The reasons for NHS England's rise and fall are not going away

NHS England was created 12 years ago, as part of one of the biggest NHS reforms in history, partly in an attempt to take the politics out of health in England. But today, politics took out NHS England instead, with the Prime Minister announcing the abolition of NHS England to bring the management of the NHS back under “democratic control”.

There were real reasons that over a decade ago politicians tried to remove their own control over parts of the country's largest public service. The status quo was not working. And the duplication of roles across NHS England and the DHSC, chronic financial woes and plummeting public satisfaction suggest that the status quo is still not working.

But the government today will find itself faced with the same dilemmas. These underlying problems are rooted in the difficult relationship between political leaders, the NHS and the public, and are not going away.

Taking the politics out of health

The original design for the creation of the “commissioning board”, which became NHS England through the 2012 Health and Social Care Act, emphasised a health service “free from frequent and arbitrary political meddling”.

This meant two different things. Firstly, there should be political distance from actual operational decisions so that these could be made nearer to “the front line” without having to stick to one national solution or getting national politicians embroiled in local arguments. NHS England would facilitate this by being independent and limited to a commissioning role.

Secondly, there should be a limited number of targets, passed down through a “short formal mandate”, so that every part of the NHS could be flexible and experiment in meeting them. This recognised the evidence that stable, long-term targets are the most effective. Politicians were even banned from adding to the mandate in between its annual cycles without asking NHS England’s board first.

Almost every part of this has gradually fallen away. The 2022 Health and Care Act explicitly reintroduced powers for the Secretary of State to adjudicate individual changes to NHS services he or she chose to, anywhere in England. By last year, the NHS was vastly overloaded with targets it had not delivered for years, and health secretaries regularly came up with new ones mid-year, to be added to future mandates as a formality.

Yet the problems in overly close and frequent political involvement remain clear – above all, to the politicians themselves. Within a year of the 2022 Act, the Conservative government came to be quite nervous about the prospect of the Secretary of State being on the hook for every slight ward downgrade, and carefully rebuilt layers of processes to separate them out.

The current Health Secretary, Wes Streeting, has specifically emphasised cutting down the number of targets to “empower local health leaders” and stated that limiting trust freedoms was a “retrograde step”. The risk is that vesting more power closer to political leaders makes it easier to intervene and change course, and harder to deny calls to do so.

The free market

Another clear motivation for creating NHS England was to help create a competitive world where NHS providers would respond to market incentives. It is often forgotten now, but in its original iteration the new body was a commissioning board, the head of a hierarchy of purchasers who bought care in from separate providers.

Part of its job was to purchase nationally – from GPs and the most specialised hospital services and to delegate clinical commissioning groups to commission other forms of secondary care on its behalf. This freed up Monitor, a separate regulator, to enforce fair competition among trusts and private providers, managed only by the market.

But these changes had barely got going before moves were underfoot to shift the emphasis away from competition and towards collaboration. The 2014 Five Year Forward View – published just 18 months after Monitor was given specific responsibility for promoting competition – set in train a move from competition towards collaboration between health care providers.

This gradual departure from competition was cemented in the 2019 Long Term Plan and subsequent legislation. The Health and Care Act abolished the requirement for NHS organisations to run competitive tenders for services above a certain value and removed the formal role from the Competition and Markets Authority (CMA) and Monitor (by then known as NHS Improvement) to enforce competition between NHS providers. By the Covid-19 pandemic, the place of competition in the NHS was a footnote.

Meanwhile, NHS trusts, trapped between the money available and demands to spend more on staff for safety and deliver on targets, started to overspend their budgets, relying on a complex cycle of deficits and bailouts that we continue to chronicle to this day. They broke through the rules of the market and revealed the reality that government policy choices, rather than the invisible hand of the market, determined what they spent.

These tensions, too, have not gone away. The new government has shown a clear interest in market forces and financial levers to achieve its goals, pledging that “money will increasingly follow the patient, and incentives will drive improvements in waiting times”. And yet how can these work if the money for incentives is too low for providers to make a profit, and trusts who simply spend more are bailed out?

Even more fundamentally, this exists alongside a continued very strong emphasis on cooperation and local systems. Integrated care systems, which include a statutory duty on local organisations to collaborate, are firmly here to stay. And the government’s focus on neighbourhood health signals a continuation of the emphasis on collaboration, not competition.

Freeing the path for public health

The most ambitious goal of all in the creation of NHS England was that it would free the Secretary of State and their Department to think far beyond the NHS. With the health service farmed out to an independent body, Andrew Lansley believed that Whitehall could instead have a “Department of Public Health”, strategically focused on preventing illness and disability, not treating it. Responsibility for the delivery of several key public health services, such as drug and alcohol treatment, was taken out of an NHS perceived to be neglecting them and given to local authorities.

But things did not go according to plan. As targets proliferated and trusts overspent their budgets, the Department remained as focused on controlling the health service as ever, with little focus given to a strategic approach to public health. And funding for public health has continued to be neglected. As our colleague Sally Gainsbury has documented, between 2016/17 and 2022/23 the public health grant fell by 21% in real terms, shrinking its share of total health spending from a paltry 3.6% to an even smaller 2.3%.

The new government too wants a shift towards prevention, with politicians committed to “change the NHS so that it becomes not just a sickness service, but able to prevent ill health in the first place”. But no structure or goals have, so far, proved able to overcome the temptation to spend money for tomorrow hitting – or getting closer to hitting – targets today.

The menace in the mirror

NHS England represented the most recent in a series of attempts to use structural changes to solve complicated political problems – funding constraints versus capacity, markets versus cooperation, treatment against prevention. But the NHS still has a single point of national power in the national government, where funding, political blame and credit, and statutory accountability all ultimately rest. And these politicians, under relentless public scrutiny, still have the power to change again. The human pilot can always override the system and always fears a crash.

Whether a new model can deliver more coherent results will depend on whether the government can be brave enough to choose its answers on these questions and stick to them. Perhaps the only truly permanent solution would be to give up the single point of national power altogether – something which, for the moment, is unthinkable.