The state of integrated care systems 2024/25: delivering through change

Introduction

ICSs have experienced an undeniably challenging year, marked by constrained public finances and significant structural changes across the public sector. These challenges have remained and, in some cases, are greater than when this research was conducted. Yet, as this report shows, ICS leaders remain committed to delivering the government’s vision for change and continue to drive meaningful improvements in health and care outcomes for their populations.  

In March 2025, the government announced a range of measures to reduce duplication and provide better value for money across the NHS. This includes a 50 per cent cut in the running and programme costs of ICBs, the return of NHS England to the DHSC and reducing providers’ corporate cost growth. To deliver cost reductions, ICBs have established clustering arrangements and a proportion of ICBs are set to merge into bigger footprints in April 2026. However, the original deadline of end of September for delivering cost reductions quickly proved to be too ambitious. 

There are also many instances where ICBs have struggled to get the clarity they need from DHSC and NHS England to progress their change programmes. Currently, the lack of decision on whether there will be national funding to meet redundancy costs is putting ICBs in the very challenging position of being unable to begin the finance and HR processes needed to implement their restructures effectively and in a way that minimises impact on staff. 

These announcements preceded the publication of the government’s 10 Year Health Plan in July 2025. The plan sets out measures to improve our health and care system, many of which NHS leaders have been calling for. New legislation is expected to be laid before parliament in 2026 to implement several of these changes.  

Local government is also undergoing major change, with two-tier areas and smaller or failing unitary authorities reorganising and the government intending for strategic mayoral authorities to cover the whole of England by the end of this parliament.  

The State of Integrated Care Systems is the ICS Network’s flagship annual report. It sets out the views of ICS leaders on progress, how they will deliver the 10 Year Health Plan and how they are adapting to the rapidly changing political and policy landscape. 

Methodology

This report is based on data collected through secondary research and quantitative and qualitative methods. 

Through a national survey, we invited leaders of the 42 ICSs in England to share their views on ICS development, the 10 Year Health Plan and NHS and local government reform. It was open to ICB chief executives and chairs and ICP chairs from 21 July to 20 August 2025. We received 53 responses, representing over 80 per cent of systems (34 out of 42). The survey was undertaken before the appointment of chairs and chief executives to the new ICB clusters. 

Responses were split across 20 ICB chairs, 21 ICB chief executives, 10 ICP chairs and two joint ICB/ICP chairs. All respondents were asked the same questions except for an additional set of questions on the future of ICBs for ICB respondents only. At times we have compared responses to last year’s survey, but comparison is limited by different wording of questions and by different individuals completing the survey. Qualitative responses were analysed using inductive thematic analysis to identify emerging themes. We also undertook individual interviews with 12 leaders from different roles across ICBs and ICPs, including survey respondents, place leaders, ICB directors of strategy and chief financial officers, to discuss the findings and the wider context in greater depth. 

Since this data was collected, the operating context has become even more challenging. Various changes and disruptions, in particular a lack of decision around national funding to meet redundancy costs, have impacted ICBs’ ability to deliver their change programmes within the very contracted timescales.

ICSs are already progressing the government’s priorities

3.1 Confidence in the four core purposes of ICSs remains high

Overall, most ICS leaders feel confident that their system is currently able to fulfil each of their four purposes: 

• improving population health and healthcare outcomes
• tackling inequalities in outcomes and access
• enhancing productivity and value for money
• helping the NHS to support broader social and economic development. 

Looking back to survey responses in 2023 and 2024, this confidence is at its highest level since ICSs were put on a statutory footing in 2022 (figure 1). A larger proportion of leaders report feeling ‘very confident’ or ‘fairly confident’ across all four purposes, while the percentage of respondents who feel ‘not very confident’ or ‘not confident at all’ is at its lowest. 

ICS leaders are clearly starting to see the results of the work they have been doing with their teams to drive transformation over the last three years. This ranges from supporting providers, to improving productivity and efficiency and targeted work on prevention. 

Figure 2 shows survey results that respondents feel most confident about improving population health and healthcare outcomes (92 per cent), followed by tackling inequalities (85 per cent) and enhancing productivity and value for money (81 per cent). Confidence is lowest in supporting the NHS to support broader social and economic development with over a quarter (26 per cent) not very confident in their ability to deliver this purpose, which is consistent with findings from previous year’s survey.

The NHS has a key role to play in contributing to economic growth and has increasingly been active in supporting those currently economically inactive due to long-term sickness. But there is still more progress to be made to harness the opportunities of partnership working between the NHS and other local partners. 

For one ICP chair: “Economic development isn’t a core purpose [of the NHS]. How does the NHS press into the economic development leadership that local and upper tier local authorities bring and have as a responsibility?” 

