The reshaping of NHS national bodies has only just started. How will it finish?

Nine months into its term, the government has decided to radically reshape how the NHS is nationally led and managed (as part of a wider plan to reshape what the Prime Minister has called ‘an overcautious flabby state’).

Earlier this week, it was reported that NHS England will be brought more closely under the control of the Department of Health and Social Care (DHSC), with the combined overall size of the two bodies shrinking by about 50%. The 42 local integrated care boards (ICBs) will reportedly experience similar seismic changes, with reported cuts of 50% to their running costs.

We now know the changes are not just seismic but existential – NHS England will be abolished and its functions fully integrated with the DHSC within two years.

A brief history of NHS England

If you want the full history of the early years of NHS England, read Nicholas Timmins’ excellent report The World’s Biggest Quango. Here is a shorter summary of what ended up being a very different organisation to what was originally envisaged.

NHS England was created as the NHS Commissioning Board, as part of the ‘Lansley reforms’ of 2012. The original intention was to take the existing ‘NHS Executive’ leadership embedded within the Department of Health (as it was then called) and create a new statutorily independent organisation that would be both ‘lean’ and ‘free from day-to-day political interference’.

The NHS Commissioning Board was supposed to receive a three-year ‘mandate’ from the Department of Health to set out the high-level outcomes politicians wanted the NHS to achieve, and the Commissioning Board would then be responsible for the day-to-day oversight and organisation of NHS services. But the Commissioning Board would expressly not be the ‘headquarters’ of the NHS but instead would be part of a new constellation of national bodies that would collectively administer the NHS (see the Liberating the NHS White Paper).

Things didn’t quite pan out that way. By 2013, the NHS Commissioning Board had already been renamed NHS England (a name that would only be confirmed in legislation in 2022). And by 2025 it had become a Frankenstein-like mish-mash of other bodies. NHS Improvement (which itself had been formed through a merger of two separate bodies that oversaw NHS trusts and foundation trusts) would merge with NHS England in 2022. And by spring 2023, NHS Digital and Health Education England had also been merged with NHS England.

What had already been labelled the ‘world’s biggest quango’ on its inception had grown even bigger (albeit not always by its own choice or design) and came to account for nearly half of all government spending on arms-length bodies.

As a result, what NHS England actually does is now incredibly complex and wide-ranging. It includes:

• allocating funding and resources across the country, for example, deciding how much funding local integrated care boards and NHS trusts will be given each year to plan and deliver services

• sharing good practice, for example, through central teams of experts in the ‘Getting it Right First Time’ programme, who identify where local areas can improve how they run their operating theatres or save money on the goods and services they buy

• co-ordinating and organising large national programmes, for example, the vaccination and screening programmes and response to winter crises

• planning how many staff the NHS will need in the future

• negotiating commercial arrangements on behalf of the NHS overall, for example, regarding the prices of medicines, or building central data warehouses in which to store NHS patient data.

The DHSC – invoking the Darzi review of NHS performance – has said that ‘the number of people working in the centre has more than doubled since 2010, when the NHS delivered the shortest waiting times and highest patient satisfaction in its history’. That is true. But there are also quite a few other things that are different compared with 2010. I don’t remember collapsing RAAC hospitals, endemic staffing crises or the enduring impact of a global pandemic being a feature of my life back then. And when assessing how well NHS England did its job, we need to remember that its ‘job’ changed repeatedly as ministers reorganised the health service and merged bodies into it. And that its Health and Care Secretary ‘boss’ also changed – at times more frequently than one could count, with each change bringing a new set of priorities.

To put it lightly, the news that NHS England will be abolished has caught people – it has caught me – on the hop. So for now we have more questions than answers. Here are just some of them.

Are ministers clear about why they are doing this (and when will they explain their thinking)?

The changes must be about more than saving money. The reported £175 million that will be saved through the cuts to the national bodies pales in comparison to the almost £7 billion financial deficit NHS trusts are anticipating next year. And while I fully accept that there is some unnecessary duplication across parts of DHSC and NHS England, I would need convincing that there is enough duplication to justify halving the workforce (particularly given how much larger NHS England is compared with the DHSC).

The corollary of this is that if money has to be saved (and it does if the NHS is going to balance its books next year) then more changes should be expected as part of the current NHS financial reset.

If this isn’t solely about saving money, then what is it? You could argue that changes are needed to ensure that democratically elected politicians have more say over an important public service. But anyone who has read Nicholas Timmins’ interviews with previous health and care secretaries (or been on the receiving end of a motivational phone call from a Secretary of State during the depths of a winter crisis) knows that political control has never left the NHS. That was true even before the creation of NHS England – when he was reminded by an official that he couldn’t sack a local NHS chief executive, Alan Johnson memorably didn’t say ‘I’d better change the annual mandate from DHSC to NHS England next year then’. He said ‘Piss off. I’m dealing with this.’

To be fair to politicians, even if they retained more power over NHS England than the legislation might imply, it also left them with the ultimate accountability and responsibility for NHS services. When things went wrong, it was Health and Care Secretaries who stood in the house to get a rollicking (even if the recent Public Accounts Committee and Health Select Committee appearances show that NHS England leaders were not immune from the same treatment). The questions now will be even more pointed towards politicians. For example, if there is an unforeseen crisis like a cyber-attack or another pandemic occurs during this transition period, it would be legitimate for politicians to expect to be asked questions as to whether the NHS would have been better able to respond if staff in national teams had not been worried about whether they would have a job in the next few months.

