Lord Darzi's Independent Investigation into NHS Performance

There will be a debate on Lord Darzi's Independent Investigation into NHS Performance on Monday 7th October 2024. This debate will take place in the House of Commons chamber.

Why was the Darzi report commissioned?

In July 2024, Wes Streeting, Secretary of State for Health and Social Care, commissioned Lord Darzi to carry out an independent investigation into the NHS in England. As set out in the terms of reference, the investigation would focus on:

• Patient access to healthcare
• The quality of healthcare being provided
• The overall performance of the health system.

The investigation would also consider health inequalities and unwarranted variation across these themes.

The aim of the investigation was to provide an independent and expert assessment of the performance of the NHS in England and the challenges facing the healthcare system. The findings would form the basis of a new, 10-year plan for health. The government said the findings would open up “an honest conversation with the public and staff about the level of improvement that is required, what is realistic and by when.”

The investigation did not include a public consultation due to the short time frame involved, but the government said this will feature in the creation of a 10-year plan.

Lord Darzi is an independent peer, although he was originally appointed as a Labour peer and served as the Parliamentary Under-Secretary for the Department of Health from 2007 to 2009. He is a former surgeon, and in 2008 led a review of the NHS titled High Quality Care for All.

Publication of the Darzi report and main findings

The final report of the investigation (‘the Darzi report’) was published on 12th September 2024, alongside a technical annex containing the analyses used in the investigation.

A summary of the report in provided in a letter to the Secretary of State for Health and Social Care.

Lord Darzi ultimately concluded that the NHS is in “serious trouble”. He began the report by explaining said that the deteriorating health of the nation has impacted upon NHS performance and demand on the system is rising. Lord Darzi makes links in the report between the NHS and national prosperity. He said a “virtuous circle” can be created if the NHS helps more people back into work and the economy grows, creating more funding for public services.

Access and quality of care

Lord Darzi went on to say that patient access to NHS services is poor, whilst the quality of NHS care is mixed. In particular, he noted issues with poor and varied access to GPs, growing waiting lists and long waiting times. Lord Darzi emphasised that resources must be shifted into community health services and social care in order to reduce the strain on hospitals. He argued that whilst this has been a central tenet of health policy for some time, it has been undermined by financial flows and “knee-jerk” responses from ministers that focus spending on hospitals. He said this funding distribution is reinforced by performance standards that focus on hospitals.

Lord Darzi said that productivity in the NHS is too low despite growth in hospital staff numbers, largely because patients do not flow through the system and staff must spend time dealing with process issues.

Lord Darzi commented on persisting inequalities in the impact of the deterioration in access to care. He highlighted challenges in access and experience for some groups, including those in poverty, people experiencing homelessness, people with a learning disability, and carers. He also noted disparities in access to and outcomes of care for some ethnicities, highlighting longer waits for elective care for Asian people and the disproportionate use of the Mental Health Act with Black or Black British people.

Lord Darzi also focused on the importance of health promotion and protection and described cuts to the public health grants as “perverse”. He said there needs to be political will and a willingness to invest in public health and noted a lack of action on obesity and regulation of the food industry.

Drivers of NHS performance

On performance, Lord Darzi highlighted that the NHS is not meeting the promises to the public set out in its constitution. He said the following inter-related drivers of performance have contributed to the “dire state” of the NHS:

• Funding, investment and technology. Lord Darzi highlighted the impact of austerity and said there has not been sufficient capital investment. He also emphasised the need to invest in technology in the NHS, including AI, digital health records, and patient-facing digital tools, to improve NHS productivity and patient outcomes.
• The covid-19 pandemic. Lord Darzi said that austerity and a lack of capital investment meant the NHS went into the pandemic with low resilience. He noted that the NHS delayed, cancelled or postponed more routine care during the pandemic than other comparable health systems. He said this led to a bigger backlog than other health systems.
• Patient and staff engagement. Lord Darzi said the patient and public voice is not loud enough whilst staff feel “disempowered and disengaged”.
• NHS structures and systems. Lord Darzi discussed the impact of the Health and Social Care Act 2012 on NHS management and structures. He described the act and subsequent reforms as “disastrous”, leaving the NHS in a state of “constant reorganisation” and dissolving the management line. He said this had left current management capability behind where it was in 2011. He also highlighted the growth in the number of people working in regulatory functions and organisations that can instruct the NHS. He said this “encourages too many to look upwards rather than to those they are there to serve.”

Key themes for the 10-year plan

Lord Darzi concluded the report with a list of themes to be considered in the upcoming 10-year health plan, which are as follows:

• Re-engage staff who do want to improve care despite low workplace morale. Empower patients by giving them more control over their care.
• Move care closer to home by re-directing funding to grow GP, community and mental health services.
• Streamline a system for a neighbourhood NHS by working collaboratively between different services.
• Increase hospital productivity by improving the flow of patients and investing in buildings and equipment to improve waiting times.
• Embrace technology and digitalise NHS systems.
• Use the NHS to reduce the number of people out of work for health-related reasons and therefore benefit national prosperity.
• Reform to make the structure of the NHS deliver, by ensuring that roles are understood, management is well-distributed and key processes such as capital approvals are strengthened. This should not be enforced through top-down reorganisation.

