Abolishing NHS England: risks and opportunities

NHS England (NHSE) was always an uneasy compromise, caught between the NHS and ministers. Designed as the NHS headquarters and free to operate without day-to-day political involvement, it is nevertheless accountable to ministers for NHS performance and achieving ministerial goals.

Unsurprisingly this led to duplication of activities between NHSE and the Department of Health and Social Care (DHSC) which monitors it on behalf of ministers. Both organisations need expertise in relevant areas, and continuous supervision inevitably leads to tensions and rivalry. Part of NHSE’s role is to hold NHS organisations to account for performance and, again unsurprisingly, the same duplication, tensions, and rivalry occur.

It is also no surprise that at this time of crisis and financial pressure politicians are frustrated and want to cut out this intermediary and take back direct control. There are, however, many risks and downsides. Success will depend on how this massive change is managed and on creating a workable future relationship between ministers and NHS organisations.

Any reorganisation risks losing focus and vital skills and wasting time and money. Performance is likely to fall, and targets and timetables may well be missed. Ten thousand families must be feeling that their whole futures are in doubt due to job losses at NHSE. It is important to look after their needs as well as possible—for their own sake, but also because the whole system risks losing expertise, continuity, and corporate memory (for example, knowing what has been tried and failed).

I can only imagine what people feel about being labelled “checkers and blockers.” NHSE has great expertise in areas such as prescribing, education, training and development, IT and digital, international links and learning, and developing new practice in primary care. All are vital in helping the NHS transform into a more community based service that embraces disease prevention and is facilitated by technology.

Reabsorbing these functions risks deflecting DHSC from its wider roles that go far beyond healthcare delivery— for example, ensuring public safety through regulation of health professionals, medicines and therapies, research, public health, and influencing local government and central government departments. It is also responsible for adult social care—important in itself, not just for getting people out of hospital.

A senior NHSE clinician stressed the need for a vision and change plan. They also reminded me that the NHS is all about people and that standard management theories—Six Sigma, Lean, and others—are less effective in an organisation where 70% of costs are staffing. In efforts to design out human error these theories can also design out human judgment and creativity. This control has led some clinicians to write despairingly about “diagnosis by algorithm” and “evidence-dictated medicine.”12

People based organisations improve their productivity (and, of course, quality) mainly through motivation and training, not through new structures and systems. Relationships are key. Moreover, most NHS employees are largely motivated by wanting to make a difference. This is a huge asset. John Reid, when he was Secretary of State for Health, called the NHS the “largest army for good in the country.”

I never worked for NHSE, but in 2000 was appointed to run both the NHS and the then Department of Health. It was another time of major crisis and the launch of an earlier NHS Plan. The NHS was firmly part of the Department of Health. Some people worked on NHS issues, others departmental ones, and the top leadership oversaw both. This solved many of the external boundary issues with clear lines of accountability for the NHS. Internally the key to success was building relationships.

For about four years, government ministers, my senior team, and I had a shared vision. We understood each other’s roles, had a good degree of mutual trust and respect, and acted as a “guiding coalition” for the whole process of change.3 It worked well, leading to enormous progress with the fastest ever set of NHS improvements, which continued for the next few years.4

Looking forward, there are no easy structural solutions. It’s about relationships, and new leaders will need the ability to navigate uncertainty, flexibility, and the ability to create good working relationships across the board. There are some clear parameters: politicians need to do what only they can do. They must resist the temptation to try to run the NHS, but instead hold management to account, creating a shared vision, manage the politics, remove barriers only they can influence, and promote cross government action. Equally importantly, NHS leadership needs to relate to NHS organisations through a single channel, not allowing multiple top-down contacts, but having “a single conversation.”

In January 2024 The BMJ Commission on the Future of the NHS argued that the government should declare a national health and care emergency and engage all sectors— including communities, schools, employers, and businesses—in creating the conditions for people to be healthy.5 Publication of the new NHS plan this year provides the ideal opportunity for this.

In the meantime, I hope ministers will move on from their rather macho and confrontational narrative and develop a positive, inclusive one. There are many people—including GPs, outside organisations, and a group of young health professionals called Hope for the Future, who are already working to build a positive future.678