Healthcare delivery
driver of inconsistent delivery. FOI responses suggest that high-performing ICBs are explicit about who holds accountability – often their Chief Medical or Nursing Officer, supported by established committees, such as System Quality Committees or Quality and Performance Committees. Yet interviewees stressed that “accountability is dependent on people rather than organisations”, with culture shifting when key individuals move on and formal corporate governance structures not always translating into meaningful accountability for programmes on the ground. Process-heavy governance is also slowing
innovation and decision making. Several ICBs described long, bureaucratic approval routes for business cases, especially for new technologies, with one leader reflecting that internal approvals “don’t change anyone’s lives” and that systems have “nested in the governance space” instead of enabling senior leaders to make the sort of bold decisions that entail transformation. At the same time, national focus on league tables and multiple metrics can obscure priorities, leaving providers unsure whether to prioritise comparative rankings, CQC ratings or longer- term population health aims. Accountability to patients is, in many places,
limited or superficial. The MTG’s previous work on Meaningful Patient Involvement described patients as often “thought of, but not included” in planning and delivery. FOI responses for this report suggest that this remains the case, with public Board meetings often attended by the “professionally interested” rather than reflecting wider communities. While some ICBs are beginning to embrace digital feedback and outcome measures, this is far from universal, and patients’ experiences and expectations are not consistently used to shape decisions.
Where accountability is strong Despite these challenges, the report identifies clear examples of what good looks like, highlighting ICBs that combine explicit accountability with structured innovation pipelines and integrated outcomes monitoring.
Dorset, Gloucestershire, and Bristol, North Somerset and South Gloucestershire (BNSSG) stand out in FOI data for established pipelines to evaluate new technologies through Digital Transformation Boards, Area Prescribing Committees and Clinical Advisory Groups, underpinned by frameworks such as Dorset’s four-pillar value-add model and Gloucestershire’s Evaluation Oversight Group. Though ring-fenced innovation budgets remain rare, targeted funds and micro-grants in some systems signal commitment to adoption and spread. BNSSG is presented as a consistently
strong performer and an illustration of mature system governance. Accountability sits clearly with the Chief Nursing Officer and Chief Medical Officer, supported by formal structures including a Clinical Information Committee and Digital Boards, and the ICB has adopted NHS England’s CoDE process to evaluate emerging technologies. Outcomes monitoring is embedded in mainstream reporting, with initiatives such as a COPD digital self-management programme used to inform future service configuration rather than sitting on the margins of performance discussions. NHS England’s 2023/24 annual assessment supports this, recognising BNSSG for strong leadership, effective governance, productivity improvements and progress on health inequalities. The MTG notes that this alignment between FOI evidence and national assessment suggests that structured innovation governance and integrated outcomes monitoring are not just internal good practice, but drivers of improved system performance and readiness for new responsibilities such as specialised
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commissioning. Sussex offers a further example, where embedding PROMs and PREMs aligns with national recognition for work to tackle inequalities of access, outcomes and experience. By contrast, the report also describes ICBs
where lines of accountability are vague, no structured approach to innovation is evident and patient outcomes are not monitored systematically. In these systems, weaknesses in governance mirror limited progress on productivity, persistent variation in outcomes and slower preparation for delegated responsibilities. These gaps in accountability translate directly into poorer performance for patients.
Recommendations: building accountability for an era of reform Across all themes, the most effective ICBs are characterised by transparency about who is accountable, embedding best practice into routine governance, collaboration with partners such as Health Innovation Networks and regional joint committees, and budget signalling that demonstrates commitment even when resources are constrained. The MTG’s recommendations are designed to
move accountability beyond short-term targets and fragmented oversight, and towards the sort of sustained and transparent delivery parts of the system are starting to model. First, the report calls for multi-year accountability contracts between DHSC, regions, ICBs and providers, setting clear expectations for financial balance, productivity and outcomes. This would see Boards reviewing progress
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