Weeknote, w/c 10 March 2025

I’m currently reading Secondhand Time: The Last of the Soviets by Svetlana Alexievich. The book is an oral history that creates a tableau of what happened when the Soviet Union collapsed and what that felt like. The theme of the book that I’m most interested in is the tension between a grand idea and the reality of its implementation. How do you square your ideals, which you still think are the right ones, with a lifetime of evidence about how the system chews up the people it is meant to support? Can you hold onto what you were originally trying to accomplish when material reality is a crushing grind of compromises? After enough time just trying to get by, will you even remember what the point of the endeavour was in the first place?

This week brought two rounds of major news. First, on Monday, of a plan to reduce the size of NHS England (NHSE) by 50%. Then, three days later, of a plan to abolish NHSE altogether and merge the remaining people back into the Department for Health and Social Care (DHSC). I don’t understand why the news broke the way it did and there isn’t much more detail available about what this will mean in practice, but at the end of the week what we know is that things are going to change radically. It has been possible to divine elements of these changes from various interviews and media blurbs for a while, and there have been people predicting the merger since the election, but when the Secretary of State formally announced the changes in the House of Commons this week it was still a huge shock to most people, me included.

These changes are going to have a human toll – people are going to lose their jobs. And these changes are going to be a distraction – I’m sure senior leadership and our new CEO are doing their level best to steward us through this, but the scale of the mandated change is hard to even conceptualise. These changes are going to make delivering work harder for some time – not knowing what teams will look like in a year makes it hard to plan how we support live services. All that said, sitting here on Saturday, with 48 hours to process things, I’m looking for reasons to be hopeful. Let’s say I’m thinking about how to manifest a new reality (lol sorry).

When I joined NHS Digital (NHSD) in 2022, I joined an organisation and a team in transition. I knew NHSD was about to be merged into NSHE. I knew the main consultancy partner for the NHS App was about to change. But whatever, I’d just been through a merger in my previous job (Futuregov being folded into TPXimpact) and the project I’d signed up to do seemed like the best possible thing that I could spend my energy on: a digital product with a grand mission at the centre of the healthcare system and huge potential for improvement. I honestly couldn’t ask for a better thing to work on. I was full of hope and energy and enthusiasm. Enter stage left: reality.

It didn’t take long to figure out that effecting significant change to the way the NHS App works was going to be hard and take a long time. When I arrived, the teams working in NHSD were still trying to physically and emotionally recover from having put in one heck of a shift during Covid. Despite what most of the public think the NHS is (ahem), the reality is a wildly complex network of overlapping organisations that range in scale from one to 14,000 people. There isn’t one single way to do anything. Decision-making in the NHS as a whole is both centralised and devolved at the same time, with opinions on how to best deliver services for the populace varying immensely. We’re not organised around delivering whole services. All of which is to say: the work is harder than it needs to be.

Over the past two-and-a-half years, I’ve proposed changes for the shape of my team (and some of our neighbours) that were intended to make this easier. Stepping back, it is clear enough to me that the digital part of NHSE (the “Transformation Directorate”) could do more if we were better integrated with policy colleagues. This was one of the key ideas set out in the Wade-Gery review, but it has never felt to me like this relationship was ever fully realised. Closing NHSE and bringing the parts that aren’t cut into the DHSC should make this more possible. I have my fingers crossed that this can really be done, whether I have a job in the new organisation or not (which, like everyone else I work with, remains to be seen).

I do not in any way want to minimise how the closing of NHS England is going to affect the people who work here. I will not pretend to fully understand why the government is doing what it is doing. And to be clear: this is going to suck. But what if, just maybe, things could end up in a place that makes it easier to deliver good services? I’d like to help do that.