Following the publication of Lord Darzi’s investigation into the state of the NHS, Anna Colivicchi and Maya Dhillon look at what it will mean for general practice and answer the most important questions around the review
Why was the investigation commissioned?
Newly-appointed health secretary Wes Streeting commissioned the independent investigation within a week of the general election, having repeatedly claimed that the NHS was ‘broken’. He said that the ‘rapid’ review was needed to ‘diagnose the problem’.
He touted the investigation as a raw and honest review of the NHS, and declared that this new Government would not hide behind excuses like the previous one. The focus lay in a ‘fundamental reform’ of the health system guided by consultations with patients and staff, rather than short-term ‘sticking plasters’.
Who is Lord Darzi and why was he chosen to do this?
Lord Ara Darzi is a cancer surgeon and former Labour minister, who served from 2007 to 2009. His name may ring a bell for many GPs – he worked on Labour’s GP ‘polyclinic’ model (also known as Darzi centres) from 2008 until they were scrapped in 2011 by the Coalition Government.
He also previously argued that the GP partnership model was out of date, and that bringing general practice services ‘into the fold’ would create a ‘joined-up, unified NHS.’ In an opinion piece last year, he lamented that his big regret from his time as health minister was failing to persuade GPs to change how they work.
As to why Lord Darzi was chosen to lead the investigation, this is not the first time he has been tasked with an analysis of the NHS. In 2008, he led a national review of the NHS to plan a course for the next 10 years. The final report, High Quality Care for All, aimed to improve accountability in clinical practice and was generally well-received. Mr Streeting has called him ‘one of the NHS’s leading experts.’
What are the main points about general practice made in the review?
The review found that the health service is in a ‘critical condition’ but can be saved, with increased general practice funding. It has taken more than a decade for the NHS to fall into this level of disrepair and the service is now ‘in serious trouble’, according to Lord Darzi.
His review looked at the reasons why this happened, blaming austerity, underinvestment by the previous Government and the pandemic. The main points were:
- There is a shortfall of £37 billion of capital investment into the NHS – these missing billions are what would have been invested if the NHS had matched peer countries’ levels of capital investment in the 2010s. And Lord Darzi estimates this money could have rebuilt or refurbished every GP practice in the country;
- Despite more than a decade of underinvestment, currently GPs are ‘expected’ to manage and coordinate increasingly complex care, but they do not have the resources, infrastructure and authority that this requires;
- There must be ‘a shift’ in the distribution of resources towards community-based primary care services, because spending in primary and community settings has a superior return on investment when compared with acute hospital services;
- Care ‘should be delivered in the community’, closer to where people live and work, and hospitals ‘should be reserved for specialist care’;
- The current GP standard contracts ‘are complex’ and can mean that ‘doing the right thing for patients can require doing the wrong thing for GP income’ and that ‘cannot be right’;
- GPs ‘have the best financial discipline’ in the health service family as they cannot run up large deficits in the belief that they will be bailed out;
- The primary care estate ‘is plainly not fit for purpose’ as 20% of it predates the founding of the health service in 1948;
- The Health and Social Care Act of 2012 ‘was a calamity without international precedent’ – by dissolving the old structures rather than reforming them, GPs ‘were to all intents and purposes set up to fail’;
- There is a need for more GPs – while the review points out that there have been ‘positive developments’ in growing the wider workforce in general practice (such as clinical pharmacists and occupational therapists), Lord Darzi says that these ‘should be supplements’ rather than substitutes to GPs. In particular, more GPs ‘are needed in under-doctored areas’, he says.
What has the response from GPs been so far?
According to some GP leaders, the review ‘accurately identified many of the major issues’ facing general practice, including poor buildings, lack of IT and an over focus on hospital, rather than community care.
‘As GPs we are heartened he recognises how under-resourced we have been and the inequity between primary and secondary care resourcing,’ says Dr Lizzie Toberty, the Doctors’ Association UK GP lead.
The BMA welcomed the findings, highlighting that the review touched on many of the concerns already raised by the union. ‘One might expect that Lord Darzi’s review would be met with a sense of relief—finally, someone understands,’ says Professor Philip Banfield, BMA council chair.
‘While the findings are unsurprising, seeing this report so clearly call attention to just how broken our beloved NHS has become, with the devastating impact on our patients, is deeply sobering.’
GP partner and Tower Hamlets LMC member Dr Selvaseelan Selvarajah said that this is ‘finally’ a report that ‘doesn’t blame general practice for the woes’ and sees GPs ‘firmly’ as one of the solutions to rebuild the NHS.
Is it going to have an impact on Government policy around general practice?
The Government said that the Darzi review will inform a 10-year plan to ‘radically reform’ the NHS, with three ‘fundamental shifts’ outlined by Mr Streeting: from analogue to digital, from hospitals to communities and from sickness to prevention.
And doctor leaders hope that the findings will have a strong impact on new polices. The DAUK went as far as saying that the publication of this report is the moment for ‘the revival and rebirth of general practice’, and called for clarity from the Government as to how it intends to solve the problems highlighted in the review.
The BMA says it is ‘imperative’ that Mr Streeting trusts doctors and experts and takes action swiftly, including engaging GPs and funding them ‘properly’ as ‘the expert gatekeepers to the rest of the healthcare system’.
