Over a year after most of its contents were announced to the media last March, the Health Bill is finally making its way through parliament. It represents the most significant reorganisation of NHS structures and governance in England since the 2012 Health and Social Care Act and, in many ways, it tries to reverse the main features of those reforms.

Andrew Lansley’s legislation deliberately moved power away from ministers and into an operationally independent NHS England. Now much of that power is heading in the opposite direction.

At its core, the legislation is about who runs the NHS and who has the biggest say in how services are delivered. NHS England will be abolished entirely, with many of its functions, staff and responsibilities moving into the Department of Health and Social Care (DHSC). Around half of NHS England’s workforce is expected to go as part of the process.

History suggests that NHS reorganisations rarely deliver the promised benefits. What they almost always deliver is significant cost to the taxpayer, disruption to services and the loss of experienced staff. The current reforms are no exception. At least 20,000 jobs in NHS England, arm’s-length bodies and Integrated Care Boards are expected to disappear, and that figure does not include the thousands more jobs being lost in NHS trusts.

The reorganisation is already underway, causing major disruption at a time when there is a real opportunity to improve patient care and deliver meaningful reform. Instead, NHS organisations are embroiled in consultations, restructures and redundancy programmes. Experienced staff have already left the service and thousands more are still to go.

And all of this started before the bill was even published.

Ministers have argued that bringing NHS England back into the department will eliminate duplication and reduce bureaucracy. There is undoubtedly some overlap between the two organisations, but the scale of the proposed cuts raises serious questions. NHS England employs around 15,000 staff and the DHSC around 3,000. How can such a large proportion of those roles genuinely be duplicating one another?

The biggest irony in NHS reform is that efforts to reduce bureaucracy often end up creating more of it. Each reorganisation demands significant management time and diverts workforce attention. And with three major restructures in a little over a decade, NHS staff are exhausted. Rather than a vehicle to improve productivity, it’s a recipe for further attrition.

The bill grants the DHSC and the secretary of state a significant range of new powers. These include greater oversight of trusts and ICBs, responsibility for workforce planning, influence over funding decisions and the ability to appoint chairs and board members across the system. Ministers will also have more powers to direct NHS organisations, including ICBs. As it stands, these powers will give politicians a much greater say in the day-to-day running of services—the only notable exception is that DHSC won’t be able to interfere with individual clinical decisions.

The government says this is simply restoring the pre-Lansley model of accountability. If ministers are held to account on the performance of the NHS, they argue, they should have more control over how it’s run.

But the bill goes much further than clarifying accountability and, in some areas, reaches even further back than Lansley. For example, ministers have not had the power to appoint and dismiss members of NHS boards since 2001. That marks a significant shift backwards, raising concerns about greater political interference in day-to-day decisions.

This new suite of central powers also sits at odds with much of the Ten Year Plan. The plan talks about empowering local systems by giving them more say in how they deliver care and designing services around the needs of local communities. Yet this legislation concentrates power and decision-making in Whitehall. You cannot simultaneously devolve power and centralise it without the two approaches coming into conflict.

These additional powers also raise questions for the future. Wes Streeting was able to begin dismantling national structures and make large-scale workforce reductions before parliament had even seen—let alone approved—the necessary legislation. What could a future secretary of state with even more powers do without the approval of parliament, NHS leaders and the public?

MiP believes the government must do more to show how this concentration of power will lead to better outcomes for patients, staff and the public. NHS managers and leaders should be given direction and left to get on with the job – guided by the best interests of patients and the public, rather than political expediency.

The Health Bill will also expand ICB’s commissioning responsibilities and reshape the membership of boards to focus more squarely on commissioning rather than partnerships, removing ICBs’ duty to have representatives from local councils, GPs and NHS trusts. It introduces a new requirement for ICBs to have a board member representing any mayoral authority within their area.

Taken together, these changes mean ICBs will be taking on more responsibility while simultaneously seeing their workforce and budgets cut by around half. Commissioning Support Units, which have provided vital expertise and management capacity to ICBs, are also being abolished. As a result, ICBs are likely going to struggle to take up the ‘strategic commissioner’ role the government expects of them.

The bill also attempts to introduce a single patient record and enable greater sharing of patient data among healthcare organisations in different parts of the system. While there is broad support for better data sharing in the NHS, there are still serious concerns about data governance, patient consent, cybersecurity and the practical challenge of integrating multiple legacy IT systems across the health service.

Alongside these changes, the bill abolishes Healthwatch, the statutory body that champions patient experience, absorbing its statutory functions into the DHSC. It also merges the Health Services Safety and Investigations Body (HSSIB), which investigates patient safety incidents, with the Care Quality Commission. The rationale for these changes is unclear and there is a risk that independent patient voice will be diminished.

With its relentless focus on structures and power, the biggest omission from the Health Bill is management capacity and capability.

Thousands of NHS managers have already lost their jobs before parliament has fully scrutinised or approved the reforms. Yet there is no recognition in the legislation that successful reform depends on having the right people in the right place to deliver it.

MiP members are not opposed to reform—they are usually the people who make it happen. But the events of the last year have led to avoidable harm and disruption for members and the services they work hard to manage. These problems have arisen because a major shakeup was not properly assessed and planned, or implemented with sufficient care.

This approach must change. The Health Bill is an opportunity to do things differently.

MiP believes that before embarking on major structural change, ministers should be required to assess the impact on management capacity, communicate with and consult affected staff and trade unions, and demonstrate how services will continue to operate safely and effectively throughout the transition. MiP wants to see the bill amended to reflect this.

We have been and will continue to brief MPs on these amendments and on the value of managers to a reforming government. Parliamentarians now have an opportunity to strengthen this bill and help ensure that reform delivers better outcomes for staff, services and the public alike. //