Lord Darzi was commissioned to undertake this rapid investigation of the state of the NHS by the Secretary of State for Health & Social Care. The report was prepared over a nine-week period between July and September 2024. Lord Darzi was tasked with examining areas such as the health of the nation and the social care system insofar as they impact the NHS, although these were outside the formal scope of the investigation. Read Lord Darzi’s letter to the Health Secretary (12/09/2024). See our follow-up article: Sir Keir Starmer’s Reforms of the NHS – referenced in part against Lord Darzi’s Report.
The commissioning of this report appears to have been a governmental initiative to get an independent, expert assessment of the current state of the NHS in England, likely to inform future policy decisions and reform efforts.
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Table of Contents
Findings categorised
Without further delay most of the findings are summarised into categories below.
A. Waiting Times and Access:
1. 7.6 million people waiting for NHS treatment (June 2024)
2. Over 300,000 people waiting over a year for treatment
3. 1.75 million people waiting 6-12 months for treatment
4. A&E attendances seen within 4 hours: 96.6% in 2011, 74.5% in 2024
5. Around 1 million people waiting for mental health services (April 2024)
6. 345,000 referrals waiting over a year for first contact with mental health services
7. 343,000 children and young people under 18 waiting for mental health services (109,000 waiting over a year)
B. Workforce and Productivity:
1. GPs per 100,000 population declined by 1.9% per year between 2016-2024
2. UK has 15.8% fewer GPs per 1,000 population than OECD average
3. Hospital workforce increased 17% between 2019-2023
4. NHS productivity at least 11.4% lower than in 2019
5. UK has 86.7% fewer nurses and midwives working outside hospitals compared to OECD average
6. Sickness absence: One working month (22 days) per nurse and midwife per year
C. Funding and Investment:
1. NHS budget in 2024-25: £165 billion
2. £37 billion shortfall in NHS capital investment compared to peer countries over 2010s
3. Backlog maintenance in NHS stands at £11.6 billion
4. Public health grant cut by more than 25% in real terms since 2015
5. NHS spending as % of GDP increased from 10% in 2019 to 11% in 2022
6. Share of NHS budget spent on hospitals increased from 47% in 2006 to 58% in 2021
D. Health Outcomes and Prevalence:
1. Estimated 14,000 additional deaths per year due to long A&E waits
2. Decline in childhood vaccination rates since 2013-14
3. Prevalence of diabetes increased from 5.1% in 2008 to 7.5% in 2022
4. Prevalence of depression increased from 5.8% in 2012 to 13.2% in 2022
5. 2.8 million people economically inactive due to long-term sickness (up 800,000 since pre-pandemic)
E. Service Provision and Infrastructure:
1. 13% of NHS beds occupied by patients waiting for social care support
2. Around 1,200 pharmacies closed since 2017
F. Complaints and Litigation:
1. Clinical negligence payments increased to £2.9 billion in 2023/24 (1.7% of entire NHS budget)
2. Formal complaints about NHS services increased from 14,615 in 2011-12 to 28,780 in 2023-24
G. Administration and Regulation:
1. Staff in NHS statutory bodies with ‘regulatory’ type functions increased from about 2,000 in 2008 to over 7,000 in 2024
2. Department of Health and Social Care staff numbers increased from 1,920 in 2013 to 3,185 in 2024
What do the findings mean
- Long waiting times: Millions wait for treatment, impacting A&E and mental health services particularly hard.
- Workforce shortages: Declining GP numbers and fewer nurses/midwives compared to other developed countries.
- Funding gaps: While the NHS budget has increased, capital investment and public health funding lag behind, impacting infrastructure and preventative care.
- Declining health outcomes: Long A&E waits potentially contributing to thousands of deaths, increasing prevalence of chronic conditions, and rising economic inactivity due to ill health.
- Strained service provision: Bed shortages exacerbated by social care bottlenecks, and a decline in pharmacy numbers.
- Rising costs: Clinical negligence payments consume a growing portion of the NHS budget.
- Growing bureaucracy: Significant increase in administrative and regulatory staff within the NHS and overseeing bodies.
Mental health services
Waiting Times:
- Around 1 million people were waiting for mental health services as of April 2024 (p 32).
