The NHS is in a ‘critical condition’ but can be saved, with increased general practice funding a ‘fundamental strategic shift’ required, the Darzi review has concluded.
The Government tasked Lord Ara Darzi, a cancer surgeon and former Labour minister, to lead a ‘rapid investigation’ into the NHS, which will feed into a new 10-year plan ‘to radically reform’ the health service.
In the report, Lord noted that ‘spending in primary and community settings had a superior return on investment when compared with acute hospital services’ and it ‘therefore makes sense that this should be the fundamental strategic shift that the NHS aspires to make’.
The NHS has been ‘chronically weakened’ by a lack of capital investment which has lagged other similar countries ‘by tens of billions of pounds’, while the demands placed upon the NHS ‘have grown’.
And GPs are ‘expected’ to manage and coordinate ‘increasingly complex care’, but do not have the resources, infrastructure and authority that this requires, the report noted.
Meanwhile, there is an overall NHS shortfall of £37bn of capital investment which ‘could have rebuilt or refurbished every GP practice in the country’.
It said: ‘These missing billions are what would have been invested if the NHS had matched peer countries’ levels of capital investment in the 2010s.
‘That sum could have prevented the backlog maintenance, modernised technology and equipment, and paid for the 40 new hospitals that were promised but which have yet to materialise. It could have rebuilt or refurbished every GP practice in the country.’
The report argued that ‘care should be delivered in the community’, closer to where people live and work, and that hospitals ‘should be reserved for specialist care’.
It said that there must be ‘a shift’ in the distribution of resources towards community-based primary care services.
It added: ‘It builds on the fact that general practice is how most people commonly interact with the health service and GPs’ expertise as generalists.
‘Indeed, research by the NHS Confederation has demonstrated that spending in primary and community settings had a superior return on investment when compared with acute hospital services.
‘It therefore makes sense that this should be the fundamental strategic shift that the NHS aspires to make.’
But he said that in order for this to happen, this change in financial flows must be locked in by the Government.
The report said: ‘Lock in the shift of care closer to home by hardwiring financial flows. General practice, mental health and community services will need to expand and adapt to the needs of those with long-term conditions whose prevalence is growing rapidly as the population age. Financial flows must lock-in this change irreversibly or it will not happen.’
Lord Dazi also highlighted that with primary care doing more work for a lesser share of the NHS budget, he heard ‘significant irritation felt by GPs’ who perceive that ‘more and more tasks are being shifted from secondary care back to primary care’, with a ‘never-ending flow’ of letters demanding follow-ups and further investigations.
‘This frustration is understandable when the hospital workforce appears to have expanded to the amongst the highest levels in the world,’ he added.
He also said that GP practices 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.
But that despite rising productivity, an expanding role, and ‘evident’ capacity constraints, the relative share of NHS expenditure towards primary care fell by a quarter in just over a decade, from 24 per cent in 2009 to just 18 per cent by 2021, continuing a downward trajectory from their peak in 2004
The problem is that to provide high-quality, multidisciplinary care in the community requires resources ‘that often are not there’, the report said.
It pointed out that GPs ‘are seeing more patients than ever before’, but with the number of fully qualified GPs relative to the population falling, waiting times are rising and patient satisfaction is ‘at its lowest ever level’.
‘We have underinvested in the community,’ Lord Darzi added. ‘We have almost 16 per cent fewer fully qualified GPs than other high income countries relative to our population.’
The investigation also pointed out that the primary care estate ‘is plainly not fit for purpose’ as 20% per cent of it predates the founding of the health service in 1948.
It added: ‘More recent buildings are bedevilled by problems with the management of LIFT (PFI-type) schemes that give GPs too little control over their space and that some GPs described as having charges that are unreasonably high during visits to the frontline as part of the investigation.
‘It is just as urgent to reform the capital framework for primary care as for the rest of the NHS.’
Lord Dazi concluded that there is a need ‘to rebalance the system’ towards care in the community rather than ‘adding more and more staff to hospitals’.
And he said that the NHS is ‘in critical condition’ but ‘its vital signs remain strong’.
But the system and its staff ‘have turned things around before’, and he is confident this will happen again.
Other findings included the CQC being ‘not fit for purpose’, with Lord Darzi noting that ‘too many people holding people to account, rather than doing the job, can be counterproductive’.
Lord Darzi said: ‘In the last 15 years, the NHS was hit by three shocks – austerity and starvation of investment, confusion caused by top-down reorganisation, and then the pandemic which came with resilience at an all-time low. Two out of three of those shocks were choices made in Westminster.
‘It took more than a decade for the NHS to fall into disrepair so it’s going to take time to fix it. But we in the NHS have turned things around before, and I’m confident we will do it again.’
RCGP Professor Kamila Hawthorne said that it ‘makes absolute sense’ to shift resources into primary care and it is ‘encouraging’ to see this made clear in Lord Darzi’s report.
She said: ‘The report makes for stark reading but it echoes much of what the college has been warning about, and what our members are telling us.
‘Lord Darzi acknowledges that primary care is consistently delivering more care, with a shrinking proportion of the NHS budget. This must be rectified.
‘Recognising the problems and their causes is a good first step. We now look forward to seeing how the recommendations in this report will be put into practice, and are keen to work with the government to make their vision to shift more resources into the community a reality.
‘Resetting the way we deliver health in England is now imperative. General practice is under enormous pressure, but with the right investment and initiatives – including to recruit and retain more GPs – we can turn things around, allowing GPs to deliver the safe, timely and appropriate care our patients need and that we are trained to, and want to, provide.’
