Why do politicians restructure the NHS?

Introduction

Sometimes, the NHS needs to be restructured.

Imagine a world where our health service had been set in aspic. We would still have care delivered out of a mix of poor-law and voluntary hospitals. Doctors with Gladstone bags would be walking around on their way to wealthy patients. And ministers would have sole responsibility for deciding whether new medicines are cost-effective, because bodies like the National Institute for Health and Care Excellence (NICE) would never have been created.

Reorganising a £200 billion health service employing over 1 million people is not a pain-free lever to pull. But reorganisation has been a constant companion to the NHS despite these costs: over the past ten years alone, national bodies have been created, split asunder and then crashed together (Figure 1). And local NHS bodies have gone through their own changes, with commissioners waxing from just over 300 primary care trusts 20 years ago to under 30 integrated care boards (ICBs) now.

And this stuff really matters. One interviewee in an Institute for Government report said 20% of senior staff time in Public Health England (PHE) was spent managing PHE’s abolition – during some of the worst months of the Covid-19 pandemic. And every minute a local commissioner spends worrying about whether they will have a job is a minute they could have spent planning improvements to local services (Figure 2).

Because the stakes of pulling the ‘NHS restructure’ lever are so high, it is only more important to pause and ask just why so many politicians are drawn to pulling it.

Seven reasons for why politicians restructure the NHS

1. Restructures save money and reduce duplication or bureaucracy

Twelve years ago Andrew Lansley created NHS England. He said his reorganisation would mean ‘cutting out waste, reducing bureaucracy and simplifying NHS structures.’

Fast forward to the present day, and Wes Streeting has said he will abolish NHS England because ‘we have been left with two large organisations [NHS England and the Department of Health and Social Care] doing the same roles with an enormous amount of duplication… such bloated and inefficient bureaucracy cannot be justified.’

So, even though they took different paths to do it, these two health and care secretaries had the common goal of slashing bureaucracy and redirecting savings to the front line.

But do restructures achieve these goals? Who knows. Partly because health and care secretaries rarely stay in post long enough to see the consequences of their restructures, there is little pressure for contemporaneous analysis of whether red tape was actually slashed or money actually saved (for example, the post-implementation review of the Health and Care Act 2022 is not expected till October 2026, by which time the next Health and Care Act it will probably be working its way through Parliament).

2. Restructures help politicians on-shore or off-shore accountability

Sometimes the NHS is restructured to create more relational distance between politicians and the service. For example, about 20 years ago NICE was set up to oversee medicines approvals and Monitor was set up to oversee quasi-autonomous NHS Foundation Trusts. Here, restructures – in theory – help remove some of the political control over how the day-to-day running of the NHS.

And sometimes, the restructures do the reverse. The latest NHS restructure will give more formal power to Whitehall – with everything from NHS staff education and training to digital strategy sitting under more direct ministerial control.

But regardless of how the NHS is structured, the public are rarely confused about where accountability lies – when something goes wrong in the NHS, it is often a politician who will be held to account. And politicians know that – which is why restructures rarely hold them back from intervening in the day-to-day running of the NHS. For example, when Alan Johnson as Health and Care Secretary wanted to remove the chief executive of Mid-Staffordshire NHS Foundation Trust he was advised that he couldn’t. Nick Timmins picks up the story:

Bill Moyes, Monitor’s Chief Executive and chair, piped up and asked, in one sense entirely correctly, ‘under what legal authority, secretary of state, are you going to do that?’ – given that under Labour’s legislation it was Monitor who approved foundation trust status and had the power to replace boards and chief executives. Johnson replied: ‘Look, this is what we are going to do. I’ve spoken to the Prime Minister about it. I’m up in the House tomorrow answering questions about it. I am the Secretary of State for Health. And I’m responsible. And that’s what we are going to do. I don’t give a damn what the legislation says.

So ultimately, whether you are restructuring to on- or off-shore political accountability, as the former health secretary Enoch Powell wrote half a century ago ‘the whole idea of non-ministerial management of a health service wholly financed from taxation is a chimera.’

3. People advise them to do it

It is very rare that an incoming health and care secretary is told ‘everything is fine, don’t change a thing’. And in part, that’s because although there’s always someone who benefits from the status quo, there’s also someone for whom the status quo isn’t working.

So, I remember someone telling me about the influence of the charismatic GPs who advised Andrew Lansley to give primary care a greater role in commissioning NHS services, which could at least part-explain the 2012 Act’s proposals around primary-care led clinical commissioning groups (CCGs). And you have charismatic hospital leaders who argue for hospital chains are the answer to unwarranted variation in services. Which helps lead to policy changes like the introduction of ‘provider collaboratives’.

Ultimately, the point is that when you are the health and care secretary there will always be someone to whisper the word ‘change’ in your ear. Exactly who gets to whisper, and how much they are listened to, can have a huge influence over how the NHS is organised.

