The Medical Technology Group’s recent report on accountability across Integrated Care Boards arrives at a time when many NHS leaders feel unsettled. Mergers, changing responsibilities and the loss of familiar national structures have left a quiet but persistent question hanging in the air. Who is really accountable for what now ?
What stands out most is not how complicated the system has become. We already know that. It is how consistently the report points to the same thing. Where accountability works, it is rarely because the structure is neat. It works because leadership behaviours are clear and people understand where responsibility sits.
That reflects what we see at Xytal. Systems rarely fail because people lack commitment. They struggle when accountability becomes blurred, overly procedural, or disconnected from day to day delivery. When accountability turns into a reporting exercise rather than a shared responsibility for outcomes, momentum slips.
The report highlights wide variation between ICBs. Some have clear ownership for outcomes, embedded innovation and visible leadership. Others are held back by fragmented decision making and unclear lines of responsibility. What feels different now is the risk that ongoing change locks this variation in rather than reducing it.
Accountability needs to sit closer to the work
A key message is that accountability cannot live only at the centre. It has to sit close to neighbourhoods, teams and communities. When accountability is pushed upwards, local leaders become cautious. When it is pushed down without support, people feel exposed. Getting that balance right matters.
Leadership capability makes the difference
Leadership capability is central to this. Accountability is about confidence to make decisions, to take proportionate risk, and to learn when things do not go to plan, not just about governance or sign off. The stronger systems described in the report consistently show trusted leaders, supported by collective governance, who are allowed to act.
The same applies to innovation. Too often it is talked about rather than adopted. The report is clear that progress happens when innovation is treated as part of everyday delivery, not as something separate. In our experience, that only happens when leaders are accountable for outcomes, not just process.
Accountability without patients is incomplete
There is also a clear reminder about patients. Accountability that does not include the public voice is incomplete. Systems that listen to patient experience tend to make better decisions, not because the data is perfect, but because it keeps accountability grounded in real lives.
A leadership challenge, not another reorganisation
As the NHS moves into its next phase, rebuilding accountability should not be seen as another structural fix. It is a leadership challenge. One that asks for clarity, trust and a shared focus on outcomes that matter to patients and staff.
That is where progress really starts.
Read the full report by the The Medical Technology Group – Rebuilding Accountability in a Changing NHS: A Review of ICB Leadership, Innovation and Patient Outcomes
