NHS England: divorced, beheaded, died
BMJ 2025; 388 doi: https://doi.org/10.1136/bmj.r555 (Published 20 March 2025) Cite this as: BMJ 2025;388:r555
A butterfly flaps its wings in the Amazon, said the mathematician and meteorologist Edward Lorenz, and later a tornado rages thousands of miles away.1 By contrast, will the demise of NHS England, the behemoth “quango” that oversees the NHS, raise more than a flutter on the “front line” of clinical care? It’s hard to argue that NHS England was ever wanted or loved or that it delivered to expectations, but in a world at war on bureaucracy, of vanishing fiscal space and a need to grow defence budgets, every billion counts.
However, redirecting funding to the so called front line is one of the official narratives for disbanding NHS England (doi:10.1136/bmj.r521).2 Cutting several thousand of the staff who run the overlapping bureaucracies of NHS England and the Department of Health and Social Care will save less than £1bn—a big number that nonetheless accounts for a tiny percentage of the NHS’s £192bn budget for the next financial year (doi:10.1136/bmj.r535).34 Whether the few hundreds of millions that might be subsequently released can have a direct impact on clinical care is hard to believe, but whether the opportunities outweigh the risks more broadly requires consideration.
Andrew Lansley’s reforms of 2012 gave birth to the NHS Commissioning Board, which became NHS England, an arm’s length body in theory divorced from politics that would run the NHS. Malcolm Grant, chair of the commissioning board at its inception, said, “With the launch today of the NHS Commissioning Board we enter a new phase in the history of the NHS. The board is the centrepiece of a set of reforms whose purpose is to liberate the NHS from day-to-day political management.” To describe the move as unpopular is an understatement (doi:10.1136/bmj.e1729).5 People were angry—not with the intention to depoliticise the NHS but with the structural reforms.6The BMJ has argued in the past for an independent NHS (doi:10.1136/bmj.a497),7 as idealistic and unfeasible as that may sound, rather than what we got: an arm’s length body that ripped the heart out of public health.
Lansley, at the time, had also couched the transformation as a step towards putting clinicians in greater control. “The Health and Social Care Act will deliver more power to clinicians,” he promised. “It will put patients at the heart of the NHS, and it will reduce the costs of bureaucracy. We now have an opportunity to secure clinical leadership to deliver improving quality and outcomes; better results for patients is our objective.”8
What happened? Public health is a shadow of the force it once was, now relying on the defiance of local public health leaders (doi:10.1136/bmj.r509)9 and sporadic guidance from the National Institute for Health and Care Excellence on things such as gambling harms (doi:10.1136/bmj.r323 doi:10.1136/bmj.r447 doi:10.1136/bmj.r331).101112 Population health is in an alarming state, still struggling to shake off the reckless damage of austerity measures (doi:10.1136/bmj.r525)13—a mistake that looks set to be repeated. The harms caused by austerity and the Lansley reforms were clearly articulated last year in Ara Darzi’s NHS review (doi:10.1136/bmj.q2032).14
Ironically, given Lansley’s stated intentions, clinicians have rarely felt less in control, and clinical care is struggling to meet demand. Stroke care, for instance—a high profile initiative that was once a success story—has “deteriorated” over the past decade (doi:10.1136/bmj.r500).15 When new research shows the benefit of intraoperative ultrasound during carotid endarterectomy in reducing stroke complications (doi:10.1136/bmj-2024-082750 doi:10.1136/bmj.r385),1617 will the new structure be better at adopting it in clinical care? The government has promised that faster uptake of technologies is another rationale for change.
NHS staff are demoralised, abused, and overworked (doi:10.1136/bmj.r542).18 Our regular columnists—a general practitioner, a hospital consultant, and a GP employed by an integrated care board facing major cuts (doi:10.1136/bmj.r531)19—are dismayed at the disruption that will result from NHS England’s sudden demise (doi:10.1136/bmj.r524 doi:10.1136/bmj.r526 doi:10.1136/bmj.r536).202122 It’s a view shared by many policy experts (doi:10.1136/bmj.r537).23
Yet NHS England had lost the confidence of doctors, in particular. The workforce crisis, compounded by an ill thought out expansion of physician associate roles, has destroyed morale. New research by Trish Greenhalgh and Martin McKee (doi:10.1136/bmj-2025-084613) shows how the patient safety aspects of physician associates’ work in the UK are little studied.24252627 The ongoing Lucy Letby case is another example of how patient safety concerns haven’t been tackled properly under the current system (doi:10.1136/bmj.r538).28
Risk and opportunity
The arrangement clearly wasn’t working. If the government won’t sanction an independent NHS, and the relationship with NHS England is dysfunctional, then is it worse if the government retakes direct control? Nigel Crisp— NHS chief executive in the era before the Lansley reforms, when his job involved running the NHS and the Department of Health—sees risks but also opportunities (doi:10.1136/bmj.r553).29 It’s little surprise that some other prominent policy makers of that time, who now closely advise Wes Streeting, are involved with this return to the good old days.
To tip the balance in favour of opportunity, the government will need to convince on how it plans to deliver its trumpeted three shifts (particularly the shift to primary and community care, since there’s little faith that Streeting will wrestle power and funding from acute hospital trusts); how it will genuinely allow clinical leadership at a time of crisis in clinical leadership (doi:10.1136/bmj.r483 doi:10.1136/bmj.r519)3031; and how it will restore belief among staff that they are respected and valued, they have worthwhile careers, and their patient safety concerns are properly acknowledged. Above all, the government will need to demonstrate how it will exercise power with accountability. For the government to say that it is ultimately accountable for almost £200bn spent on the NHS is a statement of fact, but spending it wisely is in the realm of fiction. For example, where’s the demand and the clamour in government for the evidence based and cost saving strategies of reducing waste and promoting high value care (doi:10.1136/bmj.q949)?32
When the beheading of NHS England’s leadership was followed by the death of the organisation itself, Keir Starmer surfed the populist wave of taking back “democratic control.” In Ben Ansell’s 2023 BBC Reith lecture on the future of democracy,33 he clearly articulated the importance of understanding the limits of government power in a successful liberal democracy: courts, media, and institutions hold a government to account on behalf of the public. They limit a government’s excesses in the interests of the people.
How will this be achieved now that power over the NHS is entirely centralised? The BMJ Commission on the Future of the NHS proposed an independent office of NHS policy and budgetary responsibility that would review health plans and policies and report yearly on progress (doi:10.1136/bmj-2023-078903).34 Taking back democratic control is one thing. Delivering more than government control is quite another.