Keir Starmer has said he wants to change Britain, in fact he has said it 66 times in Parliament since the election, MPs have said it 5577 times, change is the beat this government marches to.
The abolition of NHS England is part of that plan for change, and when it was announced it was to great surprise and not much sadness. While many in NHSE rightly feel proud of their contribution, across the political spectrum politicians and officials welcomed it. Ministers welcomed it for strengthening their hands in their own departments where civil servants are worried they might be next. Those who worked with NHSE found it to have some exceptionally talented individuals, but the whole layer was duplicative, with some skills that need retaining, while most was already being done at ICBs and in the DHSC. Politically it is expedient to talk about the massive changes, the fundamental shift in policy making we are seeing, but is the abolition of NHS England actually a change? Instead, we should see the abolition of NHSE as a return to before the Health and Social Care Act 2012.
Sitting back at the heart of the Health Service is Alan Milburn, former Health Secretary, close political ally of Wes Streeting, true Blairite believer and font of the last significant Labour led NHS reform. The abolition of NHS England is not change, reform or revolution, it is a return to the NHS Alan Milburn created.
While the rhetoric around the abolition of NHSE centres on transformation, this structural move signals a shift back to centralised accountability and ministerial responsibility, a return to pre-2012 models. Milburn has described the NHS as “a million times worse” than during his time in office — but his solution isn’t to invent something new. It’s to resurrect the structure he knows. Under Blair and Milburn, reform meant high performance through central targets and local accountability. The current direction mimics that model: cutting bureaucracy, reducing duplication, but with sharper performance oversight through DHSC, not arms-length bodies. ICBs are now expected to take on many of the day-to-day functions once managed by NHS England — very much in line with Labour’s emphasis on place-based policy making without weakening central control.
MPs were deeply frustrated they could no longer rely on ministers to intervene when something went wrong for a constituent. NHS England allowed, and even forced, ministers to abdicate responsibility. Abolishing NHS England has put ministers, including Streeting, directly in the firing line — a bold political move, but one consistent with New Labour’s hands-on governance style. The public narrative is that reform must come with accountability — and voters want to know who to blame (or credit) for NHS performance, one of the key pillars the 2029 electoral strategy is built on. The real test is not in the ideology, but in delivery. Practitioners across the board are worried change means distraction, that changing targets means a focus on a small number of fixed issues, not the holistic change most agree is required.
What to be ready for:
- Metrics to monitor performance targets set by DHSC
- Muscular intervention in underperforming trusts
- Capital and project expenditure, but not annual increases
- Services leaving hospitals, an emphasis on prevention and community-based care
For the NHS, this means clearer lines of authority but also renewed political pressure to deliver results fast. We should expect to see the reintroduction of metrics similar to strong central targets, tighter performance management of local systems like ICBs, and a more assertive Department of Health and Social Care shaping service delivery from the top down. There will likely be a sharper focus on outcomes, especially waiting times and productivity, alongside efforts to modernise technology and workforce structures. If Labour follows through on its rhetoric, the cultural change Starmer, Streeting and Milburn have all insisted is needed — shifting from reactive crisis response to prevention and community care — will require not just structural tweaks, but a fundamental reorientation of NHS priorities and incentives.
Introducing advanced technologies, including AI, in diagnostics and healthcare delivery will be expensive, but Labour hopes they will provide the savings needed to spend more on treatment without increasing the overall budget for the NHS. Modernisation is not just a cost issue but is critical to increasing NHS productivity and reducing reliance on outdated, bureaucratic systems. Targets improved outcomes, but they never shifted culture. The risk remains that targets will never address the root causes of the problems the NHS faces and may worsen them over time. While budgets remain siloed, costs can creep up, treatment metrics can improve, but outcomes can get worse.
The scale of this challenge is not to be underestimated and will require the restoration of GPs, doctors and nurses to positions of authority, and ICSs and Trusts empowered to lead on patient care, not just deploy a strategy from the centre. Ultimately, many leaders agree the structural shifts won’t matter unless they address a core constraint in the system, patient flow – through A&E to discharge and beyond.
Social Care remains the undiscussed issue, the sector knows NHSE has little to do with them but worry it will only draw more attention. Stephen Kinnock has been given responsibility for GPs, dentists, and social care — but the latter is far from his first concern, but the sector is furious about Employer NICs changes. The sector will face significant change and disruption before it gets the attention it wants.
As ICBs are cut, and ICSs are merged, the biggest Trusts will start to represent the decision making ICBs currently undertake. Without significant planning, innovation is at risk, where the market is reduced, and lead providers make decisions for whole ICSs. This process of mergers will return the NHS to a situation that looks significantly like it did when we had the 28 Strategic Health Authorities that Milburn set up as Health Secretary. There’s a risk that innovation becomes more centralised too — entrenching a ‘winner takes all’ system where large providers dominate, and new entrants struggle to scale.
What this means for:
- Trusts– more pressure, more power
- ICSs– consolidation and role clarity needed
- SMEs– harder to scale, unless explicitly protected
- Ministers– no more excuses
While many of these shifts are likely, the true test will lie in how these plans translate from political ambition to frontline action. Across government there is a belief there is still plenty of fat to trim, waste to cut, so that by 2029 waiting times can come down and outcomes can improve. That is the bet Streeting has taken, but also the bet ministers are making in other departments. In their minds the fate of the next General Election rests on it, the fate of the next Leader of the Labour Party rests on it too.
