Abolishing NHS England Became "Inevitable" – But What Happens Next?
Health Secretary Wes Streeting said he was "putting the final nail in the coffin" of the Tories' "disastrous top down reorganisation of the NHS" (Alamy)
9 min read
Prime Minister Keir Starmer has announced that NHS England will be abolished and absorbed into the Department for Health and Social Care (DHSC), in a shock move that will be the biggest structural reform of the NHS in more than a decade.
NHS England (NHSE) had already been undergoing a restructure, with staff having been told last month that there would be a 15 per cent staff cut. Amanda Pritchard stepped down as the body's chief executive at the end of February, and this week a number of directors stood down before it was announced there would be a 50 per cent reduction in staff, accompanied by a similar cut to staff in DHSC.
On Thursday, Starmer and Health Secretary Wes Streeting announced that NHSE will be absorbed into DHSC. "I am bringing management of the NHS back into democratic control," Starmer said.
"That will put the NHS back at the heart of government where it belongs, freeing it to focus on patients."
NHS England was originally set up by the Conservative government in 2012 as part of Andrew Lansley reforms, which have since been widely criticised by both Labour and Tory senior figures. In his independent review of the NHS last year, Lord Darzi wrote that the Health and Social Care Act of 2012 was a "calamity without international precedent" which proved "disastrous".
In the 13 years since, government figures have grown increasingly frustrated at the lack of distinction between the roles of NHSE and the health department, with some feeling that NHSE was "encroaching" on the department's role, as it started to undertake more policy work when it was originally meant to focus on delivery. Many ministers and officials felt that the creation of NHSE had essentially created duplicate units.
While a restructure was expected under this government, the announcement on Thursday that NHS England will cease to exist altogether came as a surprise to many within the organisation itself. PoliticsHome understands that while some senior NHSE officials learned the news a day before Starmer's speech, many NHSE staff were informed only an hour before the prime minister made the announcement, and some found out after Starmer had delivered the news.
This had not always been Labour’s plan for the healthcare system upon entering government, according to a source close to Wes Streeting. They told PoliticsHome that upon becoming health secretary, Streeting was “as far removed as possible as from wanting to cause any major structural upheaval for the sake of structural upheaval”.
However, they said that “over the last few weeks” it had become “increasingly clear that this would be an inevitable step”, and that Streeting was determined to “reorientate the system towards his manifesto commitments” by streamlining healthcare into “one pillar of communication and delivery”.
Prime Minister Keir Starmer gave a speech on a visit to to Reckitt Benckiser Health Care UK Ltd in Kingston upon Hull (Alamy)
Multiple experts have said reform has been much-needed due to significant duplication of work across NHS England and DHSC, and the restructure has received a cross-party endorsement in Parliament.
Senior figures who have previously worked in DHSC have described an awkward relationship with NHS England, telling PoliticsHome that the government would sometimes struggle to obtain data from the arms-length body. There were communications frustrations, too, with government officials complaining that NHS England would announce 'good news' stories that ministers ought to be fronting.
While Streeting told Parliament on Thursday of the need to “decentralise” the NHS, some are viewing the restructure as an effort to do the exact opposite, giving Streeting more authority as secretary of state by shedding layers of bureaucracy.
One NHS England source said that the restructure was happening because Streeting “wants to control what the NHS does” and “make it work for him and work for the government priorities”. Describing him as a “media-savvy secretary of state”, they suggested that Streeting particularly wanted more control over policy and communication of waiting lists – the area often used as the primary measure by which the media and public judge NHS performance.
“He doesn't necessarily see all the bigger picture,” they added. “I don't think we're seeing much from him on the A&E ambulances, GPs, dentistry, mental health, cancer. There is an obsession sometimes to focus on things that work for the media.”
The restructure will mean that while Streeting will have more control over NHS operations, he will also be more directly accountable. “That’s going to be really challenging for him," the NHSE source admitted. "I'm not sure if he's maybe thought that through – from here on out, he can't blame the NHS.”
