The Axe has Fallen on NHS England, and it Might Not Be a Bad Thing.

06 May 2025

By Alistair Jenkins, Neuro surgeon

Wes Streeting recently announced the axing of NHS England, outlining plans for the NHS to be brought back under direct government control. Of course, this elicited a range of responses, with many perceiving the idea of a shrinking NHS, at face value, as a negative move.

However, as a surgeon with over three decades of experience, I’ve seen the growth and impact of a bureaucracy that has taken over the NHS. NHS England is part of that bureaucracy: a bloated, expensive waste of time and resources. There are managers in the Department of Health… and duplicate managers in NHS England. There are administrators in the Department of Health... and duplicate administrators in NHS England. NHS England is a parallel hierarchy, which, since it was set up by former Conservative Health Minister Andrew Lansley in 2013, has failed to deliver any tangible benefits.

Of course, the loss of 7,000 jobs (and, at the time of writing, another 41,000 to over 100,000 jobs in the wider non-clinical NHS workforce have just been targeted for cuts) is devastating for those affected, and may initially appear to be a drastic and ill-considered move. But it is crucial to acknowledge that these cuts are in areas which are inefficient and overlapping. With the NHS in a state of crisis, the focus must be on genuine improvement, not a false sense of efficiency and control.

NHS England has done little to improve patient care, and its axing will streamline services and free up resources. If we continue to maintain it in its current state, it remains a self-perpetuating machine in which a frontline service is turned into a backroom full of unnecessary managers and administrators (and layers of both), whose focus – even if unconscious – is on maintenance and growth of the system of administration, rather than patient care.

When I first started my career in the NHS, there was a much simpler management system. The Hospital Secretary – the rather more democratic forerunner of today’s Chief Executive – and a handful of administrators helped senior nurses and doctors with the administrative aspects of running a hospital, with decision-making a collaborative effort and, crucially, aligned with patient care. They did not consider themselves ‘managers’. As the NHS became more complex, managers and administrators with no experience of care delivery were brought in - shifting the expertise from care to management. This was not only a shift in infrastructure but also hierarchy, with those ‘at the top’ in charge of decisions that directly affect patient care – and, just as crucially, they assumed charge of the clinical staff too.

Of course, it was necessary for the NHS to adapt and evolve with the times, but I believe that was the origin of the management monster. It should be clear to all that the massive proliferation of ever more complex management systems, largely divorced from patient care, has been highly successful for the management class, but increasingly unpopular with the people actually delivering that care. The very fact that in spite of all this purported efficiency the Health Service is on its knees is testament to this. Like NHS England, it is an experiment that has not worked. We must stop feeding the monster.

Axing NHS England will not fix the NHS. But it is a firm step towards admitting that this over-inflated system is as far from its original model as it could be, and requires urgent and drastic action. By restructuring the system, we release money to plug the holes created by years of inefficiency and short-sightedness, allowing us to retrain our focus more directly on the delivery of patient care and frontline services. In short, in returning to the health service once lauded as the best in the world.

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