Is NHS England facing a silent coup?
The role and future of NHS England is a hot topic in health policy circles at the minute. Amidst the much more public planning for the 10 Year Health Plan (10YHP) and Spending Review, there lies an unanswered question around the survival of NHS England.
The latest Operational Guidance was released at the start of February, and alongside the waiting list targets, and greater power for Integrated Care Systems (ICSs), were announcements on job cuts within NHS England, which were communicated to the organisation by Wes Streeting on the same day.
Whilst the big, strategic planning on the 10YHP and the operational 18-week targets make the headlines, there are grumblings at policy-wonk level are around further centralisation of powers within the Department of Health and Social Care, and the potential removal of powers from NHS England – and its possible demise. But is this mere speculation around the future of a deeply unpopular organisation, which has come under increased scrutiny in recent weeks, or a signal of future intent around policymaking in health and care?
For years, NHS England provided a layer of insulation between political decision-making and operational healthcare management. It allowed clinical and operational leaders to focus on long-term planning without being at the mercy of short-term political cycles.
‘Central’ NHS bodies have only recently been “rationalised”, with NHS Digital, NHS X, Public Health England and other ALBs being merged into NHS England in 2022 to cut back on duplication of work, which was accompanied by a reduction in head count of those organisations.
The most recent planning guidance has recommended a further reduction in 2,000 staff from NHS England.
Alongside this, recent appointments to the Department of Health and Social Care point to the “levers of power” and broader policy-setting work being centralised into DHSC under Wes directly, and backed up by recent appointments there, including figures like Alan Milburn and Lord Darzi.
Ministers, who were once content to set broad strategic objectives, are now taking a direct hand in shaping the specifics of policy and reform.
On paper, the Operational Guidance looks like a push for decentralization of some power and responsibility to ICSs, who are being given greater autonomy over operational and financial decision-making. There is much consternation across the sector that ICSs haven’t truly taken up the role that was envisioned when they were created a few years ago. Many are facing increasing financial pressures, and are faced with difficult choices on spending. Recent comments from Paul Corrigan point to a great use of private finance to deliver big capital and technology projects; but this would mean ICSs taking on debt out with Government finance, and create real risks for the organisations.
NHS England is also facing a serious leadership crisis. Amanda Pritchard, the current CEO, has come under pressure in recent weeks. MPs who attended her recent Health and Social Care Select Committee hearing found her evasive and ill-prepared, raising concerns about her ability to drive the NHS through its most challenging period. The Public Accounts Committee has also raised concerns about the lack of bold leadership in NHS England, further undermining confidence in its ability to deliver transformation.
With rumours swirling around her future at the organisation, it is interesting to consider the future shape of leadership in NHSE whilst the Government develops the long-term plan for health and care.
Penny Dash, the newly appointed chair of NHS England, comes with an impressive pedigree, both as a clinician and for her time served on the ICS frontlines and in DHSC. Her role within NW London ICS gives her the experience of the potential and limitations of ICSs, and the role that they can play in the system, and help to drive devolution to those bodies.
The Labour government’s 10-Year Health Plan, which promises to deliver on major reforms, may well be implemented by an entirely new leadership team, handpicked to align with ministerial priorities.
For frontline NHS staff, the implications of this shift are profound. Decision-making would become more politicized, with ministers exerting greater influence over priorities, funding allocations, and strategic direction. The loss of NHS England’s independent voice may make it harder for clinicians and system leaders to advocate for long-term, evidence-based reforms, particularly when they contradict the government’s short-term political interests. It would also place a greater political accountability for NHS deliver on Ministers and their teams – and the risk of micro-management and more reactive policy-making, based on political challenges and public demand. There would be additional pressures and accountability on ICSs to deliver. For this to become a reality, there needs to be a greater focus on long-term delivery, true integration, and a power shift from providers.
And on that basis, NHS England is not going to be abolished overnight. That would be too politically incendiary. There are also functions that NHSE is best-placed to lead, including developing and delivering some of the big, national projects – particularly those relating to Digital, Data and Technology. It is perhaps in this guise that NHSE may survive – a delivery arm of DHSC’s national programmes.
The next few years will determine whether this power shift marks a new era of streamlined healthcare delivery—or whether it spells the slow, quiet dismantling of NHS England as we know it.
