There is no quick fix in sight for the NHS Lord Darzi's report shines a light on the state of the NHS, from our ever-extending waiting lists to the rise of child poverty. With 3.6 million people currently awaiting mental health services and a firefighting mindset amongst healthcare staff, the question we have to ask is can technology fix it? Or is it too late?
Check out Hartesh's post below:
Lord Darzi’s report on the state of the NHS in England and Wales laid bare the extreme pressures that the health service is under and the challenges it must overcome if it is to become a health service fit to meet the demands of an ageing and increasingly multimorbid population.
Whilst the NHS provides life-saving treatment to thousands of patients every day, it now finds itself in “critical condition” and needing intensive treatment to ensure its own survival. Investment to enable digital transformation is proposed as a key remedy, but what does that mean for the future of digital health innovation in the NHS?
While described by some commentators as “sobering”, much of the report will come as no surprise to clinicians, like me, who have become accustomed to the daily living realities of NHS pressures.
Nevertheless, the density of figures presented is undeniably stark: over 1 million people in England are on waiting lists for community services; over 300,000 have been on a waiting list for treatment for over a year; and 3.6 million people are currently accessing mental health services – a rise of 1 million from only 8 years ago.
From paediatric waiting lists to social care for the elderly, musculoskeletal disease to cancer care, it seems no part of the NHS is in good health. Notable in its absence was commentary on gynaecology services, which have experienced the greatest proportional rise in waiting lists from the pre- to post-pandemic period according to the Royal College of Obstetricians and Gynaecologists.
Welcomed by many is Darzi’s holistic appraisal of health and the social determinants of health. Not only does the report expose inefficiencies within the NHS, but it also explores the impact of socioeconomic factors on the health service, and vice versa.
Child poverty has risen alarmingly throughout the 2010s while cost of living pressures have caused those in the most deprived households to eat fewer fruit and vegetables.
Unhealthy lifestyles and material deprivation have contributed to a rise in chronic disease and mental illness, which themselves have contributed to a rise in long-term workplace sickness absence, further exacerbating the country’s macroeconomic woes.
The report acknowledges that such deeply entrenched issues that have been well over a decade in the making will not be quick to fix; this task is to be undertaken as part of a 10-year plan. While specifically avoiding making policy recommendations, Darzi sets out what he thinks are the central tenets of NHS recovery.
So where does Primary care fit into all this?
Primary care’s role features prominently in the plan.
Bucking the trend set by acute hospital services, productivity in primary care is rising, no doubt in part because it has “the best financial discipline in the health service.” “Extraordinary” and “remarkable” is how Darzi describes some of the innovations that have occurred in GP practices across England in response to ballooning workloads, exerted partly by work-transfers from elsewhere in the health system, which has paradoxically seen rising staff headcounts.
However, while primary care has shown immense resilience in the face of a one quarter reduction in the proportion of total healthcare spending it receives, Darzi suggests that reform is needed if we are to maximise the benefits derived from its efficiency. He takes aim at the perverse incentives that exist in primary care, whereby good care can necessitate taking a hit on practice income.
This must be addressed if the aims of enabling a “left shift” into efficient community care, and providing better preventative care, are to be realised.
While the report rejects top-down reorganisations of the NHS or integrated care boards (ICBs) as being either necessary or desirable, the role of digital transformation to enable a shift in the model from “diagnose and treat” to “predict and prevent” is said to be a missed opportunity over the last two decades. The claimed £37 billion black hole in capital investment is criticised, as is the decline in numbers of clinical academics whom Darzi explains are “an essential resource in bridging the gap between research and clinical practice so that research focuses on the areas of greatest need and patients in the clinic benefit from breakthroughs faster.”
Can Artificial Intelligence transform care?
Artificial intelligence (AI) is proposed as technology that could “transform” care for patients. The report describes its utility in radiology but rightly suggests it should be used in many more ways to enhance patient care.
Considering the report’s major remedial themes (a left shift into the community; prediction and prevention; and digital, specifically AI, transformation) it seems the agenda is set for the NHS to focus on investment in research and innovative practice that will identify patients with prodromal or early disease, in the community, and deliver targeted therapies to prevent disease progression and future morbidity.
It might not be the most alluring of technological innovations to pursue but I, and Darzi, would argue that augmenting obesity, diabetes and cardiovascular disease care and prevention with digital technologies has immense potential to alleviate the future burden of disease.
We must escape the ingrained firefighting mindset whereby technology must be seen to result in immediate and direct efficiency savings, and instead accept that prevention has a much longer return on investment. Investment to improve and ideally automate care processes in primary care could additionally help liberate staff time.
Of course, none of this thinking is new, and while the technology is one aspect, implementation is another.
The question, therefore, is what will the political response be to overcome the barriers to implementation at policy, structural and workforce level? GPs have learned to become sceptical of talk to shift even more work into primary care (even with more funding), and as Darzi writes, staff across the NHS have become disengaged, putting in less “discretionary effort.”
It remains to be seen what staff and structures will be deployed, where and how they will work, and what mechanisms may need to be employed to ensure that desirable behaviours are appropriately incentivised.
The Darzi review has succeeded in laying out the broad spectrum of issues confronting the NHS in England and, for the government, has fulfilled its purpose in demonstrating that the NHS must reform to tackle the challenging health and social care needs across the country. Crucially, the NHS must move from reactive crisis management to proactive, preventative care, with primary care at the heart of this transformation.
Digital innovation, particularly with AI, holds significant promise for improving patient outcomes and driving efficiency. The key to success will lie in the well-considered implementation of appropriate structures and incentives to deliver digital innovation, and careful political manoeuvring to engage and cooperate with a GP workforce that is deeply sceptical of further shifts of work into primary care.
Thanks for reading!
Hartesh Battu is a GP in Glasgow, Scotland, a senior innovation fellow at the Digital Health Validation Lab, University of Glasgow, and the innovation clinical theme lead for primary care at the NHS West of Scotland Innovation Hub.
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