Will Yvette Cooper and Andy Burnham still abolish NHS England?

The abolition of NHS England required legislation (the Health Bill), which is currently in parliament and is due to come back to the Commons for its report stage and third reading in the coming weeks. The future shape of the health service – and even whether the abolition will go ahead – will depend on decisions made in the coming days. 

These decisions will of course be made not by Streeting and Starmer but by Yvette Cooper and Andy Burnham, who have a rare chance to address some of the important questions that have been fudged or ignored in the process to date.

The decision to abolish or keep NHS England is most pressing

The most pressing question, and the one from which all other decisions flow, is whether Cooper and Burnham want to push ahead with the abolition of NHS England at all. The process is well underway: the government has made staff redundant and merged teams. And though the initial announcement was poorly handled, the previous institutional arrangement was an oddity. Stopping the abolition now would be the wrong decision. 

But the final form of the abolition is still not decided. The current path diverges sharply from Burnham’s vision of a more devolved set of public services, given they work to centralise a lot of powers in Whitehall. Indeed, the merger will bring operations of the entire NHS into the department of health and social care (DHSC). 

The bill will also transfer powers to the secretary of state – over appointments of senior staff in NHS trusts, over funding allocations for integrated care boards, and over performance management of frontline services, among others. ⁷ https://www.gov.uk/government/publications/health-bill-oversight-of-the-health-system-fact-sheet/health-bill-oversight-of-the-health-system-fact-sheet  

Political leadership is desperately needed

Within government, the process is in limbo. Senior leaders in DHSC and NHSE are deadlocked, battling over different visions of the future of the service. DHSC want to reduce duplication, provide ministers with a single view of what is happening in the service, and clarify lines of accountability. They want to absorb everything that is currently in NHSE into the department. NHSE takes a different view. Its leaders think that operations of the NHS should remain at some distance from political control, potentially in an organisation other than DHSC. 

There is no right answer. The NHS has spent its history swinging between these two positions. But the process has stalled because some fundamental decisions rely on one of these views taking precedence.

So the problem is a political one. Staff we speak to who work in NHSE report that the Starmer administration stopped making substantive decisions soon after the announcement. They did not pay enough attention to the process and or fully utilise structures – such as the oversight committee – where these decisions were supposed to be made. Cooper needs to provide that leadership, at which point DHSC and NHSE leaders will push towards her vision.

Operational decisions will be key

Assuming the government chooses to press ahead with the abolition of NHSE, there are still vital questions that will shape the future of the health service. 

Staffing is one of the most obvious areas. First, do Cooper and Burnham want to stick to the 50% headcount cut that Starmer and Streeting targeted? That is a drastic reduction. When combined with cuts of the same size in integrated care boards, it risks reducing the NHS’s capacity to unworkable levels. 

The current plan is to bring all NHSE staff into the department, making them civil servants. That too could be problematic. NHSE staff are paid much more than their DHSC counterparts. There are also large cultural differences between the two organisations. Contacts in NHSE tell us that there is a real risk that many important NHSE staff will choose to leave rather than join DHSC.

An alternative way to keep key NHSE talent would be employing those staff in an organisation outside the civil service. This might open the door for other functions to be outside the department, particularly where a civil service salary makes it difficult to attract and retain the right staff. But whatever form such an organisation then takes – maybe an executive agency, or else keeping the NHS regions which the government is abolishing – it will retain some of the issues with the current NHSE/DHSC split: duplication of roles and responsibilities, ministerial distance from operational decisions, and unclear accountability.

If Cooper and Burnham opt for a separate NHS organisation, the questions then become which functions should sit within it and what form it should take. NHSE staff would argue that operations should be kept out of the department. Speaking at an NHS conference earlier this year, Jim Mackey, CEO of NHSE, warned against giving ministers too much control, arguing that without some form of operational independence the NHS will “grind to a halt”. ⁸ https://www.hsj.co.uk/policy-and-regulation/ministers-to-consider-scrapping-separate-national-nhs-ceo/8023668.article  

Whatever the path chosen, big decisions are needed soon 

The timing of this bill will be unwelcome to Burnham and Cooper. They have had no chance to develop a vision of what a more devolved health service looks like and instead are inheriting legislation that is pushing in the opposite direction. Worse still, the bill’s imminent return means they may have to fast-track what are really quite consequential decisions. 

If Burnham does go ahead with the bill in its current, centralising form, he will need to explain how it aligns with his devolutionary agenda. As well as a narrative challenge this may also go on to become a legislative one, meaning that he has to unpick some of the legislation within the next few years as he devolves more powers over the NHS.

If instead he wants to make substantial amendments that, for example, place more powers in mayors’ hands or establish a new organisation to manage the operations of the NHS, then the government will likely have to delay the bill’s report stage to allow time for the policy to be reworked and amendments to be drafted. That will set the timetable back significantly – another tricky outcome given that the government is aiming to complete the abolition of NHSE by April 2027. 

Living in limbo

Most importantly, though, Burnham and Cooper urgently need to provide the political leadership which has been so sorely lacking for the last 18 months. Leaving the process in limbo wastes the time and effort of staff and risks delaying any improvements in performance that may flow from the new system.