Abolition of NHS England seeks to put ministers in control of the NHS

In the end, enough was enough. Having promised not to undertake a top-down reorganisation of the NHS, that is exactly what Wes Streeting and Keir Starmer decided to do.1 NHS England is being abolished.

The government’s decision was prompted by growing frustrations on the part of ministers at the duplication of responsibilities between NHS England and the Department of Health and Social Care and the need to find savings. Pressures on public finances have increased since last autumn’s budget, in part because of the government’s commitment to spend more on defence.

With the Office for Budgetary Responsibility warning of the need to plan for increases in NHS spending to meet changing population needs, and the resources to do so shrinking, the government is acting to control NHS finances.2 A new leadership team in NHS England, led by Jim Mackey, has been charged with reducing projected deficits in 2025-26 and accelerating the pace of reform. Streeting has signalled that further cuts in management costs are likely, including by abolishing other unspecified NHS quangos.

Putting ministers back in control brings welcome clarity to roles and accountabilities and leaves no doubt as to where the buck stops when things go wrong. It reflects the reality that separating the NHS from politics was never going to be easy in a public service accounting for such a large share of government spending. Time will tell whether ministers live to regret their decision.

Parallels can be drawn between these developments and the policies pursued by the New Labour government in the early 2000s under the then health secretary, Alan Milburn, who is now the lead non-executive director in the Department of Health and Social Care and one of Streeting’s principal advisers. Now as then, greater freedoms have been promised for organisations performing well as part of a broader commitment to devolve more responsibility for decision making. It remains to be seen what devolution means in practice with little detail having been released.

One option would be to streamline and coordinate the functions of NHS England’s regional offices and integrated care boards. This could build on work in the North East and Yorkshire where close collaboration between leaders in the region has led to effective use of leadership talent.3 There are also likely to be mergers between integrated care boards who have already been told to cut their management costs by 50 per cent by the end of 2025.

NHS trust leaders may argue for more radical changes, including the merger of regional offices and integrated boards to reduce the burden of regulation. If this happens, the work being done by some integrated boards in place based partnerships and collaboration with local authorities and the voluntary and community sectors may be at risk. Starmer and Streeting have claimed that their changes will increase democratic control of the NHS but achieving this locally may become more difficult as the management capabilities of integrated care boards are reduced.

In weighing these issues, it is wise to be circumspect about another top-down reorganisation, however well intentioned. History shows that organisational change is often distracting, resulting in the loss of experienced leaders, taking time and attention away from work that directly impacts on patients and the public, and having unanticipated consequences. Devolution may also result in greater variations in how care is delivered and put pressure on ministers to use their powers to ensure greater consistency across England.

A more profound question is whether the NHS is capable of being controlled by ministers. Its depiction as a unified organisation with a hierarchy linking different levels of responsibility risks creating an illusion of control which belies its size and diversity. The NHS is best viewed as a complex adaptive system in which the relationship between leaders nominally in charge and staff delivering care to patients is tenuous.

Getting the balance right between reform led by ministers who are impatient to see results and improvement led by staff from within the NHS will not be easy. Leadership of a high order—political, managerial, and clinical—is needed involving as many people as possible. Changes at the top may ease the frustrations of ministers but these changes must translate into better patient care in every part of England and increased accountability to local communities. More detail on how the government will achieve this is awaited.