Keir Starmer's decision to abolish NHS England is a high-risk strategy

Just six weeks or so ago, Wes Streeting, the Secretary of State for Health and Social Care, made clear that while he (quite rightly) wanted much closer working between his civil servants and NHS England – something that had already started to happen – he had no plans to abolish NHSE.

“I could,” he said, “spend a hell of a lot of time in Parliament and a hell of a lot of taxpayers’ money changing some job, titles, TUPEing over staff [back into the department] and changing some email addresses and not make a single difference to the patient interest.”

On Thursday, the prime minister announced he was going to do just that, with all the risks that Streeting outlined. It is quite a turn up for the books. 

There are no immediate answers about what will replace NHS England

It marks the end of a near 12-year experiment of running the NHS much more independently of ministers and it begs a whole load of questions about what will replace NHSE and its functions – questions to which there are no immediate answers. Indeed, right now, it feels as though the abolition of NHSE threatens to be almost as chaotic as was its creation back in the 2010s at the start of the coalition government.

With the benefit of hindsight, the writing has long been on the wall for Andrew Lansley’s original 2010 concept of a truly independent board that would finally put an end to what he dubbed the “political micromanagement’’ of the service.

Plenty, though not all, former health secretaries, once out of office, could see the case for greater independence in the running of the NHS – a clearer divide between policy and operations – although given the tax-funded nature of the NHS the sort of complete independence that Lansley envisaged was never going to happen.

Things have come to this pass in part because Simon Stevens, as chief executive of NHS England, pretty much annexed policy making as well as taking on operations. From Matt Hancock’s day onwards, ministerial frustration with that, and the performance of NHS England mounted, and the empire, in the shape of the department, struck back. Hence the new powers of direction over NHSE taken in the 2022 Health and Care Act, and a steady growth in the number of civil servants monitoring what NHSE is up to. The result has been the creation of two overlapping fiefdoms – with all the duplication of policy and operational teams that Streeting is quite rightly determined to tackle.

Doing away with NHSE means more than simply rolling it into the DHSC

Complete abolition of NHSE, if the promised legislation happens, is however a radical step, not least because Streeting conceded in his Commons statement on Thursday – and in a perhaps unfortunate echo of Andrew Lansley who said the same thing about his mighty Act – that much of the change that he wants (NHSE and the department operating as one team) “can be delivered without the need for primary legislation”.

Abolishing NHSE involves much more than just rolling it back into the department. It requires a new definition of ministers relations with the NHS. It is almost inconceivable that they will in fact seek to run the NHS day-to-day, so some sort of operational function will have to be devised – perhaps on the lines of the previous NHS Executive which worked inside the department. 

NHSE has seven regional offices which act among other things as performance managers. Are they going to become civil servants? Or, more likely, do they remain part of the NHS as some sort of regional authority? In which case the legislation is going to have to define their functions. They, along with the 42 Integrated Care Boards that oversee the NHS locally, are part of the same 50 per cent cut in running costs – which mainly means staff reductions – to which NHSE and DHSC are being subjected. So along with many thousands of redundancies there is the likelihood of mergers of ICBs and quite possibly regions, with re-definitions, or clearer definitions then needed of what these tiers do.

Abolishing NHSE could bring real gains – but it is a risky approach

In addition there are all sorts of things that NHS England now does – such as IT, specialist commissioning, the sharing of good practice, negotiations on the price for individual new drugs and much else – that will have to go somewhere, with that somewhere not necessarily being a hugely enlarged health department.

In other words, by accident or design, nine months into its term of office the government is embarking on a major reorganisation of the superstructure of the NHS that is not fully thought through and which it did not intend to do in the first place. One which it says will take two years fully to complete – and all at the same time as it is desperately seeking to improve performance and hoping this will not prove a distraction from that.

It is just possible there will be some real gains from this that could not have been achieved by a more evolutionary approach. But if there are they will be a long way down the road, and the risks are precisely those that Mr Streeting set out six weeks ago.