The third report by Ara Darzi (Department of Health and Social Care, 2024) has been published. The first Darzi review was commissioned by Alan Milburn in 2001 when the independent MP Dr Richard Taylor, a retired Kidderminster consultant, was elected to represent the Wyre Forest constituency after plans were put in place to downgrade the Kidderminster Hospital. Although Kidderminster Hospital in Worcestershire lost some services, investment in increased elective surgery as well as other local services was secured (House of Commons, 2001).
The second report High Quality Care for All (Department of Health, 2008), set out the ambitions for the NHS building on the previous 60 years and progressing from a focus on the quantity of care to a focus on the quality of care, offering patient choice based on sufficient information, personalising services and tackling unwarranted local variations in care quality.
As in the most recent report, the second report recommended a focus on health promotion to reduce health risks and improve health outcomes, including those related to mental health. The second report also recognised the importance of general practice and its key role in meeting most population health needs and recommended investment to achieve responsive, accessible and high quality primary and community care services.
The latest and third report by Darzi (Department of Health and Social Care, 2024) makes depressing reading with its enumeration of the numerous health challenges facing the English population across all age ranges, the shortfalls in health provision including primary and community care, variable care quality, declining patient satisfaction and a large proportion of money flowing to hospitals rather than to primary care.
As has been the case over the years of the tenures of various Secretaries of State for Health and Social Care, Darzi has again recommended that care should be moved closer to home but this time it should be ‘locked in’ through a financial framework so that the change cannot be reversed (Department of Health and Social Care, 2024). He also recommended an expansion of general practice, mental health and community services and a neighbourhood NHS delivery system drawing upon multidisciplinary models of care. Time will tell whether Darzi's recommendations flow into the 10-year health plan promised by the current Secretary of State, especially as the British Medical Association has already demanded that increased funding for general practice should not impact increased funding for hospitals.
‘The Darzi report makes depressing reading with its enumeration of the numerous health challenges facing the English population across all age ranges, the shortfalls in health provision including primary and community care, variable care quality, declining patient satisfaction and a large proportion of money flowing to hospitals rather than to primary care.’
The historical power of hospitals and their consultant workforce within the NHS has been a feature throughout my professional life, alongwith the various unsuccessful attempts to improve the productivity of hospitals. For example, the National Audit Office (2013) concluded that while significantly increasing the cost of employing consultants, the 2003 new consultant contracts had not achieved value for money. This was reiterated by the Public Accounts Committee which stated:
‘The new contract was a missed opportunity to deliver a step-change in consultant performance and has provided poor value for money to the taxpayer…consultant productivity has continued to decline…the contract also does not facilitate around-the-clock care for patients as it allows consultants to refuse to work in the evenings and at weekends’ (House of Commons, 2013).
The Darzi report has also noted that hospital care takes too much of the NHS budget and that the productivity of hospitals has continued to decline despite receiving increased funding over the years (Department of Health and Social Care, 2024).
Reforms to general practice have similarly not always benefitted the NHS and patients. The 2004 new GP contract removed the responsibility for arranging out of hours cover from GPs and allowed GPs to opt out of providing 24-hour care, reducing around-the-clock care and continuity of care in primary care. The Public Accounts Committee noted:
‘The scene is set for a refocusing of the NHS resources towards primary care and community nursing, and other services, alongside reconsideration of the legislative framework surrounding assisted dying. Both these changes provide the right moment for the British Journal of Community Nursing to have a new consultant editor.’
‘Over the first three years, the contract cost £1.8 billion more than originally expected because the department underestimated the cost of delivering services such as out-of-hours care…GP partners have benefitted most from the new contract, with an average pay increase of 58% and decreased working hours. Other staff, such as practice nurses and salaried GPs, have had small pay rises despite taking on a larger proportion of the workload in general practice. GP productivity has actually decreased’ (House of Commons, 2008). One can only hope that this Labour government will be able to devise a sustainable strategic plan for the NHS with all the healthcare workforce in agreement with the plan.
