There has been enough improvement in NHS performance over the past year to make the picture more complicated than the familiar story of relentless decline. The proportion of patients waiting less than 18 weeks has improved, cancer activity is rising and this summer A&Es managed record demand while seeing more patients within four hours. Yet the scale of the unfinished job remains enormous. At the end of July, England’s elective waiting list stood at 7.3 million pathways and only 65.4 per cent were within 18 weeks, still a considerable distance from the constitutional standard of 92 per cent.

Sitting between national policy and the hospitals trying to improve those numbers are seven NHS England regions, an unusually powerful part of the health service that attracts comparatively little attention outside it. NHS England describes its regional teams as responsible for the “quality, financial and operational performance” of NHS organisations within their patch. That makes the people charged with regional operational leadership important figures in the recovery of the NHS, particularly as responsibility for provider performance has shifted more explicitly towards the regions from April this year.

Across England, that means regional operational leadership covering the East of England, London, Midlands, North East and Yorkshire, North West, South East and South West. The individuals occupying these roles will inherit very different challenges, and comparisons need some caution. London finished 2025/26 with 66.9 per cent of patients within 18 weeks and A&E four-hour performance reaching 79.8 per cent in March, while the East of England ended the year at 61.3 per cent within 18 weeks, albeit after reducing its waiting list by almost 52,000 in a year. Geography, deprivation, workforce, historic performance and provider configuration all matter, which is precisely why simply ranking regional COOs against one another would tell us relatively little.

There is, however, a more useful question to ask. If regional teams have responsibility for overseeing operational performance, what should their contribution actually look like? The NHS has spent years constructing an elaborate architecture of accountability around organisations whose operational leaders are already acutely aware of where their problems sit. Hospital COOs generally do not need another meeting to discover that their emergency department is congested, their theatres are losing capacity, their discharge processes are slow or their waiting lists need validating.

What they frequently need is the authority and organisational cover to do something about it. A hospital COO can be accountable for access, flow, productivity and financial performance while navigating Trust governance, ICB relationships, regional oversight, national programmes, workforce controls, procurement processes, digital governance and repeated demands for plans, trajectories and assurance. Somewhere within that architecture, the distinction between holding somebody accountable and allowing them to operate has become blurred.

There is a danger here that regional COOs become highly sophisticated assurance officers when the NHS needs them to be operational leaders. Asking for a recovery plan, reviewing its trajectory and escalating when it misses a target can all be necessary, particularly where performance is deteriorating. But none of those activities, by themselves, create another theatre session, discharge a patient earlier, remove an unnecessary outpatient appointment or find somebody who has disappeared from a waiting list. Regional leadership adds most value when it can remove the obstruction preventing those things from happening.

Interestingly, NHS England’s own reforms recognise much of this. Its 2026/27 Oversight Framework promises a simpler system in which success brings greater freedom, organisations facing difficulty receive meaningful support and persistent failure results in firmer intervention. NHS England explicitly says the approach should replace unnecessary bureaucracy with clearer “guardrails”, while capable, high-performing providers should receive lighter-touch oversight. The real test is whether regional management now changes its behaviour as decisively as the national framework has changed its language.

For regional COOs, that should mean a much simpler bargain with the people running hospitals. Set the outcomes, define the financial and safety boundaries and give capable operators considerably more freedom over how they deliver. Autonomy should be earned rather than indiscriminate: strong organisations should receive less routine interference, those struggling with specific problems should receive practical support, and persistently underperforming organisations should expect intensive intervention. That model creates clearer accountability because there is less ambiguity about who is responsible for execution.

Regions also possess an advantage that individual hospitals cannot replicate: they can see across dozens of organisations simultaneously. NHS England’s new acute trust league table illustrates just how much performance varies within and between regions, with high-performing organisations distributed across the country rather than concentrated in one part of England. A regional COO should therefore know not merely which hospital has a theatre productivity problem, but which hospital has already solved a comparable one and what would be required to transfer that approach.

That ability to spread execution should become a much bigger part of how regional leadership is judged. If a provider materially improves discharge, elective validation, cancer pathways or theatre utilisation, the regional response should move quickly beyond congratulating the organisation and presenting its work at another learning session. The question should be why the operating model cannot be adapted in five or ten other hospitals facing the same constraint. NHS England already has regional learning and improvement networks intended to spread good practice; regional COOs are well placed to turn that learning into faster operational adoption.

Perhaps we therefore need a different scorecard for the regional COO. Waiting times, emergency flow, cancer performance, productivity and financial delivery obviously belong on it, but so should measures of what regional leadership has enabled. How many duplicated reporting requirements have disappeared? How many decisions have been devolved? How many barriers to delivery have been removed, and how many successful operating models have travelled from one provider to another?

The NHS does not need seven regional COOs attempting to operate hospitals from above, and there is little reason to believe the people holding those jobs want to do so. What it needs from them is something more valuable: the confidence to protect good operators from unnecessary bureaucracy, intervene decisively where leadership is failing and use their regional reach to make successful ideas travel faster. If NHS England genuinely wants an operating model built around clearer accountability and greater autonomy, its regional COOs now have an opportunity to prove what that looks like in practice.

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