During a recent visit to the University of Pennsylvania, Ara Darzi, Lord Darzi of Denham, spoke with Wharton management professor Michael Useem about the British National Health Service (NHS) and how it plans to meet the challenges of delivering quality health care in England over the next decade. Darzi, a surgeon, was appointed Health Minister by British Prime Minister Gordon Brown in June 2007.
An edited transcript of the conversation follows.
Knowledge at Wharton: Welcome to Philadelphia. Based on almost two years in office as Health Minister, are there general guidelines for the structuring and operating of national health systems that you can offer?
Darzi: Thank you. It’s nice to be in Philadelphia. May I just add that first, I am a clinician academic and continue to be a clinician, working two and a half days a week. But at the same time, the Prime Minister very kindly asked me to serve, and it’s been my privilege to do so for two years. Working in the National Health Service (NHS) and also being part of policy making for the NHS, I’m a great fan. Last year, we celebrated its 60th anniversary. It has stood its test of time.
What really attracts me about the NHS is one of its principal values: Everyone has access to care, irrespective of their ability to pay. For free. That is a very unique value. We have a universal health care system. I think that value actually is more relevant 60 years down the line than it’s ever been. As you know, it’s a tax-funded system. The government has significantly increased the expenditure in the NHS from somewhere around 42 billion pounds in the year 2002 to somewhere approaching 110 billion pounds next year. That’s massive growth. We’ve done many reforms in the NHS over the last seven or eight years. I had the privilege of designing where we are heading for the next phase of our reform, which I articulated in my report last July. [It contains] a very clear statement: “Quality will be the organizing principle of the NHS.”
Knowledge at Wharton: Let me ask about the last six months which, with the financial crisis, have been very difficult on major economies just about everywhere in the world. It has now morphed into an economic crisis for many countries, certainly the U.S. and the UK. Given the fact that GDP in the coming 12 months may actually be negative, certainly in the U.S. — and also, I believe, in the UK — talk through some of the implications for providing health care given the downward pressure that comes from fewer taxes, fewer pounds coming in from the tax rolls, and other consequences of the economic crisis. What is being done to cope with the fact that this is going to be a very difficult 12-month stretch?
Darzi: I think most of us have grave concerns about the economy, and I think all governments across the globe are working very hard dealing with the causation of this problem. As far as health goes, certainly within the NHS, I made the point earlier, we’ve increased the expenditure to about 110 billion pounds. That’s more than doubling the expenditure in the health system. What drove my report at the time was [that] quality was an organizing principle. There are two things that the NHS has as unique advantages during these difficult economic times.
First, because it’s a health care system that looks after you from cradle to the grave, it should start with — and we are investing in — prevention. Prevention is better than cure. Prevention is cheaper than treating illness. Many of our interventions are: “How do we introduce evidence-based measures in prevention?” — whether these happen to be lifestyle-based diseases or [others]. I’ll give you obesity as a good example. We look at obesity as seriously as climate change, because we believe, from a health perspective, that it could have the biggest impact on the health of our population.
The second thing is quality. It’s like many other sectors. Let’s not forget that quality may be cheaper in health care. Quality’s not more expensive. It may be cheaper. Doing things right the first time, giving patients access at an earlier stage of their disease — that in itself will make health care costs cheaper. So on the one hand, I’m reassured because we have a universal health care, which is tax-funded.
Knowledge at Wharton: One of the central thrusts in your report, which is going to guide your actions in the next several years, is to focus on developing ownership and leadership on the part of all players, all participants, in the health system: patients, physicians, nurses, administrators, pharmacists. It’s a difficult goal to achieve, especially on the massive scale that you have proposed. If you could say a couple words about how you’re going to go about developing that sense of identity as a leader on the part of all of the players, so that they indeed feel that they own the system, that the problems are theirs, and that they have an obligation to address the problems and solve them.
Darzi: I couldn’t agree more. I think one of our biggest opportunities is to invest in the tremendous leadership pool we have in the NHS. The question is, how do you activate that? How do you promote that leadership gene that exists in the system? That, in itself, requires more than just saying, “Go out there and be a leader.” Leadership has to have a purpose. It’s leadership for quality that I’m looking for from the Health Service, from those who work in the Health Service.
To do that requires a mindset change, a behavioral change, across the system. That is the type of transformational change that we are thinking of at the moment. More importantly is what we’ve learned from the next stage review, which I led. There were 10 regional reports. Clinicians felt that they were actually involved, challenging themselves with evidence-based care, and designing the pathways of care. So there was ownership in that process.
Besides the ownership, we need to move on to the next phase, in which they feel empowered to make that change happen. I think what’s important for us, as clinicians — and I will say “us,” me, too — is that when you are empowered, accountability comes with it. I think, for the first time, and certainly in this phase of reform, it’s not just individual accountability; it’s a collective accountability around the team looking after a patient.
