The NHS was established on July 5, 1948, as part of the post-World War II welfare state reforms led by the Labour government under Prime Minister Clement Attlee and Health Minister Aneurin Bevan. The foundation of the NHS was driven by the Beveridge Report of 1942, which identified the need to eliminate the “five giants” of social inequality: want, disease, ignorance, squalor, and idleness. Prior to the NHS, healthcare in Britain was a fragmented system of private, voluntary, and municipal hospitals, with access largely determined by income.

NHS England, established in 2013 under the Health and Social Care Act 2012, was designed to function as an arm’s-length body (ALB) responsible for overseeing the NHS, allocating resources, and implementing healthcare policies independently from direct government control. This structure was introduced to create a more efficient, patient-focused system by decentralizing decision-making and reducing political interference.

However, its existence and effectiveness have been subject to ongoing debate. Some argue that NHS England’s role has introduced additional bureaucracy, undermined local autonomy, and led to inefficiencies, warranting its closure or reintegration into the Department of Health and Social Care (DHSC). Others contend that NHS England plays a vital role in maintaining operational stability, strategic planning, and national oversight, and that its removal could lead to greater political interference and inconsistency in healthcare delivery.

A BIT OF HISTORY OF “NHS ENGLAND”

NHS England was formed as part of a broader restructuring of the NHS under the coalition government, led by then-Health Secretary Andrew Lansley. The primary rationale behind its creation was to increase independence from political control, enhance efficiency, and foster competition among healthcare providers. The restructuring transferred commissioning responsibilities to Clinical Commissioning Groups (CCGs), aiming to place more power in the hands of healthcare professionals and reduce bureaucratic inefficiencies within the NHS (Timmins, 2021).

The arm’s-length model was intended to improve long-term strategic planning by insulating NHS decision-making from short-term political pressures. It also sought to provide greater transparency in resource allocation and allow a more business-like approach to healthcare management. However, over the years, critics have argued that NHS England has instead added complexity to the system, leading to fragmented accountability and decision-making (Ham, 2019).

WHY CLOSE?

INEFFICIENCY?

One of the key criticisms of NHS England is that it has introduced an additional layer of bureaucracy without delivering proportional improvements in healthcare efficiency. Research has indicated that decision-making within NHS England is often slow, and its relationship with other NHS bodies, such as NHS Improvement and the Care Quality Commission (CQC), has led to overlapping responsibilities and inefficiencies (Walshe & Smith, 2020). Some argue that reintegrating NHS England’s functions into the DHSC could streamline decision-making and reduce administrative costs.

Furthermore, the presence of NHS England as a separate entity has arguably diluted ministerial accountability, making it difficult for the government to intervene in NHS operations when necessary. Unlike direct government-run health systems in some European nations, the UK’s current model creates confusion over who holds ultimate responsibility for healthcare outcomes—politicians or NHS England executives (Klein, 2022).

COST?

Moreover, NHS England’s role in commissioning services has been controversial, particularly in relation to outsourcing and the increased presence of private sector involvement in the NHS. Critics argue that its approach has favored marketization rather than prioritizing public service delivery, leading to inefficiencies and inconsistencies in care provision (Pollock et al., 2019). By dissolving NHS England, some believe that service commissioning could be simplified and more directly aligned with public healthcare priorities rather than market-based models.

Another argument for closing NHS England is the cost associated with maintaining it as a standalone body. Running a large bureaucratic entity requires significant administrative spending, and some critics argue that these funds could be better utilized in frontline services rather than managerial oversight (King’s Fund, 2021). By removing NHS England and integrating its functions back into the DHSC or regional NHS bodies, there may be opportunities to cut administrative overhead and improve financial efficiency.

FRAGMENTATION?

The separation of NHS England from direct government control was intended to decentralize power and give more autonomy to local healthcare commissioners. However, in practice, critics argue that NHS England has instead created a centralizing force, exerting control over CCGs and other local health bodies through rigid guidelines and financial constraints (Imison et al., 2020).

Abolishing NHS England could enable a more localized approach to healthcare governance, allowing Integrated Care Systems (ICSs) and regional NHS bodies to have greater control over funding and decision-making. This could improve responsiveness to local health needs and reduce inefficiencies caused by a one-size-fits-all approach imposed by NHS England.

KEEP OPEN?

COORDINATION?

One of the strongest arguments against closing NHS England is its role in maintaining a coordinated national approach to healthcare strategy and funding allocation. NHS England plays a critical role in setting long-term healthcare priorities, ensuring consistency in service delivery across the country, and managing major national health initiatives such as vaccination programs and digital transformation efforts (Maguire & Dunn, 2022).

If NHS England were to be dissolved, there is a risk that decision-making could become overly fragmented, leading to disparities in healthcare quality and access across different regions. Without a central oversight body, individual health authorities might struggle to coordinate large-scale initiatives such as pandemic preparedness, workforce planning, and NHS infrastructure investment (WHO, 2021).

PROTECTION?

A major reason for establishing NHS England as an ALB was to shield the NHS from political micromanagement. Allowing healthcare professionals and independent experts to make evidence-based decisions rather than politicians driven by short-term electoral cycles was seen as a way to ensure more stable and long-term planning (Klein, 2022).

Reintegrating NHS England into the DHSC could reintroduce political pressures into NHS management, potentially leading to policy changes driven by political considerations rather than healthcare needs. Political control over NHS decision-making might result in inconsistent policies depending on changes in government, creating instability within the healthcare system (Timmins, 2021)

IMPLEMENTATION CHALLENGES?

Dismantling NHS England would be a complex process requiring significant restructuring of healthcare governance. There would need to be a clear transition plan to avoid disruptions to service delivery, funding allocation, and workforce management. The risks associated with this kind of major structural change include loss of institutional knowledge, confusion over roles and responsibilities, and potential gaps in leadership during the transition (Ham, 2019).

Additionally, past NHS reorganizations have demonstrated that large-scale structural changes often fail to deliver the anticipated benefits. The 2012 Health and Social Care Act reforms, which created NHS England, were themselves highly disruptive and led to years of uncertainty within the healthcare system (Timmins, 2021). A further major reorganization could create similar challenges, diverting focus away from service delivery and patient care.

WHAT DOES THIS ALL MEAN?

The debate over the closure of NHS England as an arm’s-length body is multifaceted, involving considerations of efficiency, governance, political autonomy, and healthcare quality. Proponents of closure argue that NHS England has added unnecessary bureaucracy, increased costs, and reduced local autonomy, making its dissolution a logical step towards streamlining NHS governance. However, opponents highlight the crucial role NHS England plays in maintaining strategic oversight, protecting the NHS from political interference, and ensuring national coordination in healthcare planning.

While reforming NHS England to enhance efficiency and accountability may be warranted, outright closure presents significant risks, including governance fragmentation, political instability, and transitional disruptions. Rather than abolishing NHS England outright, a more balanced approach may involve refining its role to improve coordination with regional health bodies while maintaining its independence from direct political control. Ultimately, any decision on NHS England’s future should be based on robust evidence and careful consideration of the long-term implications for the UK’s healthcare system