Mission improvement: insight from system improvement leaders
The NHS is undergoing one of its most substantial transformations in decades and facing significant restructures, job losses and financial constraint. In his speech at the recent NHS ConfedExpo, Wes Streeting highlighted that while the Spending Review brought some favourable news to the health and care context, investment itself cannot be sufficient for the changes that need to happen. We need reform and a different way of working, through devolution to patients and frontline teams, a strong focus on outcomes, and dissolving boundaries between parts of the health care that too often operate in silos. As integrated care boards (ICBs) adapt to new operating models, the role of improvement has never been more critical.
System improvement helps to deliver more holistic, place-based care that expands beyond the confines of the NHS to create the conditions and change required to improve health outcomes for the population. Improvement approaches are a key way to ensure change is sustainable and long-lasting. Indeed, the Hewitt review set the ambition for integrated care systems (ICSs) to become ‘self-improving systems’, combining high levels of autonomy and accountability to deliver the quality of patient care and outcomes. These messages around autonomy and accountability resonate with the direction the government is taking.
The Health Foundation, NHS Confederation and the Q community have partnered to create spaces for peer learning and connection around system improvement. Following a successful peer learning programme in 2024, which brought together over 150 system improvement leaders, we convened a smaller group in early June 2025 to make strategic sense of the Model ICB blueprint and explore how improvement approaches can facilitate change.
We share key insights from the session, offering a set of reflections and provocations for how improvement approaches can help ICBs navigate change, support staff at all levels, and keep population needs at the heart of transformation.
Improvement must be the mission, not just a function
Improvement is too often seen as a ‘nice to have’ and a technical function that is brought in when a specific change is required or identified. In the current context of upheaval, improvement is not a luxury – it is a strategic necessity. We need to build continuous improvement into our systems if we expect to adapt to our rapidly changing populations and effectively tackle inequalities, productivity and quality.
Improvement professionals bring essential skills in systems thinking, change leadership, facilitation and data interpretation. They are skilled to navigate complexity, support adaptive change and hold the long-term view amid short-term pressures. If we are serious about transformation, we must invest in the people and practices that make it possible and sustainable as everyday culture.
In the context of current changes, improvement must be reframed as a mission. This means embedding improvement approaches into the way ICB leaders think, act and lead. It’s not about fitting improvement approaches in – it’s about leading with these.
“The future ICB needs to be an improvement organisation.”
The four core functions outlined in the Model ICB blueprint are not just areas where improvement skills and approaches can be applied. The improvement leaders we convened argue that these functions are, in essence, improvement in action.
Understanding local context involves gathering insight into population needs, inequalities, lived experience and current provision. It includes data analysis, community engagement, and horizon scanning.
This aligns with a diagnostic phase of improvement, emphasising the problem definition, seeing the whole picture, and co-production of what is needed to ensure high-quality care for all.
Developing long-term population health strategy involves a data-driven, integrated approach to setting a strategic direction to improve health outcomes over time. It includes identifying aims and priorities and aligning efforts across the systems.
This aligns with the planning and design phase of improvement, where we define what good looks like, where we intervene and innovate, and how we know if we’re making progress.
Delivering the strategy through payer functions and resource involves what is purchased and how this delivers required outcomes. This requires close collaboration with providers, effective budget management, and a strong focus on value for money.
This aligns with the “doing” phase of improvement, where structured improvement and implementation methods can play a critical role, such as through providing frameworks for testing and refining service models, enabling data-driven decision-making and supporting adoption.
Evaluating impact involves assessing outcomes, learning from what works (and what doesn’t), and using insights to inform future decisions.
This phase enables learning, adaptation and refinement – and could extend to scaling or stopping interventions based on evidence. Evaluation and measuring for improvement can help close the loop, ensuring that change is not just implemented but understood, improved upon and sustained.
Delivering change requires an asset-based, inclusive approach
Change at scale cannot be delivered by a few individuals or isolated teams. It must involve everyone – from the frontline to the boardroom. This means recognising the assets that people already bring, while also addressing skills gaps where they exist. This is not just about engagement. It’s about unlocking and mobilising the system’s full potential.
ICB leaders are navigating significant operational changes and new ways of working. Improvement approaches can play a key role in helping to create the conditions for inclusive change through giving people permission to act, putting problems in the hands of those closest to them, and fostering a culture of curiosity and courage.