The new government has also promised to consider a legislative change regarding assisted dying. Before the Suicide Act 1961, it was a crime to die by suicide and anyone who attempted suicide and survived could be prosecuted and imprisoned, and the families of those who died by suicide could potentially be prosecuted as well. The Suicide Act 1961 decriminalised the act of suicide in England and Wales which meant that a suicide attempt would no longer be prosecuted. However, the Suicide Act 1961 created the new criminal offence of ‘assisting, aiding or abetting suicide with a potential jail sentence of 14 years in England, Wales and Northern Ireland’ and it governs how coroners and police forces act when dealing with ‘assisted’ deaths.
Section 2.1 states:
‘A person (D) commits an offence if (a) D does an act capable of encouraging or assisting the suicide or attempted suicide of another person, and (b) D's act was intended to encourage or assist suicide or an attempt at suicide.’ Thus, there is criminal liability for anyone complicit in another person's suicide and it is the pivotal clause in discussions about assisted dying or voluntary euthanasia in England and Wales. The law is different in Scotland and those who assist a suicide may be prosecuted for murder or manslaughter. There have been several attempts to introduce a new law covering assisted dying (Dignity in Dying Scotland, 2024).
The ‘Assisted Dying for Terminally Ill Adults (Scotland) Bill’ is currently at Stage 1 in the Scottish Parliament (2024). The Bill was introduced by Liam McArthur, Member of the Scottish Parliament, on 27 March 2024 to allow eligible terminally ill adults in Scotland to lawfully request, and be provided with, assistance by health professionals to end their own life. The evidence including consultations were considered at the Lead Committee on 1 October 2024. Legislative change is also being considered in the Isle of Man and Jersey.
At least 27 jurisdictions, including Australia, New Zealand, Canada, the Netherlands, Switzerland, Belgium and ten states in the US currently permit some form of assisted dying so it is unsurprising that the new Government is considering a possible legislative change. Over the years the topic has been hugely contested with strong opinions held on both sides of the debate, with various members' bills being discussed in the UK Parliament (House of Commons, 2024). On 29 November, the House of Commons held an emotionally charged 5-hour debate on the Terminally Ill Adults (End of Life) Bill before approving the second reading of the Bill with 330 votes for and 275 against it. The Bill will now continue its progress through Parliament, commencing with the Committee Stage where MPs can table amendments before the Bill returns to the House of Commons for further scrutiny and voting by the House of Commons and the House of Lords. The Bill may not be given approval to go to the House of Lords as some MPs were clear that they may vote against the Bill when it returns after the Committee Stage. Even if approval is ultimately given for the Bill, there is unlikely to be a change in the law within the next year and thereafter, it will take time to implement the necessary service changes to enable terminally ill people to exercise the new choice
A recent report by the Nuffield Council on Bioethics (2024) made an interesting contribution to the ongoing discussions by describing the deliberations of a Citizens' Jury, which took place during April and June 2024. The Citizens' Jury comprised 30 individuals identified through stratified sampling to create a ‘mini-public’ broadly representative of the English population, recruited by a civic lottery method. The Jury considered information and evidence together with three questions during seven Jury sessions over the eight weeks. These questions were:
At the final Jury session, before a vote each question was considered in depth together with its importance to society. The majority of the Citizens' Jury members voted in favour of a change in the law to permit assisted dying; 20 out of 28 members either strongly agreed (16) or tended to agree (4). This exercise complements the evidence from opinion polls that the public is increasingly in favour of some form of assisted suicide in defined circumstances, such as having a terminal condition and the capacity to make a decision. The Nuffield Council on Bioethics will publish a final report of the Assisted Dying Project in early 2025.
The scene is set for a refocusing of the NHS resources towards primary care and community nursing, and other services, alongside reconsideration of the legislative framework surrounding assisted dying. Both these changes provide the right moment for the British Journal of Community Nursing to have a new consultant editor. I hope Julie Green will enjoy nurturing the British Journal of Community Nursing as much as I have over the last 27 years.