NHS abolition was not on my bingo sheet for Keir Starmer’s Government. But here we are. A political earthquake. Kissinger has gone to China. The party most closely associated with Britain’s healthcare system are the ones who finally be replacing it with a much more successful European-style social insurance system. Finally, fewer Britons will die compared to world-leading healthcare systems, like Australia’s.
Reader, I have fooled you. None of this is true.
What Starmer has in fact abolished is NHS England. While this may be a gift to headline writers, it is not a radical step, it’s a bureaucratic reorganisation. A separate quango will no longer be responsible for overseeing the budget, planning and delivery along with commissioning GPs and some other services. Instead, this function will be bought in-house to the Department of Health and Social Care. The nameplates on several buildings will be changed, new stationery ordered and different email addresses in use. But fundamentally, the NHS will remain the same.
Today’s announcement puts the final nail in the coffin of the Conservatives’ 2012 reforms, introduced by then Health Secretary Andrew Lansley. It was only at this reorganisation that NHS England was even created. The hope was that giving power to an arms-length body, along with Clinical Commissioning Groups, would help depoliticise the NHS. In this regard, the structure was an abject failure.
When the state operates, delivers and spends hundreds of billions of taxpayers’ money on a healthcare system, it never really can be independent from politics. Inevitably, ministers are expected to account for every single part of the NHS. This was, in the words of the NHS founder Aneurin Bevan, the entire point of the system: ‘If a bedpan is dropped on a hospital floor in Tredegar, I want the noise to reverberate in the corridors of the Palace of Westminster.’
In practice, Lansley’s operationally independent NHS was already long-dead before today’s announcement. Former Health Secretary Matt Hancock – best known for office antics outside the scope of this piece – undertook reforms back in 2021 to grant more powers to the Health Secretary to intervene in local services and veto some appointments and abolished the Clinical Commissioning Groups.
Getting rid of NHS England is not entirely ineffectual. It is useful to give up on the fiction of operational independence, and the associated attempts at buck-passing. There is some duplication between the quango and the department: like communications and strategy teams. There may just be some cost-saving in reducing the 15,000 staff currently employed by NHS England. In the context of the NHS budget, however, this is unlikely to mean a substantial amount redirected to frontline services.
More fundamentally, increasing ministerial control without altering the fundamental structure of the NHS is unlikely to yield significant improvements in patient care. Merely consolidating oversight within the department, often involving the same personnel operating under unchanged protocols, does not constitute meaningful reform.
Despite Starmer’s assurances, this reform is unlikely to reduce bureaucracy. Large-scale systems like the NHS, especially those devoid of market-driven incentives, are inherently prone to bureaucratic expansion. The core issue lies in excessive centralisation, irrespective of whether it emanates from the department or an autonomous agency.
The world’s most successful healthcare systems operate without bodies like NHS England, nor are their departments of health expected to plan service delivery or commission certain services. In social insurance systems, the role of the department typically revolves around regulation and oversight, rather than direct management. In the likes of Germany, multiple funds compete to offer services, ensuring localised and patient-centred care, with significant incentives for efficiency and innovation. This not only results in less bureaucracy, but in better patient outcomes at lower costs.
Perhaps next time we read headlines about ‘NHS abolition’ it will mean something a bit more meaningful than a bureaucratic restructure.
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