It’s hard to know how NHS management and staff are supposed to interpret the hugely confusing barrage of statements and policy announcements from Health and Social Care Secretary Wes Streeting and NHS England boss Jim Mackey. It’s not at all clear what they want to come out of the latest disruptive changes
A massive process of decapitation has stripped out 18,000 staff from leading national and local bodies – and the survivors have yet to be given, or work up a plan on where to go from here, and how.
Rose-tinted view
A letter from Mackey to trusts and Integrated Care Boards (ICBs) claimed (perhaps appropriately on April 1) that the NHS is thrusting triumphantly forwards, having come “within a cat’s whisker of delivering our key operational imperatives on referral to treatment (RTT) and urgent and emergency care (UEC),” having also “landed the money in 2025/26,” and also “navigated industrial action and winter.”
In making these claims Mackey has to ignore the financial problems facing many trusts, the renewed strike action by angry and frustrated resident doctors, the minimal percentage reduction in the waiting list, and the dire state of Emergency Care for the patients with the most serious needs, with almost one in three emergency admissions suffering trolley waits of more than 12 hours from arrival in hospital.
Mackey’s letter also exaggerated the modest improvement in responses on the NHS in the latest British Social Attitudes (BSA) survey, claiming (on the strength of just 26% of British adults stating they were satisfied with how the NHS runs) that “While we still have a long way to go, our patients have seen and felt a big improvement this year after two terrible years.”
The annual BSA survey did show a 6 percent increase in satisfaction with the NHS in 2025 (just 3% above the margin of error), compared with 2024. But half of those responding were dissatisfied, and only 16% of all respondents thought the standard of NHS care would improve in the next 5 years compared to 53% who said they expected care to get worse.
Satisfaction with social care (a key factor in NHS performance) also remains particularly low, with just 14% of respondents saying they were satisfied with social care.
A tough regime
And despite Mackey’s cosmetic show of optimism, the grim financial reality facing many major trusts is reflected in a brutal new ‘failure regime’, the National Provider Improvement Programme (NPIP). This claims to be offering tough love (“support”) to the most “challenged” trusts: but its “suite of measures” includes “withholding of very senior manager annual pay awards and use of NHS England’s enforcement powers.”
The official summary explains:
“Each organisation will receive a tailored improvement approach, designed jointly with local leadership and focused on delivery, including changes of leadership where necessary. NHS veterans with a history of success will be brought into underperforming areas, with the merging or separating of trusts where necessary so resources can be reallocated based on need and improving access to capital for crumbling estates.”
In case anybody missed the barely veiled threats in this new “support” system, Wes Streeting spelt out the message more bluntly:
“… I’ve announced today a new Intensive Recovery programme. This will target the worst performing providers, sending in our best leaders or delivering the structural changes necessary to get them back on track. No more turning a blind eye to failure.”
He went further, promising to “drain the swamp” of NHS failure, and “clear out underperforming hospital bosses.” And he named the first trusts to be hauled over the coals under the new regime, after years of persistent management failure:
- North Cumbria Integrated Care NHS Foundation Trust,
- Mid and South Essex NHS Foundation Trust,
- Hull University Teaching Hospitals NHS Trust,
- Northern Lincolnshire and Goole NHS Foundation Trust, and
- East Kent Hospitals NHS Trust
A muted, political response from Matthew Taylor, interim chief executive of the merged NHS Confederation and NHS Providers (now renamed the NHS Alliance), chose simply to ignore the overt threats. He responded:
“It’s good to see he [Streeting] recognises that this is not down to poor local leadership, but instead often the result of historic structural issues that have never been properly addressed.”
What it means for trusts and their staff
Meanwhile, at the end of last month, NHS England once again stuck the boot into the many trusts that have failed to meet their ambitious savings targets for 2025-26, by withholding up to £500m in funding that some had expected. This cash will be given instead to the minority of trusts that are already comfortably in surplus (although they will not be allowed to spend it.)
One Chief Finance Officer told the Health Service Journal that the policy was “dreadful.” While NHSE rewards better performing trusts, “those that are struggling… and who need that cash the most, have to apply for repayable cash support (with interest)”.
