12 days to remake the State
‘Tis the season of hope and gifting. And in that festive spirit, we gift you this uplifting series of mini blogs.
Each day for the next 12 working days you can unwrap a special Re:Think detailing a radical reform that is perfectly implementable and which would take us towards a remade State. For what is Christmas if not a time for optimism for a better future.
Day 12 - Release the robots
What is the point of the NHS if people can’t access timely healthcare? As of September 2025, nearly 7.4 million people were waiting for elective care, a number that has barely shifted in recent years.
Those waiting for surgery face some of the greatest risks from these delays. Fortunately, a transformative solution is already in reach. Robotic assisted surgery (RAS) is revolutionising surgical care. Less invasive and more precise than human hands, RAS results in less tissue damage, less blood loss, and less pain. Surgeries can be completed quicker, patients recover faster and therefore outcomes are better. There are also evidenced benefits for clinicians performing the surgery.
Unfortunately, despite its well-evidenced benefits — from productivity gains, to greater gender equity, to better outcomes — uptake is limited. There’s a number of barriers to adoption and a risk these could deepen regional inequalities. Luckily, the Government has heard our call to implement robotic assisted surgery at scale and introduced national targets to drive safe and effective adoption. It’s a good first step, but now it’s time to really release the robots.
For more on how to do this and why, read: A helping hand: robotics in surgery
Day 11 - More muscle for ministers
The functioning of the State is in no small part down to the ability of ministers to get things done. That is, of course, about the talent, capability and work ethic of the ministers themselves, but it is also about the support structure around them.
The standard view is that political appointments are, at best, a necessary evil, and at worst a total waste of taxpayers money. This is a stupid take. It is ministers who are setting the priorities for government and taking daily decisions with short- and long-term consequences. It is patently absurd that they would not be given every possible support to execute their roles. And indeed we are an outlier in our approach — in countries like, France, Canada and Australia, they have multiples of the number of political appointees compared to us.
Grown-up government would allow ministers — and not just ones of the Cabinet-attending variety — to have expert teams around them who share their priorities and values. No company CEO would stand for being given a team, with no say, and simply have to get on with it even if that team were not aligned with their strategy.
The quid pro quo of being given more special advisers and being allowed to appoint more non-political roles, is that those occupying them must be better — skilled, expert, capable and qualified. In that context, it’s time to give ministers more muscle.
For a detailed look at what needs to change, and how, see: Grown up government: towards a comprehensive model of political support
Day 10 - Unleash London
It is a common – and valid – complaint that Westminster is overly preoccupied with its home city, often to the detriment of the rest of the country. Yet there are good reasons to care deeply about the state of the Capital. London may account for just 13% of the UK population, but it generates roughly 22% of national GDP, and contributes more than £40 billion a year more in tax revenues than it receives in public spending. What is good for London is good for the UK.
Yet despite its importance, London is conspicuously absent from much of today’s discussion about local government reform and devolution. The Greater London Authority recently turned 25 and, like many 25-year-olds, now finds itself at a crossroads. Once the only regional authority in town, it is increasingly overshadowed by newer combined authorities with different governance models and, in some ways, more extensive devolved powers.
The current patchwork of 32 boroughs plus the City of London Corporation is uneven and arbitrary. The relationship between the Mayor and the boroughs remains informal and ad hoc. London’s devolved powers are outdated and increasingly out of step with the rest of England. The result is fragmented, constrained governance in a city struggling with weak productivity growth.
An alternative model would build the authority and traction of the London Assembly, and create a stronger operational basis and greater powers for the Mayor. The prize from getting this right would be enormous – not just for the Big Smoke, but for the entire country. It’s time to unleash London.
Watch this space for Re:State’s proposals to do exactly that. In the meantime, you can read our early thoughts here.
Day 9 - Deprioritise doctors
The health secretary has declared “the NHS is broken”. While health spending increases, productivity and patient satisfaction plummet. The most common response, aside from (even) more money, is more doctors! The problem is, this obscures the true causes and solutions for problems.
Take A&E. The number of emergency medicine doctors has increased at a far, far greater rate than the number of A&E attendances in the past decade, yet the data shows declining performance.
Or consider hospital discharge delays. In February 2025, nearly 23 hospitals’ worth of inpatients, who no longer needed to be in hospital, were stuck on wards each day. Again, the number of hospital doctors has increased significantly, while little progress has been made on this. A seven-day discharge workforce, including pharmacists, occupational therapists, social workers, and nurses empowered to make discharge decisions, would make a far bigger difference.
Primary care has not seen the same growth in doctor numbers, but even then, while the number of GPs has largely stagnated, the number of community nurses and health visitors has plummeted. An effective primary care model needs to focus on boosting these other parts of the workforce: clinically expert nurses, and community services such as district nursing, specialist long-term condition nursing, community pharmacists, and Health and Wellbeing Coaches should be front and centre.
Doctors are, of course, a vital part of the NHS, and in some roles — particularly generalist ones — we need more doctors. But an obsession with doctors is actually getting in the way of building an effective and sustainable Service. It’s time to deprioritise the doctors.
