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Analysis

Leading NHS groups
Findings from interviews with group leaders in England

Published 22 August 2025
Time to read clock icon About 26 mins
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Key points

  • The NHS group model has become increasingly popular, despite the absence of recent national policy that explicitly encourages group formation. First articulated in the Dalton review in 2014, groups look set to play a central role in driving improvements to NHS productivity, emergency and elective care, and in implementing the 10-Year Health Plan.
  • Since the pandemic, the rate of group formation has increased markedly, according to analysis by the Health Foundation and the University of York. Almost a quarter of NHS trusts have now adopted, or have committed to adopt, a group model.
  • Groups differ in composition, size and rationale, but many possess common strategic, structural and leadership characteristics. The perceived benefits include quality and efficiency gains from standardising clinical pathways and processes; the opportunity to establish separate strategic and operational leadership functions; and economies of scale from creating central corporate service functions.
  • Research on group leadership is limited. To help address this gap, we examine two key roles: the group chief executive and the hospital site leader, exploring responsibilities, relationships, and the training and support required. These roles have a critical bearing on groups, including how they operate and their ability to achieve a positive impact.
  • Efforts to strengthen NHS management capability, while avoiding cuts in management numbers, may prove particularly beneficial for groups. But to support group formation and maximise their likelihood of success, we highlight a range of actions needed from national policymakers, regulators and groups. These include building a deeper understanding of what it takes to plan and deliver an effective group; developing a tailored national training offer; and reviewing how groups are regulated.
  • While the group model has much to recommend it, groups will be better placed to undertake their role if variations in their design, implementation and leadership practice are identified and tackled. 
 

Introduction and overview

For a growing number of NHS trusts, not least those facing financial or quality challenges, group membership is seen as a means of delivering economies of scale and greater standardisation and reliability. Group membership can also hold appeal as it brings trusts under the umbrella of a central leadership team that is often highly experienced. 

The profile and status of NHS groups is likely to increase in the years ahead. With some groups aspiring to become vertically integrated, ‘accountable care’ type organisations that span acute, community and primary care, NHS groups are well placed to benefit from the establishment of integrated health organisations (IHOs) announced in the 10-Year Health Plan. The move towards having fewer but more strategic commissioning bodies could also suit NHS groups given the scale of their geographic footprint. On the other hand, the 10-year plan introduced dynamics that will require clarification for NHS groups, including the greater emphasis on competition between autonomous, standalone providers and the reinvigoration of the foundation trust model, with greater freedoms for high-performing individual trusts. 

It is therefore important to better understand what NHS groups are, why they have been formed and what impact they have achieved. Some valuable resources and channels already exist (such as the Association of Groups platform for inter-group learning and recent NHS learning reports on the shared leadership of NHS trusts and collaboration at scale). But not enough is yet known about how NHS groups are led and run, and how this differs from other forms of leadership in the health service.

About this analysis

This analysis focuses primarily on the leadership of NHS groups, part of the Health Foundation’s wider work on NHS management capacity. Based on interviews with group leaders, it examines two key leadership roles: the group chief executive and the site leader (sometimes referred to as site chief executive or managing director). These roles exemplify one of the critical differences between the management of groups and NHS trusts: the division of strategic and operational leadership between a central group and local site-based leadership teams. It is important to understand how the two roles operate, what responsibilities each holds and how the relationship between them works. 

This analysis begins with the core characteristics of groups, their perceived benefits and the challenges they have encountered. It highlights the lack of a clear, widely understood definition, causing confusion as to what is and what is not a group.  

In addition to providing insights for new and prospective group leaders and policymakers overseeing the NHS provider community, this research will be of value to those charged with developing training and support offers for group leaders. It should be especially timely given that an NHS leadership and management framework is due to launch this year and plans are in motion to establish a new College of Executive and Clinical Leadership and to regulate managers.

 

Understanding NHS groups

What is a group and what are the perceived benefits?

An ‘NHS group’ usually takes one of two forms. The first is a formal partnership between sovereign, legally independent NHS trusts. The second is a single NHS trust with multiple hospital or care service sites. Both forms usually operate a distinct leadership structure comprising 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. Most NHS groups consist of acute hospital trusts or sites, but some involve mental health, community, specialist or ambulance trusts, or a combination of different trust types. Some groups have ambitions to become vertically integrated organisations that include primary care services.

