Bringing NHS England back under closer political control: lessons from history

In March 2025, the Labour government announced plans to scrap NHS England, the national body responsible for the day-to-day management of the English health service.¹ The restructure was not in Labour’s manifesto or early plans for the NHS. But the Prime Minister, Keir Starmer, said the changes are needed to cut bureaucracy and bring the NHS ‘back into democratic control’ – part of his government’s efforts to reshape the ‘flabby’ UK state.²

The decision to abolish NHS England marks the end of a 12-year experiment of trying to run the NHS at much greater arm’s length from politicians – through a statutorily independent body, rather than NHS leadership embedded in the DHSC. NHS England was established under the Coalition Government’s controversial reforms to the English NHS in 2012.³ The idea was that an independent board – what became NHS England – could help end political ‘micromanagement’ of the health service. Government would set overall policy direction, while NHS England and other national bodies would be responsible for overseeing planning and spending. 

The experiment did not work as intended. NHS England operated more like the headquarters for NHS strategy under Simon Stevens, its longest serving chief executive, and the service never freed itself from political control. The size and responsibilities of NHS England also grew over time as it absorbed other arm’s-length bodies created under the 2012 act, resulting in fragmentation and duplication at the top of the NHS.

But the decision to scrap NHS England reflects a much longer-run question about the right level of political involvement in the health service.⁴ Throughout its history, there have been calls to ‘depoliticise’ the NHS and concerns about micromanagement from Whitehall. And since the 1980s, there has been a series of attempts to split policy formulation and implementation for the NHS within central government – starting with the Griffiths Review in 1983. 

The government has not yet fully defined the new structure at the top of the NHS and has a mix of options for bringing day-to-day management of the health service back into government. Learning from the past could help inform these decisions. We briefly summarise the history of efforts to define (and redefine) roles and responsibilities for managing the NHS at the centre of government, identify unresolved tensions that underpin these changes and set out implications for the latest round of reform.

After a period of relative organisational stability for the NHS, the 1970s saw the start of an almost endless cycle of reforms to the management of the health service – including a series of efforts to take politicians out of day-to-day decision making.

The early NHS

Between 1948 and 1973, the NHS was organised according to a tripartite system: hospital services, community services and primary care – all nestled beneath the purview of the Ministry of Health. Under hospital services, 388 hospital management committees and 36 boards of governors for teaching hospitals reported to 14 regional hospital boards. Community services were administered by 147 local health authorities and primary care was managed by 138 executive councils.⁵ This byzantine structure obscures even greater complexity at regional and local level.

The Ministry of Health was advised by the Central Health Services Council, established in 1946 to ‘advise the Minister on such general matters’ pertaining to the NHS and made up of representatives from professional groups, local government and hospital management.⁶ It met quarterly until it was abolished in 1980. There were also standing advisory committees for medicine, nursing and midwifery, pharmaceutical services, and dentistry. Lasting for the service’s first 50 years, they advised ministers when issues arose and when requested.⁵

The government’s approach to managing the NHS in this early period has been characterised as policy making by ‘exhortation’ and circular, rather than command and control.⁷ But right from the NHS’s inception, tensions rumbled between the centre, which wanted to exercise stricter control in the pursuit of national uniformity, and the periphery, which complained that the ministry was overly interventionist.⁸

1974 reorganisation

By the late 1960s, these tensions had developed into what social policy expert Rudolf Klein calls ‘a spectacle of mutual frustration’, with ministers exasperated by their inability to ‘translate formal power into effective power’.⁹ The tripartite system was also under strain. Critics were increasingly concerned that the three factions of the NHS operated in silos. The answer to these problems was a major reorganisation – the NHS’s first – devised in the early 1970s by the Conservative Secretary of State, Keith Joseph, who relied heavily on the recommendations of the management consultants McKinsey and theorists from Brunel University.¹⁰ The aim: unified and efficient management.

The new structure created a hierarchical planning system for the NHS, running from ministers at the top down to 14 regional health authorities and 90 area health authorities underneath them, and on to around 200 district management teams at a more local level. These tiers were matched by equally complex and tiered professional advisory machinery and an attempt to achieve coterminosity at an area level with local authorities, which retained responsibility for social care. 

