NHS England is dead.
Long live the Department of Health and Social Care.
There is no “British DOGE”, but the idea of slashing government bureaucracy seems to be in vogue all of a sudden. With their latest announcement to radically slim down, or possibly even abolish NHS England, the Starmer government is trying to tap into that vibe. But it is just that: a vibe, not a policy programme.
“NHS England” is a terrible name, because it makes it sound as if it were the England branch of the NHS, in the way NHS Scotland is its Scottish branch. NHS England is, of course, nothing of the sort.
Let’s start from the beginning. Britain spends more than £200 billion per year on healthcare, and not all of that money is controlled directly by the Department of Health. Rather, the Department of Health allocates its budget to local commissioning organisations within the NHS, who then buy healthcare services from local NHS providers (as well as a few private-sector ones). The NHS, in other words, has an internal commissioning and contracting system, where different sub-organisations buy and sell services from/to each other.
This commission system is being reorganised every couple of years. One of the largest reorganisations happened in the early Cameron years, with the creation of local commissioning boards led by GPs. This created a potential conflict of interest. GPs are, of course, also healthcare providers in their own right, so we would not necessarily want them to buy services from themselves, and mark their own homework. Thus, a new, England-wide commissioning board was created, tasked with commissioning primary and some highly specialised health services, and well as some oversight and coordination functions. It became NHS England.
At the time of writing, it is not yet entirely clear what will replace it, but it very much sounds as if its functions are simply going to be brought into the Department of Health. If so, it is hard to see where the savings are supposed to come from. It would then not be an exercise in bureaucracy-slashing, but just another reorganisation.
The reason why arms-length bodies like NHS England exist at all is that politicians have long promised to “depoliticise” the NHS: we will just let doctors and nurses get on with the job, they say, and stop playing politics with it. This sounds good, but healthcare does not work that way. You cannot just “take the politics” out of it; you also need to put something else in its place. In practice, “depoliticising the NHS” usually just means shifting responsibilities from elected politicians to semi-independent healthcare bureaucrats. This technocratic approach then creates its own frustrations, leading to politicians promising to “re-democratise” (i.e. re-politicise) the NHS.
There is a third option. The alternative to both political and technocratic management would be to have a healthcare system which is largely driven by market forces. There are good examples of such systems nearby, which combine consumer choice and competition with universal access and an extensive social safety net. Unless we are ready to have that conversation, we are stuck between political meddling and technocratic rule.
Dr Kristian Niemietz is the author of the paper “The Denationalisation of Healthcare”, and the book “Universal Healthcare Without The NHS”.
 | A guest post by
|