Groups have existed in England for a decade. They emerged in the aftermath of the Five Year Forward View, which called for new organisational forms to ‘unleash system efficiencies’. The Dalton review published soon afterwards, concluded that NHS trusts, where appropriate, should consider new organisational models that might help to deliver improved reliability, greater standardisation and value, such as the ‘multi-hospital chain’ or group. A group structure would allow cross-regional collaboration on care planning and delivery, create a single streamlined strategic decision-making structure and put an end to individual trusts in a region competing for resources. The Dalton review was followed in 2015 by an initial cohort of four groups, announced as part of the Acute Care Collaboration Vanguard programme.

Trends in group formation

We gathered evidence from interviews with 10 leaders and two middle managers from a total of nine NHS groups that vary in size, composition, geographic location, legal status and date of foundation. This qualitative research in a sample of NHS trusts was supplemented by examining publicly available documents from all 206 NHS trusts in England, as well as relevant grey literature and media articles to allow the identification and analysis of all current NHS groups and their core characteristics. Interviews with representatives from two national NHS trust membership bodies, one regional improvement alliance and one independent consultancy were also carried out.

Approval for this study was granted by the University of York Academic Ethics Compliance Committee on 25 September 2024. 

Today, many NHS trusts have formed or joined groups, while others have confirmed plans to join one in the future. Since the pandemic, the rate of group formation has increased markedly, according to analysis by the Health Foundation and the University of York (Figure 1). 

Figure 1

Our analysis reveals that almost a quarter of NHS trusts have now adopted or are about to adopt a group model (Figure 2). Examples include the Royal Free London Group, a single organisation made up of four main hospital sites and the Foundation Group, a partnership involving four sovereign NHS acute trusts in the West Midlands region. Interest in group formation has not been limited to acute hospital trusts: ambulance trusts, community trusts and community and mental health trusts are also in the process of setting up groups. Meanwhile, some groups involve trusts from different care provider sectors.

Figure 2:

Differences between NHS groups

Groups do not conform to a standard pattern. As one interviewee said: ‘If you’ve seen one group in the NHS, you’ve seen one group’. This heterogeneity is partly a consequence of the Dalton review’s recommendation that there should be ‘no national blueprint or one size fits all’ solution. The review argued NHS trusts should determine the organisational form that best meets their local circumstances, population needs and desired outcomes. 

The legal status of groups is a case in point. Some have decided that a merger between group members is too resource-intensive and contentious. They are prepared to tolerate the inconveniences of not being a single legal entity, notably that each participating trust produce its own set of financial accounts and be inspected separately by the Care Quality Commission (CQC). Meanwhile, others have concluded that only a merger provides the strategic clarity and long-term stability required. In recent years, the trend has been towards partnerships between trusts rather than full mergers, although some groups see the group model as a preliminary step to a merger.

There are also notable differences in the composition of groups. The Foundation Group in the West Midlands, for example, consists of hospital trusts of similar size and status that offer a broadly comparable range of secondary care specialties and serve similar patient populations. This structure ensures that leaders, managers and clinicians in one hospital have a good understanding of the context their peers at other sites operate within – a distinct advantage for sharing learning and innovation. On the other hand, some groups feature a mix of tertiary and acute care hospitals, each with a different profile. One benefit of this model is that it facilitates improved patient pathways between district general hospital sites and highly specialised centres, assuming that the group members operate within the same local health care system. Additionally, it may enable district general hospital sites, which often struggle more than large tertiary centres to recruit staff, to second personnel from the latter to fill their staffing gaps. 

Another distinction among groups is that some aspire to become vertically integrated structures combining aligned tertiary, acute, community, primary and social care functions –accountable care type organisations – while others are likely to remain primarily hospital-based groups for the foreseeable future. Given the government’s desire to shift more care out of hospital and into the community and promote ‘neighbourhood health’ models and IHOs, the appeal of vertically integrated models is likely to grow in the years ahead. 

Groups also differ in how they form. For some very large single NHS trusts, such as Barts Health, the decision to adopt a group operating model came when it believed it had outgrown the traditional NHS trust structure. In its view the organisation had achieved sufficient ‘critical mass’ in terms of its workforce, turnover, number of sites and size of geographic footprint to benefit from the switch to a group model. In contrast, the Foundation Group in the West Midlands has grown gradually, bringing in one sovereign NHS trust into the group at a time, when it felt it had the capacity to induct a new member. 