Streeting seems to be working hard to cheese off everyone working for the NHS, from very senior management to GPs (who have voted almost unanimously to reject their latest contract) – and resident doctors. Their anger has been increased by Streeting reneging on the government’s earlier promise to create an additional 1,000 specialist training places to help reduce the number of newly-qualified doctors who have been left out of the next stage of their training and career by appalling failures in workforce planning.
Senior managers and non-clinical staff have been under the hammer for the last year, with the initial demand that NHS England and the 42 Integrated Care Boards halve their workforce ramped up further by Keir Starmer’s instruction to scrap NHS England by merging it with the Department.
The demand has been for a total of 18,000 senior job cuts at the national and local levels – a massive reduction that has not been backed up by any clear vision for which jobs should go, what the new systems might look like, or how previous roles and responsibilities would be reallocated.
To justify this hugely disruptive cutback, Streeting and PM Keir Starmer have continued to vilify the staff concerned, effectively dismissing all non-clinical staff and their work as “wasteful bureaucracy.” They claimed the result would enable more investment in frontline services:
“We’re making the NHS more effective, modern, and responsive,” said Streeting. He went on to claim the “reforms” would “Give greater autonomy to local NHS leaders, enabling them to make decisions that best serve their communities.”
But the NPIP makes clear that ‘autonomy’ is only an option for the strongest and best-funded trusts and systems: increased top-down intervention is the order of the day for the rest.
What now for Integrated Commissioning Boards?
Now, in theory, with their 50% reduction in headcount substantially achieved, in what Mackey describes as “probably the biggest ever public service restructuring,” Streeting argues that the surviving and newly-merged ICBs are now tasked with “clear, strategic roles focused on preventing illness and improving patient outcomes.”
Twelve of the 42 ICBs have been abolished, and replaced by six new ones, leaving 36 ICBs covering England, several of which are now still in confusing “clustering arrangements” – giving no sense of permanence.
Moreover, there has been no clear plan from NHS England or the Department on how the new systems are supposed to work. Instead, Jim Mackey’s April 1 letter called on the still-disrupted and newly-merged ICBs and their local trusts to draw up plans themselves, in just over six weeks (by May 15):
“We would like you to build out your strategic commissioning narratives to describe better how, as commissioners and providers, you intend to do this together, with particular emphasis on:
-
what strategic commissioning means in your local system and how you intend to develop this over the next 3 years<
-
“>how you intend to develop neighbourhood care, what your strategic ambition is and how this links to your key challenges
-
whether you would like us to agree changes to financial flows and/or payment systems to help deliver this and, specifically, what these changes are … “
Mackey goes on to make the process even more complicated:
“To help with this, we’ve been working through some key priorities that will support the next set of “big leaps”, such as a full reset of outpatient care and bringing scheduling and appointments into urgent care. …”
Nonetheless: “We would like each ICB to provide us, via regional teams, a single document to summarise the above, by Friday 15 May. In doing so, we expect all local partners to work together to ensure a strong degree of alignment and clear identification of gaps and barriers that can be worked through together, and how you intend to do so.”
Sir Jim adds: “Hopefully, all this makes sense.” It’s not clear it does.
Indeed Mackey has himself admitted that for the public and many NHS staff it’s not clear at all what the role of ICBs might be, or indeed whether they are useful bodies going forward. He has effectively challenged the ICBs to prove themselves useful.
But he has given little or no real guidance on what answers he is looking for – except that he clearly wants a revival of the ‘market’ system, once more clearly dividing the ICBs as commissioners from the trusts as providers. Any other answer will be rejected. Mackey told the HSJ:
“If anybody comes and says ‘can you just tear it all up and give us a block contract again’, I’ll be going mad…”
However it gets more complicated still. Because after a year of waving the big stick to force mergers of ICBs (in which it seems clear no consideration whatever has been given to accountability or responsiveness of the merged bodies to the increased numbers of local communities they will be covering), Streeting has now made soothing statements appearing to sympathise with senior managers of failing trusts, even arguing that managers who take on the challenge of failing trusts are worth their substantial salaries.
He says under-performing NHS bosses are being “quietly moved on” rather than being “named and shamed”, and has rejected the equivalent of putting “heads-on-spikes” to look politically tough:
“Sometimes it is the case that you have got good leaders, good managers, but they are not the right fit. Sometimes there are people who are just not up to it. And naturally, as well as saying, ‘this isn’t the right challenge for you in the NHS’, sometimes we have to say that ‘the NHS isn’t the right place for you’, and be quite firm about that.”
