Not for the first time, the NHS is facing a major overhaul under a Labour government. A series of announcements in recent weeks – relating to job cuts and changes at the top of the health service – constitute a complete resetting of healthcare governance in England. But will it work? And can this shake-up fix our broken healthcare system?
One of the biggest reforms relates to NHS England (NHSE) and the Department of Health and Social Care (DHSC), where a cut of around 50 per cent in central staffing (currently numbering 19,000 workers) is planned. This would represent a headcount reduction far greater in percentage terms than that proposed (and delivered) by Steve Barclay as Health Secretary from 2022-2023.
Streeting’s intention is clear: to show this is a health service ‘under new management’
Addressing this central bureaucracy is necessary if the NHS is to get a grip on a colossal £7 billion deficit. If it fails, the health service is at risk – according to one of Health Secretary Wes Streeting’s adviser’s last week – of ‘collapse’.
Come July, exactly twelve months after the general election which swept Labour to power, there will be new names in almost all the most important roles in health policy, regulation and governance. There will be a new Permanent Secretary at DHSC, with interviews taking place this month. Amanda Pritchard will stand down as Chief Executive of NHSE, with Sir Jim Mackey, former chief financial officer of NHS Improvement announced as ‘interim’ chief. He has already suggested there will be a ‘big clearout’ of senior leadership.
Indeed, this has already begun. We have news of the imminent retirement of Sir Stephen Powis, medical director (the service’s ‘top doctor’). Julian Kelly, the chief financial officer will step down ‘in a matter of weeks’. So will Emily Lawson, chief operating officer. We will shortly have a new chair of the board in the form of Dr Penny Dash, current Chair of the NHS North West London Integrated Care Board.
Some of these changes have been the result of serendipity, rather than a shove, stealth or sacking, but the cumulative effect is a comprehensive clear-out.
Streeting clearly intends not just to reset personnel, so the health service is ‘under new management’, but to reform the centre and its functions quite fundamentally.
Dr Dash (the incoming chair of NHSE), is finalising a review of patient safety organisations (ordered by Streeting in the Autumn). This is likely to propose some radical changes which may see fewer bodies overall or mergers given we have – what Dash has herself calls – “a busy landscape”.
But it will be changes at NHSE and DHSC which will have the greatest significance in the short term. The new NHSE CEO must become Streeting’s “chief policy adviser”, a former chief executive of the service has suggested, to create a far closer relationship.
This is a recognition that it is the Health Secretary, ultimately, who is responsible for the performance of the NHS; that this is a fundamentally political system after all.
A ‘change programme board’ will be established between NHSE and DHSC (with a lead yet to be appointed). A new ‘delivery unit’ is being set up at DHSC which will be tasked with “tracking and challenging” the delivery of the Health Secretary’s priorities (including delivery on manifesto commitments.)
These developments are significant from a government which had as recently as the Autumn proposed ‘no top-down reorganisation’. Indeed, the Health Secretary seems to be pursuing the closest possible merging of functions, short of a merger via legislation.
But a far closer relationship between the organisations has long been needed. In 2022, the Policy Exchange reports Devolve to Evolve and Balancing the Books stressed the urgency of reducing friction between DHSC and NHSE – and that upwards of £1 billion could be saved from doing so. Last year, in Just about Managing, we called for more far-reaching reform and for an NHS Management Board to be reinstated within the DHSC itself.
With these recent developments, Streeting is making a fine start at addressing these issues.
The aim of these measures will be to make the “ship shipshape” – to rekindle a memorable phrase used by the Health Secretary from last July’s election night.
What is clear is that these changes will necessitate a tightening of focus. A trimmed down ‘Mandate’ (effectively the NHS’s ‘marching orders’ from the Health Secretary) made this clear last month with a focus on just four key operational priorities: cutting waiting times; improving primary care access; improving emergency care and sorting out the ‘operating model’.
But will these personnel and structural changes just be a case of shuffling the deckchairs on the Titanic? And how will he take the health service with him?
After all, Streeting’s own theory of change and plan to fix the health service is yet to fully emerge. Will this be driven by ‘choice’? He has talked about putting ‘patients in control’, but detail remains limited on what this will mean in practice. Will it be ‘competition’ which has ebbed and flowed over recent decades, but used to great effect to tackle waiting times under Alan Milburn’s leadership in the early 2000s? What of ‘collaboration’, the theory of change which underpinned the development of integrated care boards from the 2010s?
Perhaps Streeting will attempt to bring these approaches together through the forthcoming Ten Year Health Plan – or proceed in a new direction entirely. To deliver change through such a complex organisation, it is essential that the new leadership he is bringing in both fully understand and are able to communicate his priorities.
There is much still to do, but recent weeks demonstrate Streeting’s clear intention: to show this is a health service ‘under new management’.
Comments