The Government have announced the most significant quango cull in recent memory. NHS England, the “world’s largest quango”, will be no more in two years’ time. The decade-long experiment of “taking the politics out” of health care is over. 10,000 jobs at the Department of Health and Social Care (DHSC) and NHS England (NHSE) will go, representing a massive reduction of “the centre”. The Prime Minister has justified the decision to bring the NHS back under “democratic control”. He is right to do so.
The Government have reinforced a vital principle: that key policy and political decisions should be taken by elected politicians and Ministers; not by unelected NHS managers or departmental officials. This week’s announcement has been pitched as the final nail in the coffin of the ‘Lansley reforms’ under the Coalition Government of the early 2010s. But it also differs from the approach taken by some in the ‘New Labour’ years of the early 2000s – which downplayed direct political control in favour of professionalisation, even technocracy.
By contrast, Wes Streeting’s action represents a revival of an older Labour tradition, shadowing the politics of the Health Minister, ‘Nye’ Bevan, who drove the foundation of the NHS in the 1940s. If a “bedpan” fell in his birthplace, Tredegar in South Wales, the sound would “reverberate around Whitehall”.
The Streeting approach also owes something in spirit to the legacy of the late Sam Galbraith, a neurosurgeon who served as Labour Health Minister in the pre-devolution Scottish Office, who exerted a firm grip on appointments, orchestrating a clear out of a previous generation of health service appointees in 1997.
Policy Exchange has been at the forefront of the public debate, calling on policymakers to recognise the primacy of politics. Our 2024 report Getting a Grip on the System called for a major pushback against ‘subcontracting’ political decisions to quangos.
For many years we have called for major reforms to “the centre” of healthcare governance. In Balancing the Books (2022), we argued that “merging DHSC and NHSE” could produce savings of up to up to £1bn. In Just About Managing (2024), we called for “tiers of management” to be reduced and for the abolition of NHSE, with an NHS Management Board reintroduced at the DHSC.
As recently as last Autumn, a reform of this kind did not seem on the cards. Lord Darzi’s independent review of the NHS concluded structural reorganisation would be unwelcome. The Health Secretary insisted his Department and NHSE work as ‘one team’. Legislation seemed too disruptive.
This week’s news is a significant moment – a clear sign that the institutional dysfunction and fudge of accountability that Streeting inherited was too much. To be the patient’s “shop steward”, as was promised pre-election, he had to take back control.
The reaction to the news from those Streeting recently dubbed the ‘health establishment’ has also been telling. There has been an acceptance that the end of NHSE was an inevitability. There has been a notable shift in tone from the most recent attempt by Ministers to return (more limited) powers through the Health and Care Bill in 2021, which led one health think tank chief executive to call on the (then Conservative) Government to drop the “contentious proposals to give his role more power over the day-to-day running of the NHS”.
But this move is now seen as vital given the sheer size now of the health budget. In 2012/13 – when NHSE was established – the DHSC annual budget was just over £130bn. By next year, that budget will have reached £200bn – an increase of more than 50% in just over a decade.
But with political accountability for the NHS restored, and the Government exerting a tighter grip, there will be no hiding place if performance dips. This merely raises the stakes for a Government that have placed great expectations and emphasis on improving the NHS over this Parliament.
The Government say they will “strip back layers of red tape and bureaucracy” and that “more resources will be put back into the front line rather than being spent on unnecessary admin”.
This must be the fundamental test.
Will getting rid of NHSE make it easier for the Government to deliver on what really matters to the public? Will it be easier to access GPs? Will waiting times at A&E or for operations fall? And will satisfaction amongst the public and staff improve as a consequence?
A major restructure brings risk as well as opportunity: Streeting and his advisors must swiftly set out more detailed plans which demonstrate how this greater political control can deliver on the public’s priorities, or the momentum will be lost and the vacuum filled by those who will seek a return to arms-length policymaking.
This is a defining moment for this Government – and the future of the health service. The opportunity to reform the health system for good must be grasped.
Dr Sean Phillips is Head of Health and Social Care at Policy Exchange