The 10 Year Health Plan indicated potential changes to local government representation on ICB boards, from local authorities to mayors, which will have implications for delivering this aim. 

While the first three purposes are reflected in the Model ICB Blueprint, the fourth has received significantly less attention. At the same time, ICSs have received funding to deliver programmes on the fourth purpose and particularly around work, health and skills, including WorkWell and health and growth accelerators. Many are already working closely with their mayoral strategic authorities in this area and strategic commissioning provides an avenue to harness NHS funding to contribute to economic growth. If the lack of clarity surrounding the fourth purpose is not addressed by the government, it may erode confidence among ICS leaders and their partners in the NHS’s ability to support broader social and economic development, potentially leading to partners disengaging or ICBs having to deprioritise this crucial work.   

ICS leaders are committed to delivering on their four core purposes and focusing on making a difference to the health and wellbeing of their communities. 

As one ICB chief executive described: “We have skills, governance and structures focusing on these areas. There is still much more to do but we are having an impact on these aims.” 

ICB leaders highlight the risks of undoing or slowing some of this progress due to the distraction linked to structural changes in ICBs and local government (see section 5).

3.2 ICSs are making progress towards the three shifts

Three shifts were outlined for the NHS in the government’s election manifesto and subsequent 10 Year Health Plan: 

• moving care from hospitals to the community
• making better use of technology
• prioritising prevention over treatment. 

These ambitions have been widely welcomed by ICS leaders (see figure 3). ICS leaders believe each shift is essential to improving population health, easing pressure on hospitals and NHS staff, reducing waiting times and delivering high-quality care more sustainably and equitably. However, ICS leaders told us that delivering these shifts will be incredibly challenging. We asked them whether their system had made progress on the three shifts over the past 12 months. There was broad agreement across all three areas, although most selected ‘agree’ rather than ‘strongly agree’, indicating a sense of cautious optimism. 

ICS leaders feel they have made the most progress towards shifting from treatment to prevention with six in ten (60 per cent) respondents agreeing or strongly agreeing and only around one in ten (14 per cent) disagreeing. ICS leaders highlighted a range of preventive initiatives (see case study 3) spanning hypertension, vaccination programmes, A&E admissions avoidance, oral health, frailty and children and young people. Further work on prevention will be conducted through the prevention accelerators and demonstrators outlined in the 10 Year Health Plan, incorporating a system approach across multisector partnerships. 

A similar percentage of respondents (58 per cent) report progress in moving care from hospitals into the community. Most ICSs have made a strategic commitment to shifting care closer to home, but the challenges in making this a reality are longstanding, with the NHS experiencing a ‘right drift’, not a left shift, as outlined in the Darzi report. The NHS Confederation has already set out principles for making the left shift a reality, including a strong role for systems and measuring the movement of resources. ICS leaders highlight other key enablers such as linked financial incentives and strengthened community, mental health and primary sectors. Over the past 12 months, ICSs have continued to lay the foundations for community-based care, including through the creation of integrated neighbourhood teams. 

ICS leaders think they have made the least progress on harnessing digital technology, with just over half of respondents (52 per cent) agreeing that they have made progress and one fifth of respondents (20 per cent) disagreeing. 

One ICB chief executive explained that “progress has been made on analogue to digital but slower and much less within our control – as NHSE control the funding streams and much [of the] funding has disappeared over the last two years.” 

Although digitisation is a crucial enabler to shifting from treatment to prevention and providing more care closer to home, the NHS still lags behind other health systems in this area. 

Despite these challenges, there have been positive developments. 

An ICB chair cited “significant growth in use of the NHS app” and “implementing an EPR in their acute trusts” as examples of progress (see ‘ICSs in action’ in box below). 

ICS leaders have also been developing and implementing their digital strategies to ensure high levels of digital maturity (see case study 2), while also addressing the risks of digital exclusion. 

3.3 Longstanding challenges to systems’ progress persist

In recent decades, NHS commissioners have seen successive waves of reorganisations and ICBs are no exception. The government’s requirement for ICBs to reduce their running and programme costs by 50 per cent has initiated the establishment of clusters and the approval of the first mergers of ICBs to take place on 1 April 2026. While these cost reductions aim to balance the books and streamline the role of ICBs to focus on strategic commissioning, over half of ICS leaders see NHS reorganisation as the number one barrier to their system’s progress over the next two years. 

They described several risks associated with this level of upheaval, including distraction from delivery of the 10 Year Health Plan, more limited headspace for senior leadership and impact on staff morale. 