Similarities between NHS groups

Many groups share some common characteristics, particularly regarding leadership and structure. Groups typically have a shared leadership function, often consisting of a central headquarters that provides strategic oversight across all participating hospital sites. Generally, as one interviewee described, this headquarters function ‘determines the strategic intent of the group’ and uses its control over the group’s finances and their allocation, along with its ability to establish the group’s standard clinical and corporate policies and practices, to advance these strategic goals. As the strategic lead, the headquarters function also manages many of the group’s external relationships with partners in the local health system as well as at regional and national levels. Meanwhile, responsibility for the daily operational leadership and management of each site is usually devolved to hospital-based leadership teams. These teams can influence group strategy and policy, and are tasked with implementing them; however, the authority to establish them resides at headquarters level. 

Many interviewees saw the creation of dedicated and separate strategic and operational leadership functions as one of the group model's most ‘fundamental’ and ‘beneficial’ properties, not least because it ensures that leaders’ time is not split between multiple competing priorities. As one leader pointed out, while site-based hospital leadership teams manage local place-based relationships that are critical to operational delivery, they can leave the job of working with strategic partners, such as integrated care boards, NHS England and the CQC, to their group executive team. This allows them to focus largely on maximising the quality, safety and operational efficiency of care services. In contrast, the leaders of NHS trusts that are not group members have to juggle both commitments at a time when their system leadership responsibilities are on the rise. This leadership model enables groups to be ambidextrous, allowing them to maintain a grip on both front-line service performance and emerging strategic issues.

At the core of many group leaders' thinking is the belief that organisations as large as groups – with tens of thousands of staff, billion-pound-plus turnovers and multiple sites – require a different leadership model than the conventional one used by NHS trusts. A group has more ‘interfaces’ than a typical NHS trust – for example, between the central group and hospital sites and between the hospital sites and clinical and corporate support services. To manage an organisation of this scale and complexity effectively, one leader argued, ‘You need different structures, processes, and behaviours.’ However, close attention needs to be paid to the cultural and infrastructural ‘glue’ necessary, he said, to align a group’s many services, functions and staff communities. 

With this purpose in mind, groups have developed operating models to guide the interactions between discrete functions and services, along with governance arrangements that inform decision-making processes and the flow of information across the group. Another approach has been to establish quality management systems to integrate quality planning, control and improvement processes, ensuring alignment in objective-setting activities at both hospital and group levels. Additionally, most groups have sought to establish group-wide values and cultural norms while recognising the importance of each hospital site fostering its own identity and relationships with the local population. 

Another common group characteristic is the presence of shared corporate or clinical support functions designed to achieve economies of scale and generate savings. Efforts to standardise and align clinical practices to address unwarranted variation are also underway in many groups, usually led by the central group. For example, some have set up clinical groups composed of clinicians and operational managers, sometimes with support from central improvement and analytics teams, in a bid to agree best practice and standardise clinical pathways in particular specialties. Group membership has also enabled participating sites to take advantage of group-wide mutual aid arrangements that allow sites to plug short-term clinical and operational capacity gaps that are impairing care quality.

On the need for consistent definition

It is important to acknowledge similarities between organisations identified as groups, but overemphasising these can be misleading. The term ‘group’ lacks a consistent definition and is often applied loosely. Many self-styled groups share the core characteristics described above and broadly have the same understanding of their central purpose, form and function. 

Yet there are also NHS trusts that share a chair or chief executive but have no other joint structures or processes, which are sometimes described as groups – even if they do not use the term. The frequent conflation of these distinct organisational and partnership forms makes it harder for those in the NHS, and researchers and policymakers outside it, to understand and analyse the specific traits of each form, and to determine their advantages and disadvantages. Greater precision in the way groups, shared leadership arrangements and other organisational forms are defined and described, both within the NHS and beyond, would therefore be beneficial. 

Impact and challenges so far

Many established groups have reported performance benefits that they attribute to group membership. These benefits are often attributed to quality and efficiency gains from reviewing, redesigning and standardising clinical pathways and processes; or from creating central corporate service functions across groups. 

Nonetheless, the evidence base on the impact of groups remains underdeveloped. This is partly due to their relative novelty: many groups have not been around long enough for their impact to be understood. Meanwhile, data challenges and pandemic-related disruption have affected recent efforts to evaluate more established groups. The fact that groups vary so much in composition and form also makes it harder to assess the value of the general model to the NHS. While evidence of the impact of groups in other health care systems exists, such as in the US and Europe, where they are more common and longer established, it is unclear how applicable this learning is to an NHS context. 

