To those of us living in England, the NHS is central to our lives, and we will all need access to it at some time. It is therefore worrying when we read in the recently published report from Lord Darzi (2024a) that the NHS is in crisis and public satisfaction with it stands at an all-time low. There is a caveat of sorts that, ‘despite the challenges, the NHS vital signs remain strong’ (Darzi, 2024a:11) – this sounds a note of optimism, but others may still see the situation as dire.
The fact that the NHS is in serious trouble should come as no surprise as the media frequently highlight the latest NHS crisis – the NHS plays such an important role in our daily lives, and something always seems to be happening to it. The Darzi report catalogues many well-documented problems that have dogged the NHS for a long time, and have been discussed in past reports by many NHS stakeholders.
This report's value lies in the fact that it excellently articulates these and other problems in one place and points the way forward to trying to fix matters. It uses clear language and is an accessible read, and is accompanied by a technical annex containing 330 data analyses (Darzi, 2024b).
Patient safety, health quality and clinical negligence: overview
Darzi (2024a) covers a lot of ground and issues in this wide-ranging report, which is unsurprising given the vast scope NHS activities. This column focuses on the finding on the NHS health regulatory and governance structure, particularly quality of care, patient safety and clinical negligence litigation.
In the summary letter to the Secretary of State for Health and Social Care in the report, Darzi (2024a) states that the picture on quality of care is mixed, with most people, once in the system, receiving high-quality care. This has been a commonly held view for a long time: most people do receive high-quality NHS care, but there are significant gaps, such as maternity care. The failings tend to obscure and overshadow the good that takes place in the NHS. To take one positive patient safety finding:
‘There have been improvements in patient safety, with more error-free care in hospitals and a reduction in the number of suicides in inpatient mental health facilities, partly as a result of sustained political attention.’
This must be balanced against the negative patient safety findings expressed elsewhere in the report. The conclusion drawn is that much more needs to be done to improve NHS care quality.
In the summary letter, there is a discussion of patient engagement, saying that the patient voice is not loud enough. The number of patient complaints has increased, and a particular theme in inquiries into care failings has been that patients' concerns not being heard or acted on. Clinical negligence is also cited in the summary letter and the ‘record sums’ being paid in compensation, amounting to 1.7% of the entire NHS budget (Darzi, 2024a: 9)
A constant state of flux
The summary letter also addresses the issue of the NHS being in an almost constant state of regulatory flux. One issue cited is that too manypeople are holding the NHS to account rather than ‘doing the job’ (Darzi, 2024a:10). This can be counterproductive. The report states that regulatory-type organisations now employ some 7000 staff, or 35 per provider trust, the numbers having grown significantly over the past 20 years.
‘NHS organisations should focus on the patients and communities they serve, but the sheer number of national organisations that can “instruct” the NHS encourages too many to look upwards rather than to those they are there to serve.’
The summary letter also argues that the Care Quality Commission (CQC) is not fit for purpose, focusing on inputs rather than outcomes. These are issues that are further discussed in the report.
Maternity care
Away from the report's summary letter there is a deep dive into the problems of maternity care, with the comments about too many women, babies and families being let down. The Darzi investigation received a submission from Dr Bill Kirkup, who led the Morecambe Bay and East Kent investigations, and his comments about the issues are laid out. These comments – such as training in silos and failures in compassion – are well worth reflecting on because they indicate severe failings regarding patient safety.
Complaints and clinical negligence: more detail needed
Darzi (2024a) states that it is still striking that complaints have nearly doubled in a little over a decade, according to the data shared by the Parliamentary and Health Service Ombudsman (PHSO):
‘As the highest level to which complaints about the NHS can be directed, they received 14,615 formal complaints in 2011–12, rising to 28,780 complaints by 2023–24.’
The clinical negligence discussion in the report notes that that the NHS is an outlier in clinical negligence payments when compared with some parts of the world, with reference made to New Zealand, Australia, and Canada. High costs are also noted:
‘Aside from pensions and nuclear decommissioning, NHS clinical negligence claims are the largest liability on the Government's balance sheet.’
