Strategic health authorities and regions: lessons from history

With NHS England and NHS Improvement now a single entity, having seven regional teams to carry out work on the ground, what can be learned from previous incarnations of the NHS that relied on regional bodies? A new report by Nigel Edwards and Helen Buckingham asks the people who were there to provide some much-needed lessons from recent history to apply to the present day.


Published: 02/07/2020

Download the report [PDF 497.2KB]

Last year, NHS England and NHS Improvement aligned to operate as a single organisation, resulting in the creation of seven regional teams. But this is not the first time national oversight of health care has been supported by these kinds of regional bodies. So what lessons might be learned from recent previous experiences? What works – and what are the pitfalls for this kind of intermediate-level management?

In order to find out, supported in designing and structuring our work by Professor Sally Sheard and Dr Philip Begley at the University of Liverpool, we interviewed a range of senior representatives who were responsible for running regional health authorities in their previous incarnation. We also discussed the issues with people working in other parts of the health system hierarchy back then. Thirdly, we reviewed the relevant literature – building on analysis of the history of this regional 'tier' by PRUComm.

The interviews reveal that there are important prerequisites for successful regional management of this kind, including: 

  • Clarity and consistency of purpose
  • Understanding the local and historical context
  • A good social and cultural 'fit' between the leader and their area of influence

The regional 'tier' has had an important and often helpful role in making the NHS more manageable and in translating policy ideas into action. But getting this role right is not easy and also requires frequent adjustment in style and approach – and probably less frequent changes of structures and people.

In the midst of a pandemic, it is also noteworthy that, looking back, regions and strategic health authorities had a key role in emergency planning and took this very seriously, employing expert staff and conducting local exercises. The larger size of the 10 SHAs gave them more ability to coordinate across providers – but as with other aspects of this experience, there is a trade-off between the increased scale and capabilities that came from this and a loss of understanding of local geography, capabilities and other contextual factors resulting from authorities' wider scope and coverage.


Mark Dayan and Sally Gainsbury carried out the majority of the field work and interviews for this project, and also provided significant input at the comment and review stage. We are very grateful for their insights. 

Suggested citation

Edwards N and Buckingham H (2020) Strategic health authorities and regions: lessons from history. Research report, Nuffield Trust