Back in March, Keir Starmer announced that NHS England will be abolished, which was met with mixed reviews. HB looks at the history of NHS England, its uses, and what scrapping it might mean for the future of our health service
On 13th March 2025, in a speech in Hull, prime minister Keir Starmer announced that he would be scrapping NHS England, the arms-length body that has managed the day-to-day running of the health service in England, since its implementation in 2013. This, understandably, was met with approval, confusion, and scepticism from politicians, researchers, and NHS workers across the board. But what does NHS England actually do, and will getting rid of it really inch the NHS closer to its performance targets and restore it to its former glory?
“Bloated and inefficient bureaucracy”
The Health and Social Care Act 2012 was the biggest structural reorganisation of the NHS until Keir Starmer’s announcement, through the Conservative-Liberal Democrat coalition government’s introduction of NHS England (NHSE), which was then known as the NHS Commissioning Board. The idea was first introduced by the then-secretary of state for health, Andrew Lansley’s 2010 white paper, ‘Equity and Excellence: Liberating the NHS’. Lansley wanted to free the NHS from “political micromanagement” by moving some of its functions outside of government control.
The NHSE that came into existence on 1st April 2013 was very different from the one current secretary of state for health and social care, Wes Streeting, referred to as “bloated and inefficient bureaucracy”. Its original intent was to abolish all primary care trusts (PCTs) and strategic health authorities (SHAs) and replace them with some 210 new clinical commissioning groups (CCGs), which would partly be run by GPs. Between £60 and £80 billion of the budget was transferred to new CCGs under the independent NHS Commissioning Board, which would later become NHS England in March 2013, and transferred public health responsibility to local governments. The Bill received so much criticism at the time that, in 2011, prime minister David Cameron stopped the progression of the Bill in Parliament to conduct a “listening exercise”, where the government listened to critics and make amendments to the Bill. Streeting would later blame Lansley’s reforms as the reason for “the longest waiting times, lowest patient satisfaction, and most expensive NHS in history.”
Lansley’s acts and the formation of NHS England were widely criticised for practices that hinted towards privatisation, such as bringing in a market-based system that allowed private involvement in healthcare. Transferring fiscal powers to GPs, making them independent contractors, effectively privatised the commissioning, or financing, portion of the NHS. The Health and Social Care Act 2012 allowed private and voluntary sectors to bid to supply NHS care, although the updated Health and Social Care Act 2022 reversed this competition element of the NHS by scrapping the markets-style economic regulator, as well as GP commissioning groups, which were made into integrated care boards (ICBs). Although these portions of Lansley’s reforms were revoked, what remained was NHS England.
“The biggest quango in the world”
Since its formation, NHS England has swallowed up more and more roles, and now functions as an administrative body that manages how health services across England are run, distributing around 90 per cent of government health spending. The government gives NHSE allocated funding with a broad instruction of where it is to go, which NHSE distributes independently. This top-down approach sees the majority of money trickle down through ICBs, and then service providers, like mental health services or hospitals, rather than given to local authorities to be directly given to services.
NHS Improvement, NHS Trust Development Authority, Health Education England, NHS X, and NHS Digital all have merged into NHSE, along with their staff, over the past decade, making the NHSE’s workforce more than 14,000 strong, which makes it four times the size of the DHSC. The King’s Fund point out that is increasingly difficult to assess how well NHSE did its job when its job constantly has increased in size and in duties.
Due to its size and budget, Andy Burnham, as shadow health secretary, called NHSE “the biggest quango in the world”.
In 2022-23, NHSE received more than 45 per cent of all funding for quangos, at £159.3 billion, which swamps other allocations like the HMRC’s £45.2 billion.
“The National Health Service is in serious trouble”
When Starmer inherited the NHS, he frequently described it as “broken”. Lord Darzi’s ‘Independent Investigation of the National Health Service in England,’ published September 2024, revealed catastrophic levels of staff disillusionment, unproductivity, and financial strains within the NHS. He warned that “the National Health Service is in serious trouble.”
The report found long waiting lists across primary, secondary, and community care, with 300,000 people waiting for over a year for hospital treatment in June 2024, compared to the NHS promise treatment to start within 18 weeks, and hospital capital budgets routinely raided to fund day-to-day running costs, leading to a crumbling estate.