- 345,000 referrals were waiting over a year for first contact with mental health services (p 32).
- For children and young people under 18, 343,000 were waiting for mental health services, with 109,000 waiting over a year (p 33)
Increased Demand:
- Mental health referrals for adults have been increasing at a rate of 3.3% per year.
- For children and young people: referrals have increased by 11.7% per year from around 40,000 a month in 2016 to almost 120,000 a month in 2024.
- Perinatal mental health service referrals have risen by 23% per year since 2016.
- ADHD services:
- “The growth in demand for ADHD assessments has been so significant that it risks completely overwhelming the available resource.” (p34)
- “At current rates, it would take an average of 8 years to clear the backlog in adult ADHD assessments – and for many trusts, at current rates, the backlog would not be cleared for decades.” (p 34)
- “Implied clearance time for adult ADHD assessments based on activity and wait list size.” [Chart – (Figure II.6.10) on page 34]
- NHS England has established a taskforce on ADHD, which “will have important recommendations to make.” (p 35)
- While not specific to ADHD, the report notes that between 2004 and 2023, the number of patients on ADHD medication has been increasing by just over 10% each year. (p 19)
Prevalence of depresson:
- Shot up from 5.8 per cent in 2012 to 13.2 per cent a decade later in 2022 (p. 19).
- Talking therapies: The proportion of people with anxiety or depression who have been able to access Talking Therapies has increased from 6.1 per cent in 2013/14 to 15.9 per cent in 2022/23 (p. 44).
- Recovery rates: The recovery rate for those who complete a course of talking therapies has remained steady at approximately 50 per cent (p. 44).
- NHS practitioner health: Depression/low mood is the most common diagnosis for those presenting to the NHS Practitioner Health service, with 71.3 per cent of patients reaching the level for moderately severe and severe depression based on the PHQ9 questionnaire (p. 115).
- Economic inactivity: While not specific to depression alone, the report notes that most of the recent rise in long-term sickness leading to economic inactivity is being driven by mental health conditions, especially for two main age groups: 16 to 34 year olds and 50 to 64 year olds (p. 93)
Infrastructure: Some mental health patients are still accommodated in outdated Victorian-era facilities with poor conditions.
Impact:
- The long waiting times and increased demand are leading to a significant treatment gap in mental health services.
- The disparity between mental health needs and available resources is resulting in poorer outcomes for patients.
- The lack of timely interventions may be contributing to the rise in mental health-related economic inactivity.
- The poor state of some mental health facilities is affecting patient dignity and potentially hindering recovery.
- The lower life expectancy for those with serious mental illnesses indicates a systemic failure in providing holistic care.
Workforce Issues:
- The overall mental health workforce reduced by 9.4% between 2010-11 and 2016-17.
- The number of mental health nurses dropped by 13% between 2009-10 and 2016-17.
- It took until 2023-24 for the number of mental health nurses to return to their 2009-10 level.
Funding:
- Funding disparity: Mental health accounts for more than 20 per cent of the disease burden but receives less than 10 per cent of NHS expenditure (p. 85). This indicates a significant mismatch between the need for mental health services and the resources allocated to them.
- Historical underfunding: The report notes that during the first half of the 2010s, mental health services experienced significant cuts. For example, the number of mental health nurses fell for each of the five years following 2011 (p. 76).
- Mental health investment standard: Since 2016, the NHS has applied the “mental health investment standard“. This intervention has helped by protecting mental health budgets and keeping its share of NHS spending constant at 9 per cent (p. 76).
- Slow recovery: Despite the introduction of the mental health investment standard, it took until 2023 for the number of mental health nurses to return to their 2009 levels (p. 76-77).
- Treatment gap: The combination of chronic underspending with low productivity results in a treatment gap that affects nearly every family and all communities across the country (p. 85).
- Impact on inpatient services: The report mentions difficulties in finding mental health beds, which contributes to long waits for patients with mental health issues in acute hospital emergency departments (p. 85).
- Capital investment: While not specific to mental health, the report highlights a significant overall shortfall in NHS capital investment compared to peer countries. This likely affects the infrastructure and facilities available for mental health services (p. 100-101).
Quality of Care: There are concerns about the rigor of follow-up and risk management for patients with serious mental illnesses in the community.
