“History doesn't repeat itself, but it does rhyme”: lessons from 50 Years of NHS reforms

By Ed Cox, with insights from Anthony “Mac” McKeever

The NHS is no stranger to reorganisation. From Thatcher’s internal market to Lansley’s “liberating the NHS”, the health service has weathered countless structural overhauls. Now, as the government proposes abolishing NHS England (NHSE) and slashing running costs for NHSE, Department of Health and Social Care and Integrated Care Boards (ICBs), it’s worth asking: what can history teach us this time?

I sat down with Anthony “Mac” McKeever, a veteran of NHS reform with over 50 years of civil service and NHS experience, and a friend and colleague, to unpack some lessons from history. Our conclusions, drawing on his direct involvement with pioneers and practitioners of healthcare policy may offer a roadmap for avoiding old pitfalls.

Groundhog Day in Whitehall
Mac’s career began in Department of Health in the mid 1970s, prior to Sir Roy Griffiths’ damning report on NHS management: “If Florence Nightingale were carrying her lamp through the NHS today, she would be searching for the people in charge.” The resulting Thatcher-era reforms introduced general management and the commissioner/provider split: a move meant to inject efficiency, but which also created competition and division.

“Every reform tries to solve the same puzzle,” Mac reflects. “How do you balance central accountability with local autonomy? How do you separate policy-making from management and delivery? And why does it always end in tension?”

The nub of it all is how to separate policy-making from management. Classically, civil servants are tasked with balancing evidence, politics, and delivery, while NHS managers must navigate all those aspects, yet their primary responsibility is delivery. The challenge is how to dovetail these related but distinct functions.

Roles often blur: successful civil servants can think like managers, while accomplished managers display the skills of civil servants. It’s a dynamic that complicates reform but also offers opportunities to bridge gaps between strategy and execution.

The 1990s saw further experiments: the creation of NHS trusts, regional offices, and attempts to devolve pay decisions. Yet, as a 1997 Economic and Social Research Council report noted, reforms often stumbled over cultural clashes: risk-takers vs. risk-avoiders, ministers vs. managers, and a persistent mismatch between “proliferation of policies and parsimony of funds.”

Three lessons from the trenches

In hindsight, most changes have brought with them much needed improvements – as well some unintended consequences. So, what pointers for the future did we discern from previous experience?

1. Strategy and structure are apps; culture is the operating system
   Past reforms generally focused on structures, downplaying the “soft wiring” of attitudes and behaviours. As Mac puts it: “You can’t legislate collaboration into existence. The NHS is a family, and families squabble.” The 1993 Managing Change report looked to distinguish the particular responsibilities of different layers of management and Government agencies, yet top-down approaches persisted often stifling local innovation.

2. Local capacity matters more than ambition
   Devolving responsibility has been a consistent theme – which sounds noble. However, if local leaders lack the skills or resources to deliver, delegation will only produce failure and blame.” For example, the 1994 push for regional workforce planning collapsed without investment in training or data systems.

3. Beware the hydra of bureaucracy
   Every new body and tier - NHSE, Monitor, CCGs – has been aimed at streamlining and strengthening decision-making. Instead, they tend to complicate matters. New interfaces create awkwardness - and an agency created to fix a problem, can end up elaborating challenges rather than removing obstacles.

The 2025 reforms: rhymes with history
The current plan, scrapping NHSE and halving administrative costs, echoes past attempts to “strengthen accountability”. But experience to date shows this can backfire:

• Re-invigorating DHSC, risks reviving the “minister-centred vs. NHS-centred” tensions of the 1990s.

• Slashing ICB budgets could weaken their ability to influence system partners and perpetuate the CCG era’s fragmentation.

So, what should policymakers do?

• Ensure clear boundaries between strategy (ministers), system oversight (ICBs), and operational delivery (trusts).

• Sustain CQC’s role as an independent arbiter of quality, not just a regulator.

• Promote the NHS Mandate, as an often-neglected tool for aligning national priorities and local action.

Machiavelli’s counsel: why advisors matter
Scholars often reference’s Machiavelli’s The Prince, specifically, the Florentine’s timeless advice on leadership: “The first method for estimating the intelligence of a ruler is to look at the men he has around him.”

It’s a fitting lens for today’s NHS reforms. Machiavelli didn’t just warn against unsolicited advice; he stressed that wise leaders surround themselves with independent voices, those who challenge assumptions and bridge divides. Yet too often, NHS overhauls sideline the very people who understand the system best: clinicians, local leaders, and crucially, Non-Executive Directors (NEDs) and Chairs.

“Richard Meddings, NHSE’s former chair, turned back the healthcare clock by encouraging regular dialogue between the centre and NEDs working more locally. This might be characterised as a ‘back to the future’ moment. When the NHS has been most successful Mac notes, “Chairs and NEDs don’t just provide management oversight, they’re connective tissue. They turn ministerial ambitions into local priorities and help make them an operational reality.”

This isn’t about tokenism. Machiavelli’s “men around the ruler” are only valuable if they’re empowered to speak truth to power. For the NHS, that means:

• Elevating clinical leaders, the modern-day equivalents of Machiavelli’s “wise counsellors”, to shape reforms, not just implement them.

• Leveraging NEDs as neutral arbiters who balance ministerial rhetoric with frontline realities.

• Taking decisions on rules and regulations at the centre, without stifling the diversity of thought Machiavelli deemed essential to good governance.

The bottom line? Reforms that fail to engage those who heal, manage, and govern locally, are doomed to repeat history’s mistakes. Even Bevan recognised that you can’t reorganise a health system from Whitehall alone. The NHS isn’t a machine, it’s a living, breathing organism. It must be treated like one.

What will be different this time?
The NHS’s “Groundhog Day” of reorganisation isn’t inevitable. To break the cycle, today’s reformers can:

• Focus on outcomes, not structures by insisting that leaders at system level prioritise population health over self-interest and box-ticking.

• Invest in leadership. Skills gaps have frustrated past attempts to devolve power.

• Embrace messy pragmatism. Boundaries will blur. Define them by what each tier can be expected to control and deliver independently.”

The stakes are high. With austerity-driven cuts and post-COVID backlogs, Darzi has warned that a failure to reform successfully could fracture confidence in the NHS itself. The quote from this blog’s title is credited to Mark Twain; when history rhymes, we can move towards better times.

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Ed Cox is the founder of Ostrom Health. Anthony “Mac” McKeever has worked alongside NHS leaders since the 1980s and in his CEO roles, been on the coalface of policy implementation directly.