An ICB chair highlighted that “all attention has been on the process of reorganisation itself”, impacting their ability to focus on the three shifts while an ICB chief financial officer explained that changes in leadership can impact on organisational memory and delay decision-making. 

Lack of funding for social care is also a major concern, with over half of respondents selecting it as one of the biggest barriers to their system’s progress against the four core purposes. This remains consistent with findings from the State of ICSs survey for the past two years (see figure 5).

Rising demand and cost in adult and children’s social care continues to put pressure on local government financial sustainability. Addressing the long-term challenges facing the social care sector through the Casey Commission will be essential to delivering the ambitions of the 10 Year Health Plan. But in the short term, the government should tackle urgent capacity and interface challenges in the sector, including its limited scope to focus on transformation due to demand pressure. 

One ICB chair explained: “As we speak, there are between 300 and 400 people in our hospital beds who shouldn’t be there. Not all of them are waiting for social care but a good proportion of those people are waiting to be transferred into nursing homes or back to their own home or residential care. We’re relying on our local authority colleagues who are even more strapped for cash than we are.” 

The interface between the NHS and adult social care can also be improved. In partnership with the Association for Directors of Adult Social Services, the NHS Confederation will be setting out how the NHS and adult social care can tackle some of these challenges in the short term. 

Managing the transition to strategic commissioning

4.1 Barriers to delivering ICB cost reductions

ICB leaders are committed to reducing duplication and providing better value for money. They worked collaboratively with national leaders to develop the Model ICB Blueprint and have risen to the challenge of meeting the required 50 per cent reduction in running and programme costs, with plans underway to restructure their organisations. Most ICBs have agreed clustering arrangements with neighbouring ICBs, while a small number will be merging on 1 April 2026.

This is the second time ICBs have been asked to make considerable cuts and builds on the 30 per cent cuts from 2023-2025. The latest round of cuts is based on all ICBs achieving running and programme costs equalling £19 per head of population. Each ICB had a different baseline spend per head of population which means that the reduction each is expected to make varies, with a range from 27 to 63 per cent. As such, the process has had a differential impact on ICBs across the country.

Ninety-five per cent of ICB survey respondents are very or fairly concerned that the cost reductions will impede their ICS’s ability to deliver against national and system priorities (see figure 6). They raised concerns about the process of restructure and communication from national partners, and highlighted the lack of a clear plan following the initial announcement. Significant delays in confirming the extent to which national funding would be made available to fund staff redundancies, alongside delays to leadership appointments, have made this process challenging. 

One ICB chief executive shared that “the issue has been the lack of clarity on timescales and milestones for appointments, and funding.”

These barriers have made it difficult to efficiently implement the cost reductions requested and have exacerbated the impact of this NHS reorganisation. At the time of the survey, most ICBs indicated the absence of national funding would force them to delay redundancies across all staff to 2026/27. These ICBs could not fund the costs of the redundancies without putting their financial plans at risk and breaching their cost controls. Until this issue is resolved, ICBs remain in limbo – unable to release the necessary savings, provide certainty to staff and effectively plan for the future. 

The scale of disruption and impact on staff morale and wellbeing cannot be underestimated. The energy and focus of senior leaders and their teams has been absorbed by delivering these efficiencies and turnover of ICB leadership has been substantial, adding to this destabilisation. 

One ICB chief executive described “distraction and lack of focus at a time of uncertainty” as a “significant delivery risk for the second half of 2025/26”. 

In the long term, questions remain whether the reduced allocation will be sufficient for ICBs to effectively deliver their strategic commissioning role and implement the 10 Year Health Plan.

One ICB chair explained: “The 10 Year Health Plan sees the expectation of ICBs evolving but the cost reductions will leave them without the resource to deliver.”

4.2 Uncertainty about ICBs’ future functions

To meet the cost reductions and focus on their role as strategic commissioners, ICBs are planning to reduce, deliver differently or stop some of their existing functions. The Model ICB Blueprint, released in May 2025, provided guidance on which functions ICBs should review, with suggestions about where these functions could be transferred to, such as NHS providers, NHS England regional teams or local authorities. 

ICB respondents are most concerned about the impact of the cost reductions on the delivery of All Age Continuing Healthcare (AACE), safeguarding and medicines optimisation (see figure 7).

This concern reflects the fact that ICBs hold statutory responsibilities around AACE, safeguarding and SEND, and that these functions serve some of their most vulnerable populations. The Model ICB Blueprint identified these as functions to be considered for transfer out of ICBs, but this will require the passing of primary legislation. In the meantime, ICBs still need to deliver them within the target of £19 per head of population. 