At some point as a country, we have to stop trying to design the ‘perfect’ health care system and instead try to maximise the opportunities of the one we have. So as with all good impact assessments of major changes to government, ministers will eventually need to provide a good answer to the questions, ‘What is the specific problem to address?’ and ‘What is the best way of achieving that goal?’. Wes Streeting took the time in his speech on 13 March to praise the efforts at being ‘one team’ that DHSC and NHSE had delivered so far. The question then remains as to why a structural change is needed for a team that is already working as ‘one’.

Do ministers know just how much of a distraction this will be?

I’ve experienced one reorganisation of the national bodies and watched countless others from the sidelines. What I’ve seen suggests that they take far longer than you think, end up costing far more than you anticipate, and leave you with a distracted and demoralised workforce. The size of the cuts will also likely drive some de facto mergers between ICSs, with all the transaction costs that will incur.

And whether this is the intention or not, these reorganisations also send a powerful signal that a career as a commissioner or in a national body is only likely to guarantee you a high chance of experiencing the cycle of creation and destruction – which hardly makes for a compelling and attractive job environment.

Nor is this a transfer of power and resource. When moves to delegate specialised services (ie, for rare conditions) from NHS England to local ICBs and regions were first planned, the intention was that NHS England staff would move with the work and be closer to local services. But now, with cuts to local and national bodies, even if national NHS staff are going to be displaced, it is more likely that local NHS organisations are going to be taking people out rather than taking people on.

All this would be a hindrance at any time, let alone when the DHSC and NHS England are meant to be working hand-in-glove to develop a ten-year plan to deliver three strategic shifts for the NHS, a health mission to improve the health of the population, and contributing to a national review of the adult social care system – a set of reforms that need good planning and allocation of resources (ie, commissioning) to deliver them.

This government said it didn’t want to do a top-down reorganisation of the NHS, partly because it knows what a distraction that can be. I am increasingly concerned that a government that wants to speed down the road of reform is now in the process of erecting a massive speedbump in its own path.

Do ministers have a clear idea of what they want the remaining smaller centre of the NHS to do, and how quickly these cuts can be safely made?

We spend around £200 billion a year on the health service and it employs over a million people. With a system of that scale, there are some things that you only want to do once, and sometimes it makes sense to do them nationally.

Some of these functions are commercial (eg, using the NHS’s collective purchasing power) or data-based (eg, collecting cost data to help set national prices for care) or where a central team can build expertise that local areas can tap into (for example, cyber-security or greening the NHS). And some of these functions are statutory (prescribed by law) and so tethered to an organisation, while others are more discretionary and moveable.

Ultimately NHSE and the DHSC exist to improve the organisation, access and quality of the care we receive. Deciding which of these functions will remain at the centre, which will be moved from NHS England to the DHSC or to integrated care boards or regions, which of these functions will be stopped (and the impact on patient care of that happening), and how all of these changes in functions will be delivered while shrinking the organisation will be one heck of a job.

That brings us to the question of why should we care about this? Beyond empathy for thousands of people losing their jobs (and I imagine the tenor of the political announcements would be very different if this was a factory that was closing at the loss of thousands of jobs), it’s a valid question. If you walk into a GP surgery or A&E department the day after the announcement, the care you receive will not be any different as a result. But walk into that place in two years’ time and you might notice a difference.

The jobs we are talking about play a role in setting the national standards for those departments; they plan how many staff will be needed in the future and help arrange their education and training; they allocate the funding so that each part of the country gets its fair share to hire staff and pay the heating bills.

Recently, I was in a room with NHS leaders who were talking about how it made more sense for them to tap into an expert cyber-security team at the centre of our health service, rather than endlessly building their own local teams. Solving a problem once at the centre can be a sign of efficiency, not bureaucracy.

The government’s plan to ‘rewire the British state has been described as ‘Project Chainsaw’. But an organisation like NHS England is mind-bogglingly complex, and while that is often described as a bug, it could well be a feature of what it is required to do. NHS England has a role in everything – from setting the price for a gall-bladder removal and negotiating the price for a new medicine to developing a national programme for community-diagnostic centres and setting performance standards for A&E departments. Unravelling all that carefully and sensibly is a task better served by a carefully wielded scalpel than a wildly swinging chainsaw.

How does this step fit with the government’s overall plan to fix the ‘broken’ NHS and improve the nation’s health?

It would be unfair to say these moves to shrink the centre of the NHS and move power towards the DHSC are a complete surprise. In November 2024, Wes Streeting said: ‘I want to lead an NHS where power is moved from the centre to the local… the centre should be deciding strategy, policy and clear objectives for the system… and the centre should be smaller.’ A month later, the Prime Minister said ‘too many people in Whitehall are comfortable in the tepid bath of managed decline’. And nearly four years ago, Penny Dash – the incoming chair of NHS England – was reported as saying that ICBs could cease to exist or have a tiny role.

So as a colleague of mine pointed out – there may be some long-germinating ideas or principles guiding these decisions, but it is hard to believe that this is a long-germinating plan that is being slowly revealed as spring approaches. NHS England had only just finished a protracted and fraught round of 7,000 job cuts before reports emerged in January of a further 2,000 job cuts, before the very recent announcements of the workforce being halved. And ICSs were already enacting their 30% reduction in running costs before the recent news of a further cut to these budgets.

If anything, this feels like a plan that is being developed moment to moment. Within nine months of a new government, we have already had one operational reset – which saw the 18-week target established as the government’s key health milestone. We have a financial reset coming – with local NHS leaders summoned to help find ways of closing next year’s financial deficit. And we now have a structural reset of national and local bodies. It is hard to build momentum when you keep pressing the reset button.

So then, questions, questions, questions.

Creating and destroying England biggest quango is something so time-consuming and significant in health care policy that you’d only want to do it once. And you’d want the juice to be worth the squeeze. This government has certainly started something. But I don’t know how this is all meant to end. And more worryingly, I’m not sure who does.