With health and social care secretary Wes Streeting having previously vowed to avoid any major restructuring of the NHS, the announcement of NHS England abolition in March 2025 came as a bolt out of the blue. 

Brine said the shock announcement and fact it was not included in the later 10-Year Health Plan suggested a knee-jerk policy rather than a strategic plan. 

The subsequent fiasco that saw the stalling of the ICB redundancy programme last year due to a lack of funding has somewhat borne out this ‘written on the pack of a fag packet' interpretation. 

‘The fact that they it took nine months to agree a funding package with the Treasury backs up my theory that this was a hastily arranged abolition to fit a narrative more than it was part of a strategy,' Brine commented. 

The former health minister was also less than complimentary of the way reorganisation, which will see NHS England absorbed into the DHSC by April 2027 and the number of ICBs cut from 42 to 26, has been handled. 

‘The chief executive of NHS England, I understand, found out via their own press office that they were being abolished, and staff woke up to hear it on the news,' Brine noted. 

 

Three reasons 

Turning to the substance of the reorganisation, Brine said the Government had highlighted three reasons. 

Firstly, it said it would save ‘hundreds of millions of pounds' by halving the NHSE and DHSC workforce. 

Brine said he was sceptical about the significant savings claimed by the Government, however. 

‘We said in 2012 that the Lansley report would deliver savings,' Brine reflected. 

‘Of course, it did quite the opposite.

‘I think there are legitimately big questions about how much saving is going to go on here.'

Secondly, Streeting said a smaller centre would increase efficiency commenting ‘there's too many checkers and not enough doers'. 

Thirdly, the Government said the reorg was about democratic accountability by bringing the NHS under the direct control of the secretary of state. 

The former Health and Social Care Committee chair said there were ‘advantages and disadvantages' with making the NHS directly accountable to the DHSC. 

‘It's a publicly funded health service, the secretary of state has to be able to be accountable for decisions that are made,' Brine noted. 

‘But then look at it another way, with a lot of the dysfunction that goes on in the NHS and lot of the dysfunction that goes on between Government and NHS England, sometimes the fact that the secretary of state is not very close to decisions is actually a good thing.' 

Brine acknowledged Streeting had moved some way on cutting the number of NHS priorities but argued his successor could equally go the other way and increase central diktats. 

The former health secretary said previous inquiries had shown ‘a blame culture and even a culture of denial around ministers came from political pressure'. 

 

Different cultures 

Looking at the challenges of absorbing the NHSE workforce within DHSC, Brine noted their very different cultures.  

‘You need both cultures,' he argued. ‘You need the political nous in a very political Government department and you need the clinical advice.

‘There's lots of functions – digital, data, public health, social care, all the regional oversight that comes through the NHS England regional structure – that only lives in one of those organisations. 

‘So the department is not only going to have to assimilate them into its workplace and be 50% more efficient in doing so overnight, it's going to have to change the scope of what it does.

‘I would say that a lot of the dysfunction I mentioned between the Government and the system has got nothing to do with whether NHS England exists or not. They're about major culture change and major transformation.'

Brine noted IT as a ‘potentially very serious risk' in bringing the two organisations together indicating there were around 270 live systems connecting 26,000 organisations and 44,000 IT systems in NHS England. 

‘I'm concerned that we could have a patient safety concern out of the IT coming together,' he warned. 

‘Let's remember, NHS Digital had barely even completed its merger into NHS England before they announced the abolition of NHS England.

‘I am concerned about data, and it seems that there's an awful lot of a mindset that we will do it in house, when actually there's an awful lot of expertise out there in the private sector, which I'm not sure is being harnessed properly.'

Global lessons 

Noting that the UK could learn from other healthcare systems, Brine highlighted Denmark and Sweden as good examples of being much more devolved. 

‘The key question for me is whether the English NHS will be as centralised system as it is,' Brine said. He suggested the mayoral elections were an opportunity to give power away from the centre on healthcare. 

‘If that does happen, then ministers have got to be relaxed about different realities in the service, maybe different cancer weights in different places, which will be accentuated by difference in different parts of the country,' Brine observed. 

‘Locally elected officials are going to take up the strain of how the NHS is run. A central Government would have to then accept that. I am not entirely sure that politicians of any party, certainly of the centre left, are up for doing that at the moment.'

ICBs 

Turning to ICBs, Brine expressed concerns over increasing centralisation noting the progression from 106 CCGs to 26 ICBs that had taken place over the years. 

‘If you've got a regional newspaper that covers a whole county, it's clearly going to have less focus on one city within that county. Is that going to be the same here?' Brine asked. 

‘The danger is, the ICBs basically become sort of commissioning post boxes rather than system leaders, which is what we envision them being in the first place.

‘ICBs have got to focus on population health. They've got to focus on service integration and outcomes, not day to day performance management.'

Major distraction 

Brine highlighted the distraction of reorganisation as another risk of the reforms. 

‘I think it's already proving a major distraction,' he noted. 

The former minister said delivering the reorganisation by the April 2027 deadline was a ‘very tall order', but could be done. 

He observed the passage of the Health Bill to implement the reforms was fraught with political risk, however. 

‘Legislation in Parliament tends to amplify divisions within a Government and health bills do that more than any other,' he noted, highlighting how Labour had backed off from welfare reform. 

Brine was less pessimistic about reorganisation impacting the Government's elective care target but questioned whether the 18-week target was the priority that it should be pursuing anyway. 

‘If you had 100 members of the public in the room and you asked, who has a problem getting access to general practice? Who has a problem getting access to NHS dentistry? I think you'd probably get two-thirds of hands go up,' he argued. 

‘If you ask them, who's waiting for an NHS elective procedure? I think you'd get less than that.'

Summing up, Brine said the test of NHS reorganisation would be whether patients experience the NHS differently. 

‘Patients have got to experience the NHS differently, and if they do, then  reorganisation will have been a great success,' he concluded. 

He warned Streeting may be disappointed, however, if he is seeking to reap any political capital from the reforms. 

‘If reorganisation works then Wes will have been an historic success of a secretary of state,' Brine observed. 

‘You never really know whether you've been a good secretary of state until long after long after you've left office.'