Greg Dropkin, Keep Our NHS Public Merseyside 20 September 2024
Lord Darzi’s Independent Investigation of the National Health Service in England is a double-edged sword. Yes, it is a no-holds-barred look at how the NHS is failing to deliver in line with what the public rightly expects from their health service. It makes an uncompromising argument that these problems cannot be resolved without ending Austerity and refunding the NHS to the level required. KONP summarised those aspects, which echo other recent analyses of a failing NHS, when Darzi’s report was published on 11 September.
At the same time, Darzi rewrites NHS history, omits a key founding principle of the NHS, does not oppose privatisation, is silent on a major current controversy, and sets the stage for Labour’s intended “reforms”. For those reasons, Darzi’s approach is both deficient and dangerous.
The rest of what Darzi did and did not say
Darzi lays the entire blame for the current NHS crisis on Coalition and Tory governments since 2010, their political choice to pursue Austerity, and the Health and Social Care Act 2012.
NHS Austerity began under Labour in 2009 with the “Nicholson Challenge”, when the government accepted and implemented the recommendations of the McKinsey Report commissioned by Gordon Brown. This aimed to save £15-20bn per year from the NHS budget by ongoing “provider efficiencies” (work harder for less pay), promoting community services in place of hospitals, and removing some procedures from the NHS (whether or not the public needed them). Coalition and successive Tory governments did not invent this policy, they continued it.
Darzi is silent on the many “reforms” introduced by the Blair government, including Health Secretary Alan Milburn’s Concordat with the private sector for elective treatments, proliferation of Private Finance Initiative (PFI) hospitals, Foundation Trusts, Choose & Book, Independent Sector Treatment Centres, Personal Health Budgets, Practice Based Commissioning, the Framework for External Support for Commissioning (FESC)…
Darzi targets the HSCA 2012 but explicitly welcomes the Health and Care Act 2022, which gave legal status to the top-down restructuring imposed by NHS England under Simon Stevens. This stretched from the Five Year Forward View (2014), through STPs (2016), Accountable Care Organisations (2016), Accountable Care Systems (2017) quickly rebranded – unchanged – as Integrated Care Systems (2018), and the NHS Long Term Plan (2019). US health insurance corporations including UnitedHealth and big accountancy firms including PricewaterhouseCoopers (PwC) promoted the project. Many such companies and their subsidiaries were accredited by NHSE on the Health Systems Support Framework (HSSF) to develop Integrated Care Systems. The project aligns NHS financing with the US model of “Accountable Care”. That is why many campaigners call it “Americanisation” of the NHS.
What about the private sector? Darzi is certainly opposed to replacing the NHS by an insurance model. He writes (p16):
Nothing that I have found draws into question the principles of a health service that is taxpayer funded, free at the point of use, and based on need not ability to pay. With the prominent exception of the United States, every advanced country has universal health coverage – and the rest of the world are striving towards it. But other health system models – those where user charges, social or private insurance play a bigger role – are more expensive, even if their funding tends to be more stable. It is not a question, therefore, of whether we can afford the NHS. Rather, we cannot afford not to have the NHS, so it is imperative that we turn the situation around.
But nothing in Darzi’s quote says that the health service should be publicly provided. Darzi’s version of the principles omits “publicly provided”, as if Bevan had not nationalised private hospitals when founding the National Health Service.
Darzi refers to the NHS as a universal service, but never mentions how those who cannot prove their entitlement are charged. The word “migrant” or “immigrant” never appears, nor does the “Hostile Environment” or in fact any reference to any NHS patient being charged for anything. Darzi simply says he is opposed to replacing the NHS model by “other health system models – those where user charges, social or private insurance play a bigger role”. As if none of the migrant charging scandals – including those affecting the Windrush generation – had ever occurred.
Darzi appears to think that the NHS Long Term Plan and privatisation are mutually exclusive. On p133-4 he promotes patient choice, then attacks the compulsory clinical tendering in the HSCA 2012, and then writes:
Yet despite all-but eliminating the role of markets, the NHS is yet to fully embrace the planned alternative. The NHS Long Term Plan was published in 2019, but was quickly superseded by events with the outbreak of the pandemic the following year.
“All-but-eliminating”? Yes, the HCA 2022 repealed Section 75 (compulsory tendering of clinical services) of the hated HSCA 2012. But it did not remotely eliminate the role of markets. Reports by the Centre for Health and the Public Interest (CHPI) and the KONP privatisation databases show how the private sector has penetrated the NHS from service provision through to commissioning, a saga running from Blair’s FESC to the HSSF.
Darzi refers to multidisciplinary teams, but does not mention Physician Associates, Anaesthesia Associates, or Surgical Care Practitioners, whose roles are highly contested including within his own profession. The great expansion of Medical Associate Professionals is set out in the NHS Workforce Plan and was signalled in the NHS Long Term Plan which Darzi welcomes.
