30th June 2025
Reflections from NHS Confed and the TU’s Role in Making Lasting Change
At this year’s Confed, the mood was clear: there is no shortage of ambition. Across the system, leaders are committed to transformation, local freedom, better outcomes, and deeper collaboration. But there was also a strong sense of realism. With no ‘real terms’ new funding on the horizon, rising productivity demands, and the need to bring the public along, the challenge is far more than planning the change – the real challenge is making it happen – the delivery of change.
Here, we consider the key messages we heard, and how the TU are positioned to potentially support health and care in achieving these ambitions.
Neighbourhood and System Working
Neighbourhood and whole system level working was widely recognised at Confed as a key driver of transformation. But what does that look like in practice?
Strong foundations for this approach include well-established relationships across a wide range of stakeholders: health and care providers, acute hospitals, community health services, local authorities, schools, the voluntary and community sector, residents, and communities themselves.
One of the most important foundations is a shared purpose and a clear, collective vision of what neighbourhood working is aiming to achieve. But vision alone is not enough. Systems also need to design the target operating model that will make that vision a reality; defining roles, responsibilities, governance, and practical ways of working that bring neighbourhood models to life. This may be an iterative process, evolving over time, as the inherent flexibility and agility of neighbourhood working should be embraced and leveraged.
There is already strong evidence and many examples of promising practice in neighbourhood working, particularly where both local government and health partners have been actively involved. Some of the most successful models have emerged from this kind of joint leadership and collaboration. In recent years, the demands of COVID may have diverted attention and capacity, particularly within health systems. But as the focus shifts back to integration and local delivery, there is now a timely opportunity to renew that shared commitment and give neighbourhood working the attention it deserves.
This could be the moment for the system to act as one. Achieving that will require shared learning, joined-up collaborative approaches, and a commitment to building on what already works.
More Local Freedom, Less Central Control
The shift from centralised to local decision-making was strongly endorsed. But what does that mean for risk and responsibility?
One of the strongest messages at Confed came from national leaders, who reinforced the need to shift power and decision-making closer to local systems. The call was for greater autonomy for providers the ability to set strategic priorities and make decisions that reflect the needs of their populations, without being overly constrained by central directives. This direction was broadly welcomed by system leaders. But there was also a note of caution. Many asked whether this freedom will be sustained when pressure mounts. Old habits of central control can be hard to shake, and systems will need clarity, consistency and support to make the most of this opportunity.
This shift also brings a new balancing act. Greater local freedom can unlock innovation, but it also introduces variation, and with that, a degree of risk. Systems will need to navigate the space between encouraging bold, locally led solutions and maintaining accountability, safety and equity. Finding the right balance between innovation and risk appetite will be critical to making local autonomy work in practice.
A Shift to Outcomes, Not Activity
If we want to improve what matters most, we need to start measuring what matters most.
One of the most prominent themes at Confed was the move towards outcomes-based commissioning. Promoted by national leaders and reflected in the NHS Confederation’s Pioneers of Reform report, this shift calls for a fundamental change in how services are planned and delivered. Rather than focusing on activity, such as the number of appointments, procedures or interventions, systems are being asked to commission for outcomes that matter to people and communities. These might include people living independently and safely at home, returning to work, or feeling more in control of their health.
For many in health, this represents a significant cultural shift. While outcomes-based commissioning has long been embedded in local government, particularly in adult social care, health systems are still developing the skills, data and confidence to apply it consistently. The approach encourages more holistic, preventative care, but also raises important questions about how outcomes are defined, measured and used to drive improvement.
Measuring outcomes is inherently more complex than counting activity. Outcomes often take time to emerge, are influenced by multiple factors, and can be difficult to define in consistent, measurable terms. For example, it is easy to record how many people received physiotherapy, but harder to assess whether they regained mobility, returned to work, or experienced an improved quality of life.
This complexity can make systems cautious. Without the right data, tools and evaluation frameworks, there is a risk that outcomes-based commissioning remains more of an ambition than a reality. Yet if we want to commission for what truly matters, not just what is easiest to measure, this is a challenge we must take seriously.
As systems begin to embrace this model, the need for practical support is clear. Not just in understanding the theory, but in applying it to real-world commissioning decisions and in bridging the gap between ambition and delivery.
Productivity Through Digital Innovation
Digital transformation is often seen as the answer to productivity challenges. But at Confed, the message was clear: it’s not just about the tools – it’s about how people use them.
Digital transformation remains a key lever for productivity. But the message at Confed was clear: technology alone is not the answer. Digital tools only deliver value when they are embedded in redesigned care pathways, aligned with clear service goals, and supported by people who are ready and able to use them.
There was strong recognition that quick wins are possible – for example, through automation of administrative tasks, virtual consultations, or AI-assisted diagnostics. However, these gains are only sustainable when built on the right foundations: robust infrastructure, interoperable systems, and a digitally confident workforce.
Speakers at Confed emphasised that digital innovation must be people centred. This means involving staff and service users in the design and implementation of digital solutions, ensuring that tools are intuitive, accessible, and genuinely improve workflows or outcomes. It also means investing in digital skills and leadership at every level, from frontline clinicians to system leaders, so that technology becomes an enabler, not a barrier.
Importantly, digital transformation should not be seen as a standalone programme. It must be woven into broader service redesign, with clear links to productivity, quality, and equity goals. For example, digital tools can support more proactive, preventative care by enabling better use of data to identify risk and target interventions. But this only works if data is shared safely and meaningfully across organisational boundaries.
As systems look to scale digital innovation, the focus must remain on delivering real-world benefits for patients, staff, and communities – not just deploying new technology for its own sake.
How the TU Can Help: Turning Ambition into Action
At the NHS Transformation Unit, we support systems not only in shaping their ambitions but in delivering them with clarity, rigour and impact. As an NHS internal consultancy with over a decade of experience, we bring a unique blend of strategic insight, technical expertise and a deep understanding of the health and care landscape.
The themes emerging from NHS Confed reflect a system committed to transformation – from neighbourhood working and local autonomy to outcomes-based commissioning and digital innovation. The TU is well positioned to support these priorities, offering a team of experienced professionals who share public service values and bring cross-sector experience from health, local government and the voluntary and community sectors.
We provide tailored support across a range of areas, including:
- Neighbourhood and system working: designing and delivering local models of care using our proven clinical redesign methodology and supporting the development of governance and operating models that enable collaboration.
- Shifting power to local systems: working with senior leaders to shape strategy, align stakeholders and build the structures that support local autonomy and decision-making.
- Outcomes-based commissioning: applying data and analytics to understand population needs, define meaningful outcomes, and support commissioning decisions grounded in real-world delivery insight and with a clear line of sight to benefits realisation and measurable impact.
- Digital transformation: developing robust business cases for digital investment, combining stakeholder engagement with detailed financial modelling and clear, compelling authorship. We also help ensure digital tools are embedded in redesigned pathways and supported by the right skills and infrastructure.
- Change management and engagement: facilitating meaningful engagement with workforce, partners and the public, and embedding change approaches that build ownership and ensure sustainability.
What distinguishes the TU is not only the breadth of our offer, but the way we work. We partner closely with systems, adapting our approach to local context and priorities. Our aim is to build capability and confidence, ensuring that transformation is both effective and enduring.
As the next phase of change unfolds, the demands on systems, leaders and communities will only grow. The TU stands ready to support that journey – not just by offering ideas, but by working alongside you to deliver meaningful, lasting results.