This insight provides an analysis of Lord Darzi’s Independent Investigation of the National Health Service (NHS) in England report of September 2024 and addresses the report’s key findings, challenges facing the NHS, and areas that were not fully explored or addressed.
1. Key Findings
The report provides a thorough analysis of the NHS, identifying a series of interconnected challenges that contribute to its current state. Here are the main findings:
A. Performance Decline Across Key Services
Emergency and Urgent Care: There has been a notable decline in A&E performance, with only 74% of patients being seen within four hours in 2024, a significant drop from 96% in 2011. Wait times have become excessively long, with older patients particularly affected. For example, nearly one-third of people over 80 waited more than 12 hours in A&E, illustrating the strain on urgent care services.
Elective Care and Surgery: The waiting list for elective procedures has grown substantially, with 7.6 million people waiting for treatment as of June 2024. Over 300,000 of these individuals had been waiting for more than a year. The report identifies a substantial gap between demand for elective care and the NHS’s capacity to deliver.
Mental Health Services: The surge in demand for mental health services has outpaced the system’s ability to respond. The report indicates that 345,000 people are waiting more than a year for their first mental health contact, with children and young people being particularly affected. The rate of referrals for young people has increased by 11.7% annually.
B. Socioeconomic Determinants of Health
Wider Determinants and Health Inequalities: The report explicitly links poor health outcomes to socioeconomic factors such as rising poverty, inadequate housing, and income disparities. For instance, nearly one-third of children now live in poverty, a stark increase from the early 2010s. These factors exacerbate demand for NHS services and contribute to the growing prevalence of long-term conditions.
Disparities in Health Outcomes: Significant health inequalities are evident in areas such as maternal care, where black women are nearly three times more likely to die during childbirth than their white counterparts. The report also notes that the most deprived groups suffer from higher rates of chronic diseases and lower life expectancy.
C. Resource Allocation Issues
Imbalance in Spending: There is an ongoing discrepancy in resource allocation, with a disproportionately high share of NHS funding directed toward hospitals rather than primary and community care. The report highlights that hospital spending has risen from 47% to 58% of the total NHS budget between 2006 and 2022, whereas investment in out-of-hospital care has been neglected.
Systemic Productivity Declines: The report emphasises that productivity within hospitals has fallen, with reduced activity levels per clinician across various specialties. Delays in discharging patients, often due to social care inadequacies, contribute to bed shortages and reduced throughput.
D. Impact of the COVID-19 Pandemic
Exacerbation of Existing Issues: The pandemic magnified many of the NHS’s existing weaknesses, leading to a more severe backlog than in comparable health systems. The report notes that elective procedures were delayed or cancelled more extensively in the UK than in other OECD countries, worsening the pre-existing waiting list crisis.
Long-term Effects on Population Health: The report discusses the lasting impact of COVID-19 on health, including an increase in long-term conditions and a surge in mental health needs. Additionally, the NHS entered the pandemic with fewer resources (doctors, beds, and capital assets) than other high-income countries, affecting its resilience.
E. Workforce Challenges
Burnout and Staffing Shortages: High levels of staff burnout, sickness, and disengagement are highlighted as major concerns. Nurses and midwives, for instance, experience up to a month of sickness leave annually on average. The report attributes this to pandemic-related fatigue and ongoing systemic pressures.
Insufficient Workforce Expansion: Despite some increases in staff numbers, there are still significant shortages, particularly among GPs, community nurses, and social care workers. There are 16% fewer fully qualified GPs relative to the population compared to other high-income countries, exacerbating access issues.
F. Capital Investment Deficit
Underfunding of Infrastructure: The report indicates a £37 billion shortfall in capital investment, which has led to outdated facilities, equipment shortages, and an £11.6 billion maintenance backlog. This lack of capital has prevented the modernisation of NHS infrastructure, contributing to lower productivity.
Delayed Projects: Many promised infrastructure projects, including the construction of 40 new hospitals, have not materialised, further straining the system.
