The surgeon Ara Darzi likes to listen to music while he operates. “Led Zeppelin, Pink Floyd, something like that,” he says as he changes into his hospital scrubs in an untidy locker room at St Mary's Hospital, Paddington. Today, however, possibly because he has a reporter and a photographer with him, he doesn't put anything on the CD player when he enters the operating theatre.
The room is crowded with doctors, anaesthetists and students, standing as if in a tableau around the operating table on which lies a patient almost completely shrouded in sheets. The four-hour laparoscopic operation is already under way, with one of Darzi's team working to remove a rectal cancer from a woman in her seventies.
The surgeon, now formally known as Lord Darzi of Denham, watches for a while and, as he takes over, comments that his colleague is doing “a beautiful operation. I'll probably mess it up now”. A man with a very steady hand controls a camera on the end of a probe that has been inserted into a small incision in the woman's abdomen. Darzi watches the pictures on a screen and operates two scopes inserted via other incisions. He uses a tool attached to one to tease away tissue around the tumour and then a cauterising device, with a temperature of more than 1,000F at its tip, to seal blood vessels that have been cut away from the ball of malignant cells.
He works with dexterity, occasionally zapping a question at the highly attentive medics around him. “Does he still sweat when he operates?” he inquires of a junior from another hospital, about his boss. “As we all do, sir,” replies the young doctor.
Except, perhaps, Darzi, who has the manner of a man whose pulse doesn't rise above 60 even when agitated. He requests a different scope, deadpanning that “as a politician I need to look at things from a different angle”.
Last year Darzi, who was not a member of the Labour Party, was recruited by Gordon Brown to join his “government of all the talents”. He was ennobled, made a Health Minister and handed responsibility for what has been billed as a “once-in-a-generation” year-long review of the NHS. The exercise, costing more than £1 million, will conclude in June when he publishes a report that could have far-reaching consequences for a health service that is 60 years old this year.
From today patients should officially have the choice of more than 500 hospitals when considering where they want to be treated. Debates are now beginning about ideas for further choice thrown up by Darzi's review. One plan is a voucher scheme, under which patients with acute conditions such as multiple sclerosis and motor neurone disease would be given control over their budgets for the long-term care that they require.
“I had major doubts about whether I should do this review. It's unknown territory,” says Darzi, who had previously led a review into the NHS in London. But the Prime Minister “very convincingly said he wanted a clinician who could lead this piece of work. The Government had made a huge investment”, now the question was “how to shift this big machine into being more clinically relevant and patient-centred”. Cynics ask: another review? Gerry Robinson, the management guru and star of Can Gerry Robinson Fix the NHS?, has criticised the constant reviews, saying: “You can run nothing if every day the policies are changing.”
Darzi, who met Robinson and declares him to be “a fascinating guy”, insists that this review is different. “This is the first time that clinicians have led the review: 1,500 clinicians across the country, not somebody sitting in Whitehall designing what the healthcare provision in different cities should be.”
He says that the exercise is important not just because the recommendations are coming from the people who work every day in the NHS and know what the problems are; but also because by handing them ownership of the report it enhances the chances of the recommendations being implemented successfully. “People feel they are being asked to take charge. That process is vital.” He says that the success of his own department at Imperial College, where he is chair of surgery and employs 104 people, is based on change achieved “because I take people with me”.
Darzi, 47, of Armenian descent, was born in Iraq. His family had fled the mass killings of Armenians by Ottoman Turks in 1915 (he uses the word “genocide” even if the Government of which he is a member does not). He attended a Jewish school in northern Iraq, but his father worked for a company that developed power stations and so they were often abroad. When he was 17 they migrated to Ireland, where he picked up his soft Irish accent, and attended medical school in Dublin before leaving for what he calls “the mainland”. He was precociously talented, becoming a consultant at 31, and was in the vanguard of the revolution in laparoscopic, or keyhole, surgery. As well as the chair at Imperial, he is Honorary Consultant Surgeon at St Mary's Hospital and The Royal Marsden Hospital, in London. He became a British citizen in 2003 and is married with a boy, 14, and an 11-year-old girl. Saturday night is sacrosanct family time. “I p*** off a lot of people by saying I can't do anything on Saturday night.” On Sundays he is often back in hospital checking on patients.
Spending on the NHS has boomed from some £30 billion a year when Labour came to power in 1997 to £90 billion (and rising). Last year a review (another one) for the King's Fund by Sir Derek Wanless, the former chief executive of NatWest, who wrote an early report on health for the Treasury, concluded that all the extra cash had failed to produce a more efficient service, or to reduce unhealthy lifestyles, and more cash would be needed.
“In 2000 I was one of the people who said we need more doctors, we need more nurses, because we had a serious capacity problem. We have all the resources now but how can we co-ordinate care around the needs of the patient?” The extent of the consultation process was hailed by Alan Johnson, the Health Secretary, as “unprecedented”.
The basic structure of the NHS is not up for debate. Darzi's search is for best practice within the system. Working groups in each of the nine strategic health authorities (SHAs) in England are examining eight areas: maternity and newborn; staying healthy; children's; acute care; planned care; long-term conditions; mental health; and end-of-life care. The groups in each SHA will submit a report and Darzi will then write his report. What if different regions have completely different ideas about how to organise, say, their stroke care? His working thesis is “localise where possible, centralise where necessary”.
