Lord Darzi may be best known as a high-flying surgeon, but he is also quite keen on knocking out reports – especially when the main subject is not the services he is most involved with. And far from there being any continuity, each report shows a fresh change of mind
Darzi’s 2007 report for NHS London, A Framework for Action, set out controversial plans for a network of 150 costly “polyclinics” to replace local GP surgeries and providing everything from primary care through X-rays, mental health care and minor operations, at an estimated cost of £3.1 billion.
According to the accompanying ‘Technical Paper’ each polyclinic would employ an average of around 90 medical and nursing staff, including 35 GPs and 3-4 consultants, be located in rented accommodation, and run on a budget of around £21m a year. 150 polyclinics would need to enlist a total of over 5,200 GPs to full-time work – slightly more than the entire complement of GPs in London in 2007.
Darzi’s report was far from a clear blueprint: there were many gaps, ambiguities, and the costings appeared to be wildly optimistic. It did not, as campaigners would have wished, reject any further privatisation or private ownership of services or facilities delivering NHS-funded treatment.
He did argue that one of several possibilities might be that some polyclinics might be privately owned:
“New polyclinics could be owned by the NHS and utilised by NHS staff and others. Or they could be owned by the independent sector – this could be a large GP practice providing some services and buying others in or it could be by a company interested in owning the asset but then letting it out to a service provider.” (p126)
However this report bucked the trend of government and NHS thinking in 2007 by only singling out examples of innovation and good practice in NHS treatment centres and units, and focusing on the development of the NHS as a public service.
The only explicit suggestion of reliance on or partnership with the private health sector came with the vague formulation that:
“The private sector will also be a partner in making this Framework happen. They will be able to provide services important to several of the clinical areas, from exercise classes to mental health inpatient facilities. They also have the experience of developing procurement relationships which provide best value for money.” (p117)
The report, and caricatures of it, caused a major stir. It proved to be unpopular both with the GPs who would have to work in them and with patients, many of whom would face longer treks to much larger, impersonal premises where almost none of the staff would know them, and there would be little chance of continuity of care.
This may be why a government-commissioned follow-up “interim” report looking at England’s NHS, published soon afterwards in October 2007, made no reference to polyclinics. It called for immediate steps including the investment of new resources “to bring new GP practices – whether they are organised on the traditional independent contractor model or by new private providers – to local communities where they are most needed.”
Unlike Darzi’s first report, the interim report spelled out a call for more private sector involvement:
“This means a shift from national procurement to locally procured services and a greater role for the private and voluntary sectors in primary and out-of-hospital care. I believe that the innovative practice that independent sector providers can bring will help realise dramatic improvements for patients and challenge the established ways of working among NHS organisations.”
The full report, High Quality Care For All, published in 2008, backed away from such explicit calls for private sector involvement, but proposed 150 “GP-led health centres”, where “people can walk in regardless of which local GP service they are registered with,” should be built to supplement existing services in England. This was not much more popular with GPs or patients.
The second report did however also push for the use of more private (aka “independent”) sector organisations (management consultants) to help draw up local level plans:
“We will support primary care trusts as they become World Class Commissioners, with both local and national development resources. As part of this, the Department of Health, on behalf of the strategic health authorities, will establish a list of independent sector organisations that can help primary care trusts [the commissioning bodies at the time] to develop the capabilities of their management boards.” (p63)
These Darzi plans were rudely interrupted by the global banking crisis, which halted plans for ongoing investment and shifted the focus towards ways of cutting back on spending.
But ten years later, in the depths of the first Tory decade of austerity and to coincide with the NHS 70th anniversary, Darzi was once more commissioned to draft a report, Better Health and Care for All – A 10-Point Plan for the 2020s, this time for the IPPR.
The final report, published in 2018, took a very different, much more negative attitude to the private sector, noting for example that:
“People are happy for data to be shared inside the NHS but worry about access for private enterprise,” (p 29).
It strongly condemned the results of Andrew Lansley’s top-down reorganisation of the NHS through the 2012 Health and Social Care Act, and rejected claims that there were any advantages in the competitive market system that had been extended by the Blair, Brown and Tory-led governments:
“The reality is that the commissioning arrangements in the NHS appear to subtract value rather than to add value. It is time to end what is very clearly a failed experiment by ending compulsory competitive tendering for services.” (p52)
The report also criticised the excess costs of the Private Finance Initiative (PFI):
“The most obvious challenge facing a large number of NHS providers is the legacy of private finance initiative (PFI) contracts. […] Across England, there are 127 schemes – mainly in the NHS but also in social care. Their total capital value now adds up to nearly £13 billion (Appleby 2017b), but the NHS is set to pay some £82 billion over the life of these PFI contracts.” (p 67)
And defending the NHS model against other systems in Europe and elsewhere, the report argues:
“Specifically on efficiency, the evidence is clear that Beveridge systems are less expensive than both private insurance systems and social insurance models (OECD 2010). It is a fundamental error of logic to say that something is unaffordable, so we should move to something more expensive.” (p 71)
It highlighted the disastrous effects of eight years of austerity and real terms cuts in NHS spending, and its main conclusion was to outline a ‘10-point investment and reform plan,’ which aimed to reverse the spending squeeze.
