Major changes to the structure and organisation of the NHS are usually the subject of intense debate in Westminster, the media and academia. The emergence of NHS groups is a notable exception.

New analysis by The Health Foundation and the University of York shows a quarter of NHS trusts in England have either joined a group, or are planning to do so in the next couple of years. 

What's more, most of these trusts have decided to do so recently since the end of the pandemic. Yet the accelerating rate of group formation has prompted little public discussion or scrutiny. 

Given that NHS groups are set to play a critical role in the delivery of the 10-Year Health Plan, not least because some are well placed to become Integrated Health Organisations, there is a clear need to boost awareness of groups. Our new research report aims to address this need by building understanding of what NHS groups are, what they do, and, crucially, how they are led. 

In doing so, it builds on important work by NHS Confederation and the Association of Groups. 

A challenge in carrying out research on groups is that they don't conform to a standard pattern. 

As one senior group leader told us: ‘If you've seen one group in the NHS, you've seen one group.' A case in point is their legal status. Some groups, like the Foundation Group in the West Midlands, are formal partnerships between sovereign NHS trusts. Others, such as Royal Free London Group, are single organisations with multiple hospital sites or care services. Groups have also been formed at different times for different reasons. This heterogeneity partly explains why groups haven't been given the attention they deserve. 

Nonetheless, groups have some common characteristics. The leadership structure is one such example. Usually this comprises of a ‘group level' leadership team responsible for the strategic leadership of the whole group and site-based leadership teams responsible for the operational leadership of individual hospital trusts, hospitals or care services. 

For many of the group leaders that we interviewed for our report, this leadership structure is one of the most ‘fundamental' and ‘beneficial' properties of the group model. It ensures that leaders' time is not split between multiple competing priorities. Site-based leadership teams can focus largely on maximising the quality, safety and efficiency of care services, leaving the job of ‘determining groups' strategic intent' and working with key external strategic partners to the group headquarters' team. As such, it is a model that enables large, complex groups with multiple sites to be ambidextrous, allowing them to focus both on immediate front-line performance and long-term strategic issues. 

The potential value of this leadership model to large groups was underlined in University Hospitals Birmingham NHS FT's recent CQC well-led review, which lifted the trust's rating from inadequate to good. The group's ‘new devolved model of leadership to hospital sites', the review concluded, had ‘secured a more granular view of issues faced and priorities for services'. Meanwhile, hospital-based staff (but notably not those working in trust-wide services) reported the changes had helped them to feel ‘more like a family working together'.

Implementation, however, is crucial. Some of the groups we investigated have avoided familiar NHS design and delivery pitfalls and have made good progress in building a coherent group infrastructure and ensuring their work is underpinned by a clear rationale supported by staff and the community. 

But this is by no means the case everywhere. Some have created problems for themselves in their haste to set up their group. Not only have they underestimated the effort and resources required to set up groups, but their strategic and business cases for doing so seem underdeveloped. 

What this shows is the importance of drawing and sharing the lessons from groups making the best progress and of greater scrutiny of decisions to form groups. Strengthening the evidence base for group formation is also critical. 

For all the promise offered by the group model, not least the opportunity to achieve economies of scale, share staff in short supply and deliver clinical and operational standardisation at scale, there remains a dearth of independently verified evidence of these benefits being realised on the ground. ‘We're in the realm of belief, rather than evidence,' one group leader admitted to us. 

A further challenge is that NHS national leadership training and development arrangements do not yet prepare leaders for the particular challenges faced by those leading groups. 

To support the process of group formation and to maximise the likelihood of success, it is vital that all these issues are addressed, and soon. If not, then groups may struggle to achieve the ambitious goals ascribed to them.