Public Accounts Committee Select Committee inquiry into devolving power in England: NHS Alliance submission

Is devolution giving areas the freedom and funding they need to enable local flexibility and long-term planning?  

The intended relationship between combined authorities and the NHS in England remains unclear. It is notable that in both sectors, separate policies to change the relationship between the centre and local leaders are now under development.

The Health Bill, currently progressing through parliament, contains little reference to combined authority devolution, with the exception of measures to replace local authority representatives on NHS integrated care boards (ICBs) with mayoral representatives. However it does not build upon or clarify what mayors’ new health duties may mean in practice for the NHS, and does not address the interface between health and social care.

Beyond the Health Bill, the NHS is currently pursuing a range of policies aimed to empower local leaders with freedoms and flexibilities, which we welcome. These include strategic commissioning, advanced foundation trusts, integrated healthcare organisations (IHOs), and neighbourhood health. All of these aim to result in more integrated services that focus on improving population health, and all explicitly encourage NHS leaders to build collaborations with local partners. This is the right direction of travel, and fits with some of the aims of devolution, but how these policies relate to the duties of mayors and combined authorities with regards to health have not been fully explained.

More broadly, it has been 17 months since the abolition of NHS England was first announced, but the future operating model of the NHS is yet to be described in detail. Of particular relevance to this inquiry is the future relationship between combined authorities, the NHS regional tier, and ICBs, and how the future operating model will support strategic alignment between NHS and local partners in the interest of better population health. To realise the potential gains of NHS reform, integration of local services and local authority devolution, it will be necessary to establish an unambiguous operating model that enables good local decision-making and robust performance management and accountability arrangements.

The ability to pool funds is a key enabler of local integration and flexibility. But existing mechanisms across the NHS and local government, such as under section 75 of the NHS Act 2006 and the Better Care Fund, remain limited in practice. For example, non-statutory primary care providers are not able to take part in section 75 budget pooling, and this will limit the potential of joining up health and local authority services. We believe the Secretary of State for Health and Social Care should use existing powers to enable mature, at scale primary care organisations such as GP federations and primary care collaboratives to become statutory organisations. This would give local systems the flexibility to fund integrated, prevention-focused models of care.

 The introduction of integrated settlements[1], and the announced move towards strategic authorities receiving a share of the income tax[2] which has been raised in their area, could provide welcome flexibility to invest in the wider determinants of health and in shifting services into communities.

Are the performance management and accountability arrangements around central government funding proportionate and effective? 

We would not comment on funding and accountability arrangements for English combined authorities. However it is worth considering the constraints affecting NHS organisations, in the context of the aspiration to increase strategic alignment between the two sectors. The NHS, like all government departments and public services, operates within an annual financial framework to provide appropriate oversight and meet capital and resource departmental expenditure limits (CDEL and RDEL). While annual financial accountability is necessary, the current approach can be detrimental to long-term planning and investment, and will continue to hamper transformation.  

Without greater flexibility, NHS organisations will continue to face incentives that favour short-term financial benefits over longer-term improvements. Providing NHS bodies with the ability to invest over multiple years, carry forward surpluses, and exercise greater flexibility in the management of capital expenditure across financial years would support more strategic decision-making and enable sustained transformation.

Similarly, the NHS’s main regulatory and performance management arrangements currently encourage a short-term focus. For example, the NHS oversight framework and accompanying league tables emphasise largely operational metrics rather than, for example, outcomes or population health measures. They also contain a ‘financial override’ which limits an organisation’s ranking based on in-year financial performance. If one object of devolution is to empower strategic authorities and their partners to focus on the long-term good of their populations, the oversight of the NHS currently pulls focus in the opposition direction.

Does local and central government have the capacity, governance and scrutiny mechanisms needed to support further devolution and deliver better outcomes for communities?  

The precise role of mayors in health, particularly how they will interact with ICBs as local commissioners, has not been fully explained, and clarity from the government would be helpful. However in general terms greater devolved powers, supported by strong relationships with ICBs and providers, could create a significant opportunity to harness the NHS’s economic influence as both a major employer and a driver of local growth. This could help strengthen links with health, education and employment, while supporting targeted employment initiatives for groups most likely to experience poor health outcomes and generate avoidable demand on NHS services.

Combined authorities and ICBs operate on large footprints, but it is important to remember that the essential collaboration between health and social care will mainly happen much more locally. For example, this is likely to happen at ‘place’ level, through a partnership arrangement to run neighbourhood services, or through providers leading integration through an IHO contract. Enabling this must be a top priority for mayors and ICBs, despite their scale. Mayors have a potentially powerful role to play in convening local partners and building consensus around common aims.

Devolution offers an opportunity to increase the integration of public services in a way that can help address the needs of the parts of the population most likely to incur avoidable costs in the NHS, while maximising opportunities for individuals and the population. Alongside strong strategic local leadership, realising these benefits will depend on ensuring that local partners and NHS organisations have the capacity, governance arrangements and scrutiny mechanisms needed to support effective collaboration.

