End of an era. So just what will the relationship between ministers and the NHS be in future?

Well, that’s that then. The end of a near 12-year experiment at running the NHS much more independently of ministers – the moment being marked by the departure of Amanda Pritchard as the Chief Executive of NHS England and Wes Streeting’s accompanying declaration that the promised 10 Year Health Plan ‘will require a new relationship between the Department of Health and Social Care and NHS England’ (NHSE). One that will require a ‘one team’ culture.

Wes Streeting has – very sensibly – set his face against legislation (not least because he is not sure quite what he would want to put in its place). There will still be an NHSE board and there will still be the mandate – the roughly annual setting out of what ministers expect – plus the other requirements of the legislation. The structures will remain and so the memory will linger on.

But it is still ‘goodbye to all that’ in terms of the original Lansley concept in 2010 of a truly independent board that would finally put an end to ‘political micromanagement’ and excessive ‘political control’ of the service. The power has once again decisively shifted.

It does, however, leave Wes Streeting with the problem of working out precisely what the relationship should now be between ministers and the management of the service – a question that has haunted the NHS for much of its history.

That first came to a head with the Griffiths management inquiry of 1983. It recommended a small strong management board – ‘and that is almost all that is necessary at the centre for the management of the NHS’ – overseen by a supervisory board on which ministers and the department would sit, with the latter setting the strategy for the former. The supervisory board did not last long. But the management board became the various incarnations of the NHS Executive that existed within the department over the years, the true extent of its room for manoeuvre depending on the personalities and inclinations of the ministers and chief executives involved. Once out of office, plenty of health ministers agreed that there was a case for some sort of more independent board, with Andrew Lansley taking that to its ultimate conclusion.

So given that it is – in effect – going, does that mean it has all been a total failure?

Well, a case can be made that it worked pretty well in the days when Simon Stevens was Chief Executive and Jeremy Hunt was Health Secretary. But as time has gone on it has become ever more clear that it worked chiefly because of their contrasting talents and personalities. Stevens was a better politician than the politicians and Hunt was content to work with him and pursue particular concerns – patient safety, for example – with the two working in tandem to obtain as much money as possible for the NHS during the long period of austerity. Stevens making the public case that it was impolitic for Hunt to make; Hunt making the private one with the Treasury and his Prime Ministers.

None of this, of course, stopped the slow but steady decline in NHS waiting time performance that had begun well ahead of the pandemic.

Unusually in NHS history, the arrangement did provide a consistent direction of travel over more than a decade: one in favour of better integrated care which started with Simon Stevens’ Five year forward view in 2014. Progress has been far slower than anyone would have wished, but some progress there has been. And it is arguable that NHS England’s existence, and its formal ability to argue about what can reasonably be delivered with the money, significantly reduced the short-term ‘£40 million for this’, and ‘£50 million for that’ announcements that ministers regularly used to indulge in. These have more recently crept back in – for example, the 2023 announcement of a short-term £25 million for women’s health hubs that came with no long-term funding.

From Matt Hancock’s day onwards, however, ministerial frustration with NHS England’s relative independence has grown, hence the new powers of direction over NHSE in the 2022 Health and Care Act, and the recent almost endless string of Conservative health ministers seeking ever more control of both the agenda and initiatives, even as they spouted the rhetoric of devolution.

The writing has been on the wall, with the numbers of civil servants in the Department for Health and Social Care growing even as the numbers in NHSE have been shrinking and are due to fall further.

That still leaves the future to be settled, with Streeting, by the time of the 10 Year Health Plan, having to decide not just one issue but the many that these events bring into greater focus.

What should the relationship be between ministers and NHSE? Will NHSE be able to speak truth to power about what is in fact achievable? How far will it retain at least some degree of genuine operational independence? And what will its relationship and that of ministers be with the service at large? Some real devolution? Or a regime heavily reliant on targets and terror and central control? The messages to date have been decidedly mixed.

One encouraging sign has been that the most recent planning guidance cut the number of national priorities significantly. Perhaps a slimmed-down centre and a slimmed-down national framework is in prospect. But given the changed relationship with NHSE, for that to happen there will need to be a self-denying ordinance by ministers.