Since Lord Darzi’s ‘Independent Investigation of the NHS in England’ was published last week, we have seen a flurry of reflections, commentary and summaries of the report and its findings. The report and analysis behind it are comprehensive and compelling, drawing responses from the Prime Minister and Secretary of State that set a clear expectation of change. However, the NHS has been here before and failed to deliver. In this article we explore what needs to be different this time and the key shifts that should be considered in the forthcoming NHS 10-year plan.
The Delivery Challenge
Lord Darzi’s report makes for highly uncomfortable reading about an institution often considered a jewel in the public services crown. The importance of the NHS and the role it plays in the life of every citizen is clearly stated but so is how often poor access, failing quality and insufficient resources impact on patient outcomes and experience, placing intolerable pressure on staff. In response, the Secretary of Health & Social Care has set out a change agenda for health services and emphasised that reform must support three key pivots: hospital to community, analogue to digital and treatment to prevention. The PM has been equally firm, stating that there will be no more resource for the health service without reform.
Lord Darzi’s report was commissioned as a diagnosis, to lay bare the scale of the challenge confronting the NHS. Nevertheless, as important as it is, much of its content echoes NHS strategic plans of the last 20 years. Indeed, Lord Darzi’s own report from 2007 made a similar case for supporting a left shift in care to the community. These plans failed to deliver, despite the new money that flowed into the NHS. This time new funds will be limited, especially in the short term, and linked to reform. Previous experience is that new money alone is insufficient to drive change at scale. The NHS also requires a fundamentally different and robust delivery approach. The 10-Year Plan for the NHS must set out both the plan for the future but also how the NHS must work to unlock the change required. We believe there are five critical shifts to drive success.
We need to focus on whole of government delivery
Lord Darzi’s report sets out very starkly the declining health of our nation. It’s also clear that many of the determinants of health sits outside of the NHS. The NHS can support the economic growth agenda of the country by decreasing the number of people unable to work because of ill health. However, increased funding for the NHS, even with a greater proportion of NHS spend in the community sector, to the detriment of other public services will not deliver a country focussed on prevention. Indeed, a greedy NHS will potentially stymy a pivot to prevention. A whole of government approach could reset a revitalised model for care, enhance a focus on prevention and encourage a changed ecosystem of agencies. This will require a sensible debate about money for the NHS, with an understanding of the timescales for prevention measures in housing, education and a new solution for social care to take effect. Alongside this, the 10-year plan needs set out expectations of the NHS as an anchor institution and simplify the mechanisms by which the NHS works with public and private sector partners.
We need community-based care to be the new default model
Resources have continued to flow into the acute sector, despite successive reforms championing a shift to greater care in the community. As a society, we remain wedded to our hospitals, and consultations setting out new community-based care models often fail to convince the public that they are not losing essential services. A lack of comprehensive data and block contracts also mask a true understanding of the community services and care pathways provided. Previously the NHS has used new resource to develop and pilot new care models to support a left shift. That approach isn’t going to be available this time around. Moving forward we need a ‘community as default’ approach, with a clear expectation about the pace of change. New ecosystems of providers will be needed to lead this reform with financial mechanisms and incentives driving a shift of resources. This shift will be enhanced if more of the NHS’s senior leaders, clinical and non-clinical, have deep community and mental health service backgrounds.
We need a new approach to innovation at pace and scale
The NHS has often struggled to deliver on the potential of innovation. Costly national transformation programmes have failed to inspire hearts and minds, and consequently stalled in their take up. A plethora of frontline innovation exists but the mechanism to comprehensively spread it is lacking. The NHS requires a new change management approach, one which encourages real-time evaluation, leading to a clear decision point: the innovation doesn’t work and should stop, or it does and it should be adopted universally. We could establish a default where a system or provider not wanting to adopt a proven innovation has to demonstrate why not rather than the ‘not invented here syndrome’ that is much more prevalent than we would like to admit.
We need a technology ready workforce
Developing community health services to support the pivot out of hospital will require a greater use of technology. Many of the major investments into new electronic patient records and the Federated Data Platform are not configured to the needs of the out of hospital sector and the NHS will need to work with suppliers to shape the market to meet its requirements at pace. But a focus on new systems and technical interoperability alone will fail. Research by the Kings Fund in 2022 revealed that the right enabling environment and a leadership commitment to collaboration is imperative for success. Any technology enabled solutions in the 10-year plan need to allow for this more rounded view on interoperability and invest not only in systems but also in training and supporting the people who use them.
We need a regulatory regime which supports improvement
There has been a huge expansion in regulatory and oversight activities across the NHS which, despite good intent, have often struggled to drive systematic improvement. Trusts and systems that find themselves in today’s intervention programmes are likely to have been in multiple recovery and escalation programmes over the last decade. The truth is that the additional regulatory and oversight burden successive restructures have imposed has rarely succeeded in lifting challenged organisations out of failure and into excellence. Going forwards the NHS needs an improvement approach which brings practical resource, expertise and support to challenged organisations but also provides advice and support to those trying new things, helping evaluate their worth for the rest of the service to learn from. This is particularly true in mental health and community services where the leadership ask will be even more onerous and where we need to support leaders to take measured risks.
Whilst change is needed, we should be hopeful for the future
Lord Darzi’s report is highly detailed and supported by a substantial and detailed technical annex, but it also presents a compelling and simple narrative. If the 10-year plan is to galvanise the NHS and public to change, its authors must construct a similar simple core narrative with a golden thread from the diagnosis and a manageable number of priorities, setting out the changes in both policy and delivery to truly pivot the system at scale. This is a huge challenge but, with a new Government, there is a window for change. And the prize is surely worthwhile if we can get it right this time.
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