Taking a chainsaw to NHS England is not the sign of a healthy state
5 min read
Yes, NHS England needed to improve. But this wasn't the way to go about it.
On 13 August 2010 Eric Pickles, then secretary of state for communities and local government met Michael O’Higgins, chair of the Audit Commission. Pickles tossed a surprise press release across the table to O’Higgins stating the government would disband the commission the next day. Pickles said the commission had "lost its way", become a creature of the "central state" and no longer served its purpose as a watchdog for taxpayers’ interests.
Sound familiar?
Last week saw the abrupt announcement by Secretary of State for Health Wes Streeting to abolish NHS England. The rationale was to cut bureaucracy, and "bring the NHS under democratic control". Around 9000 jobs are to be axed, and the running costs of the 42 NHS integrated care boards halved by October. Minsters suggest the "up to £500m" saved will be ploughed into front-line care. A further cull of quangos is on the cards.
In the news that followed, as in the case of the Audit Commission, it seemed that no one was NHS England’s friend.
Who could argue against cutting excess bureaucracy, and duplication of functions with the Department of Health and Social Care? The media was almost wholly supportive, including Conservative former health ministers Lord Bethell and Jeremy Hunt. Even NHS England’s outgoing chair, Richard Meddings in a BBC interview agreed. Away from the main narrative, a few raised risks. For example, Streeting now had no agency to blame if NHS performance lags, and the inevitable costs of structural change over the next two years. This when access to frontline care tops public concerns and the NHS is at a fragile point of recovery post-pandemic.
The context of last week’s culling of NHS England is worth charting. It includes the permissive signals from DOGE’s activities in the US, impatience with perceived hypercautious ‘blockers and checkers’ of the regulatory state slowing progress, and the ‘move-fast-and-break-things’ insurgency in the air. The sense of urgency comes from the need to boost security given threats of international conflict, in the face of persistent economic weakness and domestic overwhelm from demands on public services.
But before we buy all of that justification and move on, a few thoughts.
First, bringing the NHS under democratic control. NHS England is an arm’s length body and while operationally independent, is still accountable to the secretary of state. Mechanisms include the NHS Mandate, funding and oversight, an accountability framework agreed with DHSC, parliamentary oversight and ministerial intervention in case of serious failures. If ministers wanted to bring the NHS to heel earlier, they could. The question remains: if NHS England is so duplicative and ineffective as to require a shock abolition, then why was oversight by successive ministers and DHSC so lacking and for so long? How exactly will this be remedied in the future? One complaint about government agencies is they succumb to ‘mission creep’ and become bloated ("losing their way" in Pickles-speak). Yet as Meddings noted: "At times, some weeks, almost 20 new instructions, commissions [were] coming from government and ministers into the system."
Second, the almost Maoist creation then swift destruction of government agencies over the last three decades. The NHS Modernisation Agency, the NHS University, the Commission for Health Improvement, the Healthcare Commission, the Audit Commission, Public Health England, Monitor and NHS Improvement to name but a few. Contrast the UK Health Security Agency - set up in the middle of the pandemic – with Germany’s Robert Koch Institute (with a similar mission) which has been part of government since 1891. The colossal cost, disruption and loss of expertise have not been profiled enough, and the feedback loop to ministers responsible is lost as they move swiftly to another job.
Pickles’ abolition of the Audit Commission – a public agency responsible for appointing auditors to local public bodies in England – serves as a warning. It resulted in higher costs, reduced competition between auditors, and lower audit quality. In 2022-23, just 10 per cent of councils submitted reliable formal accounts leading to the National Audit Office’s unprecedented decision last year to "disclaim" the government accounts as not "fit for purpose",
Third, the abrupt surprise announcement. Why exactly? The secrecy may have enhanced the sense of bold disruption. But the effect on leaders needed to implement the change is chilling, avoidable, and, as many reported, very sharply demotivating. In an environment in which resources are scarce, human talent and commitment are more valuable, so why decimate this so cheaply?
When government agencies are successful, they are generally quiet and deliver. Politics today doesn’t demand quiet, however, but increasing excitement, audacity and disruptive combat to show progress. Adapting technocracies to feed this political objective given a changing cast of ministers must now surely be mandatory for their leaders.
So yes, NHS England needed significant attention and oversight to make it work better. Why is the question that needs answering now, before history is repeated. The Prime Minister said he wants a government of stability and moderation. The chainsaw approach is not a sign of a healthy state.
Jennifer Dixon is the Chief Executive of The Health Foundation.