4. It is an activity our politicians can uniquely do

The easy criticism to make is that NHS restructures are displacement activity for politicians. In fairness, I think health and care secretaries come into post and sometimes find they are left with more accountability and less formal power over the NHS than you would think.

And that energy, coupled with aspects of the English political system, might make NHS restructures more likely. The NHS is an incredibly salient political topic. There are large amounts of NHS legislation that detail everything from how local services can be reconfigured to how they are paid for. And with a parliamentary majority there are fewer checks and balances that can prevent politicians from restructuring the state.

Faced with that, and what a former NHS Chief Executive described as ‘the biggest train set in Europe’, restructuring NHS statutory bodies is something that politicians can definitively and uniquely do, because this activity sits at the intersection of politics, policy and legislation.

5. The restructure fits with wider government ideology

As a colleague of mine observed, some NHS restructures make more sense when they are looked at from a wider government lens.

For example, market-style reforms in health care in the early 2000s mirrored the wider ideology of the government of the day. The growth of hospital groups in the 2010s mirrored similar reforms in education that created academy chains.

So, if we look at the current health reforms from a wider government lens, rather than an NHS-centred lens, what might we see?

We might see that abolishing NHS England and Healthwatch is a prominent example of a much wider bonfire of the quangos. With the NHS under more of a magnifying glass because of its scale – NHS England accounts for a huge share of arm’s length body spending and there are more than 150 local Healthwatch organisations.

We might also see that folding NHS England into the Department of Health and Social Care is, like the UK Space Agency being folded into the Department for Science, Innovation and Technology, part of a wider trend to bring more operational control under ministers. Particularly from a Prime Minister who has said he wants to reduce the ability of politicians to ‘hide behind a vast array of quangos, arm’s length bodies and regulators.’

And we might see that a substantial cut in the number of local NHS commissioning bodies can be a harbinger of changes to the rest of the public sector – such as the proposed reduction in the number of police forces in England.

So, if you struggle to see why changes in the NHS happen, it might be that they are only the echo rather than the shout.

6. The restructure delivers wider political messages

Sometimes the decision to restructure the NHS is part of a wider political message to parts of the electorate. A message that demonstrates a distinctive break with the past and with previous governments.

While correlation doesn’t equal causality, the government saw a bump in public polls of how it is handling the NHS shortly after the announcement to abolish NHS England was made (though this bump was short-lived, see Figure 3).

And in a case where there definitely is causality, the day after the left-leaning Labour government announced NHS England’s abolition, it was greeted by the front page of the right-leaning Daily Mail leading with ‘Finally! Patients to be put before NHS bureaucrats: 9,300 jobs to go as ministers scrap NHS England, the “world’s biggest quango” to improve care and crack down on wokery’.

7. Because it is the right thing to do, and it is their right to do it

Not to be dismissed is the possibility that politicians come in and don’t drink the status quo Kool-Aid and instead see that change is needed.

It was politicians who were accountable for the decisions to make the Bank of England independent, to create the Office for Budget Responsibility, to create NICE. Sometimes politicians see that re-engineering the machinery of government is the only way to achieve better value for patients and taxpayers.

Seven things to consider before you restructure the NHS

The current plans to merge NHS England and Department of Health and Social Care and reduce the number and size of local bodies like Integrated Care Boards are the most significant structural changes to the NHS in a decade.

Parliamentarians have compared the restructure to HS2 because the plans were announced ‘without either delivery plans or secured funding’. And perhaps this reorganisation has created more heat than light because the government has not really explained its thinking or which combination of these seven reasons (or any others) are behind the changes.

So, what might make things a little better? Here are seven things that might be worth thinking about, before you pull that familiar ‘NHS restructure’ lever.

1. Work out what your story is and then relentlessly talk about it

Politicians need to be crystal clear on just why they are restructuring the NHS by setting out their clear and coherent vision for reform and explain why all this is necessary.

Aside from broad statements about reducing bureaucracy in the NHS, the government has yet to craft or effectively communicate its story about the current NHS reforms.

James O’Brien used to ask his Brexit-supporting callers what they would be able to do the day after Brexit that they were unable to do before. The same principle applies here – the Department of Health and Social Care and NHS England already have a shared leadership team before the law has changed. What will they be able to do the day after the NHS restructure legislation becomes a law, that they can’t do now? How do you explain that to a person on the street. In short – sell the change.

2. Say what you are building and not just what you are abolishing

For all its flaws, at least you could see the intent behind the Lansley Reforms of 2012. He knew what he wanted to create. So, CCGs were created to allow more clinical input into how the NHS spends its money. The NHS Trust Development Authority was created to produce more semi-autonomous providers who could compete in a quasi-market.

But the latest NHS restructure has a startling lack of clarity over what the new health care system should look like. How many integrated care boards should there be? Should the NHS provider sector continue to contract through mergers? Where exactly will all the functions currently performed by local and national Healthwatch go?

