The NHS is in critical condition – but with the right care it can recover | Polly Toynbee

Bsmoking but not defeated, is Lord Darzi’s verdict on the NHS in England. “My colleagues in the NHS are working harder than ever, but our productivity has fallen,” he writesconcluding: “The NHS is in a critical state.” His report contains page after page of heart-wrenching detail that would shock the public to their core, if everyone didn’t already know that the NHS was in crisis. That’s why the Tories were so resolutely hounded out. The health of the NHS is the health of the nation and the fitness of any government to govern.

But we are where we are. One aim of Darzi’s report, of course, is to lay the blame where it belongs: on the Conservatives’ unprecedented per capita underfunding of a rapidly growing, ageing and much sicker population. The public may have long forgotten the catastrophic effects of Andrew Lansley’s 2012 NHS reshuffle, but Darzi finds that the former health secretary’s “scorched earth” approach to health reform has left deep scars.

The Covid-19 pandemic compounded the disaster, hitting a health care system that was less resilient and with fewer beds than comparable countries. How patient will the country’s patients be as they wait for tangible improvements? That is the central task of this report: to explain why it will be many years before the NHS returns to 2010 waiting times. It serves as an invaluable benchmark, the starting point from which to assess progress year on year.

“Reform or die,” Keir Starmer said of the NHS today. The word “reform” sends shivers down the spines of Britons, who see it as Tory code for dismantling the NHS funding model and replacing it with some kind of private insurance that has never been defined because no private financial model is better.

Darzi makes clear that the crisis was caused by a lack of finance, particularly capital (that is, spending on one-off infrastructure costs as opposed to regular costs such as wages), not by a problem with the system of public financing. What Darzi, Starmer and the Health Secretary, Wes Streeting, mean by “reform” will be spelled out very clearly in a 10-year plan due to be prepared in the spring. It is, thankfully, not about another Lansley-style administrative disorganisation. It is about shifting resources and patients from hospital to community, from acute care to prevention. It’s a good idea, but that’s what everyone has always wanted to do – so what’s new?

Never waste a good crisis: this one demands change. The NHS is £2.2 billion in debt this year, a sum that by law must be cleared at the end of each year. Capital cuts have caused much of this crisis, leaving medical staff waiting half an hour for old computers to waste their time using outdated scanners and IT systems: according to Darzi, 13 hospitals lose productivity every day due to serious maintenance errors.

Yet hospitals have increasingly sucked up money from community services: in 2006 they took up 47% of the NHS budget; by 2022 that was increased to 58%. The public will largely judge the NHS on headlines showing the length of operating lists and A&E waiting times, so cutting hospital budgets seems unlikely. Can a cash-strapped NHS find a way to ‘double down’ – expanding community, GP and mental health services that stop people going to hospital, while also cutting waiting lists? It could, if only it had the funding.

There are things politicians and NHS managers are not allowed to say, but the outspoken chairman of NHS England dares to say them. Richard Meddingsa banker and former chairman of TSB, spoke to me this week after a meeting of the NHS Assembly and explained the problem of bed shortages: 122,000 hospital beds in 2010 have now been reduced to 97,000. Who are in them? “Three quarters are over 65s, 25% have dementia,” he said. “Many have urinary tract and chest infections which need to be caught early and treated at home.”

About 13% of patients in the ward are medically fit to be discharged, but are waiting for care to be arranged at home. Meddings wants a broad public discussion about the end of life. “Half of deaths occur in hospital, (which) is not the right place to die, but on average people are in hospital for 45 days before they die. There needs to be a national conversation about what hospitals are for and who should be in them.”

If threatened hospices collapse, the NHS will take those patients too. Honesty about death is long overdue, as is frank conversation about the tendency to keep very sick people alive a little longer with more interventions, rather than letting them die more comfortably at home.

The answer for the NHS is unlikely to be more beds: provide more beds and they will always be filled. Social care was not part of Darzi’s remit, but a rapid implementation of Labour’s promised national health service would do more for the NHS, and be cheaper, than spending money on hospitals.

Rachel Reeves was right to call out the Tories unfunded promise of an £86,000 cap on how much people in England spend on social care, and to prioritise quality care by staff on NHS career paths. And Labour’s plan to redistribution of resources within the NHS more money would shift to GPs, who now 90% of all carebut whose budget has fallen to the lowest share in eight years while their workload increased by 20% between 2019 and 2023. Indispensable community nurses, school nurses and district nurses are almost extinct and must come back.

Take it a step further and ask whether the NHS really determines the health of the nation. Poverty, inequality, insecurity, poor housing and impoverished schools are more important, with plenty of research to prove it. Sugar, salt and ultra-processed food regulation would help prevent ill health, just as clean water, clean air and less smoking have saved most lives in the past.

Coincidentally, the Financial Times published its story on the Darzi report this week alongside another report: “Funding for preschool education is at the lowest level among OECD countries”. Pause there. Wouldn’t a return to Sure Start centres that pick up on family issues from birth and ensure all children are ready for school be a better investment in the nation’s health and wellbeing than spending money filling hospital beds with older people who shouldn’t be there?

• Polly Toynbee is a columnist for The Guardian

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