The move to give the mayors of Greater Manchester and South Yorkshire greater oversight of NHS ICBs is notable, potentially marking a new phase in health devolution. Enabling ICB chairs to also serve as mayoral health commissioners, accountable to both the NHS and elected mayors, aims to test ‘the Bevanite foundation of the NHS' and whether devolved leadership can accelerate progress on prevention and health inequalities.

Whether this is a genuine game-changer remains to be seen. Greater Manchester has been here before with earlier health devolution delivering less autonomy than anticipated. ICBs will remain accountable to the secretary of state and national priorities. With limited detail on how these roles will operate, it is not yet clear whether this will result in a genuine sharing of power and influence. And some of these links are already being mirrored elsewhere, with the 10-Year Health Plan proposing mayoral representation on ICBs, suggesting the reforms may not be as unique as they appear.

At its best, this reform could strengthen the NHS's focus on prevention, shifting some accountability from Whitehall to local communities. Giving mayors a formal oversight role could shape NHS decision-making by enabling leaders directly accountable to local people to identify what is working and what isn't in their communities. As Wes Streeting said in announcing this, mayors know their regions better than ‘wonks in Whitehall'.

This matters for prevention. Improving population health requires difficult trade-offs: shifting resources upstream, investing in long-term outcomes and prioritising interventions that may not deliver immediate results. These choices benefit from local legitimacy and a close connection to communities. If this reform strengthens that link, it could support more ambitious place-based public service reform.

However, there is an equally important risk. Mayors' distinctive contribution to health lies in operating beyond the NHS. Through powers over transport, housing, skills and economic development, they are uniquely placed to act on the building blocks of health while supporting inclusive economic growth. Our Mayoral Regions Programme – which supports strategic authorities in embedding health in all their policies and strengthening action on the wider determinants of health – has underlined the potential for mayors to link health with economic growth and their wider responsibilities.

This new health commissioner role is explicitly rooted in the NHS, rather than in the wider services that shape health. This risks reinforcing a model in which health is still primarily viewed through the lens of healthcare.

Greater mayoral involvement in the NHS may also dilute and distract from this broader role. Running health services is politically and operationally demanding, requiring attention on waiting times, financial pressures and performance targets. The experience of ICBs illustrates this challenge. A formal objective to support economic development and tackle inequalities has often been crowded out by more immediate NHS priorities. At the same time, this heightened focus presents an opportunity to sharpen the NHS's otherwise vague agenda on social and economic development. There is a risk, however, that the same dynamic could play out here with mayoral attention drawn into short-term system pressures, rather than the building blocks of health where impact is likely to be greater.

There is a further risk in framing these pilots primarily as a partnership between strategic authorities and the NHS.  Improving health outcomes requires co-ordinated action across local government, public services and communities. Local authorities, in particular, bring expertise in public health and social care alongside a deep understanding of local needs.

For this model to be meaningful, more than representation around the table is needed. Meaningful change will require practical levers such as pooled budgets, joint planning and commissioning between the NHS and wider services, and new ways of delivering integrated services. Mayors will need to work closely with local government, particularly directors of public health with their statutory role and expertise in prevention, and the NHS to align priorities and resources.

There is also a question of how far this model can be replicated. Greater Manchester's experience of devolution and South Yorkshire's strong mayoral focus on health provide a foundation for these pilots. But other areas are at different stages of development. Institutional maturity, local relationships and capacity vary and boundaries between strategic authorities and ICBs are not always aligned. Changes to ICB footprints, including mergers and clustering across larger geographies may further complicate matters. A single, standardised model is, therefore, unlikely to work everywhere.

The creation of mayoral health commissioners is a significant step. It has the potential to bring the NHS closer to communities and to support a more preventative, locally led approach. The challenge now is to ensure this reform delivers on its promise: not just changing who sits around the table, but enabling a genuinely joined-up approach, where healthcare is aligned with sustained action on the building blocks of health.