Focus needs to be on the quick wins and long-term vision
In a time of limited capacity and high pressure, trying to do everything is a recipe for burnout. The improvement leaders we convened advocated for a focus on a few key priorities where change is both needed and achievable. This “mile deep, not mile wide” approach requires substantial strategic discipline but can deliver early wins, which can in turn boost morale and build confidence in the change process. They noted that times of change, like now, offer a unique opportunity to act quickly while momentum is high, but emphasised the importance of staying strategic and focusing efforts where impact is greatest.
“We need to focus on one thing that between us we have influence to change that is deliverable … what can we get done before Christmas?”
At the same time, we must not lose sight of long-term outcomes. Strategic commissioning will support long-term planning, focused on improving population health. The longer-term focus will need to consider areas outside healthcare and the NHS, such as workforce and infrastructure. At the same time, as the State of ICSs report notes, many ICS leaders have been grappling with balancing the short and long term for some time, with performance metrics from the centre often focusing on electives and urgent and emergency care.
Experiences during the COVID-19 pandemic have shown that fast mobilisation is possible. But to achieve longer-term outcomes that support population health, change much be approached strategically and with long-term vision in mind.
Data must drive insight, not just reporting and oversight
Data is everywhere – but insight is rare. Too often, data is collected but not translated into meaningful insight and action. Improvement approaches can help shift the focus from dashboards to decisions, from reporting to learning. Supporting both technical and human infrastructure is required for this.
“We really need to be interrogating the data and what they tell us.”
This includes broadening what we measure. In complex systems, success is not always immediate or linear; spotting patterns in data is a key leadership skill. System improvement leaders we convened also highlighted the importance of valuing learning, connection and unanticipated outcomes, which can serve as indicators of longer-term successes and help us see whether we’re on the right track.
“We need to measure learning as well as outcomes. That’s how we know we’re on the right track.”
Stopping is as important as starting
In a resource-constrained environment, doing more is not always the answer. Sometimes, the most strategic act is to stop. Improvement leaders can help identify work that no longer serves its purpose, freeing up capacity for what matters most.
This is difficult work – politically, emotionally and practically. But it’s essential. As one participant put it, ICBs must continue to be “guardians of the unintended consequences,” using their helicopter view to protect the system from waste and distraction.
“As improvers, we facilitate, but more importantly – we also need to consider what have we blocked. It’s our helicopter view that is valuable.”
Improvement leaders are already driving change
Being context-aware, data-driven and focused on outcomes is necessary to make the systematic changes that need to happen over the upcoming months and years. The scope of improvement approaches is not limited to small-scale test of change and Plan-Do-Study-Act (PDSA) cycles. Improvement approaches can enable large-scale transformational change, through system and pathway redesign, continuous quality improvement and targeted innovation.
Many of the improvement leaders we convened felt they were already acting as 'strategic improvers'. They approach improvement not just a set of tools – but a way of working that makes sense of complexity. Improvement approaches help systems ask better questions, test ideas and adapt in real time, while bringing organisations together to collectively improve outcomes for their local populations.
As a relational practice, improvement can support ‘teaming’ and collaboration that is essential for the strategic work that will require building relationship, trust and collaboration. A recent King’s Fund report pointed out that the model ICB’s plans risk shrinking the role that ICBs play in system convening. Yet at the same time, system convening is vital to make progress on integrated efforts – and evidence shows that building relationships across boundaries is a key enabler to making progress in improving health and wellbeing.
“... the systems that have made most progress are those that have put sustained effort into building relationships across boundaries and establishing a shared understanding of how to improve the health and wellbeing of their local communities.” 1
Considerations for ICB leaders
- Improvement approaches are vital for delivering change. We urge ICB leaders to consider how improvement skills are retained within the system and how improvement leads can support colleagues navigating the transitions and new ways of working. ICB leaders should be open to drawing on improvement skills and expertise from both partners within the system and beyond, including providers, collaboratives, local government and voluntary sector.
- To drive the three shifts (from hospital to community, from illness to prevention and from analogue to digital) the Secretary of State asked ICBs to focus on strategic commissioning. Our Pioneers of reform report on strategic commissioning highlights the critical capabilities required to implement the changes needed in a phased and sustainable way. Improvement leads already hold many of these skills, particularly for collaboration, transformation and system-wide engagement – as well as implementing new ways of working and embedding the cultural change to create lasting improvement.
Q and the NHS Confederation are committed to carrying on this conversation and continue thinking about the role of improvement in delivering the new purpose of ICBs. See our further resources on system improvement.
If you are an improvement leader and would like to join future conversations of this nature, we encourage that you to email us. We would love to hear from you.
Further reading/links
Footnotes
- 1. Naylor, C, Charles, A (2025). Will the ‘model ICB’ strengthen or undermine system working? The King's Fund. ↑
