Yesterday, the Prime Minister announced the abolition of NHS England, representing the most significant shake-up of NHS governance since the body was first created over a decade ago. The move, intended to cut bureaucracy and improve ministerial oversight, brings NHS management “back into democratic control”.
Both Starmer and Health and Social Care Secretary Wes Streeting argue that NHS England has become an unaccountable body, obstructing decision-making rather than facilitating it. Streeting went further, describing the change as an end to “the infantilisation of NHS leaders”.
The transition will not happen overnight. NHS England will continue to operate for the next two years under new Chair Dr Penny Dash and Chief Exec Sir James Mackey, overseeing procurement, innovation, and national performance targets before its functions are fully absorbed into the Department of Health and Social Care (DHSC). While ministers claim this will move power closer to local NHS leaders, it also raises concerns about how central Government will now shape NHS strategy.
A risky reset
The decision to dismantle NHS England places accountability for the health service directly in the hands of ministers. While this could allow for faster, more decisive action, as is the Government’s ambition, it also removes a critical buffer between our health system and political whim.
This represents a complete reversal of the 2012 reforms, spearheaded by former Health Secretary Andrew Lansley, which created NHS England as a way of shielding clinical priorities and delivery from short-term political decision-making. Over time, however, NHS England’s role expanded far beyond its original remit, absorbing other arms-length bodies including NHS Improvement, NHS X, NHS Digital, and Health Education England.
While some see this evolution as necessary, the Government insists it has only led to the creation of a bloated, bureaucratic system plagued by duplication between NHS England and DHSC.
Now, its abolition leaves the system fully exposed to ministerial directives, with Nuffield Trust Chief Exec Thea Stein warning against a shift that could “lead to even more top-down micro-management of local services from Whitehall”, an approach which has been “the bane of the health service” in previous iterations.
The history of NHS reorganisations suggests that structural change often leads to disruption rather than immediate benefits, a dangerous prospect at a time when the system is still grappling with a 7.43m appointment backlog while almost 50,000 people are facing more than 12 hours in A&E departments for a hospital bed.
Many across the sector have questioned what this change will mean for patients, with Sarah Woolnough, Chief Executive of The King’s Fund asking how the abolition will “make it easier for people to get a GP appointment, shorten waits for planned care, and improve people’s health.”
Cuts and uncertainty
For staff, the immediate impact is uncertainty and job losses. The Government has justified these changes by arguing that too many roles in NHS England and DHSC were duplicating work, but the scale of job cuts across the two organisations, totalling almost 20,000 staff altogether, are expected to be up to 9,000.
ICBs, which are now required to cut 50% of their costs by October, will also face widespread redundancies. With some boards already struggling to remain operational in their current form, given the 30% cut they were charged with in 2023, it’s not impossible that the structure of ICBs and ICSs may need to be rethought entirely.
The next two years will determine whether this radical reform delivers a more effective, locally led NHS in line with Government ambitions or simply marks the start of a new era of turbulence. While the Government is betting on long-term efficiency gains, the short-term impact is likely to be a downturn in NHS performance, as restructuring efforts consume time and resources that could otherwise be focused on tackling the record appointment backlog and worsening A&E waits.
