The decision to abolish NHS England, bringing to an end a 13-year experiment in handing the health service operational independence, left a slew of unanswered questions about how it will be run once the government takes direct control.
NHS reorganisations have historically proved highly disruptive, and some experts warned that the initial impact could be a further downturn in performance.
The latest data, published on Thursday, showed the NHS is still grappling with a 7.43mn appointments backlog while 47,623 people were forced to wait more than 12 hours in A&E departments for a hospital bed.
Recent weeks have seen a series of jolts, each appearing to signal the government’s displeasure with the way the service was being run. These ranged from the resignation of chief executive, Amanda Pritchard, followed this week by most of her senior lieutenants, and warnings of extensive job losses at NHS England.
But few, if anyone, had expected Wes Streeting, health and social care secretary, to scrap NHS England altogether.
However, a government official said Streeting had come to the conclusion that NHSE needed to be abolished earlier this year. “He decided we didn’t have time to waste, which is why we decided to do this now,” they noted.
Officials said there were staff working in both NHS England and the health department who were effectively doing the same job.
“I cannot tell you how frustrating it is to see two organisations with duplicating roles and coming together double-ticking everything”, they added. “It is massively wasteful and a mad way to set up the running of the NHS. This has just become clearer and clearer.”
On Thursday, Prime Minister Sir Keir Starmer said the abolition of the body would put the NHS “back at the heart of government” and free up “hundreds of millions” of pounds for frontline services.
Government officials insisted this did not amount to “a top-down reorganisation” in the mould of former Conservative health secretary Andrew Lansley’s changes, which were so extensive that the NHS’s then-CEO quipped they could be seen from space.
“This will be unsettling for staff in those organisations but this is not about disrupting the entire NHS,” one said.
Streeting and his team believe the vast majority of changes can be completed without primary legislation. They expect it will take two years to fully integrate NHSE into the DHSC and plan to introduce a bill in parliament within this timeframe.
Siva Anandaciva, director of policy at The King’s Fund, described the mood among staff he had spoken to, as quite simply one of “shock”.
He said hospital trusts were lamenting that relationships built up with their local integrated care boards and NHSE regional teams — structures set up to manage services and direct funding in their localities — might now count for nothing.
“They’re asking ‘will we even have an integrated care board or regional NHS England team at the end of this?’” he said. The NHS needed to save £7bn and the measures announced so far would net only hundreds of millions, he pointed out. “So who’s next or what’s next?”
Health officials said they were “under the impression” that Streeting’s tightening grip over NHSE would be more gradual, instead of Thursday’s “big bang”.
One added: “It feels like they are in panic mode a bit here but the finances are in a very bad state next year so they have to lead from the front and strip out all duplication at a national level. But this is a bit of a bombshell.”
Inside and outside the NHS, there was concern at the lack of clarity over how the changes would affect the NHS’s ability to deliver its services given the enormous pressures it was facing.
Nigel Edwards, a former NHS senior manager who until 2023 ran the Nuffield Trust think-tank, said NHS England had recently spent millions on consultancy to develop a new operating model but it had been predicated on the body’s continued survival.
“All of that’s now out the window,” he said. Combined with announcements of job cuts and tough new savings targets, “there’s a real danger that there’ll be a significant voltage drop in a number of the other reforms that they’re actually trying to push forward”, he added.
Bill Morgan, who was a special adviser to Lansley when the decision to create NHS England as an arms-length body was implemented, welcomed its abolition, arguing the relationship between the NHS and DHSC had become deeply dysfunctional.
“You can’t have a world where the Department of Health says they want to do one thing, NHS England says they want to do another, and everything just comes to Number 10 to decide, and that was what was happening,” said Morgan who until last year was health adviser to Conservative prime minister Rishi Sunak.
However, he cautioned that although the move was necessary, it might take four or five years for the benefits to become apparent, while the downsides of such an upheaval “are quite immediate because the disruption will be net-negative for performance”.
Even if ministers did not yet realise it, the government was in reality “accepting pain up front . . . for a fairly intangible benefit somewhere down the line,” Morgan added.
Additional reporting by Anna Gross