Care should be taken in exercising strategic authorities’ new statutory duties relating to health under the English Devolution and Community Empowerment Act 2026. The NHS has nationally-set performance standards, is highly regulated and subject to significant national oversight, reflecting its status as a national service funded through general taxation. Devolution and an enhanced role for mayors should provide strong strategic leadership to set common goals to enable the integration of services and collaboration improve the lives of local people. It should not result in an increase of targets, priorities, and oversight burden.

The government has recently reconfirmed plans for ICB boundaries to align with those of strategic authorities by the end of the Parliament, as part of the wider programme of devolution and the transfer of power from Whitehall to local areas.[3] This had originally been announced as part of the 10-Year Health Plan. While greater alignment between health services and local democratic institutions has the potential to strengthen partnership working and a focus on local population need, significant questions remain about how these arrangements will operate in practice.

Some ICB footprints already span multiple mayoral authorities. If these arrangements continue, this could require ICBs to work with several mayors, potentially with differing priorities, political mandates and policy approaches. Given the complexity and variation of local government arrangements, national guidance and policy should allow sufficient flexibility in local governance structures.

The NHS is undergoing a prolonged period of organisational change, including the merger and clustering of ICBs, which is intended to establish greater clarity of purpose and ways of working. Our ICB members tell us that major structural change can take around two years to implement effectively, requiring significant leadership and organisational capacity that might otherwise be focused on improving outcomes for local communities. Any further proposed NHS boundary changes should therefore be supported by a clear and compelling case for change.

These considerations are particularly important given the reduced capacity within many ICBs following recent restructuring. Mergers, clustering arrangements and workforce reductions have limited the resources available for both strategic engagement and operational partnership working with strategic authorities and local government. In this context, any additional responsibilities or duties arising from devolution and boundary alignment will need to be accompanied by realistic expectations about the capacity required to deliver them effectively.

In March 2026, the Starmer government announced that Greater Manchester and South Yorkshire will trial an approach in which the new chairs of the ICBs will, in effect, become deputy mayors for health, building on new powers given to mayors under the English Devolution and Community Empowerment Act 2026.[4] The approach has the potential to strengthen integration across health, care and the wider determinants of health.

For these trial areas, there are important questions about who holds ICB leaders accountable, and for what. It will be necessary to understand how ICB chairs in these areas will be appointed, and how they can be removed and on what grounds. As with all such appointments processes, this should be a transparent, rules-based system that supports ICBs to focus on their core duties as well as build partnerships locally. The resulting arrangements must create a common understanding of roles and responsibilities, and the these must match both the policy intent and underpinning statutory framework, and a lack of clarity will lead to avoidable disputes and less robust decision-making.

It will be important to avoid a scenario in which ICB chairs are forced to navigate competing lines of accountability to mayors and the DHSC, via NHS regions.  It may also be necessary to mitigate the risk that greater political involvement in health system governance could influence decisions that should be informed primarily by population need, evidence, and clinical considerations.

ICB leaders are keen to understand the governance implications of deputy mayors for health roles, including how responsibilities, decision-making powers and accountabilities will be arranged. It is also important to recognise that Greater Manchester and South Yorkshire have characteristics that may not be easily replicated elsewhere in the country. This includes established devolved arrangements, political leadership aligned to central government, and alignment between mayoral and ICB geographies. Any lessons drawn from these pilots should therefore be interpreted cautiously and with due regard to local context.

As part of our work on the Health Bill, we have called for stronger local accountability and collaboration mechanisms. One approach would be the introduction of a statutory duty on ICBs, strategic authorities, and local authorities to collaborate in the exercise of their health functions and in the interest of improving health outcomes. If representatives of strategic authorities are expected to participate in ICB governance, reciprocal arrangements should also ensure that ICBs are represented when strategic authorities and local authorities make decisions that have significant implications for health services and outcomes.

The NHS Alliance has also called for flexibility for ICBs in establishing mayoral representation on their boards. Where ICBs cover more than one strategic authority, which may have different political leadership, populations and priorities, they should be allowed to have only one nominee representing the overall mayoral perspective, rather than several, each with their own agenda. This would keep ICB boards lean and enable focus on delivering better health outcomes from communities.

The future role, composition and function of health and wellbeing boards (HWBs) also needs to be explicitly restated in the context of aspirations to integrate services at ‘place’ level, and strategic authorities’ new statutory health duties. Without considering HWBs, there is a risk that opportunities to build partnerships are missed, and that new devolved structures will duplicate existing forums, create overlapping responsibilities and increase reporting and engagement burdens for NHS organisations without delivering corresponding benefits for local communities.

Despite these challenges, there are already strong examples of the NHS working successfully with mayors and local leaders to improve outcomes in areas of shared interest, including neighbourhood health, prevention and tackling wider determinants of health. These partnerships demonstrate the potential benefits of devolution when responsibilities are clear, governance arrangements are effective and local partners have the conditions and capacity to work together. Ultimately, the success of further devolution will depend not only on the transfer of powers, but on ensuring that NHS organisations, strategic authorities and local government have the resources, capabilities and relationships needed to translate these changes into better outcomes for communities.