The news that NHS England is to be disbanded has sent ripples across the healthcare sector. For years, it was the face of national healthcare management, implementing government directives and shaping policies that affected millions of patients and healthcare professionals. But as we reflect on its legacy, we must ask a difficult question: how did so many good people, dedicated professionals, become part of a system that often acted against the very principles of care and service they set out to uphold?
Many NHS England managers have been passionate, committed individuals who wanted to make a difference. They entered the healthcare system with the goal of improving patient outcomes, supporting frontline staff, and making the NHS more efficient and effective. However, they quickly found themselves operating within a rigid hierarchy where orders from above dictated actions, even when they knew these decisions would harm the NHS and its patients. The bureaucratic structure of NHS England meant that decision-making was often centralised, with top-down directives handed down from government ministers, policy advisors, and executive boards. This left little room for individual managers to challenge or reshape policies, even when they saw the damage being done.
Time and again, providers were blamed for inefficiencies, as though the challenges facing the NHS were the result of individual failings rather than systemic flaws. The reality was different: managers knew the system was breaking under pressure, but instead of challenging harmful policies, many became complicit in defending them. To maintain their positions and progress in their careers, managers were required to present a corporate face—an illusion of control, competence, and confidence. Publicly, they defended the policies they implemented, even when privately they were disillusioned, frustrated, or even fearful about the direction of healthcare management. This professional detachment, though often a necessary survival mechanism in a highly politicised environment, created a dangerous disconnect between policy and reality. Behind the scenes, many of these managers struggled with the same frustrations as frontline staff, yet their roles required them to suppress dissent and present a united front.
Over time, this corporate culture led to the normalisation of systemic issues. Managers were expected to uphold the illusion that the NHS was operating efficiently, even when evidence showed that funding shortfalls, workforce shortages, and excessive bureaucracy were crippling the system. The pressure to meet unrealistic targets and key performance indicators (KPIs) further reinforced this culture. Instead of acknowledging that the targets themselves were flawed or unattainable given the resources available, managers were often forced to shift responsibility onto providers—doctors, nurses, and hospital administrators—who were already working at capacity.
Hospitals were criticised for not reducing waiting times, GP surgeries were blamed for appointment shortages, and social care providers were held accountable for bed-blocking, when these issues were symptoms of a system stretched beyond its limits. Managers were often aware that these criticisms were unjustified, but rather than speaking out, many felt compelled to defend the policies and directives they were given.
The reality was different: managers knew the system was breaking under pressure, but instead of challenging harmful policies, many became complicit in defending them. The fear of repercussions—being side-lined, demoted, or losing their jobs—meant that few were willing to take a stand. Even those who recognised the failures of the system found themselves rationalising their inaction, believing that they had no real power to effect change or that raising concerns would only make matters worse. Some even convinced themselves that by staying in their roles and working within the constraints of the system, they were doing better than they would by openly resisting.
The corporate culture of NHS England did not encourage independent thinking, moral courage, or the prioritisation of patient care above bureaucratic success. Instead, it rewarded those who played by the rules, who complied without question, and who could effectively manage perceptions rather than realities. This is not to say that all managers lacked integrity—many tried to advocate for better policies behind closed doors—but the structure of NHS England made it exceptionally difficult for dissenting voices to be heard.
This pattern is not unique to the NHS. It is a common feature of large bureaucracies, where maintaining institutional reputation often takes precedence over confronting uncomfortable truths. Without systemic reform, history risks repeating itself in whatever organisation replaces NHS England. The challenge now is to build a system where managers are empowered to challenge bad policies, prioritise patient care over political expediency, and operate with genuine accountability rather than corporate loyalty.
This phenomenon—where individuals within an organisation carry out harmful directives while convincing themselves they are doing the right thing—is not unique to NHS England. History is full of examples where bureaucratic obedience led to disaster. The financial crisis of 2008 showed how bank employees followed orders to approve risky loans and investments, knowing the financial system was unstable. When the inevitable collapse came, those same institutions sought to shift blame onto external factors rather than recognising their role in the crisis. Similarly, the Volkswagen emissions scandal revealed how engineers and managers manipulated emissions tests for years. Many likely knew the deception was wrong but felt pressure to meet corporate expectations.
Within the NHS itself, the Mid Staffordshire scandal demonstrated how a culture of meeting targets over patient care led to catastrophic failures. Patients suffered neglect while managers maintained that all was well. In each case, individuals justified their actions by telling themselves they were simply following orders or doing what was necessary to survive within the system. But history judges such justifications harshly.
Understanding why good people comply with harmful systems requires looking at research in psychology and sociology. The concept of the “banality of evil,” explored by Hannah Arendt, illustrates how ordinary individuals, when placed in rigid hierarchies, often commit harmful acts without malice—simply because they are following procedures. This insight is unsettling because it suggests that any hierarchical system, including healthcare management, can lead people to act against their own moral compass if they become too detached from the human impact of their decisions.
