The announcement that NHS England (NHSE) will be scrapped may have surprised the mainstream media, but for many insiders there were indications of the direction of travel. The absence of any serious defence from political parties suggests this move was overdue.
The proposed 50% job cuts across NHSE and the Department of Health and Social Care (DHSE) appear arbitrary—more of a political signal than a feasible strategy. However, reductions are inevitable. At its onset NHSE’s mission was wide and included driving the delivery of safe and high-quality healthcare for all; supporting NHS staff with training, data, and tools; and delivering value for money. The key concerns in getting rid of NHSE are what gets eliminated, what remains, and how resulting gaps will be tackled. Where will the “slack” be taken up, and duplication avoided, in an already stretched system within the DHSC.
Integrated Care Boards (ICBs) will experience the most significant administrative cutbacks—as much as 50%, which follows the 30% cuts to running costs that they had already been required to make by 2026. A major concern is that such cuts in support could undermine the community services that help reduce demand on acute hospitals. Acute and other provider trusts will not be spared the pain as they have been asked to cut their corporate costs.
ICBs were born into a storm and have faced constant upheaval since. Many ICBs were established through a “lift and shift TUPE” process from previous structures, meaning there was little opportunity for intentional organisational design. A more planned strategic approach may identify some areas where streamlining and reducing duplication could be beneficial without harming services.
Historically, NHSE has never functioned as a true quango. Due to its political significance, governments have always maintained a hands-on approach despite what previous health secretary Andrew Lansley intended. Perhaps inevitably, ministers have exercised considerable control, ensuring NHSE remained far from independent.
The appointment of James Mackey as interim chief executive officer is strong. A crucial aspect of his leadership will be ensuring his leadership team remains connected with the broader organisation.
A major concern is that these reforms may simply replicate the status quo, with improved execution rather than meaningful transformation. There is also apprehension that the acute sector will continue to be prioritised while primary care, mental health, and community services remain underfunded. Historically, commitments to these areas have been more about reducing hospital pressures rather than improving overall health outcomes.
Furthermore, the DHSC faces the daunting challenge of dismantling more than a decade of entrenched practices and institutional culture. This is no small feat and should not be underestimated. Meanwhile, the impact on the workforce remains a critical issue. Employees are understandably anxious, particularly given the current economic climate, where job security is a major concern. Clarity is needed on the NHS’s unique role in healthcare and how the new structures will be designed to fulfil that role effectively.
If the principle that organisational structure should follow function is to be upheld, then proceeding with these changes before the publication of the NHS 10-year plan seems illogical. This decision appears politically driven—an attention-grabbing announcement influenced by widespread dissatisfaction expressed during the DHSC’s engagement exercise, in which many called for NHSE’s removal.
Despite these risks, there are potential opportunities. Greater local autonomy may allow regions to implement what works best for them. Clearer delineation of roles between the central, regional, and local levels could improve efficiency. Additionally, there may be increased scope for local innovation and scalable partnerships, with a central body that can learn from and improve the entire system. A shift in power and funding from acute hospital trusts to primary care, community, and prevention initiatives could also emerge, though the extent of this remains uncertain.
The BMJ Commission on the Future of the NHS has suggested a health focused oversight body akin to the Office for Budget Responsibility.1 While this could provide valuable accountability, the current political climate, which favours reducing quangos, may render this unlikely.
For this transition to be successful, the right leadership team is essential. Wes Streeting, health secretary, has identified three key shifts: from hospitals to the community, from analogue to digital, and from treatment to prevention. Achieving these objectives will require a primary care expert with the authority to drive transformation, alongside a leader skilled in system change and people management. A digital leader with deep expertise and influence will be necessary to modernise healthcare delivery. A surgical lead will be needed to prioritise and ensure high-quality elective care, while a finance leader must understand that financial figures reflect behaviours rather than dictate them.
Additionally, an acute sector leader must be committed to population health and aware of broader healthcare dynamics. The leadership team as a whole must be aligned around a clear vision, values, mission, and strategy, inspiring, and learning from the wider NHS and social care system. The appointment of Penny Dash as NHS England’s chair is therefore a welcome step given her experience across public health, medicine, healthcare management and as a chair of an ICB. It is hoped her leadership will support the NHS further to embrace the potential of system working.
The outcome of this reorganisation remains uncertain, but its success will depend on whether it leads to genuine improvements in health and healthcare delivery or simply reinforces existing inefficiencies under a different guise.
Footnotes
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Competing interests: LS and PK: none declared. VA is chair of NHS Confederation.
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Provenance and peer review: commissioned, not externally peer reviewed.
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This article is part of The BMJ Commission on the Future of the NHS (https://www.bmj.com/nhs-commission). The purpose of the commission is to identify key areas for analysis, lay out a vision for a future NHS, and make recommendations as to how we get there. The BMJ convened this commission, which was chaired independently by Victor Adebowale, Parveen Kumar, and Liam Smeeth. The BMJ was responsible for the peer review, editing, and publication of the papers of the commission. The BMA, which owns The BMJ, grants editorial freedom to the editor in chief of The BMJ. The views expressed are those of the authors and may not necessarily comply with BMA policy.