2. Areas Not Fully Addressed
While the report provides a detailed picture of the NHS’s challenges, some key areas are not comprehensively explored:
A. Specific Policy Recommendations
The report refrains from offering detailed, actionable policy recommendations. While it outlines major themes for future strategies, such as expanding community care and increasing capital investment, it does not provide concrete steps or timelines for implementation. More specific guidance on how to achieve the proposed 10-year health plan would have strengthened the report’s impact.
B. Social Care Integration
The report acknowledges the significant impact of social care on the NHS, noting that 13% of hospital beds are occupied by patients who need social care rather than acute medical treatment. However, it lacks substantial recommendations for reforming social care funding and improving its integration with the NHS. This gap limits the report’s ability to address the root causes of delayed discharges and hospital congestion.
C. Technological Transformation
Although the report discusses the need for a digital shift, it does not provide detailed strategies for overcoming barriers to technological adoption. Challenges such as legacy IT systems, digital literacy among staff, and fragmented digital infrastructure are not fully explored. More specific recommendations on accelerating digital transformation, including the adoption of AI and electronic health records, would enhance the report’s utility.
D. Preventive Public Health Measures
The report identifies the reduction in public health funding and its adverse effects but does not delve into comprehensive strategies for strengthening preventive care. Areas such as expanding vaccination programs, reducing obesity, or promoting healthier lifestyles receive limited attention despite their potential to reduce the burden on the NHS in the long term.
E. Workforce Planning and Development
While workforce challenges are extensively covered, the report does not offer a comprehensive plan for addressing staff shortages, retention, training, and well-being. For instance, there is no detailed strategy for increasing the number of GPs or mental health professionals, nor does it address the need for enhanced career development opportunities for existing staff.
3. Key Recommendations for Further Action
To address the gaps identified in the report and ensure sustainable improvements in the NHS, the following recommendations are suggested:
A. Develop a Comprehensive 10-Year Plan
The plan should include clear, specific actions for rebalancing resources toward primary and community care, addressing health inequalities, and enhancing integration with social care. It should also outline detailed strategies for improving public health and preventive services to reduce future demand.
B. Boost Capital Investment
Urgent investment is needed to modernise NHS facilities, address the maintenance backlog, and implement digital health solutions. The government should commit to a multi-year capital funding plan that prioritises critical infrastructure and technological upgrades.
C. Strengthen Workforce Planning and Development
Implement targeted recruitment and retention strategies for areas with critical staff shortages, particularly in primary care and mental health services. Develop a national workforce plan that includes expanded training programs, improved working conditions, and support for career progression to enhance staff retention.
D. Expand Preventive Health Programs
Increase funding for public health initiatives, including targeted interventions for obesity, diabetes, smoking cessation, and mental health. A comprehensive preventive strategy could help alleviate the long-term burden on NHS services.
E. Accelerate Digital Transformation
Implement a national strategy for digital health adoption, prioritising the roll-out of electronic health records, AI-driven diagnostic tools, and telehealth services. This should be coupled with investments in digital skills training for NHS staff.
F. Integrate Social Care with the NHS
Develop policies to improve the coordination between social care and the NHS, including shared budgets and streamlined pathways for patient discharge. This integration should be supported by increased social care funding and the development of a sustainable long-term funding model.
4. Conclusion
Lord Darzi’s investigation provides a detailed and candid assessment of the NHS’s current state, emphasising the urgent need for systemic reforms in funding, service delivery, and workforce management. However, the report falls short in providing specific, actionable policy recommendations and detailed strategies for integrating social care, expanding preventive health efforts, and adopting new technologies.
For the NHS to improve its performance and meet the needs of the population, a more comprehensive approach is required. This should include a long-term plan with clear actions, increased investment in capital and workforce development, and stronger integration between health and social care. The themes outlined in the report provide a foundation for such a plan, but further work is needed to translate these themes into practical solutions.
