Dr Richard Dune

11-04-2025

Is abolishing NHS England the reform we need?

Image by YuriArcursPeopleimages via Envato Elements

As NHS governance undergoes radical reform, we unpack the risks, promises, and power shifts reshaping health and care across the UK

On 13 March 2025, the UK government made a historic announcement: NHS England will be abolished and its functions reintegrated into the Department of Health and Social Care (DHSC). Framed as the largest governance overhaul in more than a decade, Prime Minister Sir Keir Starmer and Health Secretary Wes Streeting's decision signals a fundamental shift in how the NHS is managed, funded, and held accountable.

As NHS England is phased out by 2027, the government promises streamlined leadership, cost savings, and a return to “democratic control.” But does this represent a much-needed reboot of the system - or a risky rewind to a model the country has outgrown?

In this blog, Dr Richard Dune explores the key forces behind the decision, the history of NHS structural reform, and the road ahead for healthcare providers, managers, and policy leaders.

A brief history - From centralised control to fragmentation and back

The NHS has evolved from centralised control to greater autonomy and, at times, fragmentation, with ongoing debates about the best way to manage healthcare services in the UK.

Before 2012 - Central command with management tweaks

The NHS was originally a centrally managed public service. Successive reforms introduced managerial layers - most notably through the 1983 Griffiths Report and fundholding policies of the early 1990s. However, core control remained with the Department of Health and the Secretary of State.

Tony Blair’s New Labour government introduced performance targets, NHS foundation trusts, and market-based mechanisms. While this brought local flexibility and innovation, political micromanagement persisted.

2012 - The Lansley experiment: Autonomy and complexity

Andrew Lansley’s Health and Social Care Act 2012 sought to depoliticise NHS operations. He introduced:

• NHS England as an arm’s-length body.
• Clinical Commissioning Groups (CCGs) led by GPs.
• Quangos like Monitor, NHS Improvement, and Health Education England.
• Public health responsibilities shifted to local authorities.

However, critics warned of:

• System fragmentation, blurred roles, and reduced ministerial oversight.
• Privatisation risks through contract competition.
• Loss of accountability in decision-making.

The result? A complex system was famously said to be “visible from space.”

Jeremy Hunt’s quiet undoing

Although Lansley’s reforms remained legally intact, Jeremy Hunt reoriented the NHS strategy toward integration. Bodies like Monitor and the NHS Trust Development Authority were merged into NHS Improvement. Hunt supported Simon Stevens’ Five Year Forward View, which moved the conversation from competition to collaboration.

By 2022, under Sajid Javid’s Health and Care Act, CCGs were replaced by Integrated Care Boards (ICBs), and NHS England had become a hybrid agency for policy delivery and oversight.

The 2025 reset - Starmer and Streeting take the helm

Following Labour’s landslide victory in 2024, the government vowed to address NHS backlogs, inefficiencies, and duplicated functions. In a dramatic policy reversal, they proposed to:

• Abolish NHS England
• Reintegrate it into DHSC
• Eliminate over 9,000 roles
• Cut ICB administrative costs by 50%
• Introduce primary legislation for structural change.

Health Secretary Wes Streeting positioned the move as a return to clarity and accountability. His vision? “Fewer checkers, more doers.”

Structural Overhaul - What will change?

Key changes during the two-year transition include:

• DHSC regains full responsibility for oversight, delivery, and strategy.
• NHS England’s statutory powers will be absorbed by the department.
• Senior leadership appointments: Sir Jim Mackey (CEO) and Dr Penny Dash (Chair) to oversee the transition.
• Targeted savings of £100–500 million annually, intended for frontline reinvestment in elective recovery, workforce retention, and digitisation.

What this means on the ground

The NHS reform brings significant changes, impacting staff roles, local systems, and service delivery. Here’s a snapshot of what this means on the ground.

• NHS staff - Thousands of administrative and strategic roles face redundancy. While some roles may transfer into DHSC, many skills in planning, cancer care, and digital transformation could be lost.
• DHSC - The department must evolve from policymaker to hands-on system manager, reversing a decades-old model of arm’s-length governance.
• ICBs - Local systems are expected to become leaner and more empowered, yet face deep budget cuts amid rising demand and scrutiny.
• Service delivery - The government aims to restore the 18-week treatment target. However, many experts fear that disruption during the transition could derail service continuity.

The Debate - Pragmatism or political theatre?

Not everyone welcomes the reform. Critics argue that the move risks repeating past mistakes and diverting attention from patient care.

• The Health Foundation warns that reforms must not come at the cost of care, noting that "chainsaw governance rarely yields long-term stability."
• The NHS Confederation and NHS Providers express concern that this change creates uncertainty during a period of workforce and funding strain.
• Jennifer Dixon from the Health Foundation highlights that this mirrors the 2010 scrapping of the Audit Commission, describing it as a cautionary tale in overcorrection.

Governance shift - A new era of state control?

The move represents more than a restructuring. It signals a philosophical shift in how the NHS is governed.

• The Lansley era prioritised autonomy, competition, and technocratic distance from politicians.
• The Starmer-Streeting approach promotes centralised control, ministerial accountability, and direct oversight.

Whether this produces agility and clarity - or results in short-termism and political interference - remains to be seen.

Weighing the reform - Potential benefits and key risks

As the reform moves forward, it brings both opportunities and challenges. It’s essential to consider both the potential benefits and the key risks involved.

Potential benefits

• The reform could lead to unified leadership and clearer lines of accountability.
• It may accelerate digital transformation through more streamlined decision-making.
• There is potential for cost savings, which could be redirected to improve GP access and elective care.
• Ministerial ownership of decisions could bring greater public scrutiny.
• If decentralisation is genuinely pursued, it may offer opportunities for local innovation.

Key risks

• The reform could result in the loss of institutional memory and valuable policy expertise.
• There is a risk of reform fatigue among the healthcare workforce.
• Micromanagement may replace independent strategic direction.
• Innovation might slow down if top-down control becomes too rigid.
• Patient services could face disruption during the transitional period.

A defining moment - Lessons from the past, hopes for the future

As the UK health and care sector navigates this transition, three questions loom large:

• Will political leadership respect and empower local decision-making?
• Will frontline savings genuinely reach the services and staff who need them most?
• Can the new model balance short-term delivery with long-term innovation?

What’s clear is that structure alone won’t fix the system. The real test lies in implementation - whether this reset leads to stronger outcomes or simply repeats past cycles of reform and reversal.

Final thought - Reform, reset, or repeat?

The abolition of NHS England is as much a symbolic statement as it is a structural reform. It may reflect political confidence, but the risks could outweigh the gains unless translated into better patient outcomes, stronger local leadership, and a healthier workforce. Whether this reform marks the beginning of a more agile, responsive NHS or the return of centralised bureaucracy will depend on the people, priorities, and processes implemented now.

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