Goodbye to NHS England: structural shake-up or systems step-change?

The timing and nature of the government’s decision to abolish NHS England caught many off guard. While those of us reading the tea leaves could have guessed at the shape of the change, that it was done so quickly was genuinely surprising.

Positioned as a response to years of duplication, inertia and complex accountability, the dust has now settled on Sir Kier Starmer’s big announcement. But while we have clarity about the destination, the route is very much still up in the air.

To help understand the journey ahead, we’ve asked ZPB’s Senior Advisers to share their reflections on what the next few months may look like. We’ve captured some of the key themes from those conversations below.

Execution, not intent, will define success

There’s little disagreement that the system needs reform, but the success of this transition depends on what comes next. With recent examples including NHS Digital, NHS Improvement, the formation of ICSs, structural changes is the norm. As one adviser put it, “we’ve been here before.”

The challenge is not simply removing layers, but replacing them with structures that are clear, coherent and purpose-driven. It’s still unclear how the functions of NHS England will be redistributed, or who will be accountable for delivery.

For Dr Jenny Shand, this moment calls for a smarter, more agile centre and one that “prioritises, enables and supports change, rather than controls it.” The risk, Dr Shand points out, is that without strategic clarity, we end up with disruption at the centre, just as the NHS needs focus on frontline transformation.

The centre vs the local: a new balance of power

Much of the commentary from the government has focused on a shift toward local autonomy — putting decisions closer to the public through local providers and systems. Our advisers agree this is a good thing in principle. But the idea that everything should be devolved may be misguided.

While ICSs are well placed to lead on local population health, there remains a clear role for national leadership. Areas like digital infrastructure, pandemic preparedness, workforce planning and safeguarding equity require scale, consistency and coordination.

As Dr Shand notes, “you wouldn’t ask your local bank branch to build its own app.” Likewise, the NHS needs shared tools and standards that support place-based decision-making.

Reforming the NHS alone is not enough

One of the most important reflections from our advisers is that this is a unique chance to re-examine the true boundaries of the health system.

The NHS cannot, and should not, be expected to solve everything. Health outcomes are shaped just as much by housing, employment, food, education and environment as by what happens in GP surgeries and hospitals.

If this reform is to lead to real change, it must come with a stronger interface between the NHS and wider public services. It’s also an opportunity to reset the compact between the health system and the public. That means being clearer about what people can expect from the NHS, and what responsibility individuals must take for managing their own health.

Avoiding the loss of institutional memory

One risk raised by our advisers is the potential loss of experienced staff and organisational knowledge. It may be tempting to move quickly and cut deep, but doing so without a plan for preserving core expertise could severely hamper delivery.

Nav Chana, Senior Partner at Cricket Green Medical Practice and NED at Lewisham and Greenwich NHS Trust, cautioned against “losing experienced staff just when we need them most.” The balance between acting boldly and protecting institutional memory is delicate but critical.

The blockers remain the same

Perhaps the biggest concern among ZPB’s advisers is that this reform doesn’t address the underlying system constraints.

Arvind Madan, GP and Partner at the Hurley Group, put it plainly: “Unless we fix the payment mechanisms, everything else will fail.” He notes that it’s these deep structural blockers, which set out how we fund, incentivise and measure care, that will ultimately determine whether the system delivers the well-discussed three transformational shifts.

A moment of opportunity — if we take it

The abolition of NHS England has the potential to be a true turning point, but only if it’s the beginning of a broader, bolder programme of change. A programme that rethinks the NHS’s role, rebalances national and local leadership, and prioritises enabling delivery over controlling it.

As Mike Bell, chair of South West ICB puts it, this can be, “an exciting opportunity to clarify and refocus our structures around the strategic activities that will drive the delivery of the 10 Year Health Plan and the three shifts.”

The stakes are high. Get it right, and this could lay the foundations for a smarter, more responsive health and care system. Get it wrong, and we risk yet another costly distraction.