The new regional health authorities replaced regional hospital boards and were now charged with improving health services, not just hospitals, to better integrate planning and services at regional and local levels (even if GPs retained their own family doctor committees). Various services were also brought into the NHS that had been left behind with local authorities in 1948 – including ambulances, district nursing, health visitors and much of vaccination and immunisation. 

The reorganisation rapidly became a case of ‘tears about tiers’.¹¹ Administrative staff numbers grew over the following years, and the complex and convoluted structure of the reformed service prompted huge complaints from staff when a Royal Commission examined it a few years later, along with dissatisfaction with the more centrally controlled system.¹² The idea of an independent health board at a national level was considered but rejected by the Commission, mainly due to the risk of duplication with the Department of Health and Social Security (DHSS) – though it recommended that ministers keep the idea under review.⁴

The Griffiths Inquiry

By the early 1980s, there were growing concerns about the effectiveness of decision making in the NHS and a desire to rein in public spending. In 1983, Norman Fowler, Secretary of State for Social Services in the first Thatcher government, established a review into NHS management, led by Roy Griffiths, then managing director of Sainsbury’s.

The consequences of the Griffiths Inquiry were far reaching. Out in the health service, the ‘consensus management’ introduced by the 1974 reorganisation, which effectively gave everyone in new NHS management teams a veto over key decisions, was replaced by the appointment of general managers (who soon restyled themselves as chief executives). This was a ‘transitional moment’ for the health service.¹³

At the centre, Griffiths recommended that the DHSS establish a Health Services Supervisory Board led by ministers to oversee policy and strategy. Beneath it should be an NHS Management Board with responsibility for implementation  – ‘a small, strong general management body’ –  chaired by a chief executive appointed from outside the public sector.¹⁴ This board would plan how to implement policies agreed by the supervisory board, lead day-to-day NHS management, ‘control’ performance and seek ‘to achieve consistency and drive over the long term’.¹⁴ The Management Board would be within the department – not an entity outside it.

The government accepted Griffiths’ proposals for the two boards. The Supervisory Board was established in 1983 and the Management Board in 1985. The former was chaired by Fowler, with Griffiths as an ‘independent member’. Rather than being a decision-making body, it soon became more of a ‘high level sounding board’ for the secretary of state.¹³ It met less and less often and was ultimately scrapped in 1988.

The Management Board survived for longer, albeit with modifications, renaming and diluted terms of reference. Griffiths had intended it to be a ‘quasi-autonomous corporation’, when in fact the secretary of state retained ultimate authority not just over it, but over the politically appointed regional chairs and therefore the NHS’s lower tiers. Its first chief executive was Victor Paige, who resigned after less than 18 months because he found the tensions between the ‘political and organisational elements’ of the role ultimately untenable.¹³

This had been the most radical attempt to date at resolving the problem of political control in the NHS but was ultimately undermined by that very challenge. When he left, Paige recommended that the board should either be chaired by a minister or become properly independent. Existing in the ‘uneasy no-man's land between the Department of Health and the service’ prevented much from getting done.⁷

Management after 1990

Kenneth Clarke, who became health secretary in 1988, was the Conservative minister who ‘absolutely believed that politicians should be away from the direct management’.¹⁵ In 1989, he reorganised the Management Board into the NHS Policy Board and NHS Management Executive – two bodies with similar aims to their predecessors: one for strategy and one for day-to-day management.¹⁵

The same challenges around political control continued to beset both. Duncan Nichol (NHS Chief Executive 1989–94) was besieged by politicians and managers, and both bodies struggled with what William Waldegrave (Secretary of State 1990–92) called ‘the inherent difficulty of trying to separate the management from policy’.¹⁵ The NHS Management Executive survived. But the NHS Policy Board was scrapped in 1995.

