Nick White: Is abolishing NHS England going to get Labour stuck in the mire?

Nick White is a practising consultant surgeon who has worked as a medical director in both the NHS and the independent sector.

The announcement on 13 March of the abolition of NHS England by Sir Kier Stramer dominated the news cycle for a couple of days before being relegated to the healthcare trade press and social media.

Throughout last year’s General Election and the first 8 months of the Labour government the mantra was always ‘no major re-organisation but a steady move towards tighter control by the DHSC leadership’. This rapidly snowballed in the weeks before the announcement into significant changes in personnel and deep job cuts.

The reasons behind this are three-fold.

The first is for the Starmer project to be successful and have a chance of re-election in 28/29 it must do 3 things: grow the economy, manage immigration and cut NHS waiting lists. Whatever your view on the chances of success with the first 2 the Governments long term future (and Wes Streeting’s personal future) is linked to an improved NHS by the time of the next election.

Central to this approach is an attempt to improve operational management of the NHS rather than genuine reform.

This has meant appointment of a new senior leadership team, a clear move towards increasing performance management and voicing of concerns about the competency of much of the NHSE staff. Many of the changes have been an attempt to reintroduce the approaches of the Blair 2001-2005 government in running the NHS.

The other two reasons for the abolition are focus groups and looking busy.

Labour’s focus groups with swing voters, when asked about the NHS, will be coming up with a variety of criticisms along the lines of poorly run, too many managers, sack the lot of them etc. The abolition is pandering to these views to get a short-term shift in polling as well as long term boost for the next Election.

Finally, the announcement is just that, an announcement. It is an attempt to make the government look like it is doing something and delivering change.

Royal Assent to the Act of Parliament abolishing NHS England is at least 12 months away. I cannot recall what the other announcements from the Prime Minsters Civil Service reform speech were; I suspect that is because they were also just announcements rather than impactful changes that will be rapidly delivered.

Governing is difficult and long. A headline abolition of an arm’s length body or repeal/revision of a law is a process that takes time and needs managing. The approach the government was taking prior to the announcement of the abolition was more credible and pragmatic; I suspect the decision to abolish NHS England was born out of frustration and a lack of experience in leading big change.

Most people see no future in NHS England and agree with the Darzi’s report conclusion (myself included) that its creation was a failure. There are better ways to achieve it, however, than out-of-the-blue announcements that are the opposite of what said during an election campaign.

The operating model of any organisation needs to be described before personnel changes are made.

For the NHS this means who line mangers who, what areas are in people’s portfolios and who signs what off. This is particularly true in the NHS where the disconnect between responsibility (who makes a decision) and accountability (who is accountable for the outcome of that decision) is real and the cause of so many problems.

Personnel changes at the scale talked about (50 per cent job cuts) should then be made based on the operating model.

These will be guided by the terms and conditions in people’s contracts as they undergo a management of change process. I suspect there will be statutory engagement periods which will take 6 months followed by notice periods which could also be up to 6 months. Then redundancy packages which would likely be one month’s salary for every year worked capped at £82,500 a year, with a claw-back clause which means after a year out of the NHS people can rejoin with no financial penalty.

New T‘s and C’s should really have been instituted prior to any big change to help smooth the process and reduce associated costs rather than the existing arrangements that are going to throw up obstacles. There will be an expectation that re-organisation and redundancy costs will come out of existing budgets and efficiency savings rather than additional money to cover them.

A better way would have been to just implement a recruitment freeze for all NHS England posts so when someone leaves the job is not filled. Then any important post, that has to be recruited to, could have been reconstituted as a DHSC (not a NHSE) job and someone recruited into that with a joint appointment job description covering the work at NHSE.

This was done successfully by Steve Barclay when as Secretary of State for the Department of Health and Social Care he achieved a reduction from 3,978 to 3,316 or approximately one in six of the department’s workforce.

This exceeded the Spending Review target which aimed for a reduction from a peak of 4,950 staff in 2022 to 3,650 by 2025 and was achieved 21 months ahead of target.

In parallel he instructed the 42 ICB’s to cut their headcount by 30 per cent which, left to their own devices, took the best part of 18 months to complete and distracted many ICB’s and their staff from their roles as they focused on a re-organisation. T

he abolition of NHSE has effectively stopped much work being undertaken at lower levels of the hierarchy due to changes being too rushed and poorly executed. All of this will distract employees from delivering DHSC’s improved performance goals as the system gets clogged up with people focusing on their own futures.

As Tim Knox wrote recently on Conservative Home there needs to be a serious plan for what governments do from day one and Ministers know both where they want to get to and to have strong plans on how they will get there. What little plans Streeting may have had appear to have gone out the window.

If sequenced properly there could have been changes to NHSE staff’s T’s and C’s to cut consultation periods, redundancy periods and costs. Followed by a Transfer of Undertakings (Protection of Employment) of 1/3 of NHSE’s 14,000 staff (the important roles and talented staff) out of NHSE into DHSC.

Over a 2-year period a third of the headcount could have gone through a recruitment freeze and natural wastage. Finally, in the run up to the next General Election, a big quango busting announcement of NHSE’s abolition but only having a rump NHSE left to dissolve with few staff, lower costs and no disruption to the operation of the NHS.

The announcement of the abolition of NHS England is unlikely to help deliver the outcome of a significant reduction of waiting lists by the time of the next General Election.

The individual steps will be difficult to deliver, the steps will be out of sequence and there will be opposition at every step. All this could have been avoided if the more pragmatic approach that was being followed up to now had been kept.