Redrawing the health and social care architecture

Building on our research below, we are now exploring with the healthcare sector how health and care services are financed - and how funding structures can drive change


The health and care system is rightly a source of national pride, but the service today is under significant financial and operational pressures, both of which are set to increase.  These pressures are felt throughout the system, from the patient and clinicians on the frontline, right through to the civil servants and politicians in Whitehall and Westminster.

Over a six month period, we researched what the public and staff working within the NHS think of its national architecture and explored what changes were required to better support local systems in delivering sustainable services in their areas.

“To use a sporting analogy, the role of national bodies is to set the rules including the shape and size of the pitch. It is not their role to referee every game or, worse, to play. What they do shapes the game that is played and the degree to which the crowd thinks it is successful”

Dame Gill Morgan, Chair, NHS Providers

Key findings

  • There is widespread confusion over the role of national bodies among NHS staff: a large majority of senior staff are not clear on the role of NHSE (70%) or the DH (70%), while only a minority understand the role of NHSI (16%);
  • Deep frustration exists with the separation of roles and functions in the health and care system: two in three employees (66%) identified the division between health and social care as a barrier to delivering the integrated care systems outlined in the Forward View;
  • There is little clarity about the role of local organisations in improving services: a majority of the public hold the Westminster government responsible for the quality of care in their local hospital or surgery (22%); and
  • There is a growing appetite for reform: more than 70% of NHS staff felt there was a need for change to the current system and only 11% felt that current arrangements were effective.



The current national architecture of the health and care system is a complex middle-ground between central control, devolved decision making and a market-based approach.

There is, and has always been, a tension between the national and the local in health and care. As a result, there has been no consistent answer to the question of where public accountability, financial responsibility and operational control should best lie in order to deliver the services people need at a cost acceptable to the taxpayer.

During the course of our research we identified five areas for improvement that together add complexity, lead to duplication, and frequently hinder the progress local leaders are seeking to make. These are:

  • a misalignment between national bodies’ remits and the objectives of local systems; 
  • duplication and complication of tasks across multiple organisations, especially in the roles of the Department of Health (DH), NHS England (NHSE) and NHS Improvement (NHSI);
  • an imbalance between political accountability, financial responsibility and operational control; 
  • a missing link between local systems and national bodies; and 
  • the lack of a single organisation with responsibility for securing and developing the critical resources required over the long term.

The national system is really confused at the minute and we’ve got lots of people working in other people’s territories, filling space they shouldn’t fill, and generating work and confusion, at a national and local level, so we need a very serious tidying up process.

Jim Mackey, Chief Executive, NHS Improvement

A new way forward: our recommendations

We propose a two-stage approach to redrawing the national architecture, aligning with the journey that the health and care system has begun:

  • ‘Simplification’ – focusing on short-term evolutionary changes to clarify the roles and responsibilities of national bodies and Whitehall departments and better align them with the needs of local systems.
  • ‘Reform’ – building on the simplification stage to unequivocally change the balance of power within the care system through more meaningful devolution of accountability, control and financing to local areas.

We are not so naïve to think that what we propose is a ‘silver bullet’ solution to the challenges facing the health and social care system. Indeed, there is much to be done at a local and national level to develop more personal, integrated and digitally enabled services and more empowered service users.

The new system we envisage will be a national service, in that its standards and the majority of its funding will be determined, as they are now, at the centre. But increasingly the balance of power would move towards local areas as they assume greater accountability for the financing and control of services.

Establishing this new system will require carefully phased changes to the architecture of the system and will take time to enact. By setting a firm direction of travel now policymakers can provide a clear roadmap of change. That in itself will help bring greater certainty to the care system.

Our approach

Our new research on redrawing the health and care architecture (incentivising the system) is drawing upon a wide range of sources, including:

  • a desktop review of existing literature covering evidence from comparable international systems, academia and think-tanks, and relevant comparisons with other industries;
  • five roundtable discussion groups with leaders in health and care organisations in Leeds, London, Birmingham
    one-to-one interviews with key influencers, thinkers, and decision makers; and
  • Staff polling.

Our work is being overseen by a Steering Group which is offering their views on the issues considered, suggested avenues of investigation, and challenged the analyses and conclusions developed throughout the course of the research.

Membership of the Steering Group comprises:

  • Rt Hon Alan Milburn (Chair) 
  • Richard Douglas, former Director General, Department of Health 
  • Prof Dame Carol Black, Advisor to the Department of Health 
  • Lord Kerslake, Chair, Kings College Hospital NHS Foundation Trust 
  • Robin Osborn, International Director, Commonwealth Fund 
  • Mike Farrar, Chair, Public Sector Health Board, PwC 
  • Dame Gill Morgan, Chair, NHS Providers 
  • Sir Andrew Morris, CEO, Frimley Health NHS Foundation Trust  

We would like to thank all the members of the Steering Group for offering their time, energy and advice and remind readers that the conclusions reached and views expressed in our research are those of the authors only. 

Contact us

Rt. Hon Alan Milburn

Rt. Hon Alan Milburn

Health Industries Oversight Board Chair, London, PwC United Kingdom

Tel: +44 20 78044019

David Morris

David Morris

PwC Health Services Sector Leader, PwC United Kingdom

Tel: +44 (0)7841 784180

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