What were the Lansley reforms and how did they create NHS England?

The Guardian

14-03-2025

Keir Starmer announced on Thursday that the government was abolishing NHS England. Here we look at how and why the arms-length body was set up as part of reforms initiated by former Conservative health minister Andrew Lansley in an effort to improve decision-making in the health service.
The changes introduced by Andrew Lansley, health secretary in the coalition government, represented the biggest reorganisation in the history of the NHS. One NHS leader quipped at the time that the overhaul was so big it was visible from space. Lansley promised that his Health and Social Care Act 2012 would take the politics out of the day-to-day running of the NHS. The act scrapped regional health authorities and shifted NHS commissioning power to GPs, through organisations later known as clinical commissioning groups. It also set up autonomous NHS organisations such as the NHS commissioning board, which later became known as NHS England, to run the service at arm's length from ministerial micromanagement. In addition, the act transferred responsibility for public health to local government.
No, but they introduced what critics called a 'creeping privatisation' with a market-based system for more private involvement in healthcare. Under the banner of extending choice, Lansley's act allowed providers from the private and voluntary sectors to bid to supply NHS care. Critics claimed that handing budgets to GPs as independent contractors amounted to privatising the commissioning function of the NHS.
They were almost universally criticised at the time, and there is now a general consensus they have been a disaster. Much of the criticism focused on the role of the private sector in the reforms. But experts also questioned the scale of changes at a time when budgets were being slashed under the austerity programme. The British Medical Association condemned the act as the 'end of the NHS as we know it'. In his critical review of the NHS for the Labour government, Lord Darzi pointed out that since the act public satisfaction with NHS has nosedived. Darzi described the Lansley reforms as a 'scorched earth' policy.
The reforms caused widespread upheaval but also greater bureaucracy and duplication. In his last report, Lord Darzi complained that the NHS has been in 'constant flux' since the reforms. Darzi said: 'The instability of NHS structures and the multitude of workarounds and sticking plasters that became necessary as a result of the dysfunction of the Health and Social Care Act meant that NHS processes became fiendishly complicated. The Act divided up functions among a multiplicity of new institutions. In a single decade, NHS Improvement, the NHS Trust Development Authority, Health Education England, NHS X and NHS Digital were all created and abolished, with their functions and staff rolled into NHS England.' Critics also complain of less accountability due to the complexity of the system and the increased role of private providers.
Yes, according to the health secretary, Wes Streeting. He claimed that 'the number of people working in the centre has more than doubled since 2010' referring to roles in both NHS England and the Department of Health and Social Care. The reforms also started a pattern of creating and then abolishing a number of NHS bodies, leading to more duplication and complexity.
Many of the reforms have been chipped away or significantly modified. The Health and Care Act 2022 shifted the focus of the NHS from competition to collaboration with a scrapping of a markets-style economic regulator. It also scrapped GP-led clinical commissioning groups with integrated care boards to fund and plan NHS services. These included various NHS organisations and local councils. Under the 2022 act, NHS England was also given more commissioning power for primary care, dentistry and optometry. Despite these changes, private and voluntary sector organisations continued to be involved in providing NHS care.
Only time will tell, but Streeting insists the move is 'the final nail in the coffin of the disastrous 2012 reorganisation'. He says that integrating NHS England into his department 'will put an end to the duplication resulting from two organisations doing the same job in a system currently holding staff back from delivering for patients.' However critics point out that, like the Lansley reforms, this latest upheaval comes against a backdrop of public spending cuts that threaten to undermine the good intentions behind the plans.