NHS England’s national medical director has warned health campaigners against pushing for new national mandates, arguing that such demands risk undermining the shift towards locally led healthcare. Speaking in early 2026, Claire Fuller said calls for additional national rules were often “unhelpful”, particularly at a time when decision-making authority is increasingly being devolved to integrated care boards (ICBs).
Fuller emphasised that rigid, centralised directives have historically failed to deliver meaningful improvements, stating that “we have never really made anything better by making anything rigid”. Her comments reflect a broader policy direction within the NHS, where national bodies are seeking to reduce prescriptive targets and give local systems more flexibility to design services around population needs.
Power shift towards integrated care boards
The warning comes as the NHS continues a significant structural transition, with ICBs taking on greater responsibility for planning and commissioning services across local health systems. Under reforms introduced in recent years and continuing into 2026, ICBs are expected to lead on key areas including resource allocation, service integration and population health management.
This decentralisation is intended to move the NHS away from a “one-size-fits-all” approach, enabling more tailored responses to local challenges such as health inequalities, workforce shortages and demand pressures. Fuller’s remarks suggest that additional national mandates could conflict with this direction, potentially limiting the autonomy of ICBs and creating unnecessary bureaucracy. The shift also aligns with wider government ambitions to streamline central oversight and reduce the number of national targets imposed on providers, an approach that has gained traction following criticism that excessive central control has hindered innovation and responsiveness.
Tension between campaigners and system leaders
The comments have highlighted an ongoing tension between health campaigners and NHS leadership.Campaign groups often advocate for national standards and mandates as a way to ensure consistency, accountability and minimum levels of care across the country. However, NHS leaders argue that such measures can be counterproductive if they fail to account for local variation.
Fuller’s intervention suggests that some campaign demands may be out of step with the current direction of reform. By describing new mandates as “unhelpful”, she signalled a preference for locally driven solutions rather than centrally imposed rules. This debate is particularly relevant in areas such as digital health, access to services and workforce standards, where national consistency must be balanced against local flexibility. Experts note that while national frameworks remain important, overly prescriptive requirements can divert resources away from frontline care and limit the ability of local leaders to innovate.
Implications for digital and data-driven care
The shift towards local decision-making has significant implications for the NHS’s digital strategy. ICBs are increasingly responsible for overseeing digital investment, including electronic patient records, data platforms and population health tools. This creates opportunities for more tailored, place-based innovation but also introduces challenges around interoperability and standardisation.
Without clear national mandates, there is a risk of variation in digital maturity and capability across regions. However, proponents argue that local flexibility allows systems to adopt technologies that best meet their specific needs, rather than implementing uniform solutions that may not be fit for purpose. Fuller’s comments suggest that the NHS is moving towards a model where national bodies set broad principles and standards, while local systems determine how best to deliver them. This approach is consistent with wider efforts to embed data-driven decision-making at a local level, enabling ICBs to use analytics and population health insights to guide investment and service design.
Balancing autonomy with accountability
The challenge for the NHS will be striking the right balance between local autonomy and national accountability. While devolving power to ICBs offers the potential for more responsive and efficient care, it also raises questions about how to ensure consistent quality and equity across the system. Fuller’s warning highlights the need for careful calibration. Too many national mandates may stifle local innovation, while too few could lead to variation and inequity in care provision.
For policymakers and health technology leaders, the focus is likely to shift towards developing frameworks that support local flexibility while maintaining clear expectations around outcomes, safety and performance. As the NHS continues its transition towards a more decentralised model, the debate over mandates versus autonomy is set to remain a defining issue, shaping not only how services are delivered, but also how technology, data and innovation are deployed across the health system.
