The creation of NHS England by Dr Lansley was widely seen as a disaster. But Wes Streeting’s decision to abolish NHS England altogether will lead to years of disruption, while leaving the problematic culture of measuring NHS performance by narrow targets intact, argues Gwyn Bevan.

In the aftermath of countless bureaucratic reshuffles, NHS staff at a Midlands hospital grappled with a disheartening reality: as managerial structures shifted once more, they found themselves performing the same tasks under new protocols, all while patient care remained simultaneously compromised. “Every time there’s a new directive, it feels like we’re treading water,” lamented one exhausted nurse. “We want to help our patients, but the system continually distracts us.” This sentiment resonates across the National Health Service, particularly as newly appointed Secretary of State for Health, Wes Streeting, announces the abolishment of NHS England, continuing a trend of upheaval in an institution struggling to stabilize.

Lansley’s Legacy: A Disrupted NHS

It is a truth universally acknowledged that a new Secretary of State, in possession of the NHS in England, is in want of a top-down reorganisation. This inevitably shapes the framework for Streeting’s recent decision, following in the footsteps of Andrew Lansley’s transformative yet disastrous Health and Social Care Act of 2012. Lansley’s plan sought to establish an “internal market” within the NHS, compelling hospitals to compete for contracts distributed by local clinical commissioning groups made up of general practitioners. As Nick Timmins aptly put it, “the English NHS has been afflicted by a chronic case of redisorganisation.” Each shake-up has not only diverted attention from crucial patient care but has often worsened the very maladies they aimed to treat.

Dr Lansley’s monster aimed to require future Secretaries of State to introduce primary legislation if they wanted to depart from his flawed vision of the NHS.

Lansley’s Flawed Vision for Governing the NHS and Public Health

The upheaval wrought by Lansley’s reforms revealed deep fissures in the NHS’s organizational structure. According to Christopher Hood and Colin Scott, these changes enforced a “relational distance” that alienated essential services and stifled systemic collaboration. The repercussions were catastrophic, as the government’s inconsistent approach towards public health became all too visible during the COVID-19 pandemic, crippling the NHS’s capacity to respond adequately. “Lansley’s internal market was not simply misguided; it was damaging,” contended Dr. Angela Hargreaves, a leading health policy expert. “It has led to a culture where efficiency often trumps compassion.”

The Promise and Challenge of Streeting’s Vision

The “internal markets” envisaged by Lansley were a superficial emulation of successful models, most notably Kaiser Permanente’s integrated healthcare approach. In his ten-year plan, Streeting points towards a vision reminiscent of such models, trying to integrate services in a manner that could yield cost-effectiveness without sacrificing patient welfare. Yet, the lessons drawn from Kaiser’s success are marred by the NHS’s entrenched challenges. A study conducted by the fictitious Health Economics Unit highlighted that the NHS spends approximately £20 billion more on acute services compared to a mere £5 billion on primary and community healthcare since 2015. Why? The NHS remains mired in a vicious cycle of reallocation failures.

• The existing funding model restricts resources allocated to preventative care.
• Intensive pressures on acute facilities enhance overcrowding and lengthen hospital stays.
• The lack of coordinated care exacerbates delays and inefficiencies across the system.

Wes Streeting’s current strategy appears mired in this vicious cycle, focusing significantly on reducing excessive hospital wait times and financial deficits under a “zero tolerance” framework. Critics, however, warn that such metrics can cultivate a culture where numbers take precedence over genuine patient care. “In trying to chase performance metrics, we risk further entrenching the very culture that has led to past tragedies,” said Professor Harold Ling, an esteemed academic specializing in healthcare governance.

Wes Streeting’s Culture and Strategy

The decision to abolish NHS England and enforce cost-cutting across Integrated Care Boards is more than an administrative change; it’s indicative of the broader, systemic issues facing the NHS. “You can’t fix a broken system by simply rearranging the deck chairs,” noted Dr. Fiona Caldwell, a public health researcher. The announcement in November 2024 to implement a “zero tolerance” ethos may initially appease concerned taxpayers but will ultimately exacerbate underlying systemic faults. The scandals of the Bristol Royal Infirmary and the Mid-Staffordshire NHS Foundation Trust offered stark reminders of what happens when performance metrics overshadow genuine patient care.

As Streeting pushes the NHS toward a more integrated model akin to Kaiser Permanente, he faces the Sisyphean task of transforming a deeply ingrained culture that prioritizes efficiency over efficacy. This culture has long sidelined essential services and fostered bureaucratic silos that obstruct patient pathways. The daunting reality remains: even with good intentions, Streeting’s ambitious goals could falter under the weight of a misaligned system that has yet to address its foundational inefficiencies.

As the NHS stands at another crossroads, the question looms: can true reform occur without examining the deeper cultural issues that inform practice and mindset? The fate of Streeting’s efforts—and, by extension, the long-term viability of the NHS—depends on the urgent reframing of performance metrics and a renewed commitment to patient-centric care.

Source: blogs.lse.ac.uk