The comments about clinical negligence and costs require a more detailed discussion and analysis than is given in the Darzi report in order to provide a full and fair picture of issues. The situation is more nuanced and complex, requiring more critical unpacking and discussion than is available in a report covering many NHS issues. The report is right to flag up the issues, but the problems and issues around clinical negligence run deep.
Wrong impressions
The NHS Ligation Reform Inquiry was a deep dive into clinical negligence litigation issues (House of Commons Health and Social Care Committee, 2022). Along with the expert evidence submitted, the inquiry report fully covered these issues, and is referenced by the new NHS report.
In reading Darzi (2024a), it is important not to simply come away with the impression that clinical negligence litigation is out of control, that it is too expensive and that it is a big burden on the NHS. It is not out of control, and I would argue that a current positive feature is that it is becoming, generally speaking, less adversarial in nature. NHS Resolution (2024:18) has shown how most cases do not go to court and that informal resolution methods are now being increasingly adopted.
This is just one factor that is a positive for our current way of dealing with clinical negligence claims – and there are many other positives and negatives.
Systems, incentives, oversight and regulation
Further on in the report the regulatory environment is discussed in more detail. The conclusion drawn is that there are too many people in regulatory-type functions and the problems this causes are discussed. The report makes the point that over the past 20 years the number of people employed in regulatory roles per NHS provider trust has burgeoned. The concern expressed is that the result is an ever-lengthening list being made on providers of regulatory jobs to do. In essence, we are suffering from regulatory overkill in the NHS, which I have discussed in previous columns.
In terms of oversight and regulation, there is further discussion of this and how constant NHS reorganisations are costly and distracting. Reference is made to the increasing number of staff working in NHS England. The expansion at the top causes challenges such as many people at the top of the organisation encouraging local NHS organisations to look up to them, ‘as well as outwards to the communities that they serve’ (Darzi, 2024a:122).
The CQC is addressed again in the report and how many clinicians and managers think it to be excessively focused on staff numbers and paperwork at the expense of patient experiences and clinical outcomes:
‘Despite the highest level of hospital employment in the world, there appears to be no problem for which the CQC believes the solution is something other than to add more staff.’
Darzi (2024a) also mentions the Dash (2024) report into the CQC and its preliminary findings.
A top-heavy system
We do have a top-heavy and overcentralised health regulatory and governance structure and have had so for some time. In several of my past columns I have discussed the fragmentary and overlapping nature of the NHS organisations having a patient safety remit, and how rationalisation, reform and more co-ordination are needed.
The health regulation and governance structure needs to be urgently simplified because it is confusing for both patients and clinicians. This has been echoed by many NHS patient safety stakeholders, and the Darzi (2024a) report captures this issue well.
Realistic prospects of organisational reform?
Reform of the CQC will be inevitable and is a given, but I am less confident about the realistic prospects of wider NHS health regulatory and governance reform taking place. The organisations that comprise the NHS governance framework will all have agendas, plans, expertise in staffing, and a valuable organisational memory of issues. They will all have invested considerable time and money in their functions and activities. Change will be difficult for them, as it would be in any organisation.
However, things do not stand still, certainly in the NHS and health care. Critical reflection is always crucial and central to developing an effective patient safety culture. I would argue that there needs to be another review by the Department of Health and Social Care of its ‘arm's-length bodies’, as was done in 2008 (National Audit Office, 2008).
Conclusion
There is a lot in Darzi (2024a) to fully unpack. It is a welcome report that provides an excellent insight into the many problems that currently beset the NHS and that have stubbornly done so for years. The report's findings and conclusions will come as no surprise to many.
In terms of the health regulation, governance and patient safety issues identified there is a lot to work still to do. The report presents an important agenda for reform and change. In terms of the rationalisation, reform and possible consolidation of NHS bodies that have a patient safety remit this will be no easy task. As with change in all other areas of endeavour it will be difficult. However, it is urgently needed, and I would suggest that, in addition to the changes advanced in Darzi (2024), the Department of Health and Social Care should embark on a formal review of its arm's length bodies.