Trusts in systems: Engines of transformation

Saffron Cordery profile picture

27 June 2022

Saffron Cordery
Deputy Chief Executive
NHS Providers

Next month will see big structural changes to the NHS, as integrated care systems (ICSs) become statutory bodies under the new Health and Care Act.

The Health and Care Act does not alter the statutory underpinning of trusts and foundation trusts. Many fundamentals will remain:

  • Trusts will continue to have organisational duties and liabilities based in law,

  • They will deliver many key local services, and;

  • They will continue to employ the majority of NHS staff.

But trusts are changing in other ways. The new law cements a change in mindset that has been underway for a few years. For trusts, their starting point is increasingly that they work within systems.

That means trusts' strategic focus is orientated towards how to drive forward integration, improve access to care and manage resources effectively by collaborating with local partners. The ultimate aim, of course, is to improve population health and outcomes.


Trusts supported the thrust of the Act on the basis that it would create a framework more conducive to system working. The Act is not perfect, but it does provide opportunities. Realising these opportunities will require building on the collaborations that trusts and partners – both within and outside the NHS – have been pursuing to develop more integrated models of care.

Collaboration looks different depending on local circumstances, and a range of approaches is emerging. Trusts are joining up primary and secondary care services, fostering multi-agency collaborations within 'places', often working closely with local authority and social care colleagues. They are also developing collaboratives with other trusts, sometimes covering larger geographies.

Another opportunity is to make significant progress on addressing health inequalities.

Saffron Cordery    Deputy Chief Executive

Local leadership is rightly central. In the Act, local organisations and systems are empowered to tailor planning and delivery arrangements to meet the needs of their communities and geographies. It will be important to stick to that permissive, flexible approach as the Act is implemented. Another opportunity is to make significant progress on addressing health inequalities. Trusts are enthusiastic about the national emphasis on addressing health inequalities as a priority for ICSs and the NHS as a whole.

Speak to any group of trust leaders and you will hear a wealth of ideas for how they can work differently to better support the communities they serve – particularly those experiencing inequalities of access, experience or outcome. Often these ideas build on trusts' roles as "anchor institutions". They are, and will continue to be, major employers of local people and purchasers of goods and services in communities.

This makes them well placed to help lead their systems, drawing on their experiences of managing change, their knowledge of local communities and the capabilities of their organisation's workforce. How they lead will vary. Often it will be with other partners or sometimes more directly, for instance through provider collaboratives.

Managing the risks

But this way of working also throws up wrinkles that need to be ironed out together as systems develop and mature.

Integrated care boards (ICBs) will be planning services for large populations and will involve many organisations. In some cases, they will delegate responsibilities and budgets to place leaders and provider collaboratives. This will involve running a number of system and place decision-making and oversight forums – but, as far as possible, trust leaders are keen to avoid an intricate array of new bodies which risk adding complexity and burden.

Clear lines of accountability will remain essential. Trust leaders know that the buck will – rightly – stop with them if services encounter serious problems. But, the developing arrangements – with ICBs, provider collaboratives, place-based partnerships all involved – could blur and confuse responsibility and accountability for operational and financial performance, and quality of care.

National bodies are leading work to refine the regulatory regime in this context, and, as far as possible, trusts want to see clarity and simplicity to support the robust management of risk. 

The challenge ahead

Leaders are already feeling a tension between the urgent needs of today and the imperatives of tomorrow. Foremost in mind are issues like addressing backlogs of care, improving patient flow and stabilising the urgent and emergency care pathway. These are vital for patients accessing services today.

Yet leaders also know that short term action to address today's pressures needs to be allied with supporting teams to develop ways of working, and collaborative approaches, that can deliver sustainable improvements for communities tomorrow. National leaders will have a role in ensuring they can strike that balance. Although the right thing to do, system working alone will not deal with the systemic challenges facing health and care services, and nor will the changes be immediate.

There are big issues which need national action in order to give services the best chance of meeting current demands and driving real improvements. Workforce supply (which the government resisted addressing in recent legislative debates), and adult social care services (which need additional financial support), are top priorities for national intervention. Failure to act will materially affect what ICSs can achieve.

Trusts are major local economic actors with scope to positively influence social and economic development in their communities.

Saffron Cordery    Deputy Chief Executive

In a context characterised by substantial challenges and some uncertainties, trust leaders have a central role to play in their local systems. Trusts are major local economic actors with scope to positively influence social and economic development in their communities. The services trusts deliver are core to the aspirations of ICSs; and, often in collaboration with other partners, trusts will play a key role in leading local change.

Trust leaders know that their organisations' futures lie in systems. While they are clear-sighted about the scale of the task and the dilemmas yet to be solved, they are also optimistic that, through system working, they now have an even greater opportunity to improve care.

About the author

Saffron Cordery profile picture

Saffron Cordery
Deputy Chief Executive

Saffron is NHS Providers deputy chief executive, part of the senior management team and sits on our board. She has extensive experience in policy development, influencing and communications and has worked in the healthcare sector since 2007. Before moving into healthcare, Saffron was head of public affairs at the Local Government Association, the voice of local councils in England. Her early career focused on influencing EU legislation and policy development, and she started working life in adult and community education.

She has a degree in Modern Languages from the University in Manchester, for ten years was a board member and then chair of a 16–19 college in Hampshire and is a trustee of GambleAware, a leading charity committed to minimising gambling-related harm. Read more