The UK’s National Health Service (NHS) has long stood as a symbol of universal healthcare, envied by some and scrutinised by many. 

However, in a landmark decision by the government, Health Secretary Wes Streeting announced the scrapping of NHS England, the central authority that has managed the system for over a decade. 

This decision, startling in its scope, is not merely administrative. It is a signal: the centralised health governance model may no longer be fit for purpose in a health landscape dominated by chronic illness, ageing populations, and mounting fiscal pressures.

At the heart of this move lies a question that resonates well beyond the UK’s borders: when does centralisation in healthcare cease to be efficient and begin to foster diseconomies of scale? 

And equally important, can decentralisation bring us closer to the responsive, patient-centred care needed in an age when prevention and community-based health are vital?

What went wrong?

NHS England was created to provide coherent, unified leadership over England’s sprawling healthcare system. Theoretically, it would promote equity, streamline processes, and ensure regional standards. 

In practice, however, its centralised structure has often been accused of stifling innovation, bogging down care in bureaucracy, and disconnecting decision-making from local realities.

Critics have long argued that the NHS England structure, with its multiple tiers and frequent reorganisations, failed to keep pace with the rapidly shifting demands of the health system. 

It was never designed to manage an era in which noncommunicable diseases (NCDs) — like diabetes, heart ailments, and mental health conditions — would dominate healthcare needs. Nor was it equipped for the agile, localised responses required during a pandemic. 

The idea that bigger is better — the classic logic of economies of scale — has historically driven the centralisation of health services. For some areas, such as procurement or IT infrastructure, this may hold true. 

However, healthcare is not a factory assembly line. It's a dynamic system shaped by human behaviours, social determinants, local epidemiology, and cultural norms. 

As systems scale up and layers of administration multiply, responsiveness suffers, and costs can increase due to duplication, disengagement, and systemic inertia.

NHS England became emblematic of this paradox. Larger, more centralised control brought consistency but often at the cost of local empowerment. 

Decisions about staffing, service design, or resource allocation frequently failed to reflect the lived experience of patients or the judgment of frontline professionals. 

This disconnection sowed frustration and inefficiencies — not necessarily because the people at the top were ill-intentioned but because one-size-fits-all models don’t work well in health systems.

Streeting’s decision may prove to be the canary in the coal mine for other highly centralised health systems. 

As nations worldwide grapple with ageing demographics and NCD-driven demand, shifting from reactive hospital-based care to proactive community and primary care is more pressing than ever.

The way forward

Centralisation can delay this shift. When decisions are made far from the point of care, resources don’t align with needs, and policies may lack the flexibility to engage with diverse patient populations. 

In contrast, decentralised systems — when well-designed — can foster accountability, innovation, and patient empowerment.

Countries like Sweden and Denmark offer examples of relatively decentralised systems that have achieved strong outcomes. Their regional authorities manage budgets, care pathways, and preventive strategies tailored to their populations. 

Even in the US, despite systemic challenges, experiments in localised care delivery through integrated primary care models such as Kaiser Permanente offer valuable lessons.

That said, decentralisation isn’t automatically better. Without safeguards, it can lead to postcode lotteries, where access to care varies wildly by geography.

It can also result in fragmentation, loss of data cohesion, and inefficiencies where services are duplicated or poorly coordinated.

What matters is intelligent decentralisation — the delegation of decision-making power within a strong national framework of standards, equity, and funding oversight. 

This distributed leadership approach does not mean a free-for-all where control is abandoned, but a model of shared leadership and management. The UK’s new path must strike this balance carefully.

Perhaps the most crucial driver of this change and the best lens to evaluate it is the goal of shifting care back to patients. The old, centralised model excelled at delivering standardised services for acute illness. 

Still, today, healthcare is increasingly about managing long-term chronic conditions, empowering self-care, and keeping people well in their communities for as long as possible.

These goals require flexible, locally responsive systems deeply connected to social care, education, housing, and other drivers of health. 

Simply delivering care is no longer enough; health systems must be built to enable partnerships between patients and providers. And that requires more than policy; it requires structural transformation.

Wes Streeting’s decision may thus be seen as a recognition that the age of command and control in healthcare is over. The new era demands distributed intelligence, community resilience, and a willingness to let those closest to patients design and deliver what they need.