Lord Darzi’s rapid investigation into the state of the NHS brought more than 70 organisations together in an expert reference group and sought input from NHS staff and patients through focus groups and frontline visits.   

In a damning analysis, he argues that too great a share of the NHS budget is being spent in hospitals, too little in the community, and productivity is too low. Waiting lists have swelled and waiting times for hospital procedures have surged, while A&E is described as being in “an awful state”.

Someone arriving at a typical A&E on an evening in 2009 would have been one among just under 40 people, states the report. By 2024, this number had swelled to more than 100 people. The report argues this can be attributed to underinvestment in the community. “We have almost 16 per cent fewer fully qualified GPs than other high-income countries relative to our population,” says the report. “After years of cuts, the number of mental health nurses has just returned to its 2010 level.”

Waiting lists for community services and mental health have also rocketed. Says the report: “As of June 2024, more than 1 million people were waiting for community services, including more than 50,000 people who had been waiting for over a year, 80 per cent of whom are children and young people. By April 2024, about 1 million people were waiting for mental health services.”

Cancer care is also lagging behind other countries, says the report. The UK has appreciably higher cancer mortality rates than other nations, while “no progress whatsoever” has been made in diagnosing cancer at stage one and two between 2013 and 2021.

Scarcity of capital

While growth in hospital staff numbers has increased sharply since the pandemic, rising 17 per cent between 2019 and 2023, the number of appointments, operations and procedures has failed to keep pace, leading to falling productivity. “The key reason for this is that patients no longer flow through hospitals as they should,” finds the report. “A desperate shortage of capital prevents hospitals being productive. And the dire state of social care means 13 per cent of NHS beds are occupied by people waiting for social care support or care in more appropriate settings.”

The report also notes that the NHS has struggled because of wider societal issues, with the health of the nation deteriorating significantly over the past 15 years, including a substantial increase in the number of people living with multiple long-term conditions. While the main driver of declining population health may be ageing, other external factors have also contributed.

“Many of the social determinants of health – such as poor-quality housing, low income, insecure employment – have moved in the wrong direction over the past 15 years, with the result that the NHS has faced rising demand for healthcare from a society in distress,” observes the report. “There has been a surge in multiple long-term conditions, and, particularly among children and young people, in mental health needs.”

The report continues: “Our health is the result of our genetic inheritance, our lifestyle and behaviours, and our social and economic circumstances, which shape our lives. These include income, housing and access to healthy food, among others. It has a particular impact for the most deprived and disadvantaged in society.”

Data from the Trussell Trust shows an increase in the number of food supply parcels from 1.4 million in 2017-18 to the highest recorded level of 3.1 million in 2023-24. And in regard to housing, the UK has the highest rates of homelessness in the OECD when measured by the proportion of the population in temporary accommodation. “Housing quality impacts health outcomes: poor housing is associated with increases in respiratory conditions and communicable diseases,” says the report.

“Missed opportunity”

Several drivers of poor performance are highlighted, including the impact of austerity, top-down reorganisation, and the pandemic, while the NHS estate is also in dire need of repair. The report describes a health service starved of capital, which has had to run services in “crumbling buildings that hit productivity”, while “a lack of capital means that there are too many outdated scanners, too little automation, and parts of the NHS are yet to enter the digital era”.

Overall, it describes the past decade as “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’”.

Identifying some major themes for the forthcoming ten-year health plan, the report proposes re-engaging staff and re-empowering patients; locking in the shift of care closer to home by ‘hardwiring’ financial flows; simplifying and innovating care delivery for a neighbourhood NHS; driving productivity in hospitals; tilting towards technology; contributing to the nation’s prosperity; and reforming to make the structure deliver.

Responding to the report, Prime Minister Keir Starmer said: “People have every right to be angry. It’s not just because the NHS is so personal to all of us – it’s because some of these failings are life and death.”

Hitting out at the period when the Conservatives were in power, he said: “Lord Darzi describes [the 2010s] as ‘the most austere decade since the NHS was founded’. Crumbling buildings, decrepit [portable cabins], mental health patients accommodated in Victorian-era cells infested with vermin. The 2010s were a lost decade for our NHS . . . which left the NHS unable to be there for patients today, and totally unprepared for the challenges and opportunities of tomorrow.”

As well as recognising the cost to people’s health, the prime minister also addressed the link between the state of the NHS and the nation’s economy. “It’s not just the state of our NHS in crisis – it’s also the state of our national health,” he said. “There are 2.8 million people economically inactive due to long term sickness, and more than half of those on the current waiting lists for inpatient treatment are working-age adults. Getting people back to health and work will not only reduce the costs on the NHS, but it will also drive economic growth – in turn, creating more tax receipts to fund public services.”

Three shifts

He said he intends to frame the forthcoming ten-year plan around “three big shifts” –moving from an analogue to a digital NHS; moving more care from hospitals to communities’; and being bolder in moving from sickness to prevention.

“Only fundamental reform and a plan for the long term can turn around the NHS and build a healthy society,” he concluded. “It won’t be easy or quick. But I know we can do it.”

Lord Darzi said: “Although I have worked in the NHS for more than 30 years, I have been shocked by what I have found during this investigation – not just in the health service but in the state of the nation’s health.

“We want to deliver high-quality care for all but far too many people are waiting for too long and in too many clinical areas, quality of care has gone backwards. My colleagues in the NHS are working harder than ever but our productivity has fallen.”

Sir Julian Hartley, chief executive of NHS Providers, said: “Lord Darzi’s prescription for reforming the health service – by creating a digital NHS, focusing on prevention and public health, and ensuring patients are cared for closer to home – is a big step in the right direction. This must go hand in hand with sustainable funding and investment, an end to chronic workforce shortages, and more capital investment to boost productivity and meet growing demand.”

NHS Confederation chief executive Matthew Taylor said ministers now need to work on two fronts: helping the NHS avoid a winter crisis, including providing emergency funding in the Autumn Budget to boost staff and capacity in social care; and shaping its planned ten-year strategy.

“We know this is far from easy given the perilous state of the public finances,” he said. “But the fact remains that unless we restore the NHS to the long-term average funding increases it needs, accompanied with changes to the way that local services are delivered, then we will never bring down waiting lists to the levels required, as well as preventing more illness from occurring in the first place.”