Principles to guide change

1. Devolution and the principle of subsidiarity

The health and care system’s road to recovery and reform is complex, with no quick or easy fix. The resolution must be a joint endeavour involving all ICS partners, supported by the government and NHS England. By embedding a non-hierarchical collaborative governance structure, local systems would have the autonomy they need to lead, while ensuring they align with national health priorities.

As part of this, the principle of subsidiarity should apply, with greater resource and decision-making devolved locally and a centre less focused on performance managing process, and more focused on health outcomes and the things that are best done once for the whole NHS. Local organisations and systems should be given the tools and levers to improve quality, productivity and access and drive change based on what works best locally.

Progress towards a more devolved model must be accelerated, including bolstering the role of ICBs as strategic commissioners. The resources saved by reductions to ICBs’ corporate costs should be used to support the development of mature collaborative structures on the provider side. NHS England’s work on the model region should take into account the devolved model articulated in the government’s mandate and avoid the tendency to ‘scale’.

2. A system approach to change

The centre should provide space for genuine co-design of the most appropriate delivery mechanisms for local populations, with staff and local communities, by not over-prescribing models of care or service delivery models but providing a consistent and stable direction of travel under which places can work together.

National and regional teams should organise packages of support around shared goals and co-developed strategies, reducing adversarial dynamics.

With a rapidly evolving healthcare landscape, financial challenges across health and social care and the wider public sector, and a widening disparity in health outcomes, the imperative to bolster and support leadership that helps drive through systemic change and continuous improvement has never been more pressing. Improvement is more than an add on or nice to have: it is the enabler of the wide-scale change and transformation the health and care system needs. 

To create sustainable change, the sector needs to move into a model that emphasises horizontal, peer-to-peer learning, providing support and empowerment to local leaders so they can deliver it. Leaders should be supported and empowered through the sharing of learning and good practice around how to develop and agree local outcome metrics and how effective cross-organisational teams are built, based on areas which have successfully implemented new models. Organisations such as the NHS Confederation can support the development of a culture of continuous learning, sharing and scaling. 

As part of this, the development of leadership and management capacity at all levels must be supported, including by investing in leadership training programmes for ICB, trust and primary care leaders, fostering capabilities for self-assessment. 

3. Clarity and accountability

ICSs need clarity about the outcomes they are expected to deliver. They also need appropriate governance and accountability arrangements to enable them to embed a delivery model of their choosing.

Effective transformation at neighbourhood, place and system level will require support to build capability and capacity. At the same time, stronger accountable central systems and direction are needed in key policy areas such as data, digital and innovation. There are certain things which benefit from national or regional standardisation such as procurement frameworks, data integration, clear information standards and medicines formularies.

There is a clear role for centralised procurement of essential digital platforms and tools to minimise cost and maximise benefits to the system and also in areas such as governance and regulation of fast-changing digital services (particularly in relation to AI tools) and data adherence and security. 

Other major areas, from resource allocation to oversight, will require the centre to provide clarity and alignment on national policies. There should, for example, be a shift from process compliance to a small number of high-impact and measurable health indicators that are linked to population health. There are questions about the suitability of DHSC as the host for some of these functions previously held by NHS England or whether they will be hosted in existing or additional arm’s-length bodies.