How politicians took back control of the NHS, Part 2

Part one of ’How politicians took back control of the NHS’ described how a desire to restore political accountability and direction saw the new government “bite the bullet” and announce the abolition of NHS England. It also discussed the Labour team’s view that the public did not believe the NHS had earned significantly more funding.

Part two: Two health secretaries

Labour’s re-establishing of political control over the NHS has brought about a near complete overhaul of those responsible for setting NHS policy. At times, the flow of new advisers and officials to the centre has been dizzying.

However, despite the rate of change, no-one questions that one figure remains the most influential: former Labour health secretary and now lead Department of Health and Social Care non-executive director Alan Milburn. Such is his status that one official closely involved offers the simple question: “Why is there not one secretary of state, but two?” Mr Milburn has had significant influence in other top-level hires, including the permanent secretary Samantha Jones.

Never have NEDs such as Mr Milburn and NHSE chair Penny Dash wielded such influence at the top of the service. Both are playing a substantial role in day-to-day NHS decision making. This also goes for Ms Jones, in sharp contrast to her predecessors over the past two decades.

These three, along with NHSE chief executive Sir Jim Mackey, have in recent weeks begun operating as “the quad”, making the important decisions together below ministerial level.

Mr Streeting has five special political advisers, more than many cabinet colleagues. He has brought in at least three further political expert policy advisers and overseen several politically-led civil service hires, while also calling in trusted expert outsiders for particular decisions.

Why is he so keen on such a wide group of new expert advisers? It comes back to the need to bring politics to bear on the NHS.

A close observer said of Mr Milburn in particular: “He remains a very political figure. And when the system comes back and says, ‘maybe you don’t want to do that, there are all these problems’ [he can say] ‘I’ve been here before, you can push through this.’ Wes likes having that challenge function.”

Mr Streeting had limited trust for many of the officials he inherited, and so needed his own experts, said one source central to the new machine. He also needs people who can describe policies as a marked break from the Tories – even if the substance and ethos are similar. 

Meanwhile, a senior Labour figure said the size of his advisory team echoed an approach taken to reform by Michael Gove in the previous decade. They said: “[Wes] likes discussion and makes sure things are tried and tested…

“It [also] makes you quite a powerhouse for ideas. It feels like what Gove did – building a team to start to create their ideology and their way forward.”

Mr Streeting knows plenty about the health service – as do some of his senior ministerial team, who provide important counsel. But he does not have the fixed, detailed vision of an Andrew Lansley figure. It leaves useful space for debate and flexibility, but also risks ambiguity and flip-flopping.

One senior NHS figure said they had sometimes been left wondering “who’s actually making the decisions?” They added: “There are enormous benefits to having lots of advisers, but it has made it really quite difficult at times because we weren’t quite sure who was actually steering [a] decision, and often the advisers were steering in different directions… it wasn’t really clear who was co-ordinating.”

The 10-Year Health Plan arguably revealed the risks of this way of working. In early 2025, the team gave a lot of autonomy to one lead author, Tom Kibasi. So when in May Mr Streeting decided to reject his extensive draft, they found themselves in a rush to completely rework it, hurtling towards the drop-dead publication deadline in July.

The DHSC advisory machine will now need to change gear again, as it moves from a year of reviewing and defining reform plans to holding the service to account as it attempts to translate the proposals into something deliverable. The politicians will also need to promote and defend their efforts to the public – something Mr Streeting can undoubtedly excel at.

Delivery

An overhaul of political accountability – the key motivation for abolishing NHSE – will not just impact the centre.

Local NHS organisations have been given more freedom from national rules, with a swathe of central programmes and funding pots axed.

But the role of integrated care boards has also been radically stripped back – their staffing slashed in half. Meanwhile, more and more emphasis has been placed on the role of NHS providers, with much-expanded freedoms and rewards promised for “new foundation trusts”. It is an approach that had the backing of Sir Jim, who had been neatly teed up to take over as Amanda Pritchard accepted her fate.

Ministers believe cutting out middle men in ICBs as well as NHSE will make provider management more responsive to patients and politicians. Many local leaders have been made too “remote from service delivery”, they believe, with “no pull on being more locally accountable, open and transparent”. The same ethos can be seen in ministers’ move to abolish Healthwatch and other watchdogs: these are unnecessary, they argue, if the voices of patients and politicians are amplified.

The team is particularly determined to put the rocket of public accountability under poorly performing providers.

Reinvigorated “league tables” – promised since last winter – arrived last week. They will be followed, before the end of the year, by the first batch of trusts being put into a new failure regime. It will, for the first time, spell out whether struggling trusts are deemed to have legitimate “excuses” for poor performance, like funding and geography, or whether their management must carry the can for their problems. Advisers are clear that NHS leaders who are not delivering will feel the force of central political accountability.

The political team are unabashed that – in this and elsewhere – they are drawing heavily for inspiration on the health policies of the early 2000s, the heyday of Mr Milburn and several of the other advisers. Officials are more likely to question whether these can have the same success more than 20 years on.

The gamble

So far, the restructuring of the NHS has posed little political threat for team Streeting: they are riding high in Westminster esteem, perceived as a bright light of delivery and reform, against a dull background of inaction in other departments.

This would change, says one experienced Labour figure, “if it starts looking like the timetable [for restructure] isn’t two years, it’s four years, if the legislation gets bogged down, and it looks like it’s distracting from core business”.

Knocking legislation ideas into robust specifics, and getting a bill before Parliament, is yet another big task pencilled in for the autumn.

The source added: “Let’s see how winter this year goes, and how waiting lists go.” Advisers think that even just gradual improvement – taking the list down from around seven to six million, say – may be enough to keep the public and media on side. But, they warned: “If it doesn’t go in the right direction, that is where the worry will come.”

Predecessors might reasonably argue that such incremental improvement would simply reflect the trajectory inherited by this government and not represent any kind of success.

Putting a finer point on it, one senior NHS leader who has been closely involved warns: “The job of government is to create the conditions in which the NHS can thrive and succeed. The jury is out on whether that is the case.”