At the time of the survey, ICB leaders were reviewing how they could deliver these functions at this lower cost, but with no confirmation of the timeline, process or receiver for a potential transfer of functions. Since the survey, NHS England has published best practice guidance on NHS continuing healthcare (CHC), safeguarding and SEND which recommends that all three functions remain within ICBs, with guidance on how they can be delivered more efficiently. This position may change in the government’s forthcoming NHS reform bill given the wording in the Model ICB Blueprint on devolving these functions over time and the emphasis in the 10 Year Health Plan on provider integration.

ICBs are committed to addressing the unwarranted variation in spend on CHC, with complex factors to consider when deciding how it should be delivered. The clinical and financial risk and complexity linked to CHC, means not all local areas will have organisations willing to take on delivery.

One ICB director of strategy explained: “Whatever we do in the future, that’s either going to be a huge proportion of our workforce and our budget or we outsource it but we’re still accountable.” 

Medicines are the most common healthcare intervention, cause of avoidable harm to patients and the second highest area of NHS spending after staffing.  Medicines optimisation seeks to ensure the best outcome for patients and best value for the taxpayer. ICBs have been responsible for driving forward and overseeing medicines optimisation across the system, working closely with all partners and particularly general practice. Medicines optimisation contributes to each of the four purposes and is an opportunity to drive transformation. 

An ICB chair described it as “an important budget management mechanism 
for ICBs.” 

The Model ICB Blueprint indicates that delivery should be transferred to providers over time, with ICBs retaining strategic overview as part of their commissioning responsibilities. Since the survey, NHS England has published best practice guidance which recommends that each ICB should retain senior medicines leadership to fulfil its requirements in relation to strategic commissioning of medicines and leadership of innovation uptake. 

ICB leaders are concerned because it is an “important budget management mechanism for ICBs” and a key part of their ambitious cost improvement programmes. 

While not a statutory function, ICBs have an important role as a system convenor to bring together partners across their ICS to manage challenges, solve problems and harness the power of collaboration. Mentions of this role has been minimal in recent government publications such as the Model ICB Blueprint and 10 Year Health Plan, causing uncertainty about their role as convenors going forward. Many ICB leaders feel it is important to retain this function as ICBs can bridge the gap between NHS organisations and wider partners. 

One ICB chief executive explained: “The system convenor role is about having the authority to convene but it’s non-hierarchal authority. I don’t convene provider CEOs because I’m more important or powerful but because I’m not one of them. I can convene as a neutral space that supports them to navigate some of the things they need to navigate. […] If you take away the convening role, you will just have institution, institution, institution – and the things in the middle are lost.”  

ICBs can take a step back and reflect a wider view, rather than the interests of individual organisations or sectors. 

As one ICB director of strategy described: “I think ICBs will continue with a role around convening. It won’t be for everything and I don’t think it should be and it never was. […] It’s about how we set out our vision and take a leadership role in some of it. You can lift yourself up and have a helicopter view on behalf of the population. We have to look at the total needs of the population, not just those who use a service, because we don’t want people to be patients, we want to do what we can to keep people out of the system.” 

ICB leaders are working closely with national partners to review and adapt how they deliver their responsibilities. Going forward – and ahead of legislative changes – financial and clinical risks associated with changing delivery of CHC, safeguarding and SEND should be planned for and mitigated as much as possible. ICBs must be given the resources they need to deliver these functions. This also applies to providers if functions are delegated to them in future. If these changes are not managed carefully, patient outcomes will suffer and ICBs could potentially be subject to judicial review for not meeting statutory responsibilities they have not been resourced to deliver. 

ICBs’ legacy as a system convenor should be taken forward in their role as strategic commissioners and supported with permissive and flexible guidance. Moving towards new delivery models will require buy-in from all system partners – as the budget and contract holder, ICBs are best placed to do this. 

4.3 Supporting ICBs to thrive as strategic commissioners

Alongside the Model ICB Blueprint, the 10 Year Health Plan has given ICBs a clear mandate to become strategic commissioners and NHS England’s strategic commissioning framework will provide further detail on what this entails. It aligns with the vision we set out previously on behalf of members and represents a substantial shift in expectations which will take time to embed.

ICB leaders are clear the next few months will be crucial in developing and implementing new ways of working between all parts of the system, adapting to their local contexts. For example, one ICB chief executive raised the need to do further work on the interface between ICBs’ role in contract management and the role of regional teams in provider oversight and performance management. 

ICB leaders are optimistic about the potential for strategic commissioning to improve the health of patients and residents and want to see a fundamental shift away from more ‘tactical’ commissioning. 

An ICB chair shared that they wanted to continue in their role because of the emphasis on strategic commissioning: “If we use our strategic commissioning powers, we can still get a lot done and make change happen. One of the biggest challenges as an ICB is how you move the money round. If we are to really make sense of strategic commissioning that gives us a focus on that challenge.”