Many of our interviewees, including those supportive of the group model, acknowledged these evidence gaps. ‘We’re in the realm of belief, rather than evidence,’ said one, while another questioned ‘…whether it has been clearly established that this model works.’ As such, further research is necessary to understand the overall impact of groups and the factors that help or hinder their ability to contribute positively to NHS performance. Ideally, research should also consider the counter-factual case, namely, the extent to which any benefits derived from group membership could also have been achieved through other forms of inter-organisational collaboration, such as through acute provider collaborative membership. 

That said, important learning is emerging from the way groups are being conceived, designed and implemented – all of which has a bearing on the ability of groups to achieve a positive impact. While all groups we talked to can point to things that have worked well, none have been immune from implementation challenges and setbacks. Most have taken decisions they ultimately had to reconsider due to unexpected outcomes or unforeseen external events. This is unsurprising given the complex environment in which groups operate and the paucity of mature exemplar sites from which others can learn. The leaders we interviewed saw a willingness to ‘learn from what’s working and not working’ and a commitment to adapting the group model in response to new data as vital.

Our interviewees were candid about the difficulties their groups face. Inevitably, cultures have proven harder to change than structures. For instance, separating strategic from operational leadership functions has not prevented some operational decisions from being referred to the central group for resolution. A reluctance among managers to take decisions for fear that they might be blamed if it turns out to be the wrong one – a justified worry in some cases – is one reason for this. To prevent the unnecessary escalation of site-level decisions to the central group, some groups have developed accountability frameworks that identify the level at which a decision should be taken. Others, meanwhile, have adopted a risk-based scoring method to ensure that the central group only intervenes in issues that pose risks to the delivery of their annual group plan.

It is also clear that how groups are being implemented varies markedly. Some groups are founded on a clear rationale that has been tested and refined in collaboration with their workforce, patients and regional and national stakeholders. Other groups, however, appear not to have a coherent rationale that senior leaders can consistently articulate. In some cases, the decision to join or form a group appears to have been at the behest of influential external figures, rather than being driven from within – potentially making it harder for the group to gain legitimacy and credibility in the eyes of its workforce. A desire to follow the lead of other high-profile trusts in a bid to conform to prevailing social norms and enhance reputation, may also be partly responsible for the desire among some trusts to join a group. This mirrors other learning that the ‘pressure to mimic others’ is one of the principal drivers of inter-organisational collaboration in health care.

 

Understanding the role of group chief executives and hospital site leaders

Research has identified a variety of enabling factors for effective group leadership. For example, when seeking to build and sustain trust between collaborating organisations, it helps to have authentic, empathetic, generous and visible leaders. Another important success factor is the ability to set realistic and honest expectations and plans about the partnership, together with a commitment to involving staff at all levels when establishing them. Meanwhile, clarity from leaders about the problems the partnership will solve and what each workforce, organisation and patient group will gain is key to building broad support for the collaboration. Once the partnership is in place, a stable leadership team that presents a consistent narrative about the purpose and goals of collaboration is important in maintaining and strengthening faith in the partnership.

Leadership attributes for inter-organisational partnerships are well-studied, but research on group leadership is limited. To help address this gap, the following section examines two key roles: the group chief executive and the hospital site leader, exploring their responsibilities, relationships, and required support and training. These roles have a critical bearing on how groups are conceived, planned and implemented, and, in all probability, the variation between groups identified. As such, a greater understanding of how these two roles work and the factors that can enable or impede successful performance can help shed important light on how groups operate and their ability to achieve a positive impact.

Group chief executives

The applicant pool for chief executives is mainly composed of leaders with successful operational track-records. Yet excelling in operations does not guarantee success in the strategic leadership required for the role. As one interviewee noted, it is not a certainty that ‘the best operational leaders can become the best strategic leaders’. These roles demand fundamentally different skills and mindsets.

The transition to group leadership can be challenging for those with operational backgrounds. Moving from a hands-on and highly-visible leadership role to a more strategic position, accountable for operations but not directly leading them, requires a significant shift in mindset. Respondents told us they ‘miss the enjoyable hands-on elements’, and some feel nervous about handing over operational leadership decisions to others ‘when it is your name on the door’. They expressed the need to become comfortable with taking a step back and trusting operational leaders. This transition is crucial. We heard that if group leaders fail to adapt, they risk creating friction with hospital-based leadership teams, who may feel that their authority and ability to make timely decisions are being undermined due to the perceived need to obtain group-level approval of decisions. 