A few days before the meeting at St Mary's, I had joined Darzi at a consultation event at the Nottingham Arena. More than 100 people, a mix of NHS managers and employees, patients and members of the public, were discussing early recommendations. Some of the public looked as if they were there chiefly for the per diem payments. Similar events were taking place simultaneously around the country, all video-linked to each other like a health policy Eurovision Song Contest. “Hello Bury St Edmunds!” (muffled cheer). “How are you today?”
Darzi released an interim report in September that announced MRSA screening and 150 new GP-run health centres. The report also said that the NHS should be fair, personalised, effective and safe. It's hard to imagine anyone disagreeing with that.
Many of the conclusions thrown up in Nottingham also seemed obvious. The delegates voted using electronic keypads that throw up instant results on the board. We learnt that 81 per cent thought it was “very important” that they were treated as a person, not a symptom. Similarly, large numbers wanted to be regarded as a person not a number, desired “person-centred care” and regarded it as vital to have midwives present at birth.
“It is all obvious stuff, but we have never done it this way,” admits Darzi. He says that the problem is that “if you look at a journey of a patient, it's fragmented. How do you integrate that care?” He cites the example of a patient with kidney pain who is referred by a GP to a consultant and then sent for an X-ray on a different day, then back to the consultant for an initial assessment. “If you are shopping in Tesco you wouldn't do that. You need to have access to competency at the time you need it.”
Most controversy has been attached to his enthusiasm for “polyclinics”, which would be one-stop shops where patients could go to see GPs and have diagnostic tests and basic treatment. GPs, already angry about extended opening hours, have been sceptical and often hostile, suggesting that the clinics would be expensive white elephants in many areas.
Darzi claims that he has been misunderstood. “The idea that I am going to herd all GPs into one large building is ludicrous.” He says that it will be up to the nine regions what they do locally, but “there are very good examples of federated models where you have five or six practices that have access to a diagnostic service”. He argues that GPs did the same medical training as specialists and are quite capable of sending someone off to the next room, or a centralised clinic close to their practice, for an endoscopy or an X-ray without dispatching them first for a specialist consultation.
He is reluctant to talk about too many specifics before writing his report: he says that the planning for individuals to control their own budgets is at an early stage, but it would be a benefit to both patients and the NHS. He adds that research suggests that money for a patient is less likely to run
out when the individual involved is in charge of it.
He offers further clues, too. He thinks that stroke victims should be treated in large specialist centres equipped with the technology that in recent years has improved the options for treating patients rather than merely rehabilitating them. He suggests technology can also ensure that with many conditions patients will have to do less travelling. Community matrons could monitor data transmitted to them by people recovering from heart failure in their homes, avoiding lengthy hospital stays. He is keen for a more holistic approach to the way the sick and the elderly end their lives. He wants a system where a community nurse, who knows patients' histories, would allow more people to die at home, rather than being hauled to hospital by ambulance.
He acknowledges that all this will matter little if individuals do not make lifestyle changes. Incentives, such as gym memberships for the obese, have already been tried. One working group highlighted a project in its area to give allotments to individuals recovering from mental-health problems.
Darzi says that such proposals will be “weighed against the best evidence” before he starts prescribing them. He points out that the Prime Minister's vision “is to shift the focus of the NHS from a sickness service to a wellbeing service”.
His political and medical roles sometimes overlap. One evening, Lord Brennan, a Labour peer, collapsed after tearing into the Human Fertilisation and Embryology Bill. “I could hear noises and see him collapsing,” recalls Darzi. “You forget where you are, start jumping on top of benches and I ended up resuscitating him. I used the F-word in relation to the defibrillator. I shocked him and got him back. Just happened to be in the chamber when it happened so it got attention.”
“Decisive action is what we demand from government ministers,” Brennan told the Lords when he praised Darzi at a later date. “His lifesaving skill came to my rescue at the moment of my greatest need.”
Darzi continues to operate on Fridays and Saturday mornings. The fees from his NHS and private work go to the hospitals now that he is a minister. He has twice had to leave political meetings abruptly to operate. He does an amusing impression of the aghast looks on the faces of Downing Street officials when he raced off to treat a colleague who had been taken ill back at St. Mary's. “My priorities are clear. If you are in clinical practice you have to be ultimately accountable to the patients.”
He admits that he lies awake at night thinking about how to “shift this big machine”. And he finds it hard to hear criticism. “What upsets me most is when the public are saying ‘what we need is respect and dignity'. If we are not doing that, what the hell are we doing?” Perhaps wary of headlines about his surgeon's knife, he says that the only lesson for his political job that he takes from his medical career is “not to think like a surgeon”. When his review is complete he hopes to stay as a “part of the team” at the Department of Health, but he is one minister who doesn't have to worry about his job prospects when his political career ends.
Back in the operating theatre, Darzi works for about half an hour, then hands back to his colleague. He expects that the woman patient will be recovered enough from her operation to go home in three or four days. “That's the most therapeutic thing I do every week,” he says wistfully, as he prepares to go back to his other job. “I quietly switch off from everything else.”
