The NHS faces no shortage of challenges. Across the service, leaders are focused on improving outcomes, recovering performance, increasing productivity and developing neighbourhood services.
Delivering these priorities requires clarity about who is responsible for what. Organisations cannot plan effectively, allocate resources or deliver outcomes if responsibilities and accountabilities remain unclear.
Across our membership, leaders tell us they can deliver major reforms when there is clarity about what is changing, what it means for them and what freedoms they have. What is much harder is maintaining focus on delivery while uncertainty persists about organisations' future responsibilities and the leadership model within which they will operate.
The unanswered questions matter
With April 2027 approaching, and 18 months on from the Government's announcement that NHS England would be abolished, fundamental questions remain unresolved.
What functions should sit with Government, national NHS leadership, regions, ICBs and providers? Where should decision-making powers and accountabilities lie? How should national leadership and regional arrangements support them?
These questions shape accountability, decision-making and where organisations turn for support. The longer uncertainty persists, the greater the risk that expertise is lost as people leave and that leadership attention is diverted away from delivery.
There will never be a risk-free moment to settle the NHS architecture, but continued uncertainty now presents the greater risk. The operating model will not, on its own, solve every challenge facing the NHS, but uncertainty about future roles and responsibilities is making those challenges harder than they need to be.
Start with delivery, not structure
The operating model is not an end in itself. Its purpose is to create the conditions for better outcomes and more effective delivery.
Effective systems, made up of interconnected organisations, depend on clear roles, responsibilities and accountabilities, enabling organisations to make decisions, allocate resources and deliver change with confidence.
Clarity should not be confused with centralisation; the goal is to make it easier for local leaders to lead, act and work collaboratively on behalf of their patients and populations.
Delivering the NHS's ambitions requires both capable providers who can deliver high-quality care, improve services and innovate; and strong strategic commissioners who can understand population need, align resources, work with partners and lead long-term transformation.
Six tests for the operating model
As Government finalises the target operating model, we believe it should be judged against six simple questions:
- Does it create clear accountability? Are leaders clear who is responsible for what and how decisions are made across Government, national leadership, regions, ICBs and providers?
- Does it enable strategic commissioning? Will commissioners have the capability, authority and capacity to improve population health and lead neighbourhood transformation?
- Does it help leaders focus on the right things? Will it create the conditions for leaders to focus on improving population health, modernising services and making the best use of resources?
- Does it support improvement? Does it encourage learning and create a proportionate approach to oversight rather than simply driving compliance?
- Does it provide a consistent national framework? Does it create a clear, consistent and rules-based approach, while enabling providers and ICBs to respond to local needs?
- Does it enable local leadership and reduce unnecessary bureaucracy? Are decisions taken as close to patients as possible, and local leaders empowered and trusted to act?
An operating model that meets these tests can improve delivery. But even the best-designed model will fall short without the right leadership behaviours characterised by trust, partnership and mutual accountability.
Applying these test - what does that mean in practice?
First, the NHS needs visible national operational leadership. As planned, a clearly identifiable NHS chief executive should lead the service and be accountable for its performance, distinct from but complementary to, the permanent secretary at the Department of Health and Social Care.
Second, the NHS will continue to need strong regional capability. Regions should provide support, improvement capability and specialist expertise where this adds value, without duplicating national or local responsibilities or recreating another layer of operational management.
In the short term, we have argued for a transitional arm's-length body to host regional functions and receive functions from NHS England to provide continuity and create stability while longer-term decisions are taken.
Third, ICBs need the capability, data, focus and headroom to operate as strategic commissioners. That means understanding population need, convening partners and shifting resources towards prevention and neighbourhood care, rather than operational delivery.
Fourth, capable providers should have much greater freedom to innovate, improve services and redesign care around the needs of their populations.
Finally, improving outcomes will require effective collaboration between national leadership, regions, commissioners, providers and partners.
Clarity is now a condition for delivery
Leaders do not need every detail settled, but they need enough certainty to plan, retain expertise and focus on delivery.
It's been18 months since we first learned of the Government's plans for a major reorganisation of the service. Ministers now need to provide the overdue clarity that organisations need to plan and deliver with confidence.
The success of the new operating model will not be judged by where functions sit on an organisational chart. It will be judged by whether leaders across the NHS understand their role, have the clarity, capability, trust and autonomy to fulfil it, and can get on with improving outcomes, modernising services and delivering better care for patients and communities.