The appeal of an independent board fell into abeyance during Labour’s early years, with Prime Minister Tony Blair declaring before the 1997 election that ‘we will run from the centre and govern from the centre’.¹⁶ Griffiths’ emphasis on clear objectives for the service remained: centrally defined targets and strong performance management to meet them (‘targets and terror’) became a major plank of Labour’s approach to public service reform. This was alongside, in time, the embrace of market-style mechanisms and the NHS’s new purchaser-provider split. This was a period of command and control in the NHS.

In October 2000, Alan Milburn, Secretary of State for Health, appointed Nigel Crisp as both Permanent Secretary and NHS Chief Executive – previously separate roles. He scrapped the NHS Management Executive, temporarily undoing the notion of more independent management of the NHS. In practice, however, it was not so much that the executive was scrapped, rather it took over the department. By 2005, just one of the department’s top 30 leadership positions was held by a classic civil servant – the others being NHS managers, clinicians or recruits from the wider public and private sectors.¹⁷

But the story of tighter ministerial control was not without nuance. Over the same period, the Labour governments introduced a mix of mechanisms to provide greater independence in some aspects of NHS decision making. For instance, the National Institute for Clinical Excellence (NICE) was established in 1999 to provide independent assessments of the cost-effectiveness of new health technologies – distancing ministers from detailed technical decisions about what the NHS should provide. The Independent Reconfiguration Panel was established in 2003 to advise ministers on contested proposals for NHS service changes.

The idea of an independent board did not disappear. Towards the end of Blair’s time and then again under Gordon Brown as Prime Minister, Labour debated the idea of an independent board without acting on it. The Conservatives continued to pursue the idea in opposition in the 2000s, and an independent board was also advocated by bodies seeking to influence NHS policy, including the British Medical Association (who had first trailed the idea in the 1970s).^15,18

Rise and fall of NHS England

It took a Conservative government to finally make the idea of an independent NHS board a reality – it was one of the key ideas in Andrew Lansley’s far-reaching reorganisation of the English NHS in 2012. An NHS Commissioning Board, rapidly rebranded as NHS England, began operations in 2013.

NHS England was designed to distance the secretary of state from day-to-day running of the health service. NHS England had a degree of statutory independence that previous management boards lacked. Lansley’s hope was to forge a health service ‘free from frequent and arbitrary political meddling’.¹⁹ Government would set overall policy direction and high-level NHS targets, while NHS England and other national bodies would oversee planning and spending to deliver them.

In practice, an end to political interference in the NHS did not happen. Jeremy Hunt, Secretary of State for 6 years from 2012, was at times as closely involved in the details of NHS performance and planning as any of his predecessors (for instance, directly calling up chief executives of poor performing NHS trusts).⁷ And in a strange role reversal, Simon Stevens, NHS England’s longest serving chief executive, took control of NHS strategy. His Five Year Forward View in 2014 effectively sidelined Lansley’s ‘choice and competition’ agenda in favour of the closer integration of planning and services that led eventually to today’s integrated care boards.

Over time, NHS England expanded by absorbing the roles of other arm’s-length bodies created under Lansley’s act, including the Trust Development Authority and Monitor, then Health Education England and NHS Digital.

Tensions between the department and NHS England grew during the pandemic,^20,21 and legislation in 2022 sought to bring NHS England under closer political control – for instance, with new powers to direct NHS England and intervene in service changes. But it remained a statutorily independent body until Labour’s decision in 2025 to abolish it– though the legislation needed to make that happen formally is likely to take until 2027.

Announcing his government’s decision to scrap NHS England, Starmer said he was bringing the NHS ‘back into democratic control’ – rejecting the idea of operational independence for the NHS.^2,22 But he also rooted the announcement in old ideas about overbearing bureaucracy and the threat of inefficient NHS management. Scrapping NHS England would, according to Health and Social Care Secretary Wes Streeting, ‘liberate’ NHS staff and local NHS leaders while eliminating ‘bloated and inefficient bureaucracy’, freeing up money for frontline services.^23,24 Much as the 1979 Royal Commission had feared, Streeting identified significant ‘duplication’ between NHS England and the DHSC, arguing that ‘frontline NHS staff are drowning in the micromanagement they are subjected to by the various and vast layers of bureaucracy’.²⁴

The cyclical nature of this policy history – with decisions being repeatedly made and reversed – is partly down to four underlying tensions in the management of the NHS.

