Ara Darzi comes with a very long list of accolades, titles and achievements. Professor; esteemed surgeon; refugee turned Lord; academic author of more papers than most mortals will even read; Knight Commander of the Order of the British Empire; friend of Sirs Elton John and Michael Caine.
Not that he needs it, but I'd also add ‘coiner of pithy contributions to health policy analysis’. His 2024 ‘Independent Investigation of the National Health Service in England’ was an empirically strong - if politically shaped - piece of work. It was also very well drafted.
One of Darzi’s striking phrases was ‘the right drift’. It’s a familiar story, but he tells it well:
“Since at least 2006, and arguably for much longer, successive governments have promised to shift care away from hospitals and into the community. In practice, the reverse has happened”.
Between 2006 and 2021, Darzi notes:
“…the share of NHS spending on hospitals increased from 47 per cent to 58 per cent…The ‘left shift’ could, in fact, be characterised as a ‘right drift’.”
The chart below, from some excellent analysis by the Nuffield Trust, illustrates Darzi’s point. It contrasts changes in real terms funding (adjusted for population need) between 2016/17 and 2022/23. Funding for acute care in NHS trusts grew by 21.4%, while funding for community healthcare shrank by 4.2%.
The authors note that:
“…despite the often repeated ambition to shift more care and health care resources into services ‘closer to home’…funding for NHS community health care services was cut in real terms in three out of the six years between 2016/17 and 2022/23.”
Darzi’s ‘right drift’ can also be seen through the lens of staffing. Nuffield Trust analysis shows that, between 2010 and 2020: the number of community health nurses fell by 7%; health visitor numbers by 29%; and learning disability nurses by 44%. The number of hospital-based specialists increased.
It’s an incredible story. Policy ambitions point one way; resources head off in the opposite direction. Cognitive dissonance meets health policy.
But this isn’t just a story of policy failure. The consequences are very real and very human.
Analysis for Marie Curie by (our sister team) the Health Economics Unit and Nuffield Trust shows how the right drift leads to poor quality care at the end of life. They find that 80% of spend in the last year of life goes on hospital based care; just 11% on primary and community care; and a trifling 4% on hospice care.
Failure to make the ‘left shift’ has helped medicalise death, waste resources and cause unnecessary suffering.
What has brought us here?
Darzi’s diagnosis is that:
“…the ‘right drift’ is not an accidental outcome. It is the result of financial flows that have funded hospitals for their activity and much of the rest of the NHS for their efforts. It was the choice of successive governments to exclude primary care, mental health and community services waiting times from NHS constitutional standards, which are instead focus [sic] on hospital care. This has been reinforced by the failure to invest in the measurement of primary, community and mental health services, which has obscured the real consequences of cuts to block budgets.”
Darzi also offers political explanations. In one of several shots, he notes that the right drift accelerated during reforms under the Coalition Government:
“…when the NHS’s commissioning structure was at its most distracted: from the publication of the Liberating the NHS white paper in 2010 and the passing of the Health and Social Care Act of 2012. It seems unlikely that this is merely a coincidence.”
I'm convinced that Darzi hits the mark with all of these points. Every factor he cites also appears in commentary in this area - and in recent interviews I've done, asking service leaders, clinicians and academics to explain why the left shift hasn’t happened.
But I think this analysis also misses something big. Something perhaps too close for Darzi to see.
The chart below suggests what this might be. Produced by the Strategy Unit for the report to launch the Health Foundation’s ‘REAL Centre’, this edited version shows how the growth in elective procedures has outstripped that for community services. Crucially, it looks at the drivers of that growth. It shows that the role played by demographic change is trivial relative to ‘other factors’.
In this case, ‘other factors’ is a near synonym for technological advance. There is subtlety in the findings, and readers should consult the full report, but the essence is that growth in elective procedures is explained primarily by medical breakthroughs, rapid expansions in treatment possibilities and lowering of treatment thresholds.
We can do more, and so we do. And the generation and deployment of expanded possibility is concentrated in the research and capital intensive – and hospital based – specialties. It does not, in the main, pull resources into the, relatively, low-tech community services sector.
Highly skilled, research driven and motivated specialists – such as Ara Darzi - have created the conditions for the right drift. Investment, as the Office for Budget Responsibility notes (Table 3.1), follows innovation.
This is unpalatable stuff. We want medical breakthroughs and excellent treatments; we want scientific and technological innovation; we want top-flight clinical work. And yet following these desires will not lead us to better population health - or a less hospital-centric NHS.
This unpalatability shows why the left shift will be so hard to achieve. The right drift results from some very strong, and very deep, currents – not least the relationship between innovations in treatment and NHS investments.
Pressure will build. Forthcoming Strategy Unit modelling shows that demographic change will significantly alter demand for care. The implications are more pronounced for community than for acute services: largely because of growth in the oldest population groups. Our estimates suggest that community services will need to expand at an unprecedented rate over the next decade ‘just’ to accommodate the effects of demographic change. Reshaping patterns of service provision would require more effort still.
Making the left shift means halting Darzi’s ‘right drift’, before pushing hard in the opposite direction. Doing so will be humanly, and politically, and perhaps clinically, uncomfortable. But then so too, as Darzi’s investigation showed, is the current situation.
