A NEW NHS OPERATING SYSTEM: Why Learning Infrastructure, Not Just Structural Reform, Is Key to Success
Among the most consequential yet underexamined elements of the UK Government's 10-Year Health Plan is its ambition to build a "new operating model" for the NHS. At first glance, this may sound like managerial jargon. In reality, it is the tectonic foundation on which the entire reform effort stands.
The challenge is profound: to replace an overly centralised, reactive, and fragmented system with one that is decentralised, integrated, adaptive, and accountable. It is a tall order. And it cannot be delivered by structure alone.
The government’s plan recognises that the NHS cannot function effectively if power remains concentrated in Whitehall. It calls for a more devolved system, where Integrated Care Boards (ICBs) become the strategic commissioners of local services, where high-performing NHS Foundation Trusts are granted new freedoms, and where a limited number of Integrated Health Organisations (IHOs) will be piloted to take on full population health budgets. This is a bold and necessary step. But it is not the first time such promises have been made.
Past attempts to devolve power and drive integration have foundered not just on the complexity of delivery, but on the absence of infrastructure for real learning and adaptation. Without this, structural change becomes cosmetic. Roles change. Acronyms shift. But behaviours, incentives, and cultures stay the same.
The Cautionary Tale of Integrated Care Systems (ICSs)
The recent history of Integrated Care Systems is instructive. ICSs were introduced to bring local partners together, NHS bodies, councils, charities, community groups, with the aim of aligning goals and co-producing services tailored to local needs. In theory, they were meant to break down silos and replace transactional commissioning with place-based planning.
In practice, progress has been uneven. Some ICSs became vibrant ecosystems of collaboration. Others struggled under vague mandates, unclear accountability, data fragmentation, and the persistent gravitational pull of central control. The promise of integration often dissolved into bureaucratic inertia.
Why? Because structural alignment was mistaken for systemic learning. New boards were formed, but few mechanisms were put in place to support genuine co-creation, peer exchange, experimentation, or feedback.
Where integration worked, it was probably because of relationships, trust, and shared purpose, not because of the system’s design.
A New Operating Model Needs a New Learning System
The 10-Year Plan acknowledges the need for a more responsive and locally empowered NHS. It speaks of earned autonomy, foundation trust freedoms, and closer collaboration with local authorities. But it stops short of articulating how these entities will learn to operate differently.
A new operating system is not just about structural realignment. It is about cognitive and cultural rewiring. It requires a different relationship to knowledge, authority, and change. That cannot be achieved through contracts, metrics, or central dashboards alone. It requires an infrastructure for learning.
The learning infrastructure must enable local actors to co-create solutions, share insights, and adapt practices in real time. One that connects bottom-up innovation with top-down strategy. One that builds trust through participation rather than compliance.
The Civic Health Academy: A Participatory Learning Network for System Reform
This is where the Civic Health Academy currently being developed prior to launch, could make the critical difference. It will be organised as a Participatory Learning Network (PLN). Rather than being another layer of bureaucracy, the Academy would serve as the connective tissue of the new operating system.
Branches of the Civic Health Academy, embedded in local neighbourhoods and connected across regions, would act as a local learning hub. These hubs would:
Facilitate co-creation between ICBs, providers, local authorities, and communities
Support collaborative design and testing of service models, workforce innovations, and digital tools
Provide training in systems leadership, adaptive strategy, and participatory design
Enable shared learning between neighbourhoods and across the national system
Build the civic and professional capability to participate meaningfully in system governance
In short, the Civic Health Academy would transform structural change into lived change.
What the King’s Fund Got Right in It’s Analysis of the Ten Year Plan
The King’s Fund has made clear that the plan’s vision is not new, adding:
“What would be truly radical is actually delivering it”
In a sober assessment, they warned: “history has shown us that you can’t simply co-locate different health professionals in a building and expect a neighbourhood health service to flourish.”
This insight underscores the fundamental flaw in top-down operating model changes - they assume structural integration will lead to functional integration.
The King’s Fund also emphasised the deeper behavioural and relational shift required: “Health and social care professionals will need to work differently to join up patient care.” Such a shift cannot be engineered through plans alone, it requires continuous local learning, trust-building, and joint problem-solving.
On prevention, the King’s Fund rightly pointed out that while the plan gestures in the right direction, it does not “feel sufficiently radical to provide the sea change that’s required.”
Without tackling upstream drivers of poor health - inequality, poverty, unhealthy environments - the pressure on NHS services will remain relentless, no matter how well-integrated the operating model becomes.
Finally, they issued a public reality check: “Unlike previous plans, this plan will not come with promises of significantly more funding or staff.” In that context, they argued, success depends on working differently, not just harder. That is precisely what a Civic Health Academy would enable: smarter collaboration, embedded learning, and more effective use of the assets already within the system.
Addressing the Three Core Challenges of Implementation
1. Clarity of Purpose: Structural reforms often fail because stakeholders do not share a common vision. PLNs create space for dialogue and alignment. By involving citizens, staff, and system leaders in co-creation, the Civic Health Academy fosters shared understanding of goals and roles.
2. Capability for Change: New structures demand new behaviours, but behaviour change requires support. The Academy would equip individuals and teams with the tools and mindsets needed to work across boundaries, manage complexity, and lead adaptively.
3. Consistency and Adaptation: Top-down systems often impose uniformity. Bottom-up efforts can fragment. PLNs strike a balance by enabling diverse local experimentation within a shared national framework. The Civic Health Academy ensures learning travels across contexts while respecting difference.
From Operating Model to Learning Culture
Ultimately, what the NHS needs is not just a new operating model, it needs a new operating culture. That culture must be curious, humble, collaborative, and focused on relationships, not just results. Culture change cannot be mandated. It must be modelled, nurtured, and scaled.
The Civic Health Academy is a vehicle for precisely that kind of culture shift. It makes learning visible, valued, and actionable. It recognises that system change does not come from control but from connection. And it puts the power to shape health services where it belongs: in the hands of those who use and deliver them.
Conclusion: The Real Test of Reform Lies in How We Learn
If the government is serious about creating a new NHS operating system, it must look beyond structures and invest in the capabilities that make those structures work. That means building learning infrastructure at every level, from neighbourhood to nation.
The Civic Health Academy, as a Participatory Learning Network, offers a practical and proven model for doing just that. It addresses the core implementation risks. It builds the social foundations of integration. And it ensures that the NHS is not just reshaped, but reimagined, from the inside out.
In the end, it’s not the diagram of the system that matters. It’s how the system learns. And right now, that is the reform that matters most.
On the Civic Health Academy
If you would like to know more about the plans for the Civic Health Academy as a Participatory Learning Network email us contact@enlightenedenterprise.ac