IT WAS NOT only a decapitation but also a disembowelment. Fittingly for British public servants, the death of the arm’s-length body which runs the National Health Service (NHS) in England was confirmed with an all-staff email and a stiff upper lip. Weeks after announcing her own resignation, on March 10th NHS England’s chief executive, Amanda Pritchard, said that other senior leaders—including the chief financial officer, chief operating officer and chief delivery officer—were also to depart. The number of staff could also be halved, she warned, a gutting which implies the loss of 6,500 jobs.
The creation of NHS England, an enormous experiment in public administration, began in 2013. The intention was to allow technocrats to make plans beyond the next election, and to reduce political meddling in the day-to-day operation of the NHS. Wes Streeting, the health secretary, would argue that as a result he has had no real say in the running of a public service costing £192bn a year ($250bn, or 7.5% of GDP) which yields increasingly dire results.
Some 6.2m people are waiting for hospital treatment. Productivity is still 18.5% lower than before the covid-19 pandemic, according to the Office for National Statistics. In emergency departments 12-hour waits are routine. Endless micromanagement from the centre has resulted in little financial control: without deep cuts, next month the service will start the new fiscal year with a projected overspend of £7bn.
NHS England should eventually be reabsorbed into the Department of Health and Social Care. Though a merger requires primary legislation, the government is not waiting to update the statute book to make big structural changes. It’s urgent to stop front-line workers being held back by “pointless paperwork and inefficiency”, an adviser says. This is not without risk. Previous reorganisations of the NHS have often only destabilised the system; this one is particularly radical. “Instead of using a chisel to cut back they’re now bringing in a chainsaw,” says Sir Chris Ham, a health adviser to a previous Labour government.
The change can be read as part of a broader attempt across government to project DOGE-style zeal. In January the chair of the Competition and Markets Authority was sacked when he was deemed to be insufficiently serious about growth; the antitrust watchdog is also planning to cut around 10% of its staff. As part of its planning reforms, the government is stripping environmental quangos of their power to hold up building projects. The justice secretary is quarrelling with the Sentencing Council over guidelines that appear to give preferential treatment to minorities. The government says it wants to reclaim responsibility from regulators and others.
Yet Mr Streeting’s strongest influence is not Javier Milei or Elon Musk, but Alan Milburn. A quarter of a century after he trimmed waiting lists for Sir Tony Blair’s New Labour government, the former health secretary is helping to lead the reorganisation. Early signs suggest he is drawing on his old approach: giving autonomy to local services, while a smaller centre sets strategy and standards.
Labour knows that the old tricks will not be enough. Centrally set targets can create perverse incentives. Weak public finances mean that ministers cannot pour more money into hospitals. Because the population is sicker and older, Mr Streeting’s forthcoming ten-year plan for the NHS must shift care out of hospitals into the community in a way that Mr Milburn’s own ten-year plan did not. In shaking up the NHS, Labour has signalled that it is ready to be radical. The real test of reform is yet to come. ■
Editor’s note (March 13th 2025): This article has been updated.
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