The most experienced group leaders see their role as coaching, enabling and supporting their operational leaders, often by posing questions or providing guidance when requested. This means resisting the urge to act as the ‘heroic leader’, uniquely qualified to make all major decisions on the group’s behalf, and learning to trust leadership teams at site level. At the same time, group leaders are conscious that becoming too detached from front-line operations will make it harder for them to exercise effective oversight of hospital operations, ensuring their alignment with group strategy. The aim, according to one leader, is to ‘devolve as much authority and responsibility as possible’ to hospital leadership teams, while ensuring that hospitals do not become ‘completely autonomous within the group’. If this was to happen, he argued, the group would cease to be a cohesive single entity; the group headquarters would effectively become akin to an independent regulator or a system-level body, such as an integrated care board.

Group leaders also need to strike the right balance between group and system-level leadership responsibilities. In addition to setting their own group strategy, they are expected to help shape the strategy, architecture and culture of their local health care system by leading others when relevant, working in collaboration, or offering support and challenge to their peers. Effective leaders need to have ‘one foot in the system and one foot in the group’ and be agile enough to respond rapidly to challenges and opportunities in either sphere. Sometimes the priority will be to look ‘down and in’; at other points it will be to look ‘up and out’. Judging when to do either relies on accurate and relevant intelligence on group and system-level performance, and horizon scanning that identifies emerging and future trends. Leaders’ ability to build a network of contacts with well-placed individuals across the system and within the group, who can provide timely insights, is important here. 

Site leaders

Site leaders, variously called site chief executives or site managing directors, are one of an increasing number of boundary-spanning NHS leadership roles that have emerged in recent years. Operating at the intersection between front-line services and group headquarters, site leaders must be adept at managing both downwards, upwards and sideways. The quality of their relationships with their group chief executive, site executive team and fellow site leaders at other hospitals in the group, has a critical bearing on their success and, often, length of tenure. They may not have responsibility for setting group strategy, but need to be accomplished strategic thinkers to navigate and mitigate the complexities and tensions that inevitably emerge between and within the various leadership tiers of a large group. For some site leaders, this is the ‘hardest part of the job’. Ensuring that the site-based leaders and managers who report to them feel that ‘they can do stuff and have their say’, while making sure that group leaders feel informed and involved is ‘tough’ and a ‘constant challenge’. If they fail to find the correct balance, they will not only undermine their own position but be left having to assuage frustrated site-based leaders and managers, who have been overruled or feel disempowered, and a group leadership team unhappy that decisions they see as strategically significant have been made without them. 

Leadership stability is seen as vital by site leaders in maintaining a healthy dynamic between hospital sites and group headquarters. Effective decision making relies on trust between individual leaders and familiarity with their respective leadership styles and preferences, which are difficult to achieve in organisations with a high turnover. Stability within the wider hospital senior leadership team is also highly prized by site leaders. In the eyes of our interviewees, the presence of experienced and trusted chief medical, nursing, operations and finance officers at site level was usually key to making the site leader role ‘doable’. Site leaders must work hard to retain such individuals though, who would have board-level roles if working in an NHS trust not part of a group.

Another relationship many site leaders feel is important to cultivate is that with their counterparts in other hospital sites in the group. Fostering a collaborative relationship has manifold benefits. At difficult times, it is a source of peer support that can make the job ‘less lonely’. It also allows site leaders to discuss ideas and share learning about how to deal with operational or workforce challenges in their respective settings. Our interviews suggested that site leaders have found this collaboration especially valuable if their counterparts have had different leadership journeys to their own and are able to bring a different perspective and set of skills. This suggests that groups will benefit from recruiting site leaders with varying but complementary expertise and experience.

The role of hospital site leader will appeal to all aspiring organisation leaders. Some may prefer to focus on becoming an NHS trust chief executive, despite all the attention and pressure it entails, rather than having to answer to a more senior group leader. Yet reports claiming that openings for hospital site leader posts often attract a strong field of candidates – sometimes in contrast to trust chief executive roles – suggest that the role is well-regarded in the service and seen as a desirable career move. 

