The MTG sat down with Sebastian Rees, Head of Health at the IPPR (Institute for Public Policy Research) to discuss our new report on accountability.

From the Ten Year Health Plan to the abolition of NHS England, there appears to be ample opportunity for local leadership to drive outcomes and implement change. How do you think this will transform accountability in the NHS?

The stated intent of the new operating model set out in the Ten Year Health Plan and the decision to abolish NHS England is to devolve more power and responsibility to local leaders, and in turn those providing and using health services. In principle, that’s the right direction of travel – attempting to run a system as large and complex as the NHS centrally is an experiment which has run its course. But changing the organisation chart won’t fix the NHS’s accountability problems on its own, unless there is genuine clarity on who is responsible for what.

What we’ve seen in practice is that accountability works best when national priorities are translated into clear, locally owned goals. This does not mean a long list of short-term targets, but a small number of outcomes that local leaders genuinely feel responsible for delivering. Where responsibilities are blurred across national, regional, and local layers, decisions slow down and leadership confidence drops.

For example, responsibility for capital investment in innovation is often split awkwardly between local systems that identify the need for new digital tools or modernisation of their estate, and national bodies that control approval and funding routes, meaning promising innovations can take years to progress and local leaders become cautious about proposing changes they cannot authorise.

A similar problem exists with responsibility for transforming clinical services: national programmes may promote new models of care or transformation priorities, while integrated care systems and providers are expected to implement them without clear freedom to adapt or scale approaches locally, leaving leaders uncertain about how far they can innovate without triggering intervention.

In both cases, the result is slower decision-making and a culture where leadership confidence is eroded because accountability for outcomes is not matched by control over the levers needed to deliver them.

If decentralisation is going to work, it needs three things: clear agreements between the centre and local systems about what success looks like; open, public reporting so patients can see how their local NHS is performing; and a stronger role for communities in shaping priorities. Countries like Australia and Canada show that devolving power can work well, but only when accountability is simple, visible, and consistent. Removing NHS England could, in theory, make accountability clearer but it won’t happen by accident.

A key theme from the MTG report suggests that the “corporate governance” model can sometimes encourage risk-aversion in the health service, especially around transformation and innovation. Are there examples, both at home and abroad, you can point to where strong leadership and accountability can deliver this change?

There’s no shortage of ideas or ambition in the NHS. The problem is that the way governance works can make innovation feel risky. When it isn’t clear who has the authority to make decisions, or how success and failure will be judged, leaders naturally become cautious. What is often seen as a cultural flaw in the NHS, is actually a rational response to uncertainty. Systems with clearer governance and shared expectations about risk are far more likely to try new approaches and scale what works.

The answer isn’t just to strip away layers of governance – many processes that feel cumbersome to innovators are unfortunately integral in a safety-critical, publicly funded system. It is instead to make governance and processes smarter. Innovation should be part of the core business of NHS boards, not something that sits at the margins.

Oversight needs to balance managing risk with encouraging improvement, and leaders need the confidence and capability to work across complex partnerships. Other health systems offer useful lessons. In places like New Zealand and Scandinavia, governance frameworks make it clear that responsible experimentation is expected, provided outcomes are measured and learning is shared. The NHS can do the same if the incentives and signals are right.

In a period of structural upheaval, how can the NHS ensure clarity of accountability to patients, Parliament, and frontline staff?

If there’s one thing that policymakers should have learnt over the last two decades, it is that periods of major reform always create uncertainty, especially for staff and patients. Clearly, the current restructuring has been more challenging than it needed to be. National leaders have not always set out a clear picture of what the future operating and governance model will look like.

Announcements have often come in a piecemeal way, sometimes overlapping or appearing to pull in different directions. That has made it harder for local leaders and frontline teams to understand how the pieces fit together, or where responsibility will ultimately sit. At the same time, rapid structural change has disrupted some of the personal relationships between national, regional, and local leaders that, in practice, often play a crucial role in making accountability work day to day.

That context makes clarity even more important. Confusion in the NHS tends to come not from a lack of oversight, but from overlapping roles and unclear expectations. People want to know who is making decisions, how progress is being judged, and who is ultimately responsible when things go wrong. Maintaining confidence now means being much more explicit. That includes clear, plain-English explanations of roles from the national to local level; regular, consistent updates on progress against the long-term goals of the Ten Year Health Plan; and performance information that patients and the public can easily understand.

International experience shows that transparency and consistency help rebuild trust, even during major reform. Ultimately, good accountability in a period of upheaval is about giving patients, staff, and the public confidence that the system knows where it’s going, and who is responsible for delivering it.

February 2026