David Oliver: Abolishing NHS England is no panacea for the NHS’s woes
BMJ 2025; 388 doi: https://doi.org/10.1136/bmj.r526 (Published 17 March 2025) Cite this as: BMJ 2025;388:r526
- David Oliver, consultant in geriatrics and acute general medicine
- davidoliver372{at}googlemail.com
Follow David on X @mancunianmedic
On 13 March the prime minister, Keir Starmer, announced that NHS England (NHSE) was being abolished. He described it as the “world’s biggest quango,” saying that he wanted to “bring the NHS back into democratic control” and to “cut bureaucracy,” as “the state” had become “flabby and unfocused.”1
But is such a “big bang” structural reorganisation of central government agencies any solution to the NHS’s current problems—especially when the health and social care secretary, Wes Streeting, had said repeatedly that he didn’t want to pursue more structural reorganisation but wanted to focus instead on improving services?2 The service needs to tackle record waiting lists for elective care, long waiting times, overcrowding and unsafe bed occupancy in emergency care,3 record low satisfaction among patients and staff, workforce unrest (especially among younger employees),4 and wider issues around population health, inequalities,5 and social care.6
While Starmer’s sudden announcement was a surprise even to the health policy community, it followed the replacement of NHSE’s board chair and chief executive with Streeting’s own picks and the appointment of the former Labour health secretary Alan Milburn as “lead non-executive director.”7 This month has also seen the announced departures of NHSE’s chief executive,8 finance director,9 chief operating officer and delivery officers,10 and medical director.11 They will doubtless be followed by other senior figures associated with the regime in charge during the last Conservative government, when NHS performance declined dramatically across various indicators and which has so far proved very slow to turn around.12
The Conservative health secretary Andrew Lansley’s 2012 Health and Social Care Act13 was described by the former NHS chief executive David Nicholson as “so big it could be seen from space.”14 The associated disruption, distraction, and opportunity costs were heavily criticised.1516 In the 13 years since, much of Lansley’s primary legislation has been subverted with a move from competition and contracting to more collaborative approaches from the integrated care boards replacing Lansley’s clinical commissioning groups, the merger of NHS Improvement and Health Education England into NHS England, and the pandemic era abolition of Public Health England and its replacement with the Office for Health Improvement and Disparities and the UK Health Security Agency.17
Constant change
It’s hard to see what this obsession with constant structural reorganisation has achieved. And it’s never any kind of magic bullet for the NHS’s problems. The Nuffield Trust’s 2018 collection of essays, Doomed to Repeat,18 sets out in gruesome detail the NHS’s history of endless reorganisations and explains why this is never a solution to poor performance. The NHS benefits from more long term stability and predictability when staff can focus on their core job of patient care rather than coping with constant change at the top.
So, why are Streeting and Starmer doing this? After all, set against an NHS operating budget of £183bn with around 1.6 million staff,1920 NHSE’s combined operating costs of £3.2bn—with 15 500 employees and 3500 more at the Department of Health and Social Care—have little potential for major savings, especially after any redundancy payments.2122
Firstly, it plays into a populist narrative of “slashing bureaucracy” and putting resources into the “front line,” even though the NHS does require high quality management and is arguably undermanaged.23 And some legitimate roles are best served by central agencies (or only possible through them), especially with integrated care boards also being told to cut their costs and head count by 50%, making more local accountability unlikely.24
Secondly, as Streeting recently pointed out, the separation of the Department of Health and Social Care from the arm’s length NHSE created blurred lines of accountability and duplication of staff and expertise. Before 2013, civil servants, senior NHS managers, the chief medical officer, medical and clinical directors, analysts, ministers, and special advisers all worked within the government department, which combined policy with NHS operational and strategic leadership.
Thirdly, our politicians know that when the NHS is failing they’re the ones who will be blamed, not executives and officials barely known to the public or organisations whose functions people may not understand. The desire for greater control is understandable, although politicians will no longer be able to outsource personal blame for failings.
There’s been perennial frustration across several parliaments and discussed in numerous think tank reports about the state of the state, arguing that ministers have too little control over delivery of key public services and weak levers to improve or transform their performance or productivity.25 And Streeting has reportedly expressed frustration at NHSE’s inability to respond to key challenges such as reducing pressure on acute hospitals.2
The NHS is a huge, complex, adaptive system with plenty of ability to subvert or resist change.26 It’s likely to be distracted for years by yet more primary legislation and structural “re-disorganisation” on the eve of a 10 year NHS plan, a major focus on improving performance and productivity,27 and rhetoric about “three big shifts” in the model of care.28 Vital expertise, system knowledge, and focus will be lost as staff worry about their futures or roles.
The last time the NHS saw sustained improvements in access, waiting times, and public and staff satisfaction in 2000-10, this was backed by record real terms funding increases that are no longer available. I understand why NHSE—never loved or wanted by many of us—is going. But its demise will be no panacea for the NHS’s woes.
Footnotes
Competing interests: See bmj.com/about-bmj/freelance-contributors
Provenance and peer review: Commissioned; not externally peer reviewed.