The Guardian view on the NHS: the biggest test for Starmer’s government

Lord Darzi has delivered to Keir Starmer’s government a concise and clearly argued account of the NHS’s woes in England. Some of its findings, such as those about waiting lists, are familiar. Themes and conclusions – for example, the underfunding of primary care relative to hospitals, and the rise of obesity and chronic illness – are broadly as expected. But this is a valuable piece of work by a respected doctor, and an important step towards the 10-year plan that Labour has promised next year.
It sets out how record-high public satisfaction with the NHS in 2009 was reduced by austerity to a record low. It explains that the funding promise made on the service’s 70th anniversary, in 2018, was broken. And it describes how inequalities in availability and delivery of healthcare mean that poorer people, ethnic minorities and those with mental illnesses are particularly poorly served.
Underfunding is not the NHS’s only problem. Midwives in England deliver fewer babies than in other European countries and yet outcomes are worryingly uneven. Here, and in relation to patient safety more widely, Lord Darzi points to serious concerns around leadership and culture. But the report does not shy away from the destructive consequences of the Conservatives’ failure to fund buildings and equipment. It describes this refusal to invest as “capital starvation” and notes a “staggering gap” with other nations.
On the chaos unleashed by Andrew Lansley’s radical restructuring, imposed in spite of a promise by David Cameron to avoid top-down reorganisations, the report does not hold back. More than a decade later, it finds that the NHS is still recovering from the dissolution of its management and calls this “a calamity without international precedent”. Even after the mistake was recognised, and reforms partly unwound, Conservative ministers could not resist further upheaval. They abolished the main public health body in the middle of the pandemic. Barely a week after the Grenfell inquiry’s attack on the deregulatory agenda pursued under Mr Cameron, this review is further evidence of the harm caused by 14 years of Tory government.
The new, regional structure is judged more sensible. But here too, problems are identified, with integrated care boards not clear about their role and in need of clearer direction. Nor is regulation working as it should, with the number of people in standards and regulatory roles proliferating to no useful purpose. In the worst cases, oversight distracts from clinical focus, while the different accountability measures in hospitals and community services are one reason why resources continue to flow away from the latter. Like Wes Streeting, Lord Darzi believes the Care Quality Commission is unfit for purpose.
The soundbite offered by Sir Keir on Thursday, that the NHS must “reform or die”, was crass. The country will always need its health service, as it needs prisons and schools. Workforce challenges including absence rates are among the sector’s most pressing problems, and the morale of staff as well as patients must be addressed.
This review’s terms of reference did not include the making of recommendations. Ministers did not want a prescription – just a diagnosis. But Lord Darzi does make one, which is that financial flows must be “hardwired”, presumably in law, if community care is to receive an increased share of the overall health budget – as Mr Streeting has said he is determined that it should. Ministers will have to take this on board as they craft their response to the report.