‘We have seen the constructive dismissal of general practice yet this new government has the opportunity to value doctors and save our NHS through immediate engagement and investment in GP contracts,’ Professor Banfield says.
‘The issues in secondary care cannot be fixed without addressing the crisis in general practice, driven by an insufficient supply of GPs and the growing demand from patients returning repeatedly while awaiting secondary treatment.’
Professor Banfield also pointed out that the ‘chronic’ underfunding of primary care undermines continuity of care and left GPs across England with no choice but to participate in the collective action.
He says: ‘One of this government’s key manifesto promises was to bring back the family doctor. It’s time to listen to GPs and collaborate with them to make this a reality.’
However, GPC chair Dr Katie Bramall-Stainer said that GPs are currently ‘not in a position to be able to wait for long-term plans’, as she defended the profession’s reasons for collective action following accusations of ‘sabre-rattling’ by the health secretary.
Londonwide LMCs CEO Dr Michelle Drage and deputy CEO Dr Lisa Harrod-Rothwell also called on the Government to take onboard Lord Darzi’s ‘renewed support for family doctors and their practices’.
They say that there is a need for an honest conversation about what can be delivered ‘safely’ in general practice with the available resources.
‘Whilst reform can be a part of that conversation, patients and general practice staff don’t have years to allow long term plans to come to fruition,’ they said. ‘The devil is in the detail and we look forward to being part of those open and transparent discussions about what happens next.’
How is Labour going to shift care into the community?
In December last year, Labour first revealed plans to conduct a shake-up of GP services to create new ‘neighbourhood health centres’, including ‘GP hubs’ where patients can walk in at evenings and weekends, bringing together doctors, dentists and treatment of minor injuries to take pressures off A&E.
Even at the time, these plans seemed to resemble the party’s old Darzi centres. And trialling neighbourhood centres which would have GPs and other community health staff ‘under one roof’ was one of the promises in the Labour manifesto in June.
And the Prime Minister said that shifting care from hospitals to community is something that successive governments ‘have repeatedly promised’ but that, so far, the opposite has happened.
‘This 10-year plan has to be the moment we change this, the moment we begin to turn our National Health Service into a Neighbourhood Health Service,’ he said again in his speech yesterday and added that this means ‘more tests, scans, healthcare offered on high streets and town centres and improved GP access’.
However, at present, it is difficult to come to a conclusion as to whether more services will be allocated to general practice as part of this shift.
Will this mean more money for general practice?
While Lord Darzi has argued that there is a need to invest more resources into primary care, it is unclear whether this will mean more money for general practice, and at what stage.
Yesterday, the Prime Minister said that reform ‘does not mean just putting more money in’ and added that the Government have ‘to fix the plumbing before turning on the taps’. He emphasised that there will be ‘no more money without reform’.
This is a point that was previously made by Wes Streeting too, when he criticised the RCGP plan to save general practice last year, saying that Labour ‘won’t entertain requests for blank cheques’, and the ‘era of simply pouring more money into a broken system is over’.
It’s worth remembering that Labour’s election manifesto carried no promises of increased investment in general practice – but in his previous shadow health secretary role, Mr Streeting had claimed that GPs have ‘a lot to look forward to’ under a Labour Government.
There have also been suggestions that primary care’s proportion of the NHS budget ‘ought to increase’ and Labour would seek to do this ‘over time’, and Mr Streeting he is ‘committed to reversing’ the underfunding of general practice
How is this different from previous attempts of reform?
To many, this attempt of reform doesn’t seem different from anything that has already been trialled. In response to a media question on how this reform will be different, the Prime Minister said that now the Government has ‘an honest and raw assessment of where we are really at’ thanks to the Darzi review and that this reform needs a long-term plan, ‘not a short-term set of decisions’ which characterised previous attempts.
‘We’ve got the mandate to carry this through,’ he said yesterday. ‘What has happened in the past is that there was talk of change, sometimes steps towards change and steps back again.’ But what was lacking was ‘a sense of purpose’ to fix the NHS, he said.
What will it mean for the CQC?
Lord Darzi’s review found that the CQC was ‘not fit for purpose’ – a sentiment already expressed by Mr Streeting in July.
This comment followed an independent review of the body into its regulation of primary, secondary and social care by North West London ICS chair Dr Penny Dash. Her investigation found that the health and social care watchdog lacked consistency and expertise in its inspections, as well as overall low levels of inspections.
Lord Darzi’s review supports that and highlights that there is an excessive focus on ‘staff numbers and paperwork, at the expense of patient experiences and clinical outcomes.’ He adds that the CQC’s only solution to any problem seems to be ‘to add more staff.’
Last month, the CQC announced it was introducing a new inspection model pilot. When Pulse asked if this would apply to GP inspections, we were told that this was primarily ‘exploring improving relationships with Trusts,’ suggesting that the organisation was more concerned with managing its own relationship with secondary care providers, rather than renovating inspection procedures overall.
With Lord Darzi’s damning review reinforcing the CQC’s preoccupation with admin and staff ‘rather than doing the job’, one can only hope that it may force a more stark reform in inspections.
Pretty good summary