I’ll give you an example. If you look at a patient pathway, from the day they are referred from their primary care physician into a hospital setting — treatment is done in hospitals by multiple teams — then back to the primary care physician, we need a way in which there is a collective accountability across the pathway of care. That is what we need to work on and develop within the NHS, and that’s exactly what we’re doing. I announced in my report what I call the National Leadership Council, which is the opportunity for the NHS itself to develop and promote leadership skills within that accountability framework that I described.
Knowledge at Wharton: Let me ask several personal questions. As a surgeon, you are in control of the surgical theater. As a member of the House of Lords and a Minister, that control is shared with many other individuals. There are forces over which you, indeed, can exercise very little control. Guide us through your own experience in moving from a clinician, a researcher, to a person responsible for a national health system.
Darzi: It was a fairly steep learning curve. [As for] my role in the House of Lords, I’m a member of a team of five. We are five ministers in total, and the Secretary of State for Health, who is in the House of Commons, is Alan Johnson. I’ve benefited a lot from his mentorship and the mentorship of many other colleagues in the House of Lords who welcomed me and mentored me for my initial introduction there. You started by describing me as a clinician and an academic. I’m a professional. I talk about what I know. My role in the House of Lords is to bring that clinical flavor to what I do in health care policy. That, in itself, the support that I have received from many noble Lords in the House, [means that] I’ve been very fortunate in having some fascinating debates, very interesting debates. The chamber itself is full of exceptional people with all sorts of different backgrounds. So, when you take a bill through, as I did — my first bill was the Human Fertilization and Embryology bill — I can’t remember having heard any debates of that quality ever in my life before. So it was a great privilege to be part of that, and be personally responsible for leading that bill through.
Knowledge at Wharton: Let’s go back a little bit on your career. To do it over again, would you pick a career in medicine, and in particular, would you pick a career in surgery?
Darzi: Absolutely. There’s no doubt in my mind. It’s not just picking it. There are two privileges in life. One is to serve your patients, and that is the most gratifying thing you can ever do. In surgery, you tend to see the benefits of that more quickly, because you will see the outcome of the interventions you’ve been involved in with your colleagues from a patient’s perspective. The second privilege is to serve in public service itself. I’ve been fortunate enough to do both. But ultimately, I’m a clinician, I’m a surgeon, and when I’m finished with this job, I’ll [return to practicing surgery]. Let’s not forget, as I said, that I do this two days, or two and a half days a week.
Knowledge at Wharton: Let me ask about that. You wear two hats, you have two jobs, you’re in senior administrative roles and you are part of, in effect, politics in Great Britain. But you also are in surgery several days a week. How do you balance the two very different worlds in the same week, in the same day?
Darzi: It is tough. I do work very hard. But it’s enjoyable. And let’s not forget the reason I’m doing the two jobs. That is exactly the purpose of my appointment. The Prime Minister and the government were very keen that [they have] someone who was an active clinician, who could come in and be part of a bigger team of five other colleagues in which I led a major review, where clinicians were very active players in that review, designing the future of the NHS. So I don’t see [the two different worlds] in any way opposing each other. I think they are very much aligned, and, as I always remind my civil service colleagues in the department, it’s not uncommon that I do my four days in Whitehall, and then I go to my operating theater. I am constantly asking what some of my colleagues will think of this policy or that policy. It’s my “testing bed,” as I call it. And that, in itself, has been very, very powerful for me.
Knowledge at Wharton: As I recall, the Prime Minister called you to 10 Downing Street and offered you the position you hold now. It did come as a surprise. If there’s been one surprise since then, something you have had to master that you didn’t appreciate, or didn’t really anticipate, what would that be? What is the biggest surprise you have faced since the initial offer itself?
Darzi: How long do you have? You know, when you go into a new job like this, you have many, many anxieties. In relation to that, I was tremendously surprised by the amount of positive welcome that I had from everyone, and the support I’ve received from, not just government, but people within the House of Lords and others. Everyone has this passion in our country about the NHS. That is fascinating. It’s part of our social culture now. Those positive things weren’t just within the NHS: When I went outside the NHS, that was very obvious to me as well. So, as I said, it’s been a tremendous experience for me, and I very much hope one day I can look back at it and say I had the privilege of making a contribution in the NHS.
Knowledge at Wharton: Professor Darzi, that takes me to my final question. The day will come when you do step out of your position, and as you anticipate that day sometime in the future, what do you hope will be said about your legacy in this role on behalf of the British people?
Darzi: Time will tell. Another person will have to answer that question rather than me. I believe what I would like to be said is [that I] focused our minds on what matters most – -with quality being the organizing principle of any health care system. It is quality that wakes me up in the morning to come to work, it is quality that my patients expect from me.
Knowledge at Wharton: Professor Darzi, thank you for taking time to talk with us.