How Labour responded
When Darzi’s report was published, Keir Starmer immediately made clear that additional funding for the NHS was conditional on acceptance of “reforms”, and that he was ready to challenge health unions on this. A blitz of media reports outlined the plans. For example, a report in the Financial Times (12 Sept) was headlined “NHS to receive ‘no more money without reform’, says Starmer”. The FT explained that Starmer pledged to carry out the “biggest reimagining of our NHS since its birth”. He said: “We know working people can’t afford to pay more, so it’s reform or die.” Setting out the government’s top three priorities for reform, Starmer vowed to move the NHS away “from an analogue to a digital” service, shift more care from hospitals to communities and “be much bolder in moving from sickness to prevention”.
How Darzi informs Labour’s plans
Each of Starmer’s ideas, which are hardly new, is contained in Darzi’s report.
Digital
On p17, Darzi writes:
Tilt towards technology. There must be a major tilt towards technology to unlock productivity. In particular, the hundreds of thousands of NHS staff working outside hospitals urgently need the benefits of digital systems. There is enormous potential in AI to transform care and for life sciences breakthroughs to create new treatments.
P 30 promotes the “digital front-door” and the NHS App; p108 extols the Federated Data Platform:
The NHS has made some significant investments, such as the Federated Data Platform, which have great promise and have started to show some impact locally [note 358 quotes NHSE on the FDP]. Similarly, there are dozens of examples of start-ups that have created apps that improve the quality and efficiency of care. But too many of these remain subscale. And as we have seen, the NHS App is not currently living up to its potential impact given the vast scale of its registered user base.
Neither ‘privacy’ nor ‘confidential’ nor ‘patient data’ nor the Caldicott Principles are mentioned in the report, let alone Palantir, the US spy firm awarded the contract for the FDP and now publicly engaged in support of Israel’s war on Gaza.
Community
Moving from hospital to community care runs right through the Darzi report, with 117 references to community care. For example, on p10 he writes: “If you had arrived at a typical A&E on a typical evening in 2009, there would have been just under 40 people ahead of you in the queue. By 2024, that had swelled to more than 100 people. This is because we have underinvested in the community.”
The queues do reflect the inability to move people out of A&E into a hospital bed, which is partly caused by the crisis in social care. But it is also caused by the deliberate bed cuts built in to PFI business cases, which claimed community care would replace the need for hospital beds, and which led to hospitals running at nearly 100% bed occupancy, way over the safety threshold.
Darzi blames the HSCA 2012 for the failure to actually shift funding from hospitals to community care. But both wings of the NHS need full funding, and there will be patients needing hospital care who will suffer if that is delayed by a presumption that they should be kept out of hospital.
Preventative
Darzi advocates shifting from treating sickness to preventative care. On p107 he writes:
Over the past 15 years, many sectors of the economy, in this country and internationally, have been radically reshaped by platform technologies. From the way we shop, to the way we socialise and how our politics is conducted, technology has transformed daily life. By contrast, while there are many excellent examples of technology having an important impact in the NHS – from virtual wards to remote dermatology consultations – it has not radically reshaped services. The NHS remains in the foothills of digital transformation. Indeed, the last decade was a missed opportunity to prepare the NHS for the future and to embrace the technologies that would enable a shift in the model from ‘diagnose and treat’ to ‘predict and prevent’ – a case that I made in my report High Quality Care for All, more than 15 years ago.
In truth, a shift to prevention means mostly tackling the social determinants of health and health inequalities, largely outside the remit of the health service but crucial to many other areas of Labour policy. AI and apps won’t prevent asthma for a child living in damp and mouldy private rented accommodation, without sufficient environmental health staff to intervene and the necessary funding.
Where KONP stands
KONP was launched in 2005 in direct response to Blair’s moves towards privatisation. Long before the Darzi report, KONP had written on the issues above, and recently on Labour’s Manifesto and its reform plans. The KONP Health Data Working Group has analysed issues with converting to a digital NHS – a plan which Starmer, Streeting, Milburn, and Darzi all endorse and which is Starmer’s Reform #1.
Darzi welcomes the Health and Care Act 2022 which he says restored “sanity”. KONP opposed the Act before, during, and after its passage, and invited Margaret Greenwood to address a supporters zoom meeting precisely because she was the lone Parliamentary Labour voice of sustained opposition to the Act. The Vision for a People’s NHS acknowledges that “we will need to repeal or replace some laws in order to achieve our vision”.
Darzi is right to emphasise massive capital underfunding as contributing to poor productivity. He is also right that “It is not a question of whether we can afford the NHS. Rather, we cannot afford not to have the NHS”. When it comes to our fight to restore the NHS to its founding principles, as spelled out in the Vision for a People’s NHS, it is clear that Darzi is not on our side. His report is designed for, and will be used by, Starmer and Streeting as they attempt to force through pro-market reforms for the next stage of NHS privatisation.