Point 10 called for a “long term funding settlement for health and care … returning the NHS to its long run growth trajectory,” although undermining this by calling for ringfenced National Insurance (NI) increases (regressive rather than progressive taxes) to pay for it.
The plan also called for
- a “health in all policies’ approach” across government, “getting serious about tackling obesity, smoking and alcohol consumption;”
- a “Tilt towards tech,” investing in the digital infrastructure the NHS needs;
- making social care free at the point of need by “extending the NHS’s ‘need, not ability to pay’ principle to social care, and “fully funding the service;”
- a ‘New Deal’ for general practice, mental health and community services;
- investment in “the talent of the team, “creating an integrated skills and immigration policy and providing fair pay for staff across the health and care system;”
- and a fully funded transformation fund for health and care to allow change to take hold and investing in capital to provide the building blocks for a 21st Century NHS.
None of this was what Theresa May’s government wanted to hear, and their ‘birthday’ gift to the NHS was a five-year funding settlement that fell way short of keeping pace with rising cost pressures, let alone compensating for years of cuts or restoring previous rates of growth.
Six years and a pandemic later, Darzi is back again, having swiftly assembled a report (Independent investigation of the National Health Service in England) plus 300-plus pages of “Technical Annex” including a host of statistics and graphs, not all of which coincide with the narrative of the main report.
This time Darzi’s report has been commissioned by Labour’s health and social care secretary Wes Streeting, who has for several years been ostentatiously arguing for greater NHS use of ‘spare capacity’ in the private sector – quite possibly influenced by £175,000 of donations he has received from donors linked to private health companies, although not from the private hospital sector.
But given that premise what is perhaps surprising is that Darzi makes no reference whatever to the private health sector, other than to reject “other health system models—those where user charges, social or private insurance play a bigger role” as “more expensive” than the NHS. Indeed Darzi explicitly argues that:
“It is not a question … 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.” (p131-132)
Following on from his 2018 report, Darzi is heavily critical of the impact of the 2012 reorganisation – ‘a calamity without international precedent’ – and the years of austerity funding, not least the lack of capital funding, and blames the state of the NHS almost exclusively on this.
“The 2010s were the most austere decade since the NHS was founded, with spending growing at around 1 per cent in real terms…. The 2018 funding promise was broken…. Spending increased… below the historic rate [4% per year]…. The NHS has been starved of capital and the capital budget was repeatedly raided to plug holes in day-to-day spending.”
This version of events avoids any mention or analysis of New Labour’s mixed legacy, the decade of substantial investment in the NHS from 2000, cut short by the impact of the banking crash and concluding with the secretive commissioning of the notorious McKinsey report in 2009 and local equivalents, that outlined plans (practical and impractical) to cut spending by £20 billion by 2014.
And while New Labour’s extra spending enabled improvements including record reduction in waiting times and increased staffing, some of it was also squandered on sponsoring a new expansion of private sector providers, costly PFI schemes and an increasingly ridiculous and wasteful market system dressed up as “World Class Commissioning”.
By leaving out any of this pre-history to the Tory austerity Darzi could be seen as letting Labour off lightly, and underestimating the extent to which the Lansley “reforms” built on New Labour’s policies. Nor does he mention the increased fragmentation of services and the resources wasted on tendering and outsourcing of clinical and other services, or the increasing role of the private sector on back office, data and digital services. Much more is also left out of his 160-page report.
But Darzi is not a left-wing campaigner writing a critique of health policy, and wanting to nail down every detail of NHS history up to date: he is a cross-bench peer responding to a request to expose the scale of the damage that has been done since 2010. His brief for the investigation did not include setting out solutions to the problems he uncovered.
Nor indeed is Darzi responsible for the way Streeting and the Starmer government respond to the stark picture of underfunding and neglect that he has revealed. As the Keep Our NHS Public response concludes:
“Darzi has thrown down the gauntlet. Will the Government rise to the challenge or will it mistakenly conclude that the wrong treatments – ‘reform’ and further austerity – are just what the doctor ordered? If so, this would be a rebuff to Lord Darzi and – more importantly – a huge tragedy for patients, staff and the NHS.”
Wes Streeting’s blustering but largely empty speech to Labour conference has made clear that despite the landslide majority for the party promising “change” there is no more money on offer in the short term to alleviate any of the problems as the NHS heads into another nightmare winter.
Far from seeing the private sector as a means to treat more patients, Integrated Care Boards are worried by soaring bills for treating NHS patients in private hospitals, and seeking ways to contain numbers of out of area referrals to costly and poor quality private mental health beds.
Labour’s response to every negative headline will be to blame it all on the Tories, and tell us to wait for a new ten year NHS plan … some time next year.
With Rachel Reeves in denial as she turns back to the austerity measures that got the NHS and the country into this state, it’s not clear how many patients will be consoled by hearing Streeting and co chanting their mantra of “Never forgive, never forget, never let the Tories do it again.”
Darzi’s report tells many of us enough to make us want more than empty rhetoric to rescue and rebuild the NHS.
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