To learn more about how to deploy the non-doctor workforce throughout the NHS, please read:
- Hospital of the future: ending the patient gridlock (2025)
- Prescription for prevention: a new model of primary care (2024)
- The A&E crisis: what’s really driving poor performance? (2023)
Day 8 - Break the regulation ratchet
Rules and regulations are fundamental to the functioning of the economy. Yet too much regulation creates a confusing landscape that is difficult to navigate, and costly to operate in. It stifles growth. The problem is that new rules are simply too easy — and too tempting — for governments to create, while there is little incentive to do the harder work of revisiting and removing onerous regulations.
Thus we get a ‘regulatory ratchet’ — a steady, upward drift in the size and complexity of the regulatory state, even as successive governments pledge to cut red tape. This Government is no exception. Whilst it has echoed the familiar ambition to reduce administrative burdens, at Re:State we believe that reversing this trend and genuinely rebalancing the scales requires far more radical reform to how regulation is designed, assessed and passed.
The current system offers the appearance of rigorous scrutiny and evaluation, but in practice it allows the government of the day to proceed with remarkably weak checks and balances. Departments must be held to a much higher standard of analysis when considering how to achieve policy objectives — and that the bodies responsible for scrutinising new regulations must be properly empowered to scrutinise and challenge regulations which have gone far further than intended. It’s time to break the regulation ratchet
For an insight into our early thoughts on tackling the regulatory ratchet, read our long-form Re:Think: The Law of Rule: the regulation theory of everything
Day 7 - Devolve fiscal firepower
England’s emerging network of devolved institutions is increasingly capable of shaping economic strategy, yet the one power that matters most remains out of reach: fiscal power. Mayors and combined authorities are expected to deliver local growth, regeneration and long-term investment, but they continue to rely on budgets that function more like annual allowances than real economic tools. Without the ability to influence how money is raised and spent, local leaders are held responsible for outcomes they cannot meaningfully influence.
While the recent announcement to give mayors the power to introduce local tourist levies is welcome, true fiscal devolution is not about granting narrow permissions. It requires rebalancing the over-centralised British state so that decisions on raising and spending money sit closer to where economic activity actually happens.
Giving mayors genuine fiscal powers, within a national framework that ensures fairness and equalisation, would sharpen incentives for local action and link accountability directly to the revenue they raise and the results they deliver.
Central government should set minimum standards and manage shocks, but it should not micromanage fiscal decisions for every part of the country. If we want England’s devolved institutions to succeed and deliver growth, we must devolve not just responsibilities, but fiscal firepower too.
To learn more about local government, read our report: Back from the brink: radical ideas for sustainable local finances
Day 6 - Send hospitals home
Spending on health and care exceeded £193 billion in 2024-25. Hospitals account for the vast majority of this, and acute spending has actually increased as a share of total spending.
Not only is this fiscally unsustainable and contrary to the stated objective of shifting care upstream, but it is also bad for patients. Being treated in hospital poses risks for patients, from hospital-acquired infections, to physical deconditioning, to mental health issues. And for many patients, they would be better treated at home.
Hospital-level care provided in patients’ homes — known as virtual wards — utilises remote monitoring technology, virtual communication and other technological advances. When done well, virtual ward care is more clinically effective than inpatient hospital care, especially for patients who are elderly, living with frailty or who have a long-term condition. Virtual wards also vastly improve cost-effectiveness and patient experience.
The Government is making bold strides towards sending hospitals home, most notably with the creation of a fully virtual hospital — NHS Online — as exclusively called for by Re:State. A world first, NHS Online will treat suitable elective patients entirely virtually, both boosting elective capacity and freeing up in-person hospital care for those patients who need it.
This should be the first step in delivering hospitals as a service, not a building — for both patients and the public purse, it’s time to send hospitals home.
For more on how to do this, read our report: Hospital of the future: hospital as a service not a building
Day 5 - End the poor performer merry-go-round
In any area of human endeavour the greatest predictor of success is the quality of people. There’s no substitute for talent. As Lee Kuan Yew, the first Prime Minister of Singapore, said “you need good people to have good government.”
But the civil service has a performance problem. Plenty of the best and the brightest join the civil service to serve their country and tackle the biggest challenges of the day. But, like any organisation, the civil service has staff who aren’t up to the job, and shouldn’t be there. Unlike most other organisations, the civil service is allergic to addressing it.
Civil servants are rarely, if ever, sacked. A civil servant is ten times more likely to die in post than be dismissed for underperformance. Between 2018 and 2023, the Department for Transport and HM Treasury averaged dismissals of less than 0.4% of their staff each year for poor performance.
This problem is widely known in the civil service. When surveyed, only 8% of civil servants agreed with the statement “the civil service in general manages poor performance well”. It is bad for morale, when other officials have to pick up the slack. And it has a negative effect on poorer performers too: it weakens expectations to improve. The result is a ‘poor performer merry-go-round’, like the famous “dance of the lemons” in the US public school system. Managers find it easier to let poor performers move on, even on promotion, than address it.