Political accountability and independence

First is the tension between political accountability for the NHS and the need for some independence in how the service is managed. The NHS is, by design, a highly centralised health system with a strong degree of political control. Accountability will always rise upwards to ministers in a tax-funded system like the NHS – particularly one that often tops the list of the public’s concerns. But politicians have consistently recognised the need for some degree of independent advice and oversight in managing the health service – for example, in making decisions about how funding is distributed and local services are organised. As the 1979 Royal Commission reflected: ‘In principle health ministers… are expected to have detailed knowledge of and influence over the NHS. In practice, however, this is neither possible nor desirable...’

Some efforts to take politics out of decision making have endured – for instance, with NICE continuing to shield ministers from judgements about access to new drugs in the NHS.²⁵ But others haven’t, as shown by the history of efforts to split policy formulation and implementation at the top of government. Ministers have struggled to let go. And the institutional and cultural context of the UK has often forced them to grip tighter.

Central and local control

Second is the ongoing tension between control from the centre and devolution of power to local areas and regions. Central direction has been a persistent feature in the evolution of the NHS.²⁶ But since the 1980s in particular – the advent of New Public Management – the approach of central government to driving improvement in the English NHS has typically relied on top-down targets and performance management.²⁷

Politicians have consistently embraced the rhetoric of decentralisation and localism in their narratives on NHS reform. For example, the 1989 white paper Working for Patients claimed that ‘as much power as possible will be delegated to the local level’. Similar promises have been made for the NHS by successive governments ever since. Yet central grip has persisted over the same period – and even increased.²⁸ A series of policies designed to give more power and control to NHS organisations has been limited in practice.^29,30 And the centralising tendencies of national policymakers have contributed to an unwillingness among local leaders to actually exercise autonomy.³¹

Policy and management 

Third is the balance between setting strategic direction for the health service (policy) and operationally delivering it (management) and where these functions best sit. As our brief policy history illustrates, since the 1980s, the pendulum has swung between efforts to split and merge responsibilities for NHS policy and management in central government. The decision to establish then abolish NHS England is a case in point. 

In theory, the idea of an independent body is attractive: politicians should set direction, managers should deliver it. But in practice it has proven difficult to neatly separate the two. Making health policy is hard without involvement of managers and clinicians – and making policy work is impossible without their buy-in and support. At the same time, politicians have been unable to extract themselves from questions of delivery. And what may on the surface appear to be technical decisions – for instance, about whether a local hospital is able to provide safe care – have turned out to be inherently political.

But bringing NHS policy and management together can have perverse effects, including crowding out traditional policy expertise in the DHSC, ministers focusing even less on wider health policy outside the NHS, and short-term political issues undermining the long-term focus and stability needed to manage the system. Despite the importance of good management to the NHS, policy debate has been dogged by the persistent demonisation of NHS managers, including by politicians.

Behaviours and structures

A final tension is the relationship between behaviours and structures in governing the NHS. Various organisational and legislative fixes have been tried to navigate the balancing acts between policy and management, central and local control, and the role of politicians in day-to-day NHS management – most notably the creation of NHS England. But history suggests that behaviours ‘tend to trump structures and legislation’.¹⁵ Health ministers can be idiosyncratic and unpredictable, come with their own ideas and motivations, and have each approached their role in very different ways. 

Take the job of health secretary working alongside NHS England in the 2010s. Hunt said he never felt like he ‘lacked a power’ to give direction to NHS England under the 2012 act.¹⁵ Yet his successor, Matt Hancock, felt he needed to change legislation to bring NHS England under closer political control. Personalities of NHS leaders at the top of the health service matter too – for example, in navigating this uncertainty and balancing what Paige described as the (for him, untenable) ‘political and organisational’ elements of the role. Whatever the NHS’s new structure, the way people at the top behave will have a strong role in shaping how – and how well – it works.