Groupthink plays a significant role, as teams avoid conflict and reinforce each other’s bad decisions, allowing harmful policies to become entrenched. When a group is insulated from outside perspectives and dominated by a desire for consensus, critical thinking is suppressed. In the NHS, this can manifest in senior leadership meetings where dissenting voices—often those of frontline clinicians—are ignored or dismissed as disruptive. The result is a dangerous culture where bad decisions are not just made but actively defended.
Additionally, diffusion of responsibility means that when many people are responsible for a decision, no one feels personally accountable, leading to inaction in the face of obvious problems. This psychological effect was famously demonstrated in experiments on bystander apathy, where individuals were less likely to help someone in distress if they believed others were also responsible. In large bureaucracies like NHS England, this can lead to a culture where managers assume someone else will act, allowing harmful policies to persist even when many privately acknowledge their flaws.
Another important factor is cognitive dissonance, the psychological discomfort experienced when one’s actions contradict their values. To resolve this discomfort, individuals often unconsciously alter their beliefs rather than change their behaviour. NHS managers who know that certain policies are harmful may convince themselves that they are necessary for the greater good or that resistance would be futile. This rationalisation helps them maintain a sense of integrity while continuing to implement policies they once opposed.
Beyond the NHS, similar patterns can be seen in other healthcare systems. Examining international healthcare models can provide valuable insights into the strengths and weaknesses of different approaches, helping the UK avoid repeating past mistakes.
In the United States, the rigid insurance-driven model forces hospital administrators to prioritise financial performance over patient outcomes. The fragmented system results in significant disparities in healthcare access, with those unable to afford comprehensive insurance often receiving substandard care. Despite its advanced medical research and technology, the US system is plagued by inefficiencies, with administrative costs consuming a substantial portion of healthcare spending. The lesson for the UK is clear: excessive privatisation and an overemphasis on financial targets can undermine the fundamental goal of universal, equitable healthcare.
Sweden’s healthcare model has undergone significant decentralisation, granting more power to regional authorities. This approach has improved local accountability, allowing healthcare services to be tailored to community needs. However, it has also led to disparities in service levels, with wealthier regions often providing better healthcare than poorer areas. The UK must be cautious about decentralisation, ensuring that any shift towards regional control does not exacerbate inequalities in care quality.
Germany offers an example of a well-integrated healthcare system that balances government oversight with provider autonomy. Its model includes a mix of public and private insurance, ensuring broad coverage while maintaining competitive efficiency. The government collaborates closely with healthcare providers to manage resources effectively, leading to greater resilience during crises such as the COVID-19 pandemic. The UK could learn from Germany’s structured yet flexible approach, adopting policies that encourage efficiency without sacrificing universal access.
Singapore presents another interesting case, with a highly efficient hybrid system combining government subsidies, compulsory health savings accounts, and private insurance. While Singapore’s system delivers excellent health outcomes at a lower cost than many Western countries, it relies on a high degree of personal financial responsibility, which may not align with the UK’s commitment to universal healthcare. Nonetheless, its emphasis on preventative care and cost-conscious resource allocation could offer valuable lessons for the NHS.
Each of these systems has strengths and weaknesses, but a common theme emerges: the most successful healthcare models integrate financial sustainability with patient-centred care. The UK must ensure that future reforms prioritise long-term resilience over short-term efficiency gains, fostering a system that supports both patients and healthcare professionals.
With the disbanding of NHS England, there is an opportunity to reflect and reset. If healthcare management is to regain the trust of patients and clinicians, those in leadership roles must resist the pressure to blindly implement damaging policies. Greater transparency is essential, with leaders acknowledging when policies are failing rather than covering them up. Accountability must be reinforced so that managers take responsibility for decisions and challenge harmful directives. More moral courage is needed, with leaders standing up for patients and staff even when it means pushing back against those in power.
In addition to cultural change, structural improvements are necessary. Stronger whistle-blower protections will encourage those who see wrongdoing to speak out without fear of retaliation. Clinical leadership in management must be prioritised, ensuring that healthcare professionals, not just administrators, have decision-making power in shaping policies.
This isn’t about pointing fingers—it’s about confronting the dangers of a culture where obedience is valued over integrity. NHS managers have a duty, not just to their superiors, but to the public they serve. True leadership means challenging harmful directives, standing up for what’s right, and ensuring that patient care remains the top priority. The end of NHS England isn’t just an administrative shift—it’s an opportunity to build something better. But that can only happen if we acknowledge the hard lessons of the past and use them to shape a stronger, more accountable healthcare system.
If this makes you uncomfortable, ask yourself why. That discomfort—that internal conflict—is the cognitive dissonance at play. Will you defend the status quo, or will you be part of the solution?