In the context of the continued uncertainty on the future of many statutory functions, ICB leaders are concerned about investing in and building strategic commissioning capability while maintaining the capacity and capability needed to meet their core statutory obligations. An ICB chief financial officer explained that with potentially limited scope to reduce statutory functions, there is likely to be scarce resource to invest in strategic commissioning, such as the intelligent payer functions. This is likely to result in a slower path for ICBs building their strategic commissioning capabilities and skills to deliver the governments’ three shifts. 

The Model ICB Blueprint set out four core functions of an ICB that underpin its role as a strategic commissioner. There is variation in how confident ICB respondents feel in the tools, skills and capabilities to deliver these different elements (see figure 8 below). Over four in five ICB leaders agree or strongly agree that their ICB has the tools, skills and capabilities to understand its local context (91 per cent) and develop a long-term population health strategy (83 per cent). This reflects the work they have been doing since 2022 to develop strategies with their partners and understand the needs of their populations, which built on the legacy of clinical commissioning groups (CCGs).

However, over one in five ICB respondents (23 per cent) disagree that their ICB has the tools, skills and capabilities to deliver the strategy through payer functions and resource allocation. ³  This may reflect concerns about the impact of cost reductions on capacity and capability for intelligent payer and contracting, or a lack of common understanding about what the payer function means. ICB leaders are also slightly less confident that they have the tools, skills and capabilities they require to evaluate impact, with 15 per cent of respondents feeling they do not currently have sufficient skill and capability in this domain.

There is broad agreement that some commissioning skills and capabilities were lost during the COVID-19 pandemic and during the shift in emphasis towards collaboration and partnership when ICSs were established. The ongoing cost reductions will also lead to more skilled and experienced staff leaving. During the transition period, national and regional partners should support ICBs to retain the right skills and capabilities to deliver their strategic commissioning role and other statutory responsibilities. 

ICB leaders are clear on which areas they need to focus on to rebuild their capabilities and upskill their staff. This includes leadership and organisational development to shift culture and ways of working, including support around strategic thinking. More sophisticated data analysis and drawing from health economics and actuarial science will also be important. 

One ICB chief executive described the need to “strengthen our econometric, analytical and statistical capacity and capability.” 

ICBs are moving at pace to become strategic commissioners. National guidance, rules and policies should support – not hinder ICBs – in this role and keep up with changes delivered at a local level. ICB leaders want national teams to develop new contracts and payment incentives and to support better performance measurement in mental health and community care. This will require coproduction and collaboration between ICBs and their partners and national and regional teams. At the same time as ICBs are improving their commissioning knowledge and upskilling their staff, national partners should embed expert commissioning expertise in decision-making at senior levels. The NHS Confederation will be working closely with national partners to support the strategic commissioning development programme in 2026/27 as well as ICBs directly through its Strategic Commissioning Forum.  

Achieving the three shifts will require difficult decisions, and ICB leaders need the confidence and backing of the centre to make the kind of strategic decisions that tackle immediate challenges and deliver long-term, transformational change. Ensuring ICBs can deliver the required cost reductions as efficiently as possible in 2025/26 and 2026/27 is crucial to allow them to effectively deliver their strategic commissioning function.

A new era for partnership working between local government and the NHS

5.1 Taking forward the legacy of integrated care partnerships (ICPs)

In the 10 Year Health Plan, the government announced its intention to remove the statutory requirement for ICPs. These statutory committees are responsible for producing an integrated care strategy on how to meet the health and wellbeing needs of the population. Since 2022, ICPs have been formed between the ICB and all upper-tier local authorities within the system geography, with membership of other partner organisations determined locally. 

The Health and Care Act 2022 allowed flexibility in how ICPs should operate. ICPs have taken different forms across the country, varying widely based on local arrangements with place partnerships, health and wellbeing boards and broader system structures. ICS leaders highlighted the important role of the ICP in bringing partners together and broadening the focus of the ICB outside of the NHS to work collaboratively with partners to address the social determinants of health. Although changes in national policy mean that the relationship between local government and the NHS is changing, ICS leaders reflected what the legacy of partnership working through the ICP should be built on. 

An ICB chair commented: “ICPs have provided a great multi-sectoral and statutory arrangement to collaborate and agree a joint five-year system-wide strategy and annual delivery plan. The local engagement, alignment and commitment achieved must be retained.” 

