Nick White
NHS Consultant Surgeon and Former NHS Medical Director.In his recent report, Ara Darzi acknowledges, “Everyone knows that the health service is in trouble” and highlights areas where the NHS needs to improve. The key findings show deterioration in patient access, quality of care, and overall performance, particularly in the three headline areas of capacity constraint: elective waiting lists for diagnosis and treatment, GP appointments, and Emergency Department waiting times. These are not new observations, and the report does not offer solutions. The terms of reference preclude specific policy recommendations while asking for themes for a 10-year plan. These themes are: increasing productivity, mainly through capital investment; moving care out of hospitals; and a “tilt towards technology.”
Target Performance Metrics: Prioritising Waiting Lists
The three areas of constraint are not separate but interrelated. There are 7.62 million cases, consisting of approximately 6.39 million individual patients, waiting for treatment. These, in turn, have a knock-on effect on GP appointments, where 30% of all requests for GP access are from patients on an elective waiting list with an issue directly related to why they are on that list. This creates additional demand in Emergency Departments, where a further 30% of patients attend because they either cannot get a GP appointment or have an underlying condition for which they are on an NHS waiting list. Additionally, these long waits are causing the severity of conditions presented in EDs to increase, leading to longer assessment and admission times.
These delays in Emergency Departments then impact elective capacity, as beds, staff, and other resources are repurposed at short notice to meet emergency demand. This creates a vicious cycle: waits for elective care cause waits for GP appointments, which cause waits in Emergency Departments. All of this affects patient outcomes, patient experience, and staff experience. The way to break this vicious cycle is to focus disproportionately on elective waiting lists, which is where the report’s focus on productivity lies.
Productivity
You cannot simply instruct a hospital to become more productive. Additional capital is part of the issue, but recent poor productivity is multifactorial and driven by an aggregation of many factors (https://www.nuffieldtrust.org.uk/news-item/productivity-in-the-nhs-what-s-getting-in-the-way). The report alludes to a lack of good operational management, stating that “the NHS has forgotten how to do things.” This harks back to Blair’s second term (2001–2005), but that period was also accompanied by large year-on-year real increases in funding, which do not appear to be forthcoming now. Things have changed in the 23 years since, and it is unclear whether the same approach would generate the same results today.
The difference noted in the report is the advent of new technologies, specifically artificial intelligence and preventive pharmaceutical interventions. The report draws heavily on findings from the Tony Blair Institute (https://institute.global/insights/economic-prosperity/the-economic-case-for-protect-britain-a-preventative-health-care-delivery).
Shifting Care Out of Hospitals
The report acknowledges that the approach of moving care from hospitals into the community has been advocated for at least the last two decades but has yet to be realised. The solution to this is described as “hardwiring” financial flows. However, along with the recommendation to replace block contracts with a tariff per item of activity (known as Payment By Results, or PBR), it is unclear how this can be delivered. PBR is an effective way of driving up activity but at an increased financial cost. The argument against block contracts is that they do not incentivise increased activity.
By separating General Practice, mental health, and community services from hospital care and not describing the flow of patients along pathways from the community into hospitals and back out, the opportunity is missed to integrate care. Incentivised block contracts could provide a middle ground between block contracts and PBR. Their development could enable care to be carried out at the cheapest and most local setting while also rewarding above-target activity, and—most importantly—paying for improved clinical outcomes, not just activity levels (https://www.england.nhs.uk/wp-content/uploads/2021/12/22-23NT_Dt-Guidance-on-aligned-payment-and-incentive-approach.pdf).
It is also very difficult to take funding away from hospitals and redistribute it to community providers within a single financial year. Hospitals will inevitably ask, “What do you want us to stop doing?” Asking for savings to be generated from unrealistic year-on-year productivity gains is one reason many provider trusts run annual deficits. To resolve this, community providers need to be pump-primed with funding before hospital funds are reduced. This would necessitate multi-year funding settlements and increased spending.
Management Reform
There have been 25 major reorganisations in the NHS’s 75-year history, and Darzi does not advocate another. He calls for reform to make the structure work, with clearer lines of accountability and responsibility. He also supports investing in the quality and capacity of management. The most recent policy output on this subject is from Sean Phillips and colleagues at Policy Exchange (https://policyexchange.org.uk/publication/just-about-managing/).
There are many recommendations in the Policy Exchange report that could help deliver Darzi’s management reform theme. These need not be implemented as part of a major reorganisation but could be introduced incrementally over the course of a parliamentary term. An example is the increasing use of shared appointments at Chair and CEO/executive director level across provider trusts.
Final Thought
Much attention has been drawn to the report’s call for greater capital investment. Implicit in this is the idea that the investment would come from the NHS via the taxpayer. A discussion is needed about whether this funding will be provided by the Treasury. The report does not discuss external sources of capital. Under the Blair/Brown government, Private Finance Initiatives (PFIs) and private capital were used to fund independent sector treatment centres. The question remains: where and when will this discussion take place?
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