NHS Senior Leadership Onboarding and Support

Understanding the NHS and governance

The purpose of these resources is to outline relationships and governance in the NHS. The title is ambitious because the NHS is always evolving to better meet the needs of populations and it will be useful to you to explore the other areas of this website too to better understand the NHS, such as ‘Collaborating and systems leadership for all’ and ‘Leading for great outcomes’.

The NHS is a complex system, with different organisations and sectors delivering care in concert and partnership, including social care, the third sector and private companies. NHS organisations have varied accountabilities and relationships with Arms Lengths Bodies (ALBs), Local Authorities through Health Overview and Scrutiny committees and in the case of NHS foundation trusts, governors who challenge the board of directors and hold the non- executive directors to account for the performance of the board.

The way the NHS works at a population health level is changing with organisations working together in Integrated Care Systems (ICS’s) to deliver improvements to whole population and reduce health inequalities. It should be noted that the organisation’s statutory duties remain as these new ways of working develop.  We will continue to add resources that reflect how things are changing – and if you find a great resource we’ve missed please let us know.

Robust governance enables organisations to understand and manage risk, plan for improvement and assure the board, stakeholders and the populations we serve that our organisations are safe and performing well.

This theme supports development in the Governance and Assurance domain of the Leadership competency framework.


Acronym buster by NHS Confederation 

Guidance: Integrated Care Systems These documents set out the headlines for how we will ask NHS leaders and organisations to operate with their partners in Integrated Care Systems (ICSs) from April 2022 and guidance in respect of what the employment commitment is, its application in practice and how it affects people.

Resources: ‘The NHS after the Health and Social Care act 2012’ Dated 2018

PDF guide: National Audit Office – A short guide to the Department of Health and NHS England Dated Sept 2017

Report: ‘The NHS at 70: How good is the NHS?’ Published 25/06/2018

Resource: NHS corporate governance map healthcare Healthcare Financial Management Association 2020 – Helpful tool that maps key NHS corporate governance guidance includes helpful links including around specific areas for board assurance.

Resources: How does the health and social care system work? How is it changing? The King’s Fund Key pieces of The King’s Fund work including podcasts, extensive “explainer articles” and thought pieces around health and social care across policy areas and delivery challenges.

Resources: Health and social care explained Nuffield Trust This page from the Nuffield Trust covers a wide range of resources and signposting which includes policy, numbers and data explained, toolkits and methods and a “topics explained” section where the Nuffield Trust delve deeper into subjects relevant to the health service.

Finance: Series 1 – How finance works in the NHS:

Timeline: Health and Social Care Explained – the NHS reform timeline Nuffield Trust

Animation: How does the NHS work in England The King’s Fund 2017 – This animation gives a overview of the NHS and how it all fits together as at 2017. As the animation points out, the NHS is evolving especially with advent of the Long Term Plan. While some of this has become dated, references to Accountable Care Systems rather than Integrated Care Systems and no mention of Primary Care Networks – it does give an overview of how each relates to each other.

For further information on the commissioning landscape read How Commissioning is Changing and sign up to the Future Health and Care bulletin for the latest news and events on integrating health and care across the country.

Briefing: How it works – primary care finance and primary care networks Healthcare Financial Management Association (HFMA)

Animations: How the money flows in the NHS  and Overview of NHS Costing Future Focused Finance – very simple overviews.

Briefing: Investing in The NHS long term plan – The Health Foundation

Website: Department of Health and Social Care’s agencies and partner organisations – details of health arm’s length bodies and links to their websites – helpful for understanding the range of organisations engaged around health. Updated Dec 2019

Book: HFMA Introductory guide – NHS finance Health Finance Managers Association


  • In your first few months make time to seek out other senior leaders in the organisations around you and to understand their perspectives, priorities and current relationships ahead of meeting them in the course of business.

  • Take a “no surprises” approach with partner and oversight organisations – there may be support offers.

  • Keep asking questions of your teams to ensure you know the causes of issues, how they link to other factors you are facing and that you have a credible plan and the capacity to solve or mitigate these – for your own and board’s assurance.

  • The strategic landscape is complex – keep checking your understanding and raise risks and issues.