The NHS is in ‘serious trouble’ and needs major reform – here are the pitfalls the government must avoid

The NHS is in “serious trouble” unless major reforms are made, according to the recent review by renowned surgeon and former Labour Health minister, Lord Ara Darzi.

This independent investigation into the health service in England highlights the many problems facing the NHS – including shocking waiting times for appointments and treatments, the neglected nature of the NHS estate, and a failure over many years to invest sufficiently in the latest information, diagnostic and medical technologies.

Darzi’s report also underscores the many reasons for the NHS’s current problems – citing factors such as public sector financial austerity, the Lansley NHS reforms, the COVID-19 pandemic, cuts to public health budgets, and a failure to reform social care.

Following the review, Prime Minister Keir Starmer said in a speech that the NHS was broken but “not beaten” – but there wouldn’t be additional funding without reform. Starmer also highlighted three fundamental NHS reforms the government will focus on making first, based on Darzi’s recommendations.

Designing and implementing these reforms will be a monumental challenge for the government. But if implemented successfully, they could start to transform the NHS.

Moving from analogue to digital

The NHS has struggled for years to become fully IT-enabled.

For example, while GP practices all use electronic records systems and often have app- or web-enabled service access, they don’t consistently link with other healthcare providers. And, despite most hospitals having electronic records, they’re not always used to full effect. This is particularly true for sharing information across different NHS organisations.

Darzi describes the NHS as being “in the foothills of digital transformation” – noting that IT innovations too often add to, rather than reduce, staff workloads. But when properly implemented, digital technologies could improve productivity and streamline care.

After a failed top-down national programme for NHS IT under the Blair government, there may be apprehension about how to proceed. A good place to start would be improving basic patient administrative processes.

This is a vital component of properly coordinated care – and would significantly improve patients’ experiences of the NHS. For instance, patients would spend less time recounting symptoms to different professionals and could avoid unnecessary consultations.

Although technology is a key part of enabling more modern, patient-focused care, its implementation will need careful, local attention and evaluation to ensure these potential benefits are realised.

Shifting to community and primary care

Reallocating funding from hospitals to community and primary care has been a long-term ambition for NHS policymakers. This is based on international evidence that shows most people prefer to receive care close to home provided by local doctors, nurses and care workers – avoiding hospital admission wherever possible.

Even before Darzi’s report was published, Labour announced plans to develop a “neighbourhood health service” by diverting billions of pounds from hospitals into primary care.

But to avoid fights between local NHS organisations for scarce resources, it may be wise to reform how NHS budgets are allocated. For example, joint funding across hospitals and primary care could be used to develop new forms of neighbourhood care. Evidence on integrated care shows how NHS bodies (with the right incentives) can fund and organise whole pathways of care across different organisations, making services more accessible for patients.

In a highly centralised service such as the NHS, there will be temptation to dictate reforms from the centre. But for such large-scale changes to work, they need to be led locally wherever possible – involving staff (especially doctors) and patients throughout.

From treatment to prevention

In his review, Darzi talks about “the power of prevention” – linking this to reduced pressure on NHS services, improvements in people’s health, and boosting the economy as more people could remain in work. Placing a stronger focus on preventing disease has been a long-term NHS policy intention.

Since the report’s publication, the government has already announced a new public health measure it will roll out in a bid to improve public health and prevent disease. This involves banning junk food ads on TV pre-watershed – with online ads for such products banned altogether. The government will also take forward the Tobacco and Vapes Bill, which would impose further limits on cigarette sales and vape marketing.

There are also other examples of disease prevention undertaken at the community level on which the government can draw. These initiatives have typically been developed through strong, collaborative work by local government alongside the NHS.

For example, the “Wigan Deal” was an informal agreement between the local council and its citizens to commit to their health. The council worked with local NHS and other services on an overall preventative approach – giving staff more freedom to make decisions about services when working with patients, and focusing on the strengths of local communities. Evidence so far shows it’s led to some improvements in healthy life expectancy in the area – bucking the national trend.

But moving from treatment to prevention will require long-term investment and action across government departments, as many of the determinants of ill-health are rooted in poverty, poor housing, unemployment, and lack of access to early years education. Health services play but one part in this. It’s vital local NHS organisations are supported in being part of collaborative efforts to improve health through prevention.

Potential pitfalls

To achieve its mission to reform the NHS, the government needs to avoid three major pitfalls.

First, it must avoid the temptation to do everything from the centre – trusting instead in local organisations and teams, within a proportionate framework of accountability.

Second, it must avoid poor implementation of reforms by investing significantly in management capacity to make the profound changes needed – even though this will probably be politically contentious.

Third, the reforms must avoid a major and distracting structural “redisorganisation”. Politicians and policymakers must concentrate on making tough, long-term improvements in local patient services instead of – yet again – changing NHS structures in ways that will have little effect on how care is delivered.

Judith Smith is Professor of Health Policy and Management at the University of Birmingham.

Judith receives funding from the National Institute for Health and Care Research. She is Chair of Health Services Research UK, Senior Associate of the Nuffield Trust and Senior Visiting Fellow at the Health Foundation.