities. On the NHS, Labour has committed to funding the NHS Long-Term Workforce Plan – a policy which will require a substantial uptick in funding compared to the last 14 years.

The DHSC is also working on a “10-year plan”, due to be published in spring 2025.  ⁴ https://www.hsj.co.uk/integrated-care/new-10-year-health-plan-due-next-spring/7037515.article  That will much more clearly detail how the government intends to reform the health service. The rough outline of ambitions – making the NHS more preventative, shifting care into the community, bolstering general practice, among others – are correct, but will be difficult and cut against many political incentives. If Labour manages to deliver that, it will succeed where many governments have failed.