Broken but not beaten, is Lord Darzi’s verdict on the NHS in England. “My colleagues in the NHS are working harder than ever but our productivity has fallen,” he writes, concluding: “The NHS is in critical condition.” His report contains page after page of heart-stopping details that would shock the public to the core, if everyone didn’t already know that the NHS was in crisis. It’s why the Tories were chased away so decisively. The health of the NHS stands as a symbol for the health of the nation and the fitness of any government to rule. But we are where we are. One purpose of Darzi’s report is, of course, to lay the blame squarely where it belongs: with the Conservatives’ unprecedented underfunding per capita for a rapidly rising, ageing and much sicker population. The public may long have forgotten the catastrophic effects of Andrew Lansley’s NHS re-disorganisation in 2012, but Darzi finds that the former health secretary’s “scorched earth” approach to health reform left deep scars. The Covid-19 pandemic added to the disaster, hitting a health service less resilient and with fewer beds than similar countries. How patient will the nation’s patients be as they wait for discernible improvement? That is the most important task of this report: to explain why it will take many years for the NHS to return to the waiting times of 2010. It acts as an invaluable benchmark, the starting point from which to judge progress year by year. “Reform or die,” Keir Starmer said of the NHS today. The word “reform” tends to send shivers down the spines of British people, who take it as Tory code for dismantling the NHS funding model and replacing it with some kind of private insurance, which is never defined because no private financial model would do better. Darzi makes clear that the crisis was caused by a lack of finance, especially capital (that is, spending on one-off infrastructure costs as opposed to regular costs such as wages), and not a problem with the system of public financing. What Darzi, Starmer and the health secretary, Wes Streeting, mean by “reform” will be spelled out very clearly in a 10-year plan being prepared for spring. It is not, mercifully, about yet another Lansley-style managerial disorganisation. It’s about shifting resources and patients from hospital to community, from acute care to prevention. It’s a good idea, but everyone has always wanted to do that – so what’s new? Never waste a good crisis: this one makes change essential. The NHS is £2.2bn in debt this year, an amount that must be cleared by law at each year’s end. Capital cuts caused much of this crisis, leaving medical staff to wait half an hour for aged computers to fire up and waste their time using out-of-date scanners and IT systems: 13 hospitals a day lose productivity because of serious maintenance failures, according to Darzi. Yet hospitals have sucked up more and more cash from community services: in 2006 they took 47% of the NHS budget; by 2022 that had risen to 58%. The public will largely judge the NHS on headlines showing the lengths of operating lists and A&E waiting times, so cutting hospital budgets looks implausible. Can a cash-strapped NHS find a way to “double-run” – expanding community, GP and mental health services that stop people going into hospital, while also clearing waiting lists? It could, if it only had the funding. There are things politicians and NHS managers cannot say, but the outspoken chair of NHS England dares to speak out loud. Richard Meddings, a banker and former chair of TSB, speaking to me this week after an NHS Assembly meeting, laid out the bed shortage problem: 122,000 hospital beds in 2010 are now reduced to 97,000. Who is in them? “Three-quarters are people over 65, 25% have dementia,” he said. “Many are there with urinary tract and chest infections that should be caught early and treated at home.” Some 13% of patients in wards are medically fit to be discharged but are waiting for care to be organised at home. Meddings wants a wide public discussion about the end of life. “Half of deaths happen in hospital, [which is] not the right place to die, yet on average people spend 45 days in hospital before death. There needs to be a national conversation about what hospitals are for and who should be there.” If under-threat hospices collapse, the NHS will take in those patients, too. Honesty about death is long overdue, as are frank conversations about the tendency to keep very infirm people alive a bit longer with more interventions, instead of allowing them to die more comfortably at home. The answer for the NHS is unlikely to be more beds: provide more beds and they will always be filled. Social care was not part of Darzi’s remit, but a speedy introduction of Labour’s promised national care service would do more for the NHS, more cheaply, than spending on hospitals. Rachel Reeves was right to cancel the Tories’ unfunded promise of an £86,000 cap on how much people in England spend on social care, and to prioritise quality care by staff on NHS career paths. And Labour’s plan to redistribute resources within the NHS would shift more funding towards GPs, who now provide 90% of all care, but whose budget has dropped to its lowest share in eight years while their workload increased by 20% between 2019 and 2023. Invaluable district nurses, school nurses and health visitors are almost extinct, and should be brought back. Step back further and ask if the NHS really determines the health of the nation. Poverty, inequality, insecurity, bad housing and impoverished schools matter more, with volumes of research to prove it. Sugar, salt and ultra-processed food regulation would help to prevent ill health, just as clean water, clean air and smoking reduction in the past saved the most lives. By chance, this week the Financial Times published its story on the Darzi report beside another report: “Pre-school funding ranked near lowest of OECD nations”. Pause there. Wouldn’t a return to Sure Start centres picking up family problems from birth and ensuring that all children are ready for school be a better investment in the nation’s wellbeing and health than spending money on filling up hospital beds with older people who shouldn’t be there? Polly Toynbee is a Guardian columnist