The announcements first of the departure of Amanda Pritchard, and secondly, of the abolition of NHS England raise more questions than they answer. It is not surprising that the Labour government should want to distance itself from any remaining legacy of the controversial “Lansley” reforms. It is more surprising, however, that they have chosen this way, and this point in time. After all, Lord Darzi’s report clearly indicated that his plans for wide-ranging NHS reform are possible without “top-down reorganisation”.
“in my beginning is my end”*?
A similar wish to avoid “top-down reorganisation” was promised by the Conservatives ahead of the 2010 election, yet the White Paper, “Equity and Excellence”, which amounted to precisely that, followed within weeks of the coalition government’s installation. The journey from the White Paper to the Health and Social Care Act 2012 (HSCA 2012) was arduous, and famously included a 3-month pause for the government to conduct a “listening exercise” and receive feedback from the specially-constituted NHS Future Forum.
The HSCA 2012 instituted a new NHS oversight landscape, ranging from NHS England (the NHS Commissioning Board), via Monitor and the Trust Development Authority (subsumed into NHS Improvement, itself ultimately subsumed into NHS England), among other bodies. To varying degrees this was in keeping with the more neoliberal perspective of the reforms and appeared to underscore the move towards the NHS as a market, borrowing from the regulatory model of 1980s utilities liberalisation.
NHS England seemed to complement this in its existence as a statutorily independent body (an executive non-departmental public body). Its aim – alongside commissioning and other responsibilities – was to ‘depoliticise’ the NHS in England, by reducing ministerial involvement in day-to-day operational matters. This aim had found reflection in attitudes among a range of former health secretaries, be they “glaziers [or] window-breakers”.
But is it possible to ‘depoliticise’ the NHS? It is well-established that NHS reform is difficult, often explained in terms of the NHS’ religion-like conceptualisation. Certainly its taxation-funded status would seem to question limits of possible depoliticization because of the ‘compact’ between taxpayers and the government to provide healthcare. Nevertheless, perhaps a high mark of ‘depoliticisation’ can be inferred from NHS England’s 2019 Long Term Plan forming an effective basis for the Health and Care Act 2022 (HCA 2022). This followed several years of a divergence (even dissonance) between the coalition government’s commitment to competition, and the emergence of integration as the leading NHS policy model implemented by NHS England.
Back to the future, or reverse engineering?
Stewardship of NHS England remained constant during the COVID-19 pandemic and beyond, with Amanda Pritchard in office until early 2025. This has contrasted sharply with the political turmoil of this period.
The later stages of the passage of the HCA 2022 saw the reincorporation of ministerial oversight, a move by Matt Hancock, and retained by Sajid Javid, who was Secretary of State for Health and Social Care when the legislation received royal assent. Between April 2022, when the HCA 2022 was introduced, and the UK general election of July 2024, there were no fewer than 5 Conservative Secretaries of State for Health and Social Care (Sajid Javid, Steve Barclay, Thérèse Coffey, Steve Barclay, and Victoria Atkins). This chaotic political backdrop meant, among other things, a missed opportunity to gain insight into what greater ministerial oversight alongside NHS England could look like.
The vision indicated by Wes Streeting – of a two-year alignment/subsuming of NHS England into the Department of Health and Social Care (DHSC) – has led to suggestions that new legislation will be required. Whether this will be of the scale of either the contentious HSCA 2012 (where the protracted legislative passage at least suggested a certain degree of scrutiny) or the HCA 2022 (enacted within a few months) is unclear. A series of policy workarounds in the meantime would not be surprising.
If it is possible to ‘depoliticise’ the NHS by creating NHS England (surely itself a political move), then it could logically follow that the NHS can be formally ‘repoliticised’, with accountability attaching more directly to the Secretary of State for Health and Social Care. The influence of former New Labour health figures such as Alan Milburn on current proposals may suggest a re-envisioning of the DHSC and a reconceptualising of the NHS oversight landscape as it existed in 2010/11, prior to the HSCA 2012 reforms. This may have its merits, but the devil will be in the details. A key question will be how accountability can be understood in the mid-2020s, given the upheaval of the intervening NHS reforms.
* T.S. Eliot, "East Coker".
(C) Mary Guy 18 March 2025
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