Support and training

For pioneers in any field there are advantages and disadvantages from being the first to do something. For the first wave of group leaders in the mid-2010s it was no different. On the one hand, the first group leaders were able to put their own stamp on the job. Our interviewees found the opportunity to be the first to shape the form, purpose and identity of groups to be both rewarding and exciting. On the other hand, it meant that they had to learn almost entirely on the job, with some drawing occasionally on the experiences of leaders in other health care systems and industries, in the absence of any training offer. 

Today, new and aspiring group leaders are in a stronger position given the growing number of experienced current and former group leaders on whom they can call for advice and support. Networks such as the Association of Groups, which provide senior group leaders with a means to share learning and ideas, play an important role in forging these connections. But while there are established programmes for aspiring and new chief executives, there are no formal training and development offers tailored to group leaders, chairs and group-based site leaders. A national offer for organisation and group leaders that covers the skills, knowledge and expertise required to lead at scale would help to close this gap – a point also made by HSJ last year.

Groups themselves can have an important role to play in training and supporting their leaders. Some groups have set up talent management strategies to identify and nurture the next generation of leaders from within their ranks. Given concerns about the apparent dearth of experienced NHS chief executives, and the service’s patchy record in recruiting and retaining leaders from outside the NHS, these groups calculate that their best chance of filling current and future senior vacancies is to grow their own leaders. In this sense the group leadership structure, which allows aspiring group leaders to develop crucial leadership experience by running a hospital site without the burden and scrutiny that comes with being an accountable officer, provides an attractive leadership development pathway. As one group leader argued, the hospital site leader is ‘a perfect role for getting that breadth of experience in a relatively safe environment’.

To develop their leaders, groups have set up coaching and mentoring opportunities for individual leaders and leadership teams, and tried to ensure that leaders have ready access to strategic advice and support. One group, for instance, has created a team of in-house expert senior advisers with a range of strategic, financial, medical, improvement and general management skills and expertise. None of this team have formal group leadership roles of their own, allowing for deployment rapidly across the group to support site leaders facing pressing operational challenges. The team also has the time and licence to help leaders develop and implement group-wide strategies on priority issues, such as productivity improvement and digital transformation. As well as being cheaper to procure than the management consultancy services to which many NHS trusts turn, the in-house expert team actively seeks opportunities to pass on its expertise and knowledge to the group’s leaders, especially to those new in post. This arrangement therefore serves to strengthen the group’s leadership capability while improving its strategic and operational resilience. For the group in question, the opportunity to recruit and maintain such a team has only been made possible by the group’s size and scale: none of the individual NHS trusts that make up the group would have had the resources or demand to justify or support the recruitment of such a team.   

Group leaders’ ability to perform well is dictated not only by their own capacity and capability, but by those of the people around them. One major impediment, according to some of our interviewees, is middle-management capacity and capability at hospital-site level. They drew attention to what they saw as the under-management of many hospital divisions and services, especially in the largest trusts and hospitals. While management arrangements vary across organisations, the standard divisional leadership team – consisting of a part-time clinical lead and full-time operations and nursing leads – might just be sufficient in a district general hospital, they argued, but in a major teaching hospital site it represented ‘a pretty weak amount of management capacity’. This lack of capacity was compounded, according to some, by a shortage of key skills in some management tiers, due in part to the suspension of training and development programmes during the pandemic – a point echoed recently by Jim Mackey. As a result, operational issues, one leader observed, are ‘endlessly going to creep up to the executive team’, which then has to ‘dig deep down into the organisation to rescue things’. 

These challenges are not unique to groups: all NHS trusts face some management capacity and capability constraints. The difference is scale. The net impact of these constraints on group leadership teams’ capacity is likely to be larger than on the average NHS trust executive team, given the greater number of sites overseen by groups. The group leadership structure will absorb some of this burden, but by no means all of it. This suggests that efforts to strengthen NHS management capability, while avoiding cuts in management numbers, may prove particularly beneficial for groups. Greater management capacity and capability coupled, as highlighted earlier, with efforts to build a culture that ensures managers have the permission and confidence to take operational decisions, would help to free up much group leadership capacity.

 

Conclusion and recommendations

At a time when NHS trusts are looking for efficiencies and experienced staff to fill vacancies from the boardroom to the ward, there is clear logic for entering into group arrangements with their peers. Group working offers the prospect of improved knowledge dissemination across trusts and can help to achieve greater clinical and operational standardisation. This can reduce the local variation experienced by patients, while the procurement and use of standard equipment can generate economies of scale. Equally, the group leadership model, with its division of strategic and operational responsibilities between the central group and hospital sites, has obvious attractions for hard-pressed leaders grappling with an ever-lengthening list of responsibilities. 

