It seems a bit obtuse to describe the report of Lord Ara Darzi’s “Independent Review of the NHS” as “long-awaited”, given it was only commissioned in July. But two months is a long time in politics, and the lack of Government direction in those two months about the evident, ongoing crisis in the NHS (save for repetition of the same talking points from the election campaign) has been notable.
Darzi’s report itself does not, of course, add anything profoundly new to the debate – which tells its own story. From a political perspective it allows the new Government to echo Captain Renault in “Casablanca,” (Claude Rains), pronouncing itself “shocked, shocked!” at the scale of the problems it has inherited. But it also sets the scene for the new Secretary of State with the opportunity given to set out in more detail Labour’s plans for reform.
Those plans will be familiar to most. The last ten years of health and care policymaking has been oddly consistent, focused on rowing back from what are generally seen as the disastrous effects of the Health and Social Care Act 2012; a process that began almost as soon as that Act had passed, and which gives credence to Darzi’s view that the 2010s were essentially a “lost decade” for the NHS. The 2022 Act which wholly did away with Andrew Lansley’s earlier reforms in fact plays all the same notes as Wes Streeting’s response to Darzi – the focus on early intervention and prevention, on partnership, and on health and care integration.
But the failure to act on these aspirations in the past – and a warning for the plans for reform now – are themselves reflected in the way that Darzi’s report and Government’s response is framed. This is a report into the “NHS” as an institution but also, into the “health system.” These words are used by Darzi interchangeably, but they are not the same thing. This highlights the conceptual muddle that Governments (and policymakers) have repeatedly found themselves, a muddle that has had a significant effect on the sticking-power of previous attempts at reform. There is a real tension between the untouchable and beloved yet failing NHS and the role provided by local authorities in both public health and social care with care providers.
The 2022 Act attempted to tackle this – the recognition that the NHS as an institution is part of the “health and care system” which also involves other players was an important one. But even here, the 2022 Act structures (ICPs in particular) could be seen as a way of bringing other partners’ health and care activity under the purview of the NHS from an organisational perspective. This, as ever, was a case of culture trumping structures; a recipe for suspicion and attempts at “command and control” rather than open collaborative working, especially where budgets are tight and difficult choices have to be made about service provision. Leading many to view this as we are all equal, but some partners are more equal than others.
What Government is planning constitutes the third fundamental reform of the health and care system in less than 15 years. The new government needs to decide if local accountability and devolution is the answer, and not a convenient panacea for a sidestepping of the difficult issues and answers. Any plan for further reform will therefore need to grasp that action on prevention, integration and action on wider determinants of health will have to happen in a way that engages with other partners in a way that is more fundamental than it does at present.
This is likely to involve localisation, and democratisation. Darzi has some interesting things to say about enhancing patient voice – and on increasing the focus and provision in community healthcare. But the mechanics by which local people’s needs inform health and care decision making remain opaque and unachievable in an environment where major commissioning decisions have moved to sub-regional level and where local authorities’ own commissioning decisions on care provision are highly constrained by a budget and finance framework that works against investment in early intervention. Darzi highlights the different economic models in place around health and social care as a fundamental barrier to reform (paras 21-23, p23).
Reform, then, has to be a partnership endeavour, and one that is driven by a different culture of accountability and decision-making at the most local level. This is not about structural reform because, as Darzi says the “right” structures are already present. The system-place-neighbourhood fundamentals of the 2022 Act – particularly the strategic organisational capability of ICSs – remain sound. But the way that people operate within those structures is likely to need to change profoundly. This is surely Darzi’s acknowledgement that restructure has never, and arguably could never address the purpose and ideology that underpins these agencies. The NHS as a vehicle for health intervention is at ideological odds with the need for ‘care’ which is by its nature is largely long-term, and both should be supported by the preventative work of public health.
What that means for local government suggests a more obvious directive role on health and care commissioning that pools and integrates budgets in the kind of way envisaged by the stalled 2008-2010 “Total Place” programme. One that is surrounded by a system of local accountability that helps local people, clinicians and other professionals to work together to design health and care services across localities in a way that understands and tackles trade-offs. It is a culture that shifts debate away from the number and size of hospitals and towards the work of shifting resources to ensure that people don’t need to spend time in those hospitals in the first place.
Currently the NHS operates within a broader system where its role is often prioritised, celebrated, and debated, while other crucial components are not given equal consideration. This imbalance creates tension that can lead to unintended consequences. Scrutiny task groups across the country have explored this systemic approach, whether addressing ambulance wait times or the sufficiency of care providers. For the system to function effectively, all parts must work together. However, when the focus is solely on ‘how much will this cost’—propping up parts of an already strained system while simultaneously criticising its inefficiency—this goal becomes difficult to achieve
From the perspective of system accountability, it also means an enhanced role for existing players like overview and scrutiny and Local HealthWatch (alongside, perhaps, a beefed-up role for Health and Wellbeing Boards and Integrated Care Partnerships too). The 2022 Act undeniably weakened the capability of scrutiny and HealthWatch to carry out their work at local level, in the interests of giving more powers of intervention to the Secretary of State. If localisation and partnership working are to mean anything, they are likely to mean a loosening of national control, management and accountability arrangements at national level (via DHSC and NHS England) and their strengthening at local level – with measures designed to highlight poor performance and co-design plans for the future in a way that cuts through existing cultural norms and addresses the ongoing problem with candour that Darzi highlights still exists. At the moment, approaches to local accountability are too atomised for this to happen properly.
With local areas still settling into new relationships following the 2022 Act, a further cycle of reform will not be hugely welcome. Just as the ending of Casablanca always feels like a bittersweet missed opportunity, the potential love affair of a new government with a health and care system that works on causation and not only symptoms feels like it could go the same way.
We are reminded of Marilee Goldberg’s assertion that ‘A paradigm shift occurs when a question is asked inside the current paradigm that can only be answered from outside it.’ Goldberg, 1997, The Art of the Question: A Guide to Short-Term Question-Centered Therapy. Darzi gives an accurate and detailed diagnosis on the symptoms of the patient in front of him, from a clinical perspective. But misses the more radical opportunity to call for change, for he exists in the current paradigm.
The credits have not yet played, and reform could yet work. There is an opportunity for a more inclusive and local model for health and care, a companied by meaningful financial reform (rather than just “more” funding), And more compelling still will be an approach which mediates commissioning and control arrangements through strong, effective systems of local accountability.
Watch this space, but it does feel like we should be saying – ‘Play it again Sam’.
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