Darzi report: future vision

04 July 2018 Seamus Ward

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Robots in radiology. AI in A&E. A bot by your bedside. It’s a favourite trope of science fiction that advanced machines will take over some of the services currently delivered by health and care professionals. But, looking at the needs of health and social care over the next 12 years, respected clinician Ara Darzi believes such significant technological advances should not remain in the realms of the imagination.

Of course, robots are already a feature of some hospitals – in urology and cardiothoracic surgery as well as pharmacies, for example – but Lord Darzi wants the NHS to make huge strides to increase efficiency and reduce unnecessary variation.Robotics

Although the NHS in England will be receiving an extra £20bn in real terms by 2023/24, it will also have to continue to increase its productivity. And, as part of a 10-point plan for reform and investment, Lord Darzi, a former Labour health minister, offers a vision for a technological NHS.

His final report on health and care to 2030, Better health and care for all, sees significant untapped potential for automation in the NHS. The report was commissioned by the Institute for Public Policy Research and its analysis shows a potential productivity improvement of £12.5bn a year – around 10% of the current NHS budget in England (see table). In social care, the productivity opportunity amounts to £6bn.

Echoing Nye Bevan’s famous quote on the health service, Lord Darzi (pictured) says: ‘In the 21st century NHS, it might not be the sound of a bedpan dropping that is heard in Whitehall, but that of a robot picking it up.’Lord Darzi

The report, put together with a panel of politicians from all three major parties and clinicians, says that unlike other industries, automation in health and care has the potential to complement human skills and talents, rather than replace them. It speculates on some of the new automated roles – bedside robots could help patients with meals and mobilisation (portering), while AI assessment suites could carry out a digital first triage of patients.

Perhaps more likely in the short term is the suggestion that automation could reduce administrative tasks, such as sharing medical notes, booking appointments and processing prescriptions.

Diagnostics has significant potential for improvements in productivity, the report says. There is evidence that artificial intelligence-based systems could improve the accuracy of diagnosis in radiology (X-rays, CT scans and MRIs), for example. Equally, research has shown positive results in diagnosing conditions such as pneumonia, breast and skin cancers, eye diseases and heart conditions.

There would be barriers to overcome, such as redesigning pathways, retraining staff and a lack of investment in the technological infrastructure. But the report insists the opportunity is too good to miss, recommending that a ‘sizeable’ amount of a new transformation fund should be dedicated to removing these barriers.

Some commentators have criticised the methodology used by the report to calculate the savings – though they accept there will be some savings, they doubt it will be of the same magnitude reported.

They add that using new technologies such as AI could be costly – for instance, the NHS may need to build up robust datasets to produce reliable algorithms that will deliver the right care at the right time. There are also questions about information sharing and whether personally identifiable data will be needed.

While the potential for automation to produce savings and improve the patient experience caught the eye, it was only one point in Lord Darzi’s 10-point plan to secure the future of health and social care. As well as increasing automation, the report insists the government must invest in health – by embracing health in all government departments and ‘getting serious’ about tackling obesity, smoking and alcohol consumption.

Published ahead of the government’s funding announcement, the report says the NHS needs a long-term funding settlement – ending the ‘feast or famine’ cycle of funding by returning the NHS to its long-term growth trajectory of around 4% in real terms. It recommends paying for it by ringfencing National Insurance increases.

In his interim report, published in April, he called for additional investment of at least an extra £50bn for the NHS (returning to the long-term funding trajectory) and £10bn for social care by 2030. To an extent, the government has started to address the points on investment with its announcement that NHS spending will rise by £20bn in real terms by 2023/24. However, it is short of the long-term trajectory, averaging 3.4% in real terms and applying only to NHS England funding and not the Department of Health and Social Care budget as a whole.

The government is unlikely to divulge its thinking on social care funding until later this year – a green paper that was due to be published in June or July has now been postponed until November and will likely be published alongside the NHS long-term plan.

Even if his £50bn NHS requirement is met, Lord Darzi believes radical reform will be needed to improve productivity – hence his insistence on a rapid expansion is the use of cutting-edge robotics.

In addition to the tilt towards tech, investing in health and long-term funding, the other points in the reform and investment plan are:

  • Unlock the potential for health to drive wealth – significantly increasing research and development spending (from 1.7% of GDP to 2.6% over five years) to boost economic growth and giving the National Institute for Health and Care Excellence a remit over all medicines and devices
  • Make social care free at the point of need – fully funding the service as part of a new social contract. Initially, free care would apply to those with the greatest needs, but it could be extended to others in time.
  • Establish a new deal for general practice, community and mental health services – creating a new option for integrated care trusts (ICTs) providing out-of-hospital services and shifting funds and power away from acute care by increasing the proportion of funding that goes to primary, community and mental health services each year. ICTs would be allowed to take on whole care capitated budgets for population groups.
  • A radical simplification of the system – joining up all the arm’s length bodies, including NHS England, NHS Improvement and Health Education England into a single body – NHS Headquarters – with commissioning functions handled at regional level by between five and 10 health and care authorities. Clinical commissioning groups, NHS England local area teams and NHS Improvement regional offices would be abolished.
  • Revitalise quality as the organising principle of health and care – creating a coherent strategy for health and care, overseen by a relaunched National Quality Board.
  • Invest in the talent of the team – ensuring adequate staffing by creating an integrated skills and immigration policy and offering fair pay across health and care. The government has indicated the cap on immigration for senior skilled workers will be lifted, as recommended in the report. A workforce strategy – which is in the pipeline – is needed
  • Provide time and resources to transform health and care – setting out a fully funded transformation fund, including capital funding, of 2% of NHS spend. This should be in addition to the core funding settlement for health and social care.