- Follow-up and risk management: The report states, “There are a number of concerns about the rigor with which patients who have serious mental illnesses are followed up in the community and how effectively risk is managed” (p. 47).
- Inconsistent care: The report mentions “There is significant scope for improvement in the quality, safety and consistency of care” for people with serious mental illnesses in the community (p. 47).
- Care plans: 35 per cent of patients with long-term conditions still do not have a care plan, which is described as “one of the most important tools to coordinate and manage care” (p. 48).
- Physical health checks: While there has been progress in physical health checks for mental health patients, with an annual increase of 127 per cent, this is still below the ambition set in the 2019 NHS Long Term Plan (p. 45).
- Excess mortality: Despite improvements in physical health checks, excess mortality for those with serious mental illnesses has been increasing. The report cites an estimated 130,400 premature deaths among adults with severe mental illness during 2020-2022, compared to an estimated 100,476 in 2015-2017 (p. 45).
- Out-of-area placements: The report notes that inappropriate out-of-area placements of mental health service users have decreased at a rate of 8 per cent a year since 2018, but they began to rise again in 2023, reaching nearly 6,000 in that year (p. 46).
- Waiting times: Long waiting times for community mental health services are mentioned, with 345,000 referrals where people are waiting more than a year for first contact with mental health services (p. 33).
- Emergency Care: People with mental health crises face longer waits in A&E, with some waiting up to 30 hours (95th percentile) in May 2024.
- Physical Health of Mental Health Patients: People with serious mental illnesses have significantly lower life expectancy, typically dying 15 to 20 years earlier than the rest of the population.
Outlook
Darzi states, “Despite the challenges set out in this report, the NHS’ vital signs remain strong. The NHS has extraordinary depth of clinical talent, and our clinicians are widely admired for their skill and the strength of their clinical reasoning. Our staff in roles at every level are bound by a deep and abiding belief in NHS values and there is a shared passion and determination to make the NHS better for our patients. They are the beating heart of the NHS.” (p 131)
The harsh reality lends comparison of the NHS to a patient with multiple organ dysfunction syndrome (MODS) in ITU.
- Respiratory failure requiring mechanical ventilation (analogous to the strain on front-line services)
- Circulatory shock needing vasopressors (representing funding and resource allocation issues)
- Acute kidney injury requiring dialysis (symbolising the backlog of treatments and long waiting times)
- Liver dysfunction (representing regulatory and administrative inefficiencies)
- Coagulopathy (analogous to workforce shortages and distribution problems)
- Altered mental status (representing issues in mental health services).
- CNS failure (representing NHS management)
While this patient’s heart might still be beating (analogous to dedicated staff continuing to provide care), and they might maintain a blood pressure with support (like emergency funding measures), calling their vital signs “strong” would be overly optimistic.
The ‘patient’ is critically ill, requiring multiple interventions and at high risk of further deterioration without comprehensive, system-wide treatment. But wait – with no new resources! Patient told “Improve or die!“
Conclusion
Lord Darzi’s report, commissioned by the Secretary of State for Health & Social Care, provides a comprehensive assessment of the National Health Service (NHS) in England as of 2024. The report, compiled over nine weeks, examines various aspects of the health system including patient access, quality of care, and overall performance.
The report highlights significant challenges facing the NHS across multiple areas. These include lengthy waiting times for treatments and mental health services, workforce shortages, underfunding (particularly in capital investment), declining productivity, and increasing prevalence of chronic conditions. Mental health services are particularly strained, with long waiting lists and a growing demand that outpaces available resources. The report also notes issues with A&E performance, an aging infrastructure, and a shift in NHS spending towards hospitals at the expense of community-based care.
Lord Darzi’s findings paint a picture of an NHS in “critical condition” but with “strong vital signs.” While the report identifies numerous areas of concern, it also emphasises the enduring strengths of the NHS, including its dedicated workforce and the fundamental principles of a taxpayer-funded, free-at-point-of-use health service. The report suggests that significant reforms and investments will be necessary to address these challenges and improve the NHS’s performance, but it maintains that with the right approach, the health service can return to peak performance.
Darzi’s upbeat outlook on the NHS is an insult to the intelligence of ordinary people.
