The Puzzle at the Heart of NHS Transformation

Something curious is happening across the NHS.

As Integrated Care Boards publish their new executive structures, a pattern has emerged that is worth examining carefully. Analysis by the Health Service Journal, covering 19 of the 25 remaining ICBs and clusters, found that not a single Chief Digital Officer has survived the restructures. Previously, around a third of ICBs had one. Chief People Officers have been almost entirely eliminated. Chief Delivery Officers, where they existed, have gone completely.

These are not marginal roles. They are the people responsible for leading digital adoption, workforce transformation, and implementation at system level. And they have been judged dispensable.

What makes this particularly striking is that the overall size of ICB executive teams has not changed dramatically. The average number of posts has fallen from five to four and a half. So this is not simply a cost-cutting story. ICBs are not smaller; they have made an active choice about what belongs at the top table. New roles are appearing for commissioning, strategy, neighbourhoods, and population health. Digital and workforce leadership are not on that list.

One departing Chief Digital Officer told HSJ that ICBs had been "completely stripped" of digital leadership, resulting in a "massive loss of expertise" that would undermine plans to transform services.

I want to explain why I think they are right. And I can offer a recent example that makes the cost of this concrete.

A preventative health company that a number of us had been supporting through evaluation and early implementation work has had to wind up.

Not because the product did not work. Not because it was misaligned with national strategy. It addressed all three pillars of the NHS 10-Year Plan with quiet precision: the shift from analogue to digital, from sickness to prevention, from hospital to community. Pilots were running. National funding applications were in progress. Early data was building.

And yet the company still ran out of runway.

The reason was structural. There was no clear budget owner for prevention at system level. The company could not demonstrate return on investment within the boundaries of a single Trust. Benefits that accrued slowly, or that flowed across organisational boundaries, or that would only become visible at population level over years, were genuinely difficult to justify locally.

So despite clinical interest, despite strategic alignment, and despite promising evidence, it quietly disappeared.

This is not an unusual story. It is a common one. And understanding why it keeps happening is, I think, inseparable from understanding what the removal of digital and transformation leadership from ICB executive teams actually means in practice.

The NHS 10-Year Plan is a serious document. The language around prevention, digital, and community-based care reflects genuine strategic intent. Digitising services is described as a major plank of the plan. Many of the people involved in writing it understand the scale of change required.

Where the system consistently struggles is in building the structural conditions that allow that ambition to land.

This is not primarily an innovation problem. The UK generates ideas reasonably well. We have accelerators, pilots, innovation funds, academic health science networks, and a growing cohort of clinical entrepreneurs who understand both medicine and technology.

Where we consistently struggle is in the journey from proven pilot to scaled implementation, particularly when the value of that implementation sits across organisational boundaries rather than neatly within one.

Individual Trusts carry their own financial risk. They are measured predominantly on acute activity. Business cases need to demonstrate value locally, within a timeframe that makes sense to a local finance committee. Benefits that are diffuse, delayed, or that accrue to a different part of the system are genuinely difficult to justify.

That is not irrationality. It is a rational response to the incentive structures that actually exist.

But the result is predictable. Good companies fall into the gap between what the NHS says it values and what it is currently structured to fund. The company I described is one of many. There is rarely a post-mortem. The pilot data sits in a report. The clinical champion moves on. And the problem the company was trying to solve remains unsolved.

NHS England has indicated that digital leadership should, over time, transfer to providers, enabled by national data and digital infrastructure. That may prove to be the right long-term direction. But the gap between that aspiration and the current reality is considerable. And in the meantime, the organisations responsible for system-level transformation no longer have anyone at the top table whose primary job is to lead it.

Digital transformation in the NHS is not a technical project. It is a change management challenge of considerable complexity, played out across fragmented organisations, resistant legacy systems, stretched clinical teams, and procurement processes that were not designed with innovation in mind.

The companies that navigate it successfully tend to do so because there is someone at a senior level in the system who understands what they are looking at, can translate clinical value into commissioning language, and has enough organisational authority to move things forward.

Remove that person from the executive team and you do not simply lose a title. You lose the organisational attention that the role carries. Digital and workforce transformation becomes something that happens below the top table, resourced and prioritised accordingly.

For a company trying to demonstrate value and secure adoption, that matters enormously. The gap between a promising pilot and a scaled implementation is rarely technical. It is almost always political, relational, and structural. It requires someone with both the understanding and the authority to bridge it.

Removing that person from the room makes the company story I described at the start of this piece more likely, not less.

Three things, stated plainly.

First, clearer ownership of prevention and digital transformation budgets at ICS level, with genuine commissioning power rather than a stated mandate and no executive home. The creation of new posts for population health and neighbourhoods is encouraging in principle. Whether those roles will carry sufficient authority and resource to drive real change remains to be seen.

Second, better mechanisms for sharing risk and reward across organisational boundaries. If a preventative intervention reduces acute admissions five years from now, the organisation that invested in it will not necessarily be the one that benefits. Until that asymmetry is addressed, local decision-makers will rationally continue to prioritise near-term, local returns. Changing that requires structural reform, not exhortation.

Third, more deliberate pathways from pilot to adoption. A successful pilot should not be the end of a process. It should trigger a structured transition: a named commissioner, a funded evaluation timeline, and a genuine scale decision. Without that, pilots become a way of being seen to act without actually committing to change.

The moments when innovation actually gains traction in the NHS tend to share a common feature. There is a clinician in the room who understands both the technology and the system. Someone who can translate clinical value into commissioning language. Someone who can sit in a procurement conversation and explain why the evidence matters. Someone who bridges the gap between what a product does and what an organisation needs to hear in order to say yes.

That role is not currently formalised or consistently resourced. It exists informally, wherever a motivated clinician has accumulated enough experience of the innovation ecosystem to play it. But it is not trained into the system, and it is not reliably present at the moments that matter most.

This is part of what the Clinical Innovator role is intended to address. Not as a replacement for executive digital leadership, which the system still urgently needs, but as a complementary function: a practical bridge between frontline clinical reality and the commissioning, procurement, and implementation decisions that determine whether good ideas survive long enough to matter.

The company I described at the start of this piece might have had a different outcome with that kind of support in place earlier. I cannot say with certainty. But I do know that the problem it was solving has not gone away. And the next company working on it will face the same structural barriers, unless something in the system changes.

The removal of digital and workforce directors from ICB executive teams may turn out to be a pragmatic, time-limited response to financial constraint. It may be reversed as circumstances change. NHS England's stated intention to transfer digital leadership to providers may, in time, prove to be the right model.

But right now, in the period between that aspiration and that reality, the organisations responsible for system transformation have chosen to proceed without the people whose job it was to lead it. And that choice has consequences that will not appear in any restructure announcement.

Good companies are quietly disappearing into the gap between ambition and implementation. The structural decisions being made right now are making that gap wider, not narrower.

That is the puzzle worth interrogating.