Service design, not just structure: The key to meaningful NHS reform

As NHS England is set to be absorbed into the Department of Health and Social Care (DHSC), healthcare organisations face a moment of reflection. Structural reforms like this are often framed as pathways to “efficiency” but there is a risk of disrupting frontline services if they’re not grounded in how people actually give and receive care.

The opportunity here isn’t just about reducing bureaucracy. It’s about reframing reform as a service design challenge, focusing on how services work, not just who manages them. This means listening to the people who use, deliver, and support NHS services, and designing around their real needs.

What is service design, and why does it matter?

Service design is a human-centred approach that focuses on understanding the experiences of all stakeholders, including patients, healthcare professionals, and service partners, to create services that are both effective and user-friendly. In the NHS, this means ensuring that services are designed around the real needs of those using and delivering them. By integrating digital solutions and streamlining processes, service design can help create a more accessible and efficient healthcare system.

Too often, NHS reorganisations focus on changing structures rather than improving how services work in practice. The 2012 reforms that created NHS England as an independent body were meant to reduce political interference and improve efficiency, yet they added complexity without always delivering the anticipated benefits. Without a clear understanding of the real challenges and a focus on user needs, the current reorganisation risks repeating these mistakes.

Why traditional reorganisations fail

Many past NHS restructures have assumed that moving responsibilities around will automatically improve efficiency. However, this approach can often lead to disruption rather than real progress. Organisational changes tend to focus on internal hierarchies rather than patient and staff experiences, making it difficult to achieve meaningful improvements. Restructures frequently lack clear, measurable success criteria and instead rely on broad objectives like efficiency savings, which are difficult to translate into real benefits for healthcare staff and patients.

One major risk is failing to anticipate unintended consequences. Restructuring can introduce new administrative burdens, slow down decision-making, or disrupt key services. Without a test-and-learn approach that allows for adjustments, these inefficiencies can persist long after the changes have been implemented. If the government wants this latest reorganisation to deliver results, it must avoid the mistakes of the past by ensuring that reforms are designed around service users rather than internal management structures.

Service design isn’t just for digital teams – it matters in healthcare reform too

To ensure that this restructuring leads to real improvements, NHS England should adopt a service design approach that focuses on solving the actual challenges within the healthcare system rather than simply redistributing responsibilities. Any changes should begin with a clear understanding of the problems that need to be addressed. If the goal is to remove bureaucracy, it is essential to identify where bottlenecks exist and how they impact patient care. If decision-making needs to be faster, the focus should be on improving specific processes rather than altering reporting structures.

Success should be defined in terms of measurable improvements in patient outcomes, staff experience, and operational efficiency, not just the completion of a restructure. This requires engaging with healthcare professionals and patients to understand their needs and ensure that any changes improve care delivery, reduce administrative burdens, and create a more supportive working environment for NHS staff. Without this engagement, the reorganisation risks being disruptive rather than beneficial.

The potential unintended consequences of centralising NHS England’s responsibilities within DHSC must also be considered. While this move may lead to greater political oversight, it could also slow decision-making and stifle innovation. NHS England has been a leader in digital transformation, driving initiatives such as the NHS App, AI healthcare innovations and accessible and inclusive services. Without a dedicated body leading these efforts, progress in digital healthcare may stall. Similarly, procurement processes may become more complex, creating barriers for small and medium-sized enterprises looking to work with the NHS. Identifying these risks in advance will allow for better planning to mitigate them.

The impact on ICBs

Integrated care boards (ICBs) were introduced to drive more joined-up, place-based care. But as NHS England is folded into DHSC, and with ICB budgets being slashed across the country, the pressure on these systems is growing fast.

Leaders are already facing difficult choices, cutting services, managing deficits, and responding to increasing demand. There is also a possibility of some smaller systems merging with one another to consolidate their services and drive further efficiencies. However, without the flexibility to design services around local needs, and without the resources to implement change, there’s a danger that ICBs become implementation arms rather than engines of transformation.

The impact on procurement and SMEs

For SMEs working with the NHS, the reorganisation could present both opportunities and challenges. A more centralised procurement system could create new opportunities, particularly if the government simplifies procurement routes and creates clearer pathways for suppliers. However, there is also a risk that decision-making could slow down during the transition, leading to delays in contracts and uncertainty for businesses that rely on NHS partnerships.

Ensuring that procurement remains transparent and accessible is crucial. SMEs have played a significant role in driving innovation within the NHS, and it is essential that they continue to have opportunities to contribute. If procurement processes become overly complex or inaccessible, smaller providers could struggle to compete with larger organisations, reducing the diversity of suppliers and limiting the NHS’s ability to adopt innovative solutions.

Defining success through outcomes

A successful reorganisation must be measured not by how quickly structures are changed, but by tangible improvements in healthcare delivery. The key indicators of success should include demonstrable improvements in patient outcomes, such as shorter waiting times and higher satisfaction rates. The impact on NHS staff should also be considered, with reduced administrative burdens and more efficient workflows being key measures of success. Operational efficiency should be assessed not just in terms of cost savings but also in how effectively resources are allocated to improve healthcare services.

Without these benchmarks, the NHS risks repeating the mistakes of past reorganisations by focusing on structural changes without ensuring that they translate into real benefits for patients and staff.

A reorganisation that works for everyone

The scrapping of NHS England does not have to be just another bureaucratic reshuffle. If approached correctly, it could create a more efficient, patient-focused, and innovative healthcare system. However, achieving this requires a shift in thinking, moving away from treating reform as an internal organisational exercise and instead viewing it as a service design challenge.

A service design approach ensures that every aspect of the system, from people and processes to supporting infrastructure, is aligned to achieve real improvements. Rather than simply asking how NHS England should be restructured, decision-makers should focus on how NHS staff and patients will experience the change, where potential barriers might emerge, and what measurable improvements should be achieved beyond cost savings.

By embedding service design principles into this reorganisation, the NHS can avoid another cycle of structural change that fails to deliver meaningful results. Instead, it can build a healthcare system that works better for the people who use it and the professionals who keep it running.

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Dr Erere Ikogho is a Researcher at Nexer Digital