Sir Keir Starmer, the UK prime minister, announced on March 13 that the government will move to abolish NHS England in the next two years. During this period, the government plans to bring its functions under the UK's health ministry, with the aim of bringing the health service "into democratic control". What does this mean, and what difference will it make?
Authors
- Nick Fahy
Director of the Health and Care Research Group, RAND Europe
- Hampton Toole
Analyst, Healthcare, RAND Europe
- Tom Ling
Senior Research Leader and Head of Evaluation, RAND Europe
When the NHS was established in 1948, part of the aim was to make the local health problems of patients across the country the concern of the national government. The plan succeeded. Today, the NHS is politically highly important - it matters enormously to patients and the public, and has one of the largest spending budgets in the UK.
At the same time, it is technically difficult to manage, with local needs and opportunities and complex organisation that are hard and sometimes inefficient to manage centrally.
Striking the balance between delivering high-quality patient care and addressing the technical complexity of doing so is a continual challenge for governments. The solution chosen as part of the 2012 health and welfare reforms was to establish NHS England as an organisationally independent government body to provide technical and operational leadership for the NHS - leaving ministers insulated from those day-to-day issues and free to set an overall strategy.
The government's decision to abolish NHS England marks a change back to direct ministerial grip on the system. This may reflect high public concern about the NHS and pressure on its services, as well as a desire by the recently elected government to exercise more direct control over the health service.
How does this compare to other health systems?
The NHS has long been an unusually centralised system. Although the English NHS covers more than 55 million people , it has historically been run by central government, which this change reinforces.
In contrast, although Spain has a similar NHS-style system, the Spanish health system is run by the 17 regional governments through their departments of health, with the largest covering 8.6 million people.
Europe's other large national health system, in Italy, now also has a decentralised system. The national government sets the overall principles and benefits, but the actual services are under the control of regional governments.
These decentralised systems strike a different balance between political control and operational management, by bringing them together at a more local level.
If the UK government was to extend its aim of bringing the NHS into democratic control by taking a similar decentralisation approach to other NHS-style systems in Europe, what would this look like?
The NHS already has 42 integrated care systems at the local level. These already work with upper-tier local authorities, such as county councils, and are mostly aligned with their boundaries, but are under the control of central government.
Other countries already decentralise their health systems to similar levels. In Sweden , for example, the 21 counties are responsible for financing, purchasing and providing their health services, under the democratic control of the county councillors. While there might be questions about the capacity of local government in England to take on such a role, experience from elsewhere shows that it should be possible.
Compared with those decentralised systems, the abolition of NHS England is a relatively minor change. It puts ministers more directly in charge of the English NHS, but does not change the basic structure of the service nor its control by central government.
Examples from other countries suggest that if the ambition is to bring the health service more into democratic control, there are options for much more profound change. This would strike a whole new balance between political control and local management.
Tom Ling is a member of the Labour party.
Hampton Toole and Nick Fahy do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.