Implementation, however, is crucial. Some groups have managed to sidestep many of the familiar NHS delivery pitfalls and made steady progress on building a coherent group architecture and culture, even if the impact on services and patients has proven hard to evidence. They have also worked hard to involve workforces, patients and communities in the change process, ensuring genuine opportunities to shape the group. Other groups, though, have struggled to do this in a pressured environment and have created problems for themselves in their haste to set up their group, or through failing to build a clear, widely supported and evidence-based case for change in tune with local population needs. These experiences underline the challenge involved in implementing a new model while maintaining existing services – something once described as akin to ‘redesigning the aeroplane in flight’. Further, some groups experience tensions between chief executives and site leaders, often due to unclear role boundaries.

To support the process of group formation and maximise the likelihood of success, a range of actions by national policymakers, regulators and NHS groups are needed:

  • Set out a clearer definition of an NHS group, ensuring clarity about what a group is and is not, and the different types that exist. The group model presented in the Dalton review is a flexible one that embodies certain core principles and components but allows groups to develop their own approaches that are tailored to local circumstances and needs. This is one of the main attractions of the group model, and there is no appetite among groups for creating a single standardised template. The downside of having a flexible approach is that the group model is not widely understood and frequently confused or conflated with other collaborative arrangements between NHS trusts, hindering efforts to understand the value of the group model. A clear and widely communicated description of what a group is and is not, and, crucially, what a group’s core characteristics are, would help to avoid this.
     
  • Support research to build a deeper understanding of what it takes to plan and deliver a functioning and effective group, including leadership. Understanding the success factors for groups will help leaders of prospective groups assess the pros and cons of becoming a group and their readiness to do so. Further, it will enable existing groups to identify and address areas for improvement. There is a clear need for further research, especially on group performance and outcomes, and specifically what factors can enable a positive impact. It will also be important to build on work already being undertaken by networks, such as the Association of Groups, to disseminate learning and insights.
     
  • Develop a tailored national training, development and support offer for group chief executives and hospital site leaders. While there are established and well-regarded national training and development offers in place for aspiring and new NHS trust chief executives, there are few, if any, bespoke offers for the group or site leaders of groups. Given the unique challenges facing these leaders, who constitute a growing proportion of the NHS senior leader population, it is time that this gap in provision is addressed. Plans for a College of Executive and Clinical leadership and the launch of a new NHS management and development framework this year present an ideal opportunity to do so. To maximise impact, both initiatives will need to pay close attention to the accelerating consolidation of the acute health care provider sector and ensure the delivery of an offer that is relevant to the development and support needs of those leading groups.     
     
  • Examine how groups and other inter-organisational collaborations in local health care systems can best operate alongside each other. Many groups have worked to forge strong ties with local provider collaboratives and other partnerships, ensuring their roles are complementary. However, this is not the case everywhere. We heard that in some regions a lack of clarity regarding role responsibilities and leadership has caused strategic confusion and delays. Providing clear guidance on effective collaboration and building a library of best practice examples would help groups broker effective relationships with their local partners. It will also be critical to clarify how proposals in the 10-Year Health Plan around provider competition, assessment and autonomy relate to NHS groups.
     
  • Review how groups are regulated. In our interviews, we heard a common frustration for groups that operate as partnerships of sovereign NHS trusts is that the CQC inspects the individual participating trusts rather than the group as a whole. This means no direct scrutiny of a group’s central strategic function or its collective activities. As such, there is a strong case for reviewing whether there should be specific regulatory processes in place for non-statutory organisational forms, such as groups. 

To ensure that these measures have the greatest impact, they will need to be accompanied by action across the whole of the NHS provider community to strengthen its management capability, while avoiding cuts in management numbers. This will help free up NHS group leadership capacity to focus on core leadership responsibilities, and give groups the best possible chance of delivering performance improvements.

Groups are now a fixture of the health care provider landscape. They are set to play a central role in driving improvements to NHS productivity, emergency and elective care, and in implementing the 10-Year Health Plan. But they will be better placed to do so if the variations in design, implementation and leadership practice we describe are identified and tackled. As such it is clear that further action is needed to support the effectiveness of this organisational form. 

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