Scrapping NHS England won’t cure the health service’s ills

Health Secretary Wes Streeting and the Prime Minister may have had recent differences. But they remain united on a flagship pledge made in happier times this spring: to scrap NHS England, the huge quango overseeing the country’s health service. They hope this hefty restructure will give them a firmer grip to address widespread public dismay at poor performance and perceived inefficiency.

New research between the Institute for Government and the Nuffield Trust shows that there is certainly plenty wrong at the top of the NHS. But it will take more than an abolition to address.

Mr Streeting is right to suspect that there is some needless duplication, with some officials in his department serving to stand over others in NHS England with the same duties. But his promised 50% cut in staff, announced with little planning, could cause more problems than it solves. Almost half of employees work in delivery, running national digital services to try to coordinate piecemeal NHS IT and providing medical education and training. Either they will need to go, or the vast majority of those overseeing NHS performance and implementing ministerial initiatives will be dropped.  

Learning from the past

Past experience across government shows that large abolitions like this cause a slump in useful activity. People drop daily priorities to jockey for survival, and go from redesigning services to redesigning their own organisation.

Mr Streeting is also right to say that the NHS must get a grip on the shower of targets, initiatives, and bright ideas poured down on hospital trusts and local boards. Almost every national target has been missed for many years. When everything matters, nothing matters. One figure we spoke to described a culture in NHSE and DHSC of “people who think it's their job to look at the impossible pile of things to do and take their little rock and put it on top”.

The problem is that secretaries of state are historically among the worst offenders in coming up with new promises when old ones are not being delivered. Greater control with fewer staff would allow Mr Streeting to squeeze down the number of different demands flowing out of Whitehall. It would also make it even easier to add to them.

Other areas ignored

While hospital trusts are deluged with demands, health secretaries have also often ignored other areas. Dentistry, district nursing, staff training, links to other public services, and social care have all been neglected for long periods, with serious effects on patients. Unless the course is corrected hard, the risk is that this will get even worse with fewer officials more tied to ministerial whims.

Muddled measurement runs right through the system. The DHSC, NHS England, the Treasury and Number 10 each focus on a few metrics of finance, waiting times, and process boxes ticked for new initiatives. They do not make decisions based on an accurate picture of whether the NHS is actually saving lives or making people healthy.

One senior insider at a confidential research roundtable we held said of the huge NHS budget: “two hundred thousand million pounds and we don't know what we're getting.”

Mr Streeting’s reforms will put his hands on the tiller of the NHS more firmly than his predecessors. But he is steering with poor visibility, and if he gives in to the political temptation to swing back and forth too often, the ship will continue to drift off course. 

*Mark is the co-author of Abolished to perfection? Building a better centre for the NHS, a new report by the Nuffield Trust and the Institute for Government.