Government sources have not revealed what recently spurred the acceleration of this announcement. However, PoliticsHome understands that in the last couple of weeks, ministers have briefed NHS chief executives that defence has to be the current priority for the government following weeks of intense diplomacy over reaching a ceasefire in the conflict between Russia and Ukraine.
While NHS England has had more money and staff allocated to it each year, public satisfaction with the service has been declining. With defence spending set to rise to 2.5 per cent of GDP by 2027 and the possibility that UK peacekeeping troops could be sent to Ukraine, there has been increasing pressure on the government to show it can take bold action to slim down public sector resources and cut costs across government.
For staff within NHS England, this week has been mired with uncertainty. “Morale is so bad, it's through the floor,” one source said. “We've come through one restructure straight into another one, it's a huge issue.
“[The government] changed their minds a lot, and it can feel quite random and scattergun.”
While many are likely to lose their jobs, the source close to Streeting insisted the abolition of the organisational structure “does not, by any means, mean the abolition of everyone in it”.
“It's not about abolishing a structure, per se, it's about how do we get the alignment to work as a lean, agile organisation, to deliver for a community that's very demographically different to the one that even New Labour inherited in 1997,” they continued.
According to East Midlands Mayor Claire Ward, there might even be opportunities for NHS England staff to take up new devolved health roles across the UK in the future: “We will need people who know the health service too.”
East Midlands Mayor Claire Ward (right) was previously chair of the Sherwood Forest Hospitals NHS Trust before being elected as mayor last year (Alamy)
There are many unanswered questions surrounding the restructure, including where any savings made will be allocated to, and what role devolved authorities will play in the new NHS structure.
Spending will be cut on Integrated Care Boards (ICBs), which allocate NHS budgets and commission local healthcare services. However, the source close to Streeting told PoliticsHome that the restructure was an “exciting” start to putting the levers of health policy “in the hands of local leaders” and patients.
Ward told PoliticsHome that she welcomed Streeting “wrestling back that control”. “But at the same time, what I will urge him to do is say what the mayors can do to be part of that,” she said.
“We have to start to bring together the relationship between health, wellbeing and skills and jobs and the growth of the local communities. I want to roll my sleeves up and get back into bringing those pieces together.”
There are currently two ICBs in the East Midlands region, but Ward said “it only seems right that we should have one system of health leadership within it”. The mayor said she would encourage the health secretary to engage with her and other mayors on the topic.
Those around Streeting see it as inevitable that regional mayors and combined authorities will “100 per cent” have more of a role going forwards. “Mayors, in some ways, are an embodiment of that mission-led government at a regional level,” the source said. “So they undoubtedly will have a huge amount to add to this.”
Sebastian Rees, Principal Research Fellow at IPPR, described the announcement as a “real surprise” – and said a roadmap would have to be set out quickly to determine what parts of the system are going to be cut back or moved elsewhere.
“The problem is they're simultaneously trying to cut back what's happening at the centre but also cutting back the most obvious part of the system that could be doing more, which is integrated care boards. It's going to be a bit of a difficult gamble to try to both reduce capacity at the centre and reduce capacity in systems.”
Rees suggested that bigger regional units might be formed to merge ICBs. A similar partnership has already been set up in the West Midlands, and Greater Manchester became the first region to have devolved powers over health with the signing of a deal in 2015.
However, Rees warned that mayors have historically tried to avoid responsibility for health: “It's a massive, massive increase in responsibilities for combined authorities.
“It's technical and tricky, and a lot of risk is associated with it. It would be a really interesting move if combined authorities or regional authorities are up for taking on health budgets.”
Streeting said that the aim is to complete the restructure within the next two years. One source close to government admitted this was “not much time”, and Nora Ann Colton, Professor of Leadership and Management for Healthcare at UCL Global Business School for Health, said she thought this timeline was “quite optimistic”.
It will be made even more challenging by the possibility that abolition of NHS England might require new legislation to pass through Parliament.
“It’s one of the most bold – if not the boldest – things I've seen this Labour government do so far, because they are taking on a huge task,” Colton said.
“It’s going to be somewhat of a minefield: It's not just about dismantling NHS England, it's empowering other parts of the healthcare system to deliver. The short term is going to be very rocky before we get to the hopefully better place in the end.”
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