The report labels the cost of private finance initiatives ‘a serious legacy problem’. Though trusts’ PFI payments average 5% of provider income, some are paying up to 16%. To equalise the cost of capital across the NHS, it recommends pooling total capital costs, with each trust charged a uniform rate as a percentage of capital employed.

In the foreword to the report, Lord Darzi and former Conservative health minister Lord Prior insist that a properly funded NHS is the foundation of a fair, cohesive and inclusive society.

‘We call for greater public investment: a long-term settlement that returns the NHS to its historic rate of funding growth. In return, we propose a simplified, reformed and improved service. This means embracing 21st century technology, joining up health and care around the individual, and freeing up staff on the frontline to care.’

They add: ‘Our plan for investment is also a plan for reform. High-quality health and social care is a moving target; to stand still is to fall back. In this year of anniversaries, we must embrace and accelerate change to capture all the possibilities of the decades that lie ahead.’

Saffron Cordery, the deputy chief executive of NHS Providers, welcomes the report. ‘It is right to emphasise the need for clarity over long-term funding. It is also important to ensure there is sufficient time and resources set aside to facilitate the transformation of services, so they can adapt to the changing needs of the communities they serve. And we agree that quality of care should be the organising principle for health and care. We would do well to hold fast to these principles as we shape services to meet future challenges.’

Niall Dickson, chief executive of the NHS Confederation, believes health and social care has reached a watershed moment. ‘Lord Darzi is right to identify significant action is absolutely essential for social care. An Ipsos Mori poll we commissioned recently suggested 82% of the British public backed a spending uplift in this sector,’ he says.

‘Similarly, we agree systems need to be simplified, locally led and patient-centred with care shifted away from hospitals and into the community. There needs to be more investment in primary care. The new long-term funding deal announced by the prime minister simply will not work if we carry on doing the same things in the same ways.’

The final report also includes a 10-point offer to the public, setting out what health and care services could provide if the investment and reform plan is adopted. For instance, there would be a promise of free personal and nursing care; fast and convenient access to primary care; shorter waiting times, with no trolley waits and no cancelled operations; and enough nurses and doctors in hospitals and GP surgeries.

Some of the report’s ideas may seem fanciful or some way off – robot carers, for example – but some parts of the NHS are already reaping the productivity and efficiency benefits of automation.

And Lord Darzi is in a position to bring forward some of this agenda. After the report was released, he was appointed chair of the Department of Health and Social Care’s Accelerated Access Collaborative. This will seek to ensure innovations, including medical and diagnostic devices and digital products, are adopted quickly by the NHS.

The report may have been overshadowed by the government’s five-year funding announcement, but it may be seen as a good starting point as the NHS prepares its long-term strategic plan.

Potential productivity improvement
Landmark reports in the NHS

The NHS in England has seen several landmark reports on its future since the turn of the century.

2002: the Wanless review

Former banker Derek Wanless assessed the funding needs of the NHS over the next 20 years, given the growth in public expectation and an ageing population. In his final report in 2002, Mr Wanless set out a vision for NHS needs over the next 20 years under three scenarios:

  • Slow uptake – no change in public engagement and the NHS has low productivity. An annual budget of £184bn would be needed by 2022/23
  • Solid progress – a more responsive NHS with higher rates of technology uptake and people more engaged in their health. NHS spending of £161bn a year would be needed
  • Fully engaged – where public engagement is high, use of resources is more efficient and the NHS is responsive with high rates of technology uptake. An annual budget of £154bn would be required.

Under the new plans, NHS spending will rise to £149bn in 2023/24.

2008: High quality care for all

Lord Darzi published the final report of the clinically led NHS next stage review. Marking the 60th anniversary of the NHS, it was commissioned by the Department of Health. Like Wanless, it set out the societal challenges facing the NHS and emphasised the need to prevent ill health. Recommendations included giving patients a right to choose, personal health budgets and the development of best practice tariffs – all still evident in NHS policy today.

Lord Darzi’s report was overshadowed by a row over polyclinics – a network of local clinics providing integrated and enhanced services he had proposed in an earlier report on London’s health services. Objections ranged from patients worrying the traditional doctor-patient relationship would be destroyed to claims polyclinics were nothing short of privatisation. In the end, High quality care for all suggested GP-led health centres and did not refer to polyclinics.

2014: NHS five-year forward view

This set out a vision of a more integrated service, breaking down the barriers within the NHS and between health and social care. It called for better prevention, saying the Wanless warnings on the costs of ill-health had not been heeded. New care models were outlined, including multispecialty community providers (MCPs) and primary and acute care systems (PACS). It promised a redesign of urgent and emergency care and ‘meaningful local flexibility’ in payment rules and regulation.

The gap between demand and funding would be around £30bn by 2020/21, but following the subsequent spending review and increased funding, it was estimated at £22bn. This gap has fluctuated over the following years due to increases in funding and demand to the point where it is now rarely mentioned.

Late year’s Next steps on the five-year forward view built on the original document. It focused on efficiency and integration – by establishing sustainability and transformation partnerships and local accountable care systems.

Supporting documents
Future vision - July 2018