“Better value for taxpayers and better outcomes for patients”
The need for tangible change is clear. To Channel 4, Streeting explained that scrapping NHSE would deliver “better outcomes for patients and better value for taxpayers, saving hundreds of millions of pounds that can be redeployed to the front line.
It is estimated this will save the government £500 million each year, which would be put back into frontline services, and would slash the number of head office staff in half.
Another huge factor in getting rid of NHSE was to end “two large organisations doing the same roles with an enormous amount of duplication”. This is not a revolution, with politicians and decisionmakers having complained of NHSE unproductivity for years; former health secretary Jeremy Hunt called it a “bureaucratic monster” to the BBC.
A strong argument for abolishing NHSE is that if decision-making is moved down to a local level and nearer to patients, it will be the health leaders more attuned to the needs of patients in that area making those calls. Abolishing NHSE brings the NHS and its operation under direct government control, which will also leave them with full responsibility and accountability for NHS services, successes and most importantly for a disillusioned public, any failures.
“You’d want the juice to be worth the squeeze”
What was the response to this shakeup? In his speech, the prime minister was careful to stress that the problem was not NHS staff, but rather the structure they were working in.
Jeremy Hunt appreciated the “boldness” of the structural change, while Conservative MP Alex Burghart warned that it “could be a total disaster if handled the wrong way”, criticising the lack of detail in the government’s plans. We can assume that local authorities will now have more power in decision-making and budgets, but this hasn’t yet been officially confirmed, along with many other questions which haven’t yet been met with answers.
Sarah Woolnough, chief executive of the King’s Fund, although she admits that “it is absolutely right that democratically elected politicians must have clear oversight on how the NHS delivers for patients”, is also concerned about the impacts of abolishing NHSE might have on productivity. She explains: “As with previous NHS restructures, structural change comes with significant opportunity cost, with staff who would otherwise be spending their time trying to improve productivity, ensure safety and get the best outcomes for patients, now worrying about whether they will have a job.”
Although impressive-sounding, the alleged £500 million saved pales in comparison to the £5 billion black hole the NHS is facing, and further staffing cuts (reportedly saving £175 million) won’t touch the sides of the problem. Woolnough also draws attention to the positives NHSE does bring to the health service, such as centralising training, digital services, and data; it does make sense, she points out, that these are done by a whole team of people, rather than separate GP practices.
All of these procedures previously handled by NHSE will need to go somewhere: whether kept at the centre, whether moved out locally into ICBs, or whether stopped completely (and at what consequences?) and this is further administrative work that will need to not only be figured out, but also implemented against a backdrop of more and more ambitious targets and greater pressure from the government.
When NHSE has grown so exponentially, both in size and its functions, it will be a difficult and time-consuming process to unravel it from the procedures it is intertwined with – from administrative to developing national programmes to setting performance standards – and decide what will happen to these functions. She emphasises: “Creating and destroying England’s biggest quango is something so time-consuming and significant in healthcare policy that you’d only want to do it once. And you’d want the juice to be worth the squeeze.”
The most recent staff survey saw almost a third of staff (30.24 per cent) report feeling burnout because of their work: how do we expect them to increase their output, while also facilitating speedy restructure of the entirety of NHSE?
“Madam Deputy Speaker, change is hard”
The government’s announcement gave very little away, and we were not given a specific plan of action, just that the dissolving of NHSE will take around two years. This has left healthcare workers, advisory groups, and decisionmakers with many questions; specifically, that we don’t know yet the effects this will have on frontline organisations. The only clarity we have is that integrated care boards (ICBs) will need to reduce their running costs by 50 per cent by October this year, and that provider trusts will need to make further reductions in their corporate costs, implying ICBs will take on a smaller role with less authority to make financial decisions.
We aren’t sure when relevant legislation implementing this change will come, or exactly where job cuts will be, or which roles and teams will be absorbed into the DHSC, leaving a lot of staff unsure about the future of their jobs. But the government is steadfast in their claims that this decision will reduce costs, streamline the system, and enhance productivity through diverting more resources directly to the frontlines. Streeting declared to the House of Commons that “change is hard” and yet, “this Labour […] government will never duck the hard yards of reform,” and we must wait to see if this pays off.