When asked how they would maintain joint working between the NHS, local government and wider partners, almost half of all respondents (46 per cent) said they would incorporate ICP functions into health and wellbeing boards. There is local variation in existing relationships between the ICP and health and wellbeing boards, with some smaller systems effectively merging both. While some ICS leaders acknowledge some level of duplication between both, others emphasised the risk that health and wellbeing boards are too driven by the political nature of councils. 

For one ICP chair “the ICP was a middle ground that wasn’t dominated by anyone” and it was key to focusing on local issues. 

The difference in scale between health and wellbeing boards and the larger footprints of ICBs will also need to be addressed in governance arrangements. 

An ICB chair commented: “Fundamentally those ICPs were a very good forum for bringing together all of the system partners, and if they don’t exist in the same form as they do now, the NHS has got to come up with some other proposal or structure that means they will actively engage with those other partners and it may be the health and well-being boards.” 

Alongside this, two out of five respondents (40 per cent) indicate that they will maintain joint working through partnership with strategic authorities (see section 5.3) and around a quarter (26 per cent) will retain the ICP as a non-statutory structure (see figure 9). At the time of the survey, there was still uncertainty about what the future of the ICP might look like and many ICS leaders were waiting for structural changes to be embedded before making any further decisions. 

Regardless of what form the partnership takes, collaborative working between the NHS, local government, the public and the VCSE sector is critical to address complex health and social care needs in the community. 

An ICP chair reflected: “Unless we truly integrate health and social care and bring together all statutory partners, we will never deliver prevention which is key to the long-term future of the NHS and local government to reduce demand and of course address falling healthy life expectancy.” 

Originally proposed in the Hewitt Review, ICS leaders previously supported setting up a national ICP forum to enable engagement with key government departments such as the DHSC and Ministry of Housing, Communities and Local Government (MHCLG). 

One ICP chair explained that although the context has changed, the need for cross-government working at a national level is still essential. As strategic mayoral authorities (see section 5.3) expand across the country and are encouraged to take on a stronger leadership role in health, ICS leaders will be exploring different avenues to strengthen relationships between local government and the NHS at all levels of the system – from local to regional. 

5.2 The impact of local government reorganisation

Through the English devolution and community empowerment bill, introduced in parliament in July 2025, the government intends to replace all two-tier county and district councils with single tier unitary authorities. This presents an opportunity for more standardised and improved system integration. 

We asked leaders if the reorganisation of local government, the largest in over 50 years, may present opportunities for more integrated working. ICS leaders expressed a mixed view, with many feeling that it is too early to speculate and will depend on how the changes are delivered. Over half (54 per cent) of respondents agree or strongly agree that local government reorganisation will improve integration and cross-sector working in the long term, while over a quarter (36 per cent) neither agree nor disagree (see figure 10).

ICS leaders identified some key enablers to integration and cross-sector working: alignment of boundaries where possible, buy-in of local government to health, and the strength of relationships. They also highlighted the risks of organisational redesign, and its potentially detrimental impact to existing relationships and partnership working, particularly as the NHS goes through its own reorganisation.

On the other hand, an ICP chair noted that moving to unitary authorities where housing, social care and public health are managed within one organisation, presents an opportunity for stronger engagement and integrated working on key priorities including prevention. It may still be too early to tell what the long-term impact of these changes will be. However, the scale of change in both the NHS and local government in some areas of the country will likely reduce headspace and capacity for partnership working.

5.3 The expansion of strategic authorities

The government announced through the English devolution white paper its intention to establish strategic authorities across England by the end of this parliament. The English devolution bill further states: ‘Strategic authorities should play an active role in ensuring positive health outcomes in their areas.’ This will include a new health duty for strategic authorities to give ‘regard’ to improving population health and addressing health inequalities when undertaking their role. This, while welcome, is fairly limited in its scope. 

The government built on strategic authorities’ role in health in the 10 Year Health Plan. This included alignment between strategic authority and ICB boundaries where possible, mayors sitting on ICBs boards instead of local authority representatives and the development of prevention demonstrators (see case study 3). ICS leaders can see some of the opportunities of devolution. Over two in five (44 per cent) respondents agree or strongly agree that the establishment of strategic authorities will advance the government’s broader health agenda (see figure 11). 

But there are still many unknowns. Nearly two in five respondents (38 per cent) neither agree nor disagree, suggesting that a large proportion of respondents are still unclear about how strategic authorities will contribute to health. This may reflect local variation with most ICSs not yet having a directly elected mayor in their patch. This raises questions about who sits on an ICB board in areas with no directly elected mayor.

Some ICS leaders expressed concerns about the onus on individual mayors and the variation in capability, capacity and interest among them to take on this role among their many other responsibilities. 

One ICB chair shared that “strategic authorities could be a major opportunity to accelerate integration of health, social care and public health services ... but there is a risk that individual mayors may not prioritise this as much as others.”

