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.

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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. Hence Wes Streeting’s decision to abolish NHS England is no surprise particularly as this was created (as the NHS Commissioning Board) by Andrew Lansley’s catastrophic 2012 Health and Social Care Act. That gargantuan reorganisation was implemented by the Coalition Government, despite its 2010 promise, in its Programme for government, to “stop the top-down reorganisations of the NHS that have got in the way of patient care” – the NHS had been reorganised in 1982, 1991, 1994, 1995, 1998, 2002, 2006 and 2012.

At the core of Lansley’s vision for the NHS was creating an “internal market” in which hospitals would compete for business with contracts from local clinical commissioning groups, which were run by General Practitioners.

Nick Timmins diagnosed redisorganisations as the disease of the English NHS in his entertaining account of Lansley’s shambles. Dr Lansley’s monster aimed to require future Secretaries of State to introduce primary legislation if they wanted depart from his flawed vision of the NHS and put them on the horns of a dilemma: Lansley’s NHS was obviously dysfunctional, but any remedy would entail yet further disruption. 

Lansley’s flawed vision for governing the NHS and public health

At the core of Lansley’s vision for the NHS was creating an “internal market” in which hospitals would compete for business with contracts from local clinical commissioning groups, which were run by General Practitioners. This followed the common organising principle, of the Thatcher and Blair governments, of dividing the NHS into purchasers and providers. He created England’s biggest quango, the NHS Commissioning Board, to regulate his internal market. His objective was to establish, what Christopher Hood and Colin Scott described as, relational distance from the NHS. These changes were so controversial that they distracted attention from his damaging radical reform of public health. As argued in my book, this reform undermined England’s institutional capability to fulfil the other vital function of, the control of infectious diseases. That is why England floundered in responding to Covid-19 in 2020, causing tragic loss of lives and intense burden for months on the NHS, from which it has still not recovered.

In 2019, the NHS Commissioning Board signalled the abandonment of Lansley’s internal market in its NHS long-term plan, which aimed to develop Integrated Care Systems in the NHS. The plan explained its aim for integrating primary and secondary care was hamstrung by Lansley’s legislation. Matt Hancocks’s Health and Care Act 2022 aimed to tackle that hindrance by reorganising the NHS into 42 Integrated Care Boards. The Guardian pointed out the decision, also in March 2025, to require them to cut their costs by 50 per cent by the end of this year, is on top of a cut in their costs of 20 per cent.

Wes Streeting’s NHS ten-year plan looks like trying to move the NHS to be more like Kaiser Permanente Health Maintenance Organisations.

The promise and challenge of Streeting’s vision

The “internal markets” that have been tried in the NHS are travesties of the original idea as proposed, in 1985, in Alain Enthoven’s Reflections on the Management of the NHS. He recommended ending the historic division in the NHS between primary and specialist care by reorganising local health authorities so they became like the USA’s Kaiser Permanente Health Maintenance Organisations (HMO). (Enthoven’s “internal market” aimed to enable these NHS integrated organisations to sack those providing a failing service inhouse, (e.g. orthopaedics,) and buy in better services.) Wes Streeting’s NHS ten-year plan looks like trying to move the NHS to be more like Kaiser Permanente HMO. Kaiser’s systems are designed more economical and effective than the NHS from its sophisticated information systems and its development of prevention and primary and community health care. In 2002, Richard Feachem et al, estimated that, to serve the same population, Kaiser needed 70 per cent fewer hospital beds than the NHS. Its integrated health service and information technology systems, enabled Kaiser to “provide more and better paid specialists and perform more medical interventions with much shorter waiting times than the NHS for roughly the same per capita cost”.

The NHS is caught in a vicious circle. It struggles to free resources for more effective prevention, better primary care, and to enable timely discharge from hospital.  Consequently, the NHS keeps spending more on hospitals to make good deficiencies elsewhere and in social care. Sonja Stiebahl has estimated that, between 2015/16 and 2022/23, NHS expenditure increased by over £20bn on acute and specialised services; and less than £5bn on primary and community services. The scale of the transformation required by the NHS to make better use of its misallocated resources is illustrated by an analysis of options by MSK Together for treating low back pain in Mid Nottingham:

• two interventions accounted for over 90 per cent of the benefits, but only 40 per cent of the total costs;
• reallocating 10 per cent of the wasted resources to new interventions could potentially double the benefits to the population;
• 50 per cent is tied up in acute hospitals and could not be touched.

Abolishing NHS England, and requiring draconian reductions in Integrated Care Boards, will reduce expenditure, but cause disruption for years.

Wes Streeting’s culture and strategy

Abolishing NHS England, and requiring draconian reductions in Integrated Care Boards, will reduce expenditure, but cause disruption for years. In November 2024, Wes Streeting announced his regime of  “zero tolerance” for NHS organisations that failed to reduce hospital waiting times and financial deficits. My book argued that an NHS culture that gave overriding importance to reducing waiting times and saving money enabled the appalling scandals to flourish in the NHS at the Bristol Royal Infirmary  and NHS Mid-Staffordshire Foundation Trust. That combination will devour the ambitions of the Wes Streeting’s strategy to move the NHS out of its vicious circle in Kaiser’s direction. As Peter Drucker famously observed “culture eats strategy for breakfast”. 

All articles posted on this blog give the views of the author(s), and not the position of LSE British Politics and Policy, nor of the London School of Economics and Political Science.

Image credit: Steve Travelguide in Shutterstock

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