I’ve just left the DHSC – ministers still do not know how the NHS will be run next year

Until last month, I served as the head of the Department of Health and Social Care’s strategy unit, a post I had held since March 2022.

Shortly after I left government, the secretary of state made a long-awaited announcement about the future of the NHS regions. When NHS England is abolished on 1 April 2027, the regions will be housed temporarily in a “transitional” special health authority.

Provided, of course, that the Health Bill passes in time.

And that is looking increasingly uncertain. The amendment paper currently contains more than 300 amendments, with more being tabled throughout committee. The Lords still have several thorny issues to work through, and the timetable was already tight – but since the new special health authority was announced, fresh amendments have been tabled, seeking greater clarity about its role and functions, adding further pressure to the timetable.

Even if the Parliamentary timetable holds, there is then the very practical issue of establishing an entirely new special health authority. It has taken the best part of 18 months to reach a decision to create the agency. Now the task is to get it up and running in less than five months.

And the decisions required to do so are arguably no less political than the original decision to establish it.

First, there is governance. Who will run the agency? How will it be held accountable? And how will it relate to the leadership of DHSC and the NHS Group? If it is to have a single chief executive, appointing that person within six months would itself be an ambitious timetable.

Then there is the question of scope. Ministers may want to keep a temporary agency small, with a tightly defined remit. Whereas NHSE’s leadership may see it as a practical solution to home a broader set of functions. The fact that staff in the agency will retain NHS pay and conditions may make it a more attractive destination than the department, where differences in pay and grading continue to cause anxiety.

There are then the very practical questions about corporate and back-office support. Where will the digital, technology, data and HR teams supporting the regions sit – nationally or regionally? Will parts of NHSE’s existing corporate functions transfer with them? Or will the regions need to build their own support teams, risking the creation of a shadow NHSE?

Those decisions will matter greatly to staff. Who transfers to the new authority, retains NHS terms and conditions and remains outside the departmental merger? And who does not?

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Sensitive functions

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There is another possible direction. It may suit both NHSE and the department for the agency to house some of the most politically contentious functions, including appointments. One of the loudest criticisms of the Health Bill is the risk that appointments could become politicised. Placing them within the agency might help to address that concern.

But this would establish an important precedent. If appointments sit there, what about other potentially sensitive functions, such as commercial negotiations? The result could be an ostensibly regional agency with its own CEO and support functions, while also carrying very significant national responsibilities remaining separate from ministers.

None of these questions are straightforward, and officials will need time to work through them.

Establishing the agency is also only one part of the work ahead of NHSE’s merger with the department. While detailed organisational design and the proposed 50 per cent workforce reduction may no longer be immediate priorities, an enormous amount remains to be resolved – legally, operationally and culturally.

For many staff, the secretary of state’s latest update provided welcome clarity about the broad structure, but few answers to the practical questions that matter most.

I know first-hand how much the people working on this programme care about the organisations involved and their staff. The hope must be that settling the broad structural question creates space to provide the practical answers employees now need.

The 1 April deadline was always ambitious. It may still be achievable – but only if the agency’s initial remit is tightly controlled, key decisions are taken quickly, and the legislative timetable holds. With so many fundamental questions unresolved, the chance of hitting 1 April is now vanishingly small.

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Also read the article here.