Further, mayors do not have direct levers on health and social care services, though their forthcoming new health duty will increase their influence over population health and health inequalities across their footprints. As they increasingly hold levers to influence health, including as members of ICB boards, mayors may benefit from targeted health leadership training and support. 

ICS leaders have identified that these further developments should enable improved integration and partnership working by creating an authorising environment to engage with new partners and extend into areas that impact the health and wellbeing of populations. There is an opportunity to align national and local priorities, co-develop strategy that is health-orientated across government, and leverage economies of scale to promote economic, physical and social wellbeing and resilience. 

Despite alignment between the 10 Year Health Plan and the English devolution bill, the absence of any reference to ICSs’ fourth purpose which connects health and prosperity is notable. As described in section 1, there is a lack of clarity about where this will sit in the new way of working and lower confidence among ICS leaders in their systems’ ability to fulfil this purpose, which is consistent with the two previous iterations of this report.

Delivering the 10 Year Health Plan: rising to the challenge

6.1 ICS leaders are committed to delivering the 10 Year Health Plan

ICS leaders are committed to the vision of a neighbourhood health service set out in the 10 Year Health Plan and are already progressing on delivering the three shifts (see section 3.2). Improving population health, reducing health inequalities and supporting people to stay well out of hospital is at the heart of the ICS mission. 

One ICB chair told us that “what I really like about the 10 Year Plan is the fact it started by talking to the public, and so it’s really grounded in what the public want.” 

Working closely with their local partners, ICBs are uniquely placed to bring all the different parts of the health and care system together and focus on the purpose of the plan. 

For one ICB chief executive, the ICB needs to put residents first: “keep the vision of population health and wellbeing alive” and “create an environment where people can succeed.”  

Drawing on their commissioning skills and expertise and building on the partnerships and structures established so far, including at place, ICBs also have an important role in supporting the changes to provider delivery models envisaged in the 10 Year Health Plan. This includes the development of integrated health organisations (IHOs) which can hold capitated contracts and new single- and multi-neighbourhood provider contracts. ICBs will play a key role in commissioning these new contracts from providers.

While ICS leaders support the plan’s overall vision, which builds on their own strategies, they highlight the lack of clarity on how it will be delivered, and the need for its proposals to align effectively. Greater join up is needed between different policy areas, from financial flows and accountability to data and digital. 

An ICP chair described “clear tensions in the plan in a number of areas, for example whether neighbourhood health management is primarily about changing how we work in neighbourhoods or is more about structures and buildings.”

Around a quarter of survey respondents (26 per cent) think developing IHOs holding outcomes-based contracts will make a big difference to their local communities (see figure 12). Some respondents, however, felt that the rebirth of foundation trusts (FTs) may be a “step backwards”, particularly as the 10 Year Health plan sets out that FT status is a prerequisite for becoming an IHO. The characteristics needed to be an effective FT may not be the same as those needed to be a successful IHO which financially binds together partners to jointly deliver acute, community-based, mental health and primary care services and drive population health. ICS leaders would therefore like to see a strong focus on collaboration in the inclusion criteria for the new FTs and IHOs. Closer working with primary care will be particularly important to empower neighbourhood working.

As we await further details on what this new regime will look like, ICBs will need the right levers and support from regulators to drive these changes as well as the freedom to pursue other delivery models such as alliance or lead provider approaches. The development of IHOs will also take time. IHOs are therefore unlikely to provide a solution to some of the NHS’s immediate operational and financial changes. The NHS Confederation will shortly be publishing a report on IHOs.

6.2 Enabling care closer to home

Over three in five respondents (64 per cent) think ‘shifting a proportion of health spending into the community by 2035’ is one of three changes introduced by the 10 Year Health Plan that will make the biggest difference to their local communities (see figure 12). Thirty-eight per cent of respondents chose it as their number one change when asked to prioritise among their choices (see figure 13). This is consistent with findings from last year’s survey which found that the majority of systems had made a strategic commitment to shift resource to allow more people to be treated in their local community.

ICS leaders are clear that shifting health spending into the community represents a consequential change for all parts of the health and care system. It is, however, an essential tool to implement a truly preventative approach to healthcare and make the NHS financially sustainable. 
 

An ICB chief financial officer shared that in some cases delivering care closer to home will not always be cheaper but might be “the right thing to do.”  

For one ICP chair, it is not just about shifting health spending into community health services but “enabling and empowering communities to be healthy so that they can support each other.” 

ICS leaders are also supportive of the focus on the plan on neighbourhood health, which is underpinned by a shift of health spending into the community. Over one in five respondents (30 per cent) chose establishing neighbourhood health centres and the creation of new neighbourhood health contracts as some of the top changes that will make a difference to their local communities.

