The Darzi review of NHS performance signals why radical change is needed

As each month’s performance statistics show, poor performance continues to be an issue for the NHS – with today’s likely to follow the usual trends. But Lord Darzi’s review is an opportunity for radical change rather than just tinkering, says Siva Anandaciva.

Ever heard of a ‘waiting room nurse’? I hadn’t. But a few months ago, I was shown around an A&E department that was so swamped it needed a dedicated nurse to monitor seriously ill patients in the A&E waiting room – the reception area had essentially been turned into a ward. Seeing it in person gave you the same disorientated feeling you might have if you walked into a busy hotel and saw people sleeping on beds in the lobby.

Lord Darzi, a renowned surgeon, has just completed a rapid independent review of NHS performance for the new Labour government. A&E care plays a prominent part in the review, partly because of the service’s high public profile and rich data collections. So what does national A&E data tell us?

The first is that performance woes are broad and not just the result of a few unusually challenged organisations. While there is some variation in performance, not a single hospital operating a major A&E department in England is currently meeting A&E performance standards (see Figure 1). Poor NHS performance is now a national problem, not a local issue.

The second is that the performance scars are deep. We are not just talking about performance targets being missed by a hair’s breadth or people waiting a few minutes longer in A&E than they should. The number of people waiting over half a day on a trolley for admission from A&E to the main hospital has exploded, to the extent that chart axes need to be redrawn annually to make sense of the data (see Figure 2).

So, let’s bring this all back to Lord Darzi and his review – which  focuses on ‘diagnosis, not treatment’. I find myself getting less cynical as I get older, so let me tell you my two hopes following this review.

The first is that the publication of the review enhances, rather than detracts, from the development of the government’s health mission. The review team received a huge number of submissions that will help it paint a picture that goes far beyond A&E care and includes everything from ambulances and ADHD assessments to paediatrics and podiatry. If nothing else, this will hopefully start to redress the imbalance in national focus and data that means we have such a rich time series when it comes to A&E performance but relatively little national information on what is happening outside of hospitals.

But even that broader diagnostic lens doesn’t capture the state of adult social care, public health services and other services that maintain or improve the health of the population, all of which were placed outside Lord Darzi’s remit. So there is a risk that NHS-focused audits and NHS-focused plans consume the oxygen in the room – oxygen that could be spent on developing the wider health mission that could be this government’s true legacy. Although Lord Darzi’s focus was the NHS, treatment will be needed across the whole health and care system.

My second hope is that the publication of the Darzi review builds the case for radical change rather than incrementalism. In recent years, the plan for the NHS has been to gradually increase performance levels by 2% a year in A&E. So it wouldn’t be a surprise if the current government uses Lord Darzi’s work to say that it has inherited an NHS in poorer shape than it expected, and that while the manifesto commitment to recover all performance standards in the NHS Constitution will remain, it will simply take longer to achieve and longer for all those 2% improvements to add up.

As someone who has spent more than their fair share of time in A&E departments, I am not going to sit here and argue that A&E waiting times don’t matter to patients and the public. But the pursuit of recovering performance standards could lock the NHS into keeping targets as they are, rather than evolving them to reflect advances in clinical care. It would retain a focus on waiting time process measures, rather than a broader focus on improving health and care outcomes. And it would keep a huge amount of focus and resource on acute hospital care, at a time when the government wants to shift more care out of hospital and develop the NHS into a more prevention-focused service. How the government responds could determine whether a ‘waiting room nurse’ is a short-term emergency tactic or becomes an emerging profession.

We don’t need an independent review to know that NHS performance is bad and that the government has received a troubled inheritance. What we need is a mandate for change. Wes Streeting, the Secretary of State for Health and Social Care, has already said the NHS is broken. With a diagnosis this serious, the treatment surely needs to be radical.