Close enough to care: a new structure for the English health and care system
Think tank: Reform
Author(s): Rosie Beacon
April 2, 2025
This report from UK think tank Reform argues that an overly centralised healthcare system is impeding the transition to a more preventative model of care.
In Reimagining Health: a framing paper, Reform set out the case for a radical new approach to health. Close enough to care is the first of a series of papers setting out root and branch reform of the health system. The paper argues that an overly centralised healthcare system is impeding the transition to a more preventative model of care, tailored to local population need. It sets out an alternative vision designed to align incentives in the system to prioritise health creation, reorient healthcare to focus on primary and community services, improve healthcare outcomes, and help achieve long-run fiscal sustainability.
Close Enough to Care shows how the current model, despite the move to integrated care systems, cannot deliver the NHS’s own stated vision of a service that prioritises community-based care and reduces reliance on hospitals. In recognising that the English health system is an international outlier in its degree of centralisation, it calls for a significant streamlining of the role of the centre coupled with the devolution of most of the NHS budget to metro mayors.
To achieve this NHS England should be abolished and the Department of Health and Social Care should take a more strategic role under the direction of the Secretary of State, reasserting stronger democratic accountability. The role of the Department would be four-fold: setting core service entitlements, monitoring overall system performance (including regulation), determining resource allocations, and strategic coordination. The centre would also reserve extraordinary powers for intervention in the event of service failure.
Siloed funding streams covering primary, secondary, community and social care should be pooled and allocated to elected regional leaders via block grant settlements of at least 5 years in duration. Most national contracts should be scrapped, and workforce planning and tariff rates devolved to allow local areas to innovate based on local need and priorities. Creating a single budget would remove barriers to investing upstream and the report identifies additional financial levers that can be used to drive this shift