It is becoming increasingly clear that there is no whiteboard in Whitehall with the new organogram of the NHS sketched out. And the closest we have then is a series of ‘models’, ie, the model neighbourhood, the model integrated care board, the model region. What is missing is a sense of what the overall model is meant to look like.

So, one of two things need to happen if you are restructuring the NHS. Either you need to set out clearly what you want to create and what you are working towards from the get-go, with more of a guiding hand. Or you need to let go and set out broad principles of how you want the NHS to work and let local parts of the NHS get on with it, but accept that it will get a bit messy and organic.

Want an example of the messiness? The current reforms give foundation trusts the opportunity to remove their existing council of governors, but this isn’t mandated – which could easily lead to some inertia if local leaders don’t want to incur the first-mover disadvantage of all the local scrutiny that comes from abolishing a council of local patient and staff representatives.

3. Give the existing structures a chance before you get rid of them

I always get slightly narked by when a new manager takes over a football team and tries to bring their own players in, rather than trying to work with the squad they inherited. The same principle could apply to the NHS, because politicians could give the existing structures a fair chance to see if they can deliver something different.  

So, if you want commissioning to be more clinically-led, why not try putting more clinicians on the boards of existing primary care trusts before you replace them with CCGs. If you want different parts of the NHS to work together more closely – then set a high bar before putting sustainability and transformation partnerships on a legislative footing as integrated care boards.  

Imagine how different things would be if you just gave senior leaders in the NHS a different task, rather than starting the merry-go-round of abolishing bodies and sacking staff.

4. Think carefully about who is driving and presenting the restructure

The NHS was restructured ten years ago but few people described it that way. With the publication of the NHS Five Year Forward View and other national planning guidance documents, different parts of the NHS were asked to work more closely together and focus on collaboration rather than competition. Hospitals, mental health trusts, ambulance and community services would all be grouped into 42 ‘sustainability and transformation plan’ areas.

It was barely national news and perhaps part of the reason was that the person leading this change was Simon Stevens – the chief executive of NHS England, rather than Jeremy Hunt, the Health and Care Secretary. As Jeremy Hunt said:

Had it been my document, as opposed to Simon’s document, it would have been immensely controversial. It would have been dissected. People would have said, ‘This is Lansley mark two, this is another top-down reorganisation,’ and that was the last thing the NHS wanted.

So, while the actual content of the restructure clearly matters, perhaps more light than heat could be achieved it is the NHS rather than a politician who is leading the charge.

And as a final point here – think about who might be in the driving seat after you. For example, if you are restructuring the NHS to reduce the operational independence of the NHS and pull back more powers under ministers, think through what might happen if a different political party and different ministerial team got their hands on the wheel.

5. Learn the lessons from the previous restructures and the people who led them

This is perhaps the easiest one to put into practice. If we do need more NHS legislation, then perhaps Part 1A (sub paragraph 1) should say that anyone proposing an NHS restructure must first ask for advice from the most recent health and care secretary, permanent secretary and head of the bill team who delivered the previous restructure. With the scars on their back, they might be the most helpful of sounding boards before you decide to restructure the NHS.

6. Don't make it a close hold

In an August 2025 episode of the Political Currency podcast Wes Streeting described the abolition of NHS England as ‘a decision we kept so tight…there was a handful of us who knew.’ While this is framed as a virtue in the podcast, NHS restructures are hardly a surprise so why the need for such secrecy?

We would be better served if politicians were more transparent about their plans and tested them in the open. And as noted above, at the very least you could do more to test your proposals in private, so you could see whether your plans are sensible and whether they could be more joined up with related government plans (like change to local authority structures).

7. Don't legislate unless you really have to

Colleagues at the Fund have set out several good reasons for why legislation should be avoided unless it’s absolutely necessary.

If you want more relational distance between politicians and the NHS then you can achieve it without changing the law – for example through advisory committees that decide how NHS funding is regionally allocated (which allows politicians to avoid some political bunfights and petitions over why one part of the country is more or less resourced than another).

If you want parts of the NHS to work together more closely, you can encourage that through national guidance (eg that created sustainability and transformation partnerships and provider collaboratives) or by making a political decision for national bodies to work together (eg as NHS England and NHS Improvement did for years before they were formally merged).

Conclusion

As with all things in life, a little balance is needed. We don’t want to kid ourselves that the current structure of the NHS is perfect and doesn’t need to change. And we don’t want to kid ourselves that the perfect structure is out there, but just out of reach, and that we are the chosen ones who will find it.

Restructuring the NHS shouldn’t ever be off the table, but it also shouldn’t be the only dish or even the main course on the menu. Or, as Roy Griffiths put it more elegantly all those years ago: ‘reorganisation is the thing you absolutely should do, but only when everything else has failed.’