A change of government always brings the prospect of change for the NHS. Andy Burnham’s arrival in No 10 caught no one by surprise, but with no leadership election campaign and no manifesto of his own, there’s still a lot we don’t know about how he will govern.

Burnham has said he will broadly stick with the 2024 Labour manifesto that delivered Keir Starmer’s huge majority and won’t bend ex-chancellor Rachel Reeves’s self-imposed fiscal rules on spending or taxation. That may change of course, but we will likely need to wait until the autumn budget to learn if there will be any major shifts in government spending.

In the meantime, the prime minister’s early focus has been on constitutional reform. If there’s one thing synonymous with brand-Burnham, it’s devolution. The former mayor of Greater Manchester (GM) has spent more than a decade arguing England is too centralised and decisions about public services should sit closer to the communities they serve. Now as prime minister, he has started to set out his plans to realise this.

For the NHS, this could mean yet another significant change in how services are planned, commissioned and managed.

The direction of travel was made abundantly clear with one of Burnham’s first acts as prime minister: opening No 10 North in Manchester, tasked with driving Burnham’s decentralisation agenda. The prime minister’s new northern seat isn’t subtle with its symbolism, but it does signal Burnham’s intent to shift power from Whitehall to the cities and regions of England.

This work was already well underway before Burnham’s arrival, with the English Devolution and Community Empowerment Act becoming law in April. This act creates a framework for setting up strategic authorities across England. These authorities will bring together constituent councils as well as stakeholders from public services. With initial powers over regional strategy, transport and economic development they could become increasingly powerful bodies as devolution is extended.

There will be three tiers of strategic authority. Foundation authorities will cover areas without a directly elected mayor and will initially have more limited powers. Mayoral authorities will have broader devolved powers, while established mayoral authorities will receive the greatest level of devolution, including an ‘integrated settlement’ allowing government money to be spent more flexibly across the region.

Burnham is already accelerating this approach, committing each part of England to be covered by a strategic authority by 2028. If local council leaders cannot agree on forming one, the government will have powers to create one for them.

Most notable for the NHS is the prime minister’s additional commitment to align public service boundaries, with ICBs now told their boundaries must match the strategic authority’s by 2029.

The commitment to align public service boundaries with local and regional government makes sense in principle. But it will ring alarm bells for NHS staff. Public service boundaries have developed independently for years, leaving an inconsistent web of geographies across the country. Greater Manchester is the clearest example of a strategic authority that lines up with its ICB. South Yorkshire and West Yorkshire’s boundaries also closely align with local NHS geography.

Elsewhere though, the picture is much less tidy. NHS boundaries can encompass several local authorities, while emerging strategic authorities may cover different combinations of councils. Some areas are still working out what their future devolution landscape will look like.

After being told to cut their running costs in half, ICBs have spent the last year merging, forming clusters and shedding staff in the thousands. Now they face the prospect of having to reorganise again, causing further uncertainty and disruption for staff. With many strategic authorities not yet established, some ICBs are effectively being asked to plan around boundaries that do not even exist.

If the NHS is to be mandated to reorganise again, then the prime minister and new health secretary Yvette Cooper need to convince the public and NHS staff that it will bring tangible benefits to how the NHS is run and how services are delivered.

So far, we don’t know how far this government intends to devolve health and care to regional and local government. The obvious case study is GM. The 2015 deal was the first of its kind in England and remains the most developed example of regional health and care devolution.

The agreement brought together the Greater Manchester Combined Authority, NHS England, 12 Clinical Commissioning Groups, 15 NHS providers and the ten councils covering GM. Together, they took collective responsibility for health and care spending across the region, pooling existing budgets into a combined total of around £6 billion. This was augmented by an additional £450 million transformation fund provided by NHS England and the Department of Health and Social Care.

This was not a transfer of the NHS to the mayor or the combined authority. NHS organisations retained their statutory responsibilities and remained subject to national NHS standards. GM’s own evaluation subsequently described the arrangement as closer to delegation than devolution. But the deal gave the region greater freedom over how health budgets were spent and what was prioritised.

The GM experience was an important influence on the thinking behind Integrated Care Systems and ICBs. The important difference is that ICSs brought political and other public sector partners into an NHS structure, rather than creating a regional political structure around the NHS.

GM places the NHS within a broader regional political structure. The argument is that this gives local democratic accountability while creating greater potential to connect health and care with wider policy areas, including housing, transport, employment and skills, than is possible in the current ICS landscape.

While the Burnham government’s devolution plans point towards stronger regional leadership and greater local control, the Health Bill is doing the opposite.

As we set out three months ago, the Health Bill in its current form concentrates more power in Whitehall. It gives ministers significant new powers over ICBs and NHS organisations, including powers to direct local bodies and intervene more directly in their governance.

The question is: how devolved can a health system be if central government retains the power to appoint and dismiss NHS board members, direct local organisations and exercise significant oversight over individual trusts?

GM shows that devolution is about more than giving a mayor a seat on an NHS board. Pooling funding and giving local organisations greater control over how it’s spent means decisions can be better shaped by local need.

If that is the model Burnham wants to take national, the Health Bill will need to do more than simply reorganise NHS structures. Otherwise, there is a danger of creating a system where responsibility is devolved but power remains centralised.

Burnham will have a tough task getting health devolution right. The NHS has already been through a prolonged period of instability, and managers and staff will not welcome another round of reorganisation for its own sake.

Patients and the public want to see services improve—and quickly. Present and future mayors will want meaningful powers if they are to be held accountable for improving health in their regions.

The challenge for Burnham is to make devolution more than a change to the map. It needs to give local leaders the powers, resources and management capacity required to deliver better services.

And that means learning the lesson that applies to every reorganisation of the NHS: structures are only as good as the people and organisations expected to make them work. //