Should health, care and local government departments merge?

With Andy Burnham's appointment as Prime Minister widely expected as early as the middle of this month, attention is pivoting towards what a Burnham administration may look like.Some policies are beginning to surface – stronger public control of energy and water, economic growth, tax reform, accelerating social care reform and greater devolution from Westminster to local government and the regions. In effect the nationalisation of ‘Manchesterism' – including a northern office for 10 Downing Street. But what would this ‘rewiring of the state' look like in practice and especially at the centre of government? A clue may lie in history.We are approaching 2029, the 100th anniversary of one of the most important pieces of legislation in the 20th century – the 1929 Local Government Act. It was wide reaching and swept away the system of poor law unions, reformed local government structure, overhauled central government funding of local authorities by replacing specific grants with block grants and gave powers to local authorities to take over workhouses' infirmaries and operate them as municipal hospitals. In effect the foundation of the NHS.Like Andy Burnham, Chamberlain came into Parliament from local government, where he had been a councillor then Lord Mayor – founding the Birmingham Municipal Bank – but importantly saw what life was like for the poor and excluded and in Roy Jenkins' words saw his role as minister of health ‘to improve the condition of the people'. It's also worth noting Chamberlain won his Birmingham Ladywood seat against the future far right leader Oswald Mosley, who was standing as a Labour candidate in the 1924 General Election.The legislation was the brainchild of Neville Chamberlain, who piloted the Local Government Bill through Parliament in his role as Minister of Health. In one Commons speech, lasting two and a half hours, he said that by abolishing the poor law guardians the Bill was ‘designed to create one single health authority whose duty it will be to survey the whole institutional needs of that area'.In total, Chamberlain served six years and four months across three separate terms as minister of health – making him among the longest serving health ministers in the 20th century. Following a brief stint as Chancellor of the Exchequer, when the Conservatives were re-elected in 1924, Chamberlain chose to return to health, rather than continuing at the Treasury.Alongside the 1929 Act, Chamberlain worked to improve conditions in hospitals and clinics and introduce better housing for the poorer members of society, reformed pensions and rating valuation – laying the groundwork for the Welfare State.As historian AJP Taylor noted: ‘He had efficiency, clarity and resolution…[and] did more to improve local government than any other single man in the 20th century. More tellingly his fellow historian Paul Addison claimed ‘…social services were the most advanced by 1929 and Neville Chamberlain contributed more than any other single figure'.Like Andy Burnham, Chamberlain came into Parliament from local government, where he had been a councillor then Lord Mayor – founding the Birmingham Municipal Bank – but importantly saw what life was like for the poor and excluded and in Roy Jenkins' words saw his role as minister of health ‘to improve the condition of the people'. It's also worth noting Chamberlain won his Birmingham Ladywood seat against the future far right leader Oswald Mosley, who was standing as a Labour candidate in the 1924 General Election.Chamberlain's Ministry of Health's responsibilities covered almost all aspects of the population's everyday lives – health, local government, housing and planning – giving him the opportunity to offer the nation his version of ‘Birminghamism'.If Burnham is serious about ‘rewiring the state' and devolving more power, machinery of government (MoG) changes will be core to achieving this vision. The problem is MoG changes are rarely exciting and hardly make a major public impact. But if Burnham wants to achieve changes locally, then he will need to make changes nationally. The risk is if this doesn't happen, as we are seeing with increasing social polarisation. In the words of WB Yeats: ‘Things fall apart; the centre cannot hold.'What are the expected incoming Prime Minister's options? Outside of the immovable beasts of the Treasury, Foreign, Commonwealth and Development Office and Defence, much of the Whitehall estate has frequently been chopped and changed, albeit at times it has seemed more like a shifting of the deckchairs.Why, with three devolved assemblies fully established for many years, is there still a need for separate Scotland, Wales and Northern Ireland Offices, each with their own ministers? Why can the Home Office not be reformed into a French-style Ministry of the Interior which, alongside its responsibilities many similar to the Home Office, looks after elections and relations between central government and localities. If Whitehall oversight of the devolved administrations is still required then it could sit in an interior ministry. Transport and planning are natural bedfellows and could be combined. And something more interesting could be done with the whole, business and trade/science, innovation and technology/energy security and net zero collection of responsibilities.So where does this leave health, local government, housing and social care? A ministry of place? A department for society? While titles are important to convey a brand, it's the combination of responsibilities aimed at improving the lives of the population which is more important. Social care is divided across two departments and multiple local authorities, reform seems to be continually kicked into the long grass, and its administration and delivery can hardly be called a jaw dropping success. Bringing together greater national focus for improving people's lives through national policy and regulation while supporting greater local delivery and control could be transformational.Of course, there are arguments against. The vastness of the NHS in terms of budget dwarfs local government's and could sideline the latter. But that's only if we continue to see the administrative difference between the two, and the NHS has been going through a steady devolution in recent years, with the formation of Integrated Care Boards (ICBs) and the forthcoming abolition of NHS England handing more responsibilities to the NHS Regions.As with ICB consolidation, local government restructuring needs to lead to unitarisation across the country, along with a reduction in the number of councils in England – including London – while ensuring greater co-terminosity of administrative borders.Administrative reform may not be the most electrifying aspect of public policy, but is of critical importance to ensure policy success. And as with most areas of public life, history offers insight and experience.Christopher Exeter is a global health researcher

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POLICY AND POLITICS

Should health, care and local government departments merge?

By Christopher Exeter | 03 July 2026

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