Abolishing NHS England and bringing the day-to-day management of the health service back into the DHSC – under closer ministerial control – reflects perennial challenges in the politics and management of the NHS. The timing, communication and planning of the government’s decision leaves much to be desired. At the time of its announcement, the government had no firm plan for how it would merge NHS England into the department and make the staffing cuts promised.³¹ The decision will cause disruption to the service at a time when patients most need it.³² 

But the question now is how to make the new structure work. Our analysis of similar efforts over recent decades points to three broad implications for the latest restructure. 

Maintain some split between policy and management

The history of NHS reform shows that it is not possible – nor desirable – to take politics out of the NHS. Bringing NHS England back into the DHSC was perhaps an inevitable consequence of the structure and politics of the health service in England. 

But managing a system as large and complex as the NHS is a specialised job and Griffiths’ case for some degree of separation between policy and management still stands. Does Streeting really want to run the NHS day-to-day? Could he? Many former health secretaries agree with the idea of some operational independence for the NHS after they have left office.¹⁵ And simply merging NHS management back into the department, without some kind of demarcation, risks the NHS dominating health policy even more than it does today. The government’s latest 10-Year Health Plan was really a plan for the NHS, not a coherent strategy for improving the nation’s health.³³

Government has a mix of options for maintaining some kind of split between NHS policy and management at the top of the health system. This includes some version of the NHS management boards that existed within the department from the 1980s to early 2000s, or maintaining a slimmed-down version of NHS England at arm’s length from the department, but operating with a narrower range of functions and under closer ministerial control (for instance, as an Executive Agency, with less independence). None of these options will fix the tension between policy and management or define the role of politicians in the NHS – but they could at least help the system manage them. 

Clarify the relationship between the centre and local areas

Designing a new structure at the centre of government will also depend on defining the roles and relationship between national and local NHS bodies. For example, what will be the new relationship between the department and NHS England’s seven regional offices – and how will both relate to the NHS’s integrated care boards, set to be slimmed down in size and number? The primary legislation required to abolish NHS England will need to get into these and other issues. 

The relationship between national and local bodies is currently in flux. Like other NHS plans before it, the 10-year plan commits to ‘meaningful devolution’ in the NHS.³⁴ A mix of policies are resurrected from the 2000s – including ‘earned autonomy’ for NHS organisations deemed high performers – and flexibility is promised for local leaders to design policies to fit their population’s needs. In exchange, government promises a smaller centre, fewer targets and a ‘reduction in the burden that central bodies place on systems and providers’. Yet it is not clear how this shift in power will happen in practice. And the plan simultaneously commits to a mix of measures that seem to tighten central grip on the health service, including reducing the power of integrated care boards, new measures to increase national oversight of quality, and league tables and performance management to help meet high-profile waiting times targets.³⁵ Meantime, the role of the NHS’s regional tier is uncertain. 

If government is serious about slimming down the size of the centre and devolving more power, then it will need to invest in the local leadership and management needed to make it happen. The NHS is undermanaged, not overmanaged.³⁶ Yet the government has embarked on drastic cuts to local NHS planning bodies.³⁷ More power for politicians to run the NHS nationally will not be much good to them if local NHS organisations lack the capacity to innovate and improve in response.³⁸ Another period of organisational restructuring for the health system will also distract local leaders from the task of improving care.³⁹ Minimising disruption and providing clarity quickly must be priorities.

Use other routes to generate independence 

Finally, putting the day-to-day management of the health service at arm’s length from politicians is not the only way to inject independence into NHS decision making – and is likely the hardest. More targeted policies that embed independent advice into key aspects of NHS policy, such as the establishment of NICE or the Advisory Committee on Resource Allocation in the 1990s, have proved more enduring institutions.

In abolishing NHS England, government could use the opportunity to go further in embedding independent advice and scrutiny into the policy process – for instance, by committing to greater transparency about evidence behind policy decisions. This could be done by more regularly publishing the policy advice underpinning ministerial decisions,⁴⁰ a stronger role for independent assessment of NHS funding needs to guide political judgements,⁴¹ a greater commitment to rigorous testing and evaluation of policy initiatives before more widespread implementation, and a mix of other measures. These changes could alter how central government works to improve NHS policy making – not just who sits where on the NHS organogram.