While most people are fixating on culture wars and the daily bout of political regicide, a 200-page parliamentary bill of massive complexity was quietly introduced into the House of Commons on May 14th – the NHS Modernisation Bill 2026. Bizarrely, on the very same day, the architect of the bill – Health Secretary, Wes Streeting – resigned. What has he left behind for his successor (at the time of writing) James Murray?
There are four parts to the bill: structural reorganisation; centralisation of power; changes to patient/community voice; and the creation of a single patient record. All of them are highly controversial.
Structural reorganisation
Two current pillars of the NHS architecture are directly affected. The most obvious is the abolition of NHS England, the independent arms-length body that holds and allocates health service funding. Its duties will pass to the Department of Health and Social Care (DHSC) in a bid to reduce duplication between these two centrally located organisations. Secondly, the 42 Integrated Care Boards (ICBs) that are responsible for spending NHS monies in their regions are to have their budgets and staffing axed by a massive 50%, as well as being merged into larger configurations.
ICBs will be struggling to cope with job cuts, and will now tend to look upwards to DHSC rather than downwards to their local areas. More fundamentally, there is little to suggest that the many organisational restructures of the NHS over the decades have resulted in much change. As the public policy sage, Nick Timmins, has pointed out, more often than not, behaviour trumps legislation in the NHS. Successful change is rooted in the personalities, relationships and behaviours between key individuals; structural upheaval destroys this by eroding institutional memory.
Centralisation of power
A corollary of pushing control up to central level (DHSC) is the accretion of new powers at the disposal of the Secretary of State. These will include: issuing directions to ICBs even if they are performing well; capping the amount any NHS trust can spend – currently a decision for local Foundation Trusts (FTs); and taking over the power to appoint members to the governing boards of FTs. Additionally, the removal of mandatory local councillor membership on ICBs, and the abolition of ‘partnerships’ between ICBs and local staff, charity and community representatives, all reflect this shift away from local to central level.
This is a surprising development for a government that (in other conversations) says it seeks to devolve power from Whitehall. Some commentators warn that bringing operational functions closer to the Secretary of State will increase political control over day-to-day decisions, potentially reducing system stability and stifling local innovation. And there is the not unimportant consideration that a future Health Secretary – say one from a political party ill-disposed towards the very idea of the NHS – could use these new powers in very negative ways.
Changes to patient/community voice
The elimination of organisations established to represent the voice of patients and local communities is a very concerning measure in the bill. HealthWatch England (the national body which gathers and represents the views of patients) will be abolished, along with the 150 Local HealthWatch branches across the country. At the same time the requirement for FTs to have elected councils of governors (the only direct democratic element in the NHS) will end.
Replacement arrangements – if any – are unclear: the strategic functions of HealthWatch England will, it is said, be centralised within DHSC; local functions will be transferred to trusts and ICBs; and there is no proposal to reintroduce a directly elected voice for members of the community. The mistake in abolishing elected Community Health Councils at the turn of the century is about to be repeated,
These changes have gone down badly. The Local Government Association has said they will result in the NHS ‘marking its own homework’ and will eliminate an institutionally independent voice from the NHS architecture. As the Durham breast cancer scandal (and many others) have shown, the NHS does not have a good record of listening to patients or communities. It can ill afford to become even more remote.
The Single Patient Record
This part of the bill will allow the Secretary of State to compel all parts of health and social care (including GPs, care homes and home care agencies) to disclose their data for the creation of a Single Patient Record. The north east is already a leader on data sharing via the Great North Care Record, and the NHS bill will extend and roll-out this pioneering approach.
There has been a broad welcome for the hope that this will avoid the need for patients to keep repeating themselves to different health and care providers, as well as optimistic claims that it could result in 20,000 fewer A&E visits a year. However, concerns remain about data security, especially the prospect of access by private companies – the role of the Trump-associated firm, Palantir, is especially controversial. Bringing data together across all of these agencies, especially the 20,000+ independent providers of social care, will be a massive challenge.
Is it worth it?
The bill is almost entirely focused on matters of structure and process rather than outcomes, and on the NHS, rather than the broader issue of the health of the nation. Healthy life expectancy has fallen by about two years over the last decade; deep inequalities remain in health, housing and income between affluent and deprived areas; almost 9 million people report having a work-limiting health condition; and social care remains underfunded and unreformed.
Will the NHS Modernisation Bill do much to address all of this? Probably not. The evident danger is that the new architecture becomes an end in itself. But is there a twist in the tail now that Andy Burnham looks likely to be our next PM?
It seems unlikely that James Murray will retain his post as Health and Social Care Secretary with so many Burnham backers expecting key appointments. In any case, Burnham may not be well disposed towards parts of the bill: he is a strong critic of the view that ‘Whitehall knows best’; he spent years as Shadow Health Secretary attacking the Conservative NHS restructuring of 2012; in his capacity as Greater Manchester Mayor he took a dim view of Streeting’s proposals; and most importantly he understands the difference between ‘health’ and the NHS.
The NHS Modernisation Bill could be in for a tricky passage.
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