This needs to change. The Government should make funding available to exit poor performers, including fighting employment tribunals and awarding compensation if necessary. It should set minimum standards across all roles, make internal roles conditional on references, and implement promotion boards to assess quality across departments. Accounting Officers should be accountable for the performance of their staff, as part of their responsibility for using public money well. It’s time for the merry-go-round to stop.
For more on how to do this, read our report: Making the grade: Prioritising performance in Whitehall
Day 4 - Rally neighbourhood power
Our lives do not, for the most part, play out at the scale of nations, counties, or even the whole cities in which we live. Our home, community, and (often) working lives actually happen within neighbourhoods. Strikingly, though, it is at this scale that people often feel most disempowered. In the absence of community-led forums or a (rare) active, well-run Parish council, neighbourhoods have no architecture for deciding on the hyperlocal issues that affect them most, or for making the most of locally held assets. With local government reorganisation abolishing the remaining District councils, an order of magnitude fewer councillors will now exist to hear and champion neighbourhood-scale causes.
Government has taken important steps in closing the institutional gaps that exist at the regional scale across England, but there has as yet been no attempt to do the same at the scale of neighbourhoods. A strategy is emerging, but there is no real plan yet to go with it.
To do this, local authorities should be required and funded to enable community-led activity and support Community Governance Reviews across the country. The resulting new wave of Neighbourhood Councils should be incentivised to operate in clusters so that they can share resources when needed, and combine efforts to tackle projects of different sizes. If successful, this unleashing of the latent potential of our neighbourhoods could help relieve pressure on public services and bridge growing gaps in democratic engagement and institutional trust.
For more, read our report: Local, Actually: establishing hyperlocal governance in England
Day 3 - Take the N out of NHS
We tend to assume that the default size for running the things that matter to us should be the nation-state. Sometimes this works out, and enables us to realise economies of scale. But more often than we like to admit, it actually leads to worse outcomes, because mandarins in Whitehall can’t possibly design the best service model for Weymouth and Wolverhampton and Watford.
That ‘nation-scale’ bias is baked into the NHS – it’s right there in that first letter. To the credit of successive governments, there’s been some recognition that this may not always be right. At this point the health system is delivered by a plethora of overlapping institutions at local and regional levels. Yet still it is NHS England — Europe’s biggest Quango, which is now being wound down — and the Whitehall Department for Health and Social Care that rule the roost. Which means that they also preside over a health system that is struggling to modernise, to contribute actively to health creation, to deal with its own backlog, and to improve outcomes for diverse groups of patients.
As more capable and accountable devolved institutions are established across England, health budgets should be devolved to the regional level, with the centre becoming a strategic, standard-setting, scrutinising body that does the things that are genuinely best done by the centre. The result could be a more flexible, preventative, and accountable NHS driven by local need: one that is responsive to the specific needs of each population and varies its approach, when appropriate, from place to place.
To learn more about this argument, read our landmark report: Close enough to care: A new structure for the English health and care system
Day 2 - Dismantle the Quangocracy
One of the most fundamental underpinnings of the British State is the ability of the ruling government to implement their plans. That requires a high-performing government machine. But it also means the ability to deploy that machine, with pace, to deliver on priorities. Britain’s quangocracy is now impeding that.
Quangos — or public bodies — can play a fundamental role in protecting citizens, enabling scrutiny, and providing independent facts and analysis to inform decisions. While our elected politicians should set parameters and pass (or even, ideally, repeal on occasion) legislation to determine how sectors are regulated, they should not act as regulators; nor should they be responsible for adjudicating appeals or providing forecasts or many nationally important data sets. But the British State has become ensnared in a quangocracy where in too many areas, ministers are blocked by unelected bodies whose remits have swelled. 60 per cent of day-to-day spending is via quangos, with woefully insufficient oversight and little transparency.
The PM heeded our warning, and in March pledged to dismantle the “cottage industry of blockers and checkers”. The Government has acted on our repeated calls to abolish the largest of quangos, NHS England. But it must go further. Remaking the State demands a radical rationalisation of our quangos, abolishing some, reconstituting others and tightening those left.
For more on how to do this, read: Quangocracy: the future of public bodies
Day 1 - Give the gift of governors
Mayoral Strategic Authorities (MSAs) will soon cover almost 80 per cent of England’s population. This is a good thing. Operating at a regional scale MSAs have the potential to drive economic growth and improve public services. The problem is that outside of England’s largest cities the MSA model is inappropriate.
Outside of these cities many current and proposed MSAs cover rural and less population-dense areas. This creates three problems. They are too small to operate at the required regional scale: the proposed Cumbria Combined Authority would be closer in size to a local authority. They are too incoherent – for example East Midlands Combined County Authority includes 2.2 million people but excludes Leicester, one of the region’s largest cities – which further weakens their potential impact. And they are polycentric, comprising multiple interconnected economic hubs as opposed to the ‘hub-and-spoke’ model of major cities.
A different governance model is therefore needed: Provinces. Led by directly elected Governors and covering geographies of at least three million people, these would have the required size and coherence to take on genuine regional leadership.
Proposed geographies for these Provinces are included on page 18 of our report arguing for this earlier this year: Go big or go home: governing England's polycentric regions