These words might make Streeting feel better, but they will be of little comfort to many of those who have lost their jobs in NHS England and ICBs.
As the NHS heads – freshly redisorganised – into another severely challenging year, requiring billions more in savings while dealing with ever more pressing demand for health care, and coping with staff shortages, clapped out equipment and often crumbling buildings (and with the ‘new hospitals programme’ relegated once more to a distant dream) many NHS staff, campaigners, patients and members of the wider public will be wondering whether the NHS is really the right place for Wes Streeting – and whether the right people have been “quietly moved on.”
Dear Reader,
If you like our content please support our campaigning journalism to protect health care for all.
Our goal is to inform people, hold our politicians to account and help to build change through evidence based ideas.
Everyone should have access to comprehensive healthcare, but our NHS needs support. You can help us to continue to counter bad policy, battle neglect of the NHS and correct dangerous mis-infomation.
Supporters of the NHS are crucial in sustaining our health service and with your help we will be able to engage more people in securing its future.
Please donate to help support our campaigning NHS research and journalism.
It’s hard to know how NHS management and staff are supposed to interpret the hugely confusing barrage of statements and policy announcements from Health and Social Care Secretary Wes Streeting and NHS England boss Jim Mackey. It’s not at all clear what they want to come out of the latest disruptive changes
A massive process of decapitation has stripped out 18,000 staff from leading national and local bodies – and the survivors have yet to be given, or work up a plan on where to go from here, and how.
Rose-tinted view
A letter from Mackey to trusts and Integrated Care Boards (ICBs) claimed (perhaps appropriately on April 1) that the NHS is thrusting triumphantly forwards, having come “within a cat’s whisker of delivering our key operational imperatives on referral to treatment (RTT) and urgent and emergency care (UEC),” having also “landed the money in 2025/26,” and also “navigated industrial action and winter.”
In making these claims Mackey has to ignore the financial problems facing many trusts, the renewed strike action by angry and frustrated resident doctors, the minimal percentage reduction in the waiting list, and the dire state of Emergency Care for the patients with the most serious needs, with almost one in three emergency admissions suffering trolley waits of more than 12 hours from arrival in hospital.
Mackey’s letter also exaggerated the modest improvement in responses on the NHS in the latest British Social Attitudes (BSA) survey, claiming (on the strength of just 26% of British adults stating they were satisfied with how the NHS runs) that “While we still have a long way to go, our patients have seen and felt a big improvement this year after two terrible years.”
The annual BSA survey did show a 6 percent increase in satisfaction with the NHS in 2025 (just 3% above the margin of error), compared with 2024. But half of those responding were dissatisfied, and only 16% of all respondents thought the standard of NHS care would improve in the next 5 years compared to 53% who said they expected care to get worse.
Satisfaction with social care (a key factor in NHS performance) also remains particularly low, with just 14% of respondents saying they were satisfied with social care.
A tough regime
And despite Mackey’s cosmetic show of optimism, the grim financial reality facing many major trusts is reflected in a brutal new ‘failure regime’, the National Provider Improvement Programme (NPIP). This claims to be offering tough love (“support”) to the most “challenged” trusts: but its “suite of measures” includes “withholding of very senior manager annual pay awards and use of NHS England’s enforcement powers.”
The official summary explains:
In case anybody missed the barely veiled threats in this new “support” system, Wes Streeting spelt out the message more bluntly:
He went further, promising to “drain the swamp” of NHS failure, and “clear out underperforming hospital bosses.” And he named the first trusts to be hauled over the coals under the new regime, after years of persistent management failure:
A muted, political response from Matthew Taylor, interim chief executive of the merged NHS Confederation and NHS Providers (now renamed the NHS Alliance), chose simply to ignore the overt threats. He responded:
What it means for trusts and their staff
Meanwhile, at the end of last month, NHS England once again stuck the boot into the many trusts that have failed to meet their ambitious savings targets for 2025-26, by withholding up to £500m in funding that some had expected. This cash will be given instead to the minority of trusts that are already comfortably in surplus (although they will not be allowed to spend it.)
