Scrapping NHS England: a brief history of funding and public structures

The UK government's decision to abolish NHS England marks another significant shift in the long restructuring saga of public healthcare. Established as a Non-Departmental Public Body (NDPB) in 2012 by Andrew Lansley, NHS England was meant to depoliticise healthcare decisions and promote efficiency. It grew to around 10,000 employees and, undoubtedly bloated, became an easy mark for a government eager to please the centre vote and find money for the public purse.

But we arguably put NHS England there for good reason, and its outright removal raises crucial questions. Is dismantling it inherently bad? Are NDPBs fundamentally problematic? And how do we ensure stable funding structures for complex public services that are more or less immune to being politicised by whoever happens to be in power?

A Non-Departmental Public Body is the UK term for certain quangos — public bodies that have a role in national government but are not a government department. They operate at arm's length from ministers, although ministers remain ultimately responsible to Parliament for their effectiveness and efficiency.

Funding, efficiency and evaluation

NDPBs emerged to enhance operational independence, reduce political interference and promote specialised governance. The theory: expertise-driven management, ensuring fairer, more effective spending. While criticised for democratic deficits — they're not voted in, yet effectively control a lot of power — their purpose is clear: keep day-to-day funding and its measurement away from the centre, so it isn't continually politicised and, ergo, badly managed.

To judge whether scrapping an NDPB like NHS England is a good decision, we need the history, context and reasoning that got us here — how health is funded, the structures we've built, and how we evaluate public services and their reforms. Evaluation typically rests on inputs (the number and quality of medical professionals), outputs and outcomes (better patient experiences, shorter waits, improved public-health indicators), and spending efficiency (distinguishing beneficial investment from wasteful expenditure).

Efficiency has become a dirty word — it implies cost-cutting and mindless job removal. Mr Musk isn't helping. In a world of DOGE, the narrative is that efficiency 'at scale' means taking a proverbial axe to large groups of public servants and processes, dressed up as some god-like intervention. This is a fundamental untruth that risks misguiding entire populations into thinking massively abrupt change is generally a good thing.

Tesla is not the Department for Homeland Security. You can't take an axe to your cost base, build better factories, ship more cars and move on. Public services are not cars. Nor are they private-goods companies. The public-service product is orders of magnitude more complex — you can't put it in a box and ship it — and there's a different set of dynamics, motivations and values at play, internally and with the market at large.

This is the crux of why heavy-handed private-management approaches fail when applied to public services with too big a hammer, or too frequently — or worse, both. The sad truth is the Musk/DOGE saga overshadows the fact that efficiency initiatives can be done well. Efficiency done well means a better allocation of resources to enhance outcomes — not mere cost-cutting — and it should incrementally increase trust and quality.

A brief history of healthcare funding structures

Since the NHS's inception by Clement Attlee in 1948, health funding and structures have transformed continually. Thatcher introduced outsourcing and private-sector practices ('New Public Management'); under John Major internal markets fragmented delivery; Tony Blair's frequent reorganisations brought improved funding but inconsistent managerial outcomes. The 2012 Health and Social Care Act significantly expanded private-sector involvement, leading to today's Integrated Care Systems. There's barely a year since the 1990s without changes introduced into a system that is, year on year, treating and curing more people, at more cost per capita, for more diseases.

Personally I'm more a fan of the pre-populist, review–rationalise–reform iterations Blair brought to public services — frequent but less heavy-handed, incrementally drawing out pockets of optimisation. Public satisfaction broadly tracked this: rising through New Labour and early Conservative years, then falling from Brexit onward as politics became more populist, with Covid finishing the job on the satisfaction scores.

Frequent large-scale reforms: a failed experiment?

Research consistently underscores the challenge of large-scale structural reform versus incremental adjustment. Comparative analysis from Denmark and Norway found large reforms complex and hard to implement, hampered by organisational resistance; incremental reforms build trust and smooth transitions. The King's Fund finds persistent structural shifts rarely yield demonstrable improvements in patient outcomes. Abolishing NHS England risks repeating these mistakes — consuming resources through complex transitions rather than direct patient care.

Finding the balance

NHS England's abolition, while politically symbolic, risks exacerbating systemic inefficiencies rather than resolving them. NDPBs serve essential functions — depoliticisation, specialised management, strategic stability — provided they remain streamlined and accountable. Future reforms should prioritise incremental, carefully tested adjustments that build on what works, rather than sweeping overhauls. Stability and trust go hand in hand, and trust is best built over time through consistent, well-communicated change.