16 years separate Ara Darzi’s 2008 landmark ‘Next Stage Review’ from 2024’s rapid survey of the NHS’ troubles. Yet both reviews offer the same fundamental diagnosis: the needs of the population have changed, but the provision of services hasn’t. And both reviews suggest that more care is needed in primary and community settings - and that services should prevent problems, as well as managing them when they occur.
What are the chances of success this time? Will change follow in 2024 the way it didn’t after 2008? Or will an 80-year-old Darzi need to dust off his pen for a 2040 review?
This time around, Darzi was not asked to prescribe change. But he has prepared the ground for it. While analysing the NHS’ current woes, he outlines the shape of a policy response. And Darzi’s outline is entirely supportive of the ‘three shifts’ that Wes Streeting wants the NHS to make, from:
- Hospital to community.
- Treatment to prevention.
- Analogue to digital.
As broad aims, Streeting’s shifts are uncontroversial. Ways of expressing them have come and gone, but these intentions have been a constant feature of health policy for the last several decades. Darzi notes that:
‘At the highest level, the NHS has had the strategic intention to shift spending from reactive care in hospitals to more proactive care in the community setting – but care has in fact moved in the other direction.’
Moving care into community settings is known as ‘the left shift’. Darzi notes that recent years have in practice seen ‘a right drift’: with resources and activity skewing towards the acute sector. He explains this partly in terms of policies on financial flows and incentives (discussed later), but Darzi is also clear – and brutal – about the role of politics:
‘The Health and Social Care Act of 2012 was a calamity without international precedent. It proved disastrous.’
Ouch.
On this diagnosis, political skill and policy imagination are needed to make the shifts that Streeting wants to see. So what dilemmas lie ahead? And what policies and political moves are required?
The many strands
While there are many continuities and similarities, the situation in 2024 is both more complicated and more fraught than it was in 2008. Reform must contend with many intertwined strands. Here are just a few.
Waiting lists are the most pressing and obvious problem. More than 6.3 million of us are on them, and they have been growing since around 2011. As a highly salient public issue, reducing waiting lists featured highly in the election campaign. This is the government’s immediate priority for the NHS.
Containing waiting lists to an ‘immediate priority’ will be extremely difficult. The idea that lists can be reduced, then other reforms undertaken doesn’t seem credible. As Darzi notes:
‘…it is unlikely that waiting lists can be cleared and other performance standards restored in one parliamentary term’.
Yet pressure to show progress will increase: especially as the next election begins looming into view. And addressing waiting lists will require detailed attention and support - directed largely at the hospital-based services the NHS should be ‘shifting from’.
Then there are resources. Or rather, there aren’t. The Labour governments of Blair and Brown successfully addressed waiting lists via specific policy initiatives, a significant injection of resources, and associated political case making (which was so successful that tax rises to fund the NHS even proved popular).
In 2024, Streeting – and Chancellor Rachel Reeves – have been clear: there is no immediate supply of extra money for the NHS. There will be no option to ‘double run’ by increasing capacity in primary and community services, before shifting care out of hospital. Arguments about ‘spending to save’ will not be left unscathed at Reeves’ Treasury.
Instead, the task is to rebalance and reshape care within the existing resource envelope. In principle, this is well within the NHS’ gift. In practice, it will prove extraordinarily difficult.
‘Rebalancing’ means taking resources from one area of service to give to another. More prevention means less treatment. And, given the proportion of NHS budget that goes on workforce, ‘shifting resources’ most likely means ‘moving staff’. How would the move of – say – 10% of hospital staff into community settings work in practice?
And what about the health of the population? Demand for care is partly a function of health status, so are there reasons for optimism here? There aren’t. We are becoming less healthy and more unequal. For reasons too complex to summarise here, we need - currently ‘broken’ - NHS services more than before.
The strands become a knot
Shifting resources from hospitals will be difficult and unpopular; the gravitational pull of addressing waiting lists will make it more so. As ever, the needs of the long-term (community based, preventative care) are in tension with those of the short-term (speedy treatment in hospital). And immediate needs in 2024 are far more pressing than they were in 2008.
This is an intimidatingly difficult situation. Health policy in England resembles the Gordian knot of ancient Greek myth. This knot was so complex and so tightly entangled that it could not be untied. Many came, tried and failed – leaving with exhausted fingers. Many in the NHS might wish that tiredness was so confined.
People kept trying to untie the Gordian knot because the promised reward was ruling Asia. Wes Streeting is known to be ambitious, but presumably he would settle for the more modest – but still incredibly impressive – legacy of achieving his three shifts.
If he can untangle the mass described above, he will secure a lasting place in NHS history. He would also allow Ara Darzi to retire his pen in peace.
In Part 2 of this blog, we look at how this might be done.