One Chief Finance Officer told the Health Service Journal that the policy was “dreadful.” While NHSE rewards better performing trusts, “those that are struggling… and who need that cash the most, have to apply for repayable cash support (with interest)”.
Streeting seems to be working hard to cheese off everyone working for the NHS, from very senior management to GPs (who have voted almost unanimously to reject their latest contract) – and resident doctors. Their anger has been increased by Streeting reneging on the government’s earlier promise to create an additional 1,000 specialist training places to help reduce the number of newly-qualified doctors who have been left out of the next stage of their training and career by appalling failures in workforce planning.
Senior managers and non-clinical staff have been under the hammer for the last year, with the initial demand that NHS England and the 42 Integrated Care Boards halve their workforce ramped up further by Keir Starmer’s instruction to scrap NHS England by merging it with the Department.
The demand has been for a total of 18,000 senior job cuts at the national and local levels – a massive reduction that has not been backed up by any clear vision for which jobs should go, what the new systems might look like, or how previous roles and responsibilities would be reallocated.
To justify this hugely disruptive cutback, Streeting and PM Keir Starmer have continued to vilify the staff concerned, effectively dismissing all non-clinical staff and their work as “wasteful bureaucracy.” They claimed the result would enable more investment in frontline services:
But the NPIP makes clear that ‘autonomy’ is only an option for the strongest and best-funded trusts and systems: increased top-down intervention is the order of the day for the rest.
What now for Integrated Commissioning Boards?
Now, in theory, with their 50% reduction in headcount substantially achieved, in what Mackey describes as “probably the biggest ever public service restructuring,” Streeting argues that the surviving and newly-merged ICBs are now tasked with “clear, strategic roles focused on preventing illness and improving patient outcomes.”
Twelve of the 42 ICBs have been abolished, and replaced by six new ones, leaving 36 ICBs covering England, several of which are now still in confusing “clustering arrangements” – giving no sense of permanence.
Moreover, there has been no clear plan from NHS England or the Department on how the new systems are supposed to work. Instead, Jim Mackey’s April 1 letter called on the still-disrupted and newly-merged ICBs and their local trusts to draw up plans themselves, in just over six weeks (by May 15):
Mackey goes on to make the process even more complicated:
Indeed Mackey has himself admitted that for the public and many NHS staff it’s not clear at all what the role of ICBs might be, or indeed whether they are useful bodies going forward. He has effectively challenged the ICBs to prove themselves useful.
But he has given little or no real guidance on what answers he is looking for – except that he clearly wants a revival of the ‘market’ system, once more clearly dividing the ICBs as commissioners from the trusts as providers. Any other answer will be rejected. Mackey told the HSJ:
However it gets more complicated still. Because after a year of waving the big stick to force mergers of ICBs (in which it seems clear no consideration whatever has been given to accountability or responsiveness of the merged bodies to the increased numbers of local communities they will be covering), Streeting has now made soothing statements appearing to sympathise with senior managers of failing trusts, even arguing that managers who take on the challenge of failing trusts are worth their substantial salaries.
He says under-performing NHS bosses are being “quietly moved on” rather than being “named and shamed”, and has rejected the equivalent of putting “heads-on-spikes” to look politically tough:
These words might make Streeting feel better, but they will be of little comfort to many of those who have lost their jobs in NHS England and ICBs.
As the NHS heads – freshly redisorganised – into another severely challenging year, requiring billions more in savings while dealing with ever more pressing demand for health care, and coping with staff shortages, clapped out equipment and often crumbling buildings (and with the ‘new hospitals programme’ relegated once more to a distant dream) many NHS staff, campaigners, patients and members of the wider public will be wondering whether the NHS is really the right place for Wes Streeting – and whether the right people have been “quietly moved on.”
Dear Reader,
If you like our content please support our campaigning journalism to protect health care for all.
Our goal is to inform people, hold our politicians to account and help to build change through evidence based ideas.
Everyone should have access to comprehensive healthcare, but our NHS needs support. You can help us to continue to counter bad policy, battle neglect of the NHS and correct dangerous mis-infomation.
Supporters of the NHS are crucial in sustaining our health service and with your help we will be able to engage more people in securing its future.
Please donate to help support our campaigning NHS research and journalism.
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