A long and difficult cure for Britain’s NHS

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For many who have used the NHS in England recently, Lord Ara Darzi’s dire findings on the state of the health service will be no surprise. They know the system is in “serious trouble”, emergency rooms are in an “awful state”, waiting times have ballooned and people struggle even to see their GP. But the government-ordered report by the surgeon and former health minister provides a penetrating diagnosis of what ails the NHS, and an outline of a cure. Prime Minister Sir Keir Starmer says the service must “reform or die”, and prudently insists there will be no extra funding without reform. He cannot escape the fact, however, that curing the NHS will need money too.

Without naming the Conservative party once in 163 pages, Darzi leaves little doubt where he pins the blame. A “calamity” of a reorganisation in 2012 destabilised the NHS. The “most austere decade in NHS history” meant current funding grew, in 2010-2018, at far below historical levels — with the capital budget frequently raided to plug the gap. Darzi estimates England invested £37bn less in health since 2010 than if it had matched levels in rich-country peers. Its weakened state meant the NHS had to cancel far more routine care than other countries did during the Covid-19 pandemic.

These problems were compounded by a broader deterioration in public health, and the parallel crisis in social care that means one in seven hospital beds is occupied by someone who shouldn’t be there. Crumbling and inadequate capacity help to explain why, despite having more people than in 2019, NHS productivity has fallen, with 12 per cent less surgical activity per surgeon.

The “three shifts” that encapsulate the government’s response — still to be developed into a 10-year plan — all make sense. A shift of healthcare from hospitals to community, promised by successive governments but never delivered, must finally happen, along with an associated shift “from sickness to prevention”. The vision of community hubs managing people’s health and carrying out preventive and diagnostic screening, to reduce the numbers who ever reach hospital, is compelling. Shifting “from analogue to digital”, in a woefully under-digitised service, is crucial, too, to exploit new technologies that can accelerate the shift to prevention.

All this will, though, require reforms stretching far beyond the core NHS. They must also involve rebuilding public health services traditionally provided by local authorities and, above all, a revamp of social care — on which Labour, for now, is saying very little.

More investment will also be needed. Starmer is right to make additional funding conditional on reform given the parlous public finances — highlighted by the spending watchdog on Thursday — and the need to incentivise a vast system prone to inertia. But reform and investment must happen in parallel. Curbing future NHS running costs requires spending today on infrastructure and equipment. And transiting from in-hospital to more out-of-hospital care will require years of “double running” while the preventive system is built up sufficiently to relieve demand on hospitals.

The government has ruled out any change in Britain’s taxpayer-funded health model — though, longer term, the UK would be wise to look at what it might borrow from continental European systems using social insurance models. Since it has also rejected any rise in core taxes, Starmer’s government must find other means of raising health investment — probably through borrowing, within the constraints of its fiscal rules. Other sectors, too, are crying out for funds. Yet given how central health is to all public services, and to boosting growth, fixing the NHS is surely this government’s paramount domestic policy challenge.