It is one of the odder facts about the London Health Commission: the office that convened it has no formal power to run, fund, or reform the National Health Service. The Mayor of London cannot appoint an NHS trust chief executive, close a hospital ward, or set a clinical budget. Yet in September 2013 the Mayor commissioned exactly the kind of sweeping health inquiry usually associated with national government. Understanding why requires looking past the report itself to the narrow, specific powers a Mayor of London actually holds.
The Powers a Mayor of London Actually Holds
Under the Greater London Authority Act, the Mayor’s statutory responsibilities for health are limited to two things: publishing a health inequalities strategy, and considering health and health inequalities across every other mayoral strategy the office produces, from transport to housing to policing. Neither duty gives the Mayor control over clinical services, NHS budgets, or hospital reconfiguration — all of which sit with national bodies and, more recently, Integrated Care Boards. What the office does have is a convening role: the Mayor chairs the London Health Board, bringing together NHS partners and local government to coordinate rather than command, and can use the platform of the mayoralty to champion the NHS publicly or push back against reforms judged harmful to Londoners. It is influence by voice and coordination, not by budget or statute.
Why 2013? The Vacuum Left by NHS London’s Abolition
That distinction matters because of what had just happened to the capital’s health governance. NHS London, the strategic health authority that had previously coordinated health planning across the city, was abolished as part of the 2012 NHS reforms, leaving no single body with a city-wide view of London’s health system. At the same time, London was carrying a familiar cluster of problems — a high burden of disease, persistent inequalities between boroughs, variable quality of care, and rising costs against a tightening financial settlement. The London Health Commission was the Mayor’s answer to that gap: not a substitute for NHS authority, which the office could not claim, but an independent inquiry that could examine the whole system and speak with the Mayor’s public platform behind it, at a moment when no one else was doing so at city scale.
An Inquiry, Not a Directive
The terms of reference reflect that limitation honestly. The Commission, chaired by Professor the Lord Darzi and reporting directly to the Mayor, was tasked with examining how London’s health and healthcare could be improved for the population and with advising on the specific contribution the Mayor’s office could make — not with instructing NHS bodies on what to do. Its method matched its advisory status: extensive public engagement rather than administrative fiat, gathering views from more than 9,000 people, running over 50 roadshow and NHS-based events across the city, taking 250 written evidence submissions, and holding nine oral hearing sessions. That evidence became the basis of Better Health for London, published in October 2014 with more than 60 recommendations organised around ten ambitions. Every one of those recommendations was framed as advice to be taken up by others — NHS commissioners, boroughs, national government — because the Mayor’s office had no mechanism to enact them directly.
Mayoral Powers vs. NHS Powers, Side by Side
| Area | What the Mayor Can Do | Who Actually Controls It |
|---|---|---|
| Health inequalities | Publish a statutory strategy; factor inequalities into other mayoral strategies | Shared with boroughs and NHS commissioners on implementation |
| Service coordination | Chair the London Health Board; convene NHS and council partners | NHS bodies and Integrated Care Boards hold the operational decisions |
| Hospital and clinical services | No formal authority | NHS trusts, commissioners, national government |
| Public advocacy | Full latitude to campaign, commission reviews, and speak publicly | N/A — this is the Mayor’s own remit |
| Funding of NHS services | No direct budget role | NHS England and national Treasury allocations |
A Recurring Question, Not a Settled One
The gap between the Mayor’s public profile on health and the office’s narrow statutory footing has not gone away since 2014. It resurfaces periodically in discussions about whether the Mayor should have greater formal scrutiny powers over the NHS bodies operating in London, including the Integrated Care Boards that replaced clinical commissioning groups. Those conversations are, in effect, a continuation of the same structural question the 2013 Commission was created to work around: London has a directly elected, high-profile civic office with no seat at the table where health decisions are actually made. Commissioning an independent review chaired by a leading clinician was one way to close that gap with legitimacy rather than authority. Whether that remains the right model, a decade on, is a live policy question rather than a historical one — but the reasoning behind the original choice is a matter of public record, not speculation.
This review is presented as an independent archive and commentary project. It is not affiliated with the Mayor of London, the Greater London Authority, the NHS, or Lord Darzi’s office, and none of the analysis above should be read as a statement from any of those bodies.