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The UK prime minister, Keir Starmer, has announced plans to abolish NHS England, the organisation that oversees and manages the NHS in England, employing 19,000 people.
He declared he was bringing the NHS back under “democratic control” and cutting unnecessary bureaucracy by moving oversight of the NHS back into the Department of Health and Social Care (DHSC). This will reverse plans put in place by the Conservative-led coalition government in 2013 when it tried to “take the politics out of the NHS” by having NHS England as an independent body.
The NHS is the largest public sector organisation in England, seeing 1.7 million people each day including in patients’ own homes, local GP surgeries, pharmacies and hospitals. It employs 1.7 million people, is funded largely out of general taxation, and has an annual budget of about £190 billion.
The NHS is, however, one of the most centrally organised health systems in the world. This contrasts with many European and other countries where there is typically a national ministry of health to set strategy, with the detail of how this is implemented being left to regional and local councils, health authorities and hospitals.
Some analysts have suggested that the NHS has become even more centrally managed in recent years, but the truth is it has always been held very close by its political masters.
On the face of it, there are advantages to abolishing NHS England, allowing DHSC to focus on clarifying politicians’ priorities for how and on what NHS funding will be spent. These will include reducing waiting lists for operations, making it easier to get an appointment with a GP, and ensuring that emergency departments can deal quickly with patients without resorting to “corridor care”.
In turn, local NHS organisations such as integrated care boards (who among other things organise GP, dental, pharmacy and optometry services) and NHS trusts (who run hospitals, community, mental health and ambulance services) can concentrate on making sure these policy priorities are put into practice in ways that work best for local communities.
NHS England has a range of other important roles that will need to be reallocated, whether to an expanded DHSC or elsewhere. These include planning the training of healthcare staff, organising vaccination and screening programmes, purchasing medicines, and collating huge amounts of data about NHS activity and performance.
The government has also announced plans to halve staffing in the 42 local integrated care boards, so any move of former NHS England roles to this level will probably only happen if these local boards merge, which now seems likely.
The government appears therefore to have signalled another NHS management “redisorganisation” – something the NHS has suffered on a periodic basis, a consequence of its highly centralised and political nature. Research evidence is clear that management reorganisations struggle to achieve their objectives, causing instead significant distraction away from work to improve services for patients.
In his major review of the NHS for the new Labour government in September 2024, Lord Ara Darzi – a former Labour health minister – highlighted the urgent need for more skilled and effective managers to support NHS staff in restoring and improving the service after years of economic austerity and the challenges of the pandemic. This seems to run counter to recent announcements about “cutting bureaucracy”.
With careful planning, there is, however, potential for the abolition of NHS England to lead to a slimmer DHSC (more akin to some of its European counterparts) with a smaller number of well-resourced and managed integrated care boards who could effectively steer, support and monitor local NHS trusts and primary care services.
In 2002, Alan Milburn, then secretary of state for health in Tony Blair’s government, issued a white paper called Shifting the Balance of Power Within the NHS. Milburn is now a leading figure in the Starmer government’s health team, so it is perhaps not surprising that we have these new plans to slim the policy centre, shift power and decision-making more locally, and enable stronger accountability to politicians and the public.
What is likely to happen?
What will matter as much as what is done is how these changes are made. The government has Lord Darzi’s clear and comprehensive diagnosis of the NHS’s problems. It now needs to prioritise what should be done first and what can wait, and has made a good start on this with its recent planning guidance to the NHS.
What will be much more difficult will be to decide exactly how to reduce and then abolish NHS England – doing this in a way that ensures important roles are moved smoothly to DHSC, integrated care boards and NHS trusts.
History is not encouraging. There is a big risk that NHS managers will find themselves focusing too much attention on handling a major reorganisation when they (and patients) would rather they concentrate on improving services.
The government clearly wants to hold on to setting policy direction for the NHS while letting go of the detail of implementation to local level. But ultimately, it will be held to account by a population impatient for improvements to NHS services.
Judith Smith receives funding from the National Institute for Health and Care Research for research and evaluation of health services. She has been funded by the Health Foundation to provide expert primary care policy advice. Judith is Trustee and Chair of Health Services Research UK and Director of Health Services Research with Birmingham Health Partners. She is a Senior Associate of the Nuffield Trust.