How was the Darzi Report received? Government response

In a speech to the King's Fund following the report’s publication on 12th September 2024, Prime Minister Sir Kier Starmer said that said the report had provided a “raw and honest assessment” of the NHS. He that there would be “no more money without reform”.

In a statement on the report in Parliament, Secretary of State for Health and Social Care, Wes Streeting, described the report as “damning” and said the government would respond with reform and recovery. He said that there would be three “big shifts” to secure the future of the NHS:

• From analogue to digital,
• From hospital to community, and
• From sickness to prevention.

In a speech at the Labour party conference on 25th September, Wes Streeting re-enforced the government’s plans to prioritise social care and establish a National Care Service. He also announced plans to send teams of clinicians into hospitals to implement reforms and cut waiting times. He said they will initially target areas with the most people out of work due to illness.

Opposition response

In her response to the government’s statement on the Darzi report, the Shadow Health Secretary, Victoria Atkins, noted record investment and staffing levels in the NHS, as well as the previous government’s reforms to boost community services and plans to increase productivity. She questioned why the Darzi report had not referred to the NHS productivity plan announced at the 2024 Spring Budget.

Daisy Cooper MP said the Liberal Democrats “have long argued that we need to shift healthcare from hospitals to high streets, and from treatment to prevention, because doing so improves health outcomes and saves taxpayers’ money.” She also described social care as “the elephant in the room”.

Health think tanks and NHS organisations

The Darzi report was broadly welcomed by think tanks and NHS organisations for setting out the current state of the NHS and the challenges it faces. Matthew Taylor, the chief executive of the NHS Confederation, a membership organisation for NHS commissioners and providers, agreed that the report correctly identified the central issues facing the NHS and mirrored the experiences of NHS leaders.

Similarly, a briefing published by NHS Providers (PDF), the membership organisation for NHS trusts in England, praised the report as a “timely and perceptive diagnosis of the problems facing the NHS” which upholds central NHS principles. The health think tank The Nuffield Trust praised the Darzi report as a form of “reflective listening” that showed NHS staff their experiences are recognised.

According to a BBC article (‘Wes Streeting says he will not back down on broken NHS claims’) some “senior people in the health service, as well as officials within NHS England” have expressed concern that the government’s description of the NHS as “broken” could affect public perception of the NHS and staff morale.

Stakeholders highlighted the need to consider funding flows in the NHS. In the Darzi investigation: what you need to know, the NHS Confederation called for more investment to be directed towards preventative, at-home and local healthcare. It said funding should be considered beyond single-year budgets to enable the creation of a long-term strategy for improvement across the healthcare system. However, they also noted that emergency funding would also be required to meet immediate winter demands. The Nuffield Trust agreed with this dual approach to funding, and the health think tank The Health Foundation said that “tricky trade-offs” will be needed to make up for funding shortfalls.

Another theme amongst responses was the need for cross-government working, with a focus on health promotion and prevention. The Health Foundation called for ministers “to put health at the heart of government” and make it central to policies across the board. NHS Providers (PDF) similarly said that the healthcare of children and young people should be “a cross-government priority”. The organisation stated trust leaders want to work in collaboration with the government to tackle the problems in health and social care. The King's Fund said that to address the problems outlined in the Darzi report “the treatment surely needs to be radical”. It called for a move towards prevention-based strategies as opposed to a focus on performance targets.

Multiple stakeholders noted that social care and public health were outside of the report’s remit. The King's Fund said this created a risk that reforms would focus on the NHS rather than the development of a “wider health mission”. The Nuffield Trust agreed that the terms of reference for the investigation didn’t allow room for a full exploration of social care or public health, but it said the 10-year plan will create space for discussion on these topics.

Lord Darzi shared his reflections on the review in an article published by the Guardian on 18th September. He called for:

• The establishment of a cross-government goal to increase healthy life expectancy by 10 years by 2055.
• Health to be considered across society. Positive innovation and employment practices should be encouraged whilst harmful products and insecure work should be discouraged.
• Levies against harmful products to encourage the market towards healthier practices.

A week after the Darzi report was published, Lord Darzi was also involved in the publication of a report from the Institute for Public Policy Research (IPPR). The report is the conclusion of a three-year cross-party commission chaired by Lord Darzi and Dame Sally Davies, a former Chief Medical Officer. It focuses on the links between national health and the economic state of the UK and argues for a “move from a sickness model of health policy to a health creation one”.

Further reading

The government's 10-year plan for health and care: Three future shifts (The King's Fund, September 2024)

Academy response: The Darzi review (Academy of Medical Royal Colleges, September 2024)

Patients Association response to the Darzi Review (The Patients Association, September 2024)

Our greatest asset: The final report of the IPPR Commission on Health and Prosperity (Institute for Public Policy Research (IPPR), September 2024)

Just About Managing: The Role of Effective Management and Leadership in Improving NHS Performance and Productivity (Policy Exchange, September 2024)

NHS key statistics: England (House of Commons Library, July 2024)

Capacity pressures in health and social care in England (House of Commons Library, July 2024)

The structure of the NHS in England (House of Commons Library, July 2023)