Shared leadership boards in the NHS: A pragmatic path to collaboration and reform

As the NHS continues to evolve in response to increasing demand, financial pressures, and the need for integrated care, one of the most significant shifts in governance has been the rise of shared leadership boards across NHS Trusts and Foundation Trusts.

This model, where multiple trusts share executive leadership (most notably chief executives and chairs), is gaining traction as a strategic alternative to full mergers and/or as a stepping stone towards a merger.

The rise of shared leadership boards

According to NHS Confederation, a third of NHS trusts in England now operate under shared board-level leadership arrangements. These models have emerged organically, driven by local needs and system-wide pressures, and are increasingly seen as a way to:

• Align clinical strategies across trusts.
• Share learning and resources.
• Jointly invest in infrastructure.
• Improve clinical and financial sustainability.

Rather than merging, trusts can maintain their legal independence while collaborating more deeply through “boards in common” or group governance structures.

Employment implications for joint role holders

The shift to shared leadership brings with it complex employment considerations, particularly for joint chief executives and chairs:

1. Contractual clarity: Joint role holders often serve multiple boards, which may require bespoke employment contracts that clearly define reporting lines, responsibilities, and performance expectations.
2. Governance complexity: Leaders must navigate the governance frameworks of multiple organisations, which can differ in culture, priorities, and operational maturity. This raises questions about accountability, especially when decisions impact more than one trust.
3. Capacity and resilience: There are concerns about whether individuals can effectively lead multiple organisations without compromising oversight or strategic focus. Succession planning and leadership support structures become critical. 
4. Remuneration and appraisal: With the NHS Management and Leadership Framework set to replace the Board Leadership Competency Framework from 2026/27, there will be new standards for appraisal and development of executive leaders, including those in joint roles.

Constitutional considerations

When NHS Trusts or NHS Foundation Trusts adopt shared leadership board arrangements, careful attention must be paid to their constitutions and schemes of delegation. These documents define the legal and operational boundaries within which each organisation functions. Any joint leadership model must respect the statutory autonomy of each trust, even when strategic decisions are made collectively.

Key considerations include:

• Reservation of powers: Trust boards must clearly identify which powers are retained and which can be delegated. Shared boards must ensure that decisions taken jointly do not exceed the authority granted by each trust’s constitution.  
• Delegation frameworks: Schemes of delegation and constitutions must (as applicable) be reviewed and potentially revised to reflect joint roles and shared decision-making forums. This includes defining the scope of authority for joint chief executives and ensuring that accountability and liability are clearly assigned.  
• Governance alignment: Trusts involved in shared leadership tend to harmonise their governance structures (whether in whole or part) to avoid conflicts and duplication. This may involve creating joint committees or “boards in common” with delegated powers, while maintaining oversight mechanisms within each individual trust.
• Legal compliance: All arrangements must comply with the NHS Act 2006 and the Health and Care Act 2022 and associated regulations, which outline permissible forms of delegation and joint working. Certain functions such as those involving statutory duties or financial accountability may not be delegable and must remain under the direct control of each trust’s board.

Ultimately, shared leadership boards must strike a balance between collaborative efficiency and legal integrity, ensuring that the governance arrangements that are adopted are permissible and remain robust and transparent across all participating organisations.

Strategic role in the NHS 10-year health plan

The NHS 10-year health plan, published in July 2025, outlines three radical shifts: moving care from hospital to community, transitioning from analogue to digital, and focusing on prevention over sickness. Shared leadership boards are well-positioned to support these goals by:

• Enabling system-wide coordination: Joint boards can align strategies across trusts to deliver integrated care and reduce duplication.
• Driving innovation: Shared leadership fosters cross-organisational learning and investment in digital infrastructure.
• Supporting workforce reform: The plan includes the creation of a College of Executive and Clinical Leadership, which will support leaders in joint roles with tailored development and governance support.

Looking ahead

While shared leadership boards are not a panacea, they represent a flexible and locally responsive model for NHS reform. As the NHS moves toward a more devolved and collaborative operating model, these arrangements will likely become more common and more formalised.

To ensure success, NHS England and regulators must:

• Develop standardised governance frameworks.
• Provide legal and HR guidance for joint appointments.
• Monitor the impact on service delivery and leadership capacity.

If you’re considering the use of a shared leadership board and/or any other form of joint working, please contact one of our specialists for a no obligation meeting to discuss how we can help.