NHS reform: who will hold the board to account?

A significant governance change is proposed as part of the Government’s 10-Year Health Plan reform agenda for England, one that has received relatively little public attention but raises important questions about accountability in the NHS.

The government has stated that removing the legal requirement for NHS foundation trusts to have councils of governors forms part of the wider 10-Year Health Plan’s aim to ensure that hospitals put patient experience and outcomes at the heart of decision-making, with an intention to replace councils with “more dynamic” ways of drawing on patient, staff and stakeholder insight.

NHS Providers say the government is aiming for the law to change by 1 April 2027, but this would need an Act of Parliament, so the date depends on when legislation is introduced and passed.

At its core, this is not simply a structural adjustment. It reflects a broader shift in how accountability, oversight and stakeholder voice may operate within a modernised NHS.

What councils of governors currently do

Councils of governors are a distinctive feature of the foundation trust model. They were introduced to strengthen local accountability by formally connecting NHS organisations to the communities they serve.

Governors are typically drawn from patient, public, staff and partner constituencies. Their role is not to manage the organisation, but to provide oversight and representation. This includes appointing the chair and non-executive directors, approving the appointment of the chief executive (the board appoints the chief executive, subject to governors’ approval), and holding non-executives to account for the performance of the board.

In practice, they also act as a channel through which concerns, insights and lived experience can be surfaced, often complementing more formal data and reporting mechanisms.

The case for change

From the government’s perspective, the proposed reform sits within a wider ambition to modernise the NHS and reduce complexity.

The argument is that traditional governance structures can be slow, inconsistent in effectiveness, and not always the most effective way of capturing real-time insight from patients and staff. New approaches, particularly those enabled by digital tools, data and more flexible engagement models, are seen as offering a more responsive and contemporary alternative.

The plan sets out a broader direction of travel within the NHS reform agenda: greater operational freedom for high-performing organisations, reduced central bureaucracy, and a stronger emphasis on frontline decision-making.

In this context, replacing statutory requirements with more flexible arrangements is presented as a way to improve agility while still maintaining stakeholder input.

The governance concerns

Alongside this, a number of governance questions have been raised by sector bodies and commentators.

A central issue is the lack of clarity around what will replace councils of governors. While the intention to introduce alternative engagement mechanisms is clear, the form, authority and independence of those mechanisms have not yet been defined. NHS Providers states there are currently no plans to legislate for an alternative accountability mechanism or patient and public voice mechanism to replace councils of governors.

This matters because councils of governors are not simply engagement forums, they carry formal responsibilities within the governance structure of foundation trusts. If those responsibilities are removed, there is a question as to where they will sit in future, particularly in relation to appointments, oversight and accountability.

There is also a broader point about the distinction between engagement and governance. While surveys, digital platforms and patient feedback tools can significantly enhance insight, they do not necessarily provide the same level of structured scrutiny or independence as formal governance roles.

A wider system shift

The proposed change does not sit in isolation. It is part of a wider set of reforms to the NHS architecture.

These include the planned combination of NHS England with the Department of Health and Social Care, the proposed closure of Healthwatch England and the network of 153 local Healthwatch organisations, with functions proposed to transfer to the Department of Health and Social Care, integrated care boards (for healthcare) and local authorities (for adult social care).

Taken together, these reforms are intended to streamline the system and improve efficiency. However, they also raise questions about how local accountability will be maintained within a more centralised and consolidated framework.
 A live governance debate

For governance professionals, this issue highlights a familiar and important tension.

On one side is the need for organisations, particularly large, complex public services, to operate with agility, clarity and reduced administrative burden.

On the other is the need to ensure that effective checks and balances remain in place, particularly where organisations are accountable to the public.

The question is not simply whether existing structures should be retained or removed. It is how accountability is best designed for the environment organisations now operate in, and how formal oversight, stakeholder voice and decision-making authority are balanced.

What happens next

As legislation and implementation plans develop, greater detail is expected on how these proposed changes will work in practice.

For now, the debate remains open. The removal of councils of governors may represent an opportunity to rethink how accountability operates in the NHS. Equally, it raises important questions about how key governance functions will be preserved in any new model.

For those working in governance, it is a reminder of a broader principle: structures may evolve, but the need for clear accountability, independent challenge and stakeholder representation does not diminish.

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