For one ICB chief executive, delivering through neighbourhoods is one way of implementing a social model of healthcare. It should enable people, through a physical space and/or a team of professionals to receive wraparound, personalised care and be delivered in partnership with local authorities and the VCSE sector. ICBs will be commissioning these new single- and multi-neighbourhood contracts and will play a key role in shaping the establishment of neighbourhood health centres, building on what already exists. 

The 10 Year Health Plan’s vision for a neighbourhood health service aligns with how systems are already approaching neighbourhood health. 

For one ICB chief executive, these announcements helpfully build on the work they are already doing, giving it “more prominence and a bit more structure around it.” 

At the same time, one ICB chair warned that “we should avoid having a national model [for neighbourhoods] imposed on every community in the country. They have to be built from the bottom up and avoid destroying the partnerships already established.”

Over half of respondents (68 per cent) agree or strongly agree that their system has a clear plan for supporting the shift to a neighbourhood health service (see figure 14). Across ICSs, different neighbourhood models have developed, and ICBs and their partners are focused on how to scale good practice and implement the plans they have developed. Our previous work has demonstrated a diverse range of approaches, including system-wide approaches, reflecting the important role of primary care and general practice, with communities at the heart of change.

London, for example, drawing on its unique governance arrangements, has developed a target operating model for neighbourhood health, using place-based partnerships to provide local leadership and nominate an integrator organisation which will enable integration at neighbourhood level. In the south west, Cornwall and the Isles of Scilly ICS has invested £6 million a year to develop integrated neighbourhood teams covering approximately 191,000 people and separated across three places. Each place is led by a leader based in the community and mental health trust.

For one place leader, the biggest challenge for neighbourhood development is demonstrating savings in the acute sector to maintain investment: “It’s the right thing to do but, at the same time, everyone’s asking for evidence that no one can really get because it’s so difficult to measure.” 

In a financially constrained environment and without the opportunity to double-run, we need to change financial flows to support neighbourhood health and ensure the money follows the patient. 

One ICB chair emphasised the need to “unpick all of the block contracts so we can start to properly contract these integrated community-based services.” 

All eyes are now on implementation. From September 2025, the DHSC will support 43 places through the National Neighbourhood Health Implementation Programme (NNHIP), to accelerate the work that is planned or already happening in many areas of the country, through learning together, sharing solutions, tackling challenges and delivering improvement. The NNHIP will also be joined up with parallel national 10 Year Health Plan delivery work led by NHS England. 

6.3 A new operating model

The government has set out a new operating model for the NHS that aims to devolve power and to simplify the historically complex governance arrangements in the centre and within the system, including a blueprint for the regions. The absorption of NHS England into DHSC, expected to be completed in April 2027, is an opportunity to reimagine the national team and its relationship to ICS leaders. This operating model will be further iterated and supported by legislative change in forthcoming primary legislation. 

When asked during interviews what behaviours and ways of working they expect from national and regional teams within the more devolved operating model described in the 10 Year Health Plan, most ICB respondents sought greater autonomy and trust in ICBs and providers to deliver their local plans. ICB leaders also supported the government’s overarching objective to reduce bureaucracy and provide clarity on roles and responsibilities. 

ICB leaders want to see improved cultures and ways of working to ensure “clarity, challenge and support” as well as “confidence and commitment to ICBs.” 

Implementing the new operating model will take time but a change in the role of ICBs should be accompanied by a change in how they are supported by and work with the government and national and regional bodies. 

For one ICB chief executive, there should be “a clear articulation of what the strategic commissioner role will be” and regulators working in “lockstep” with ICBs to make decisions and drive transformation. 

Conclusion and summary of recommendations

ICSs are going through an unprecedent period of change and the next few months will be crucial to their success. ICS leaders are ready to seize the opportunity for change outlined in the 10 Year Health Plan to improve population health, reduce health inequalities and ensure effective and sustainable health and care services for the future. 

Moving away from a hospital-centric health system and towards a preventative approach to health will continue to require strong partnership working between ICBs, NHS providers, primary care, local government and the VCSE sector. The progress made so far should be built on, not lost, during this transition. ICS leaders took on their roles because they believe in the four core purposes and many have recommitted to leading their organisations, inspired by the opportunity of strategic commissioning. 

ICBs commission nearly £164 billion of public money (19 per cent of public sector spending in England). To ensure ICBs can deliver on their strategic commissioning role, the government and NHS England need to provide a clear roadmap to delivering the required running cost reductions and ensure they have the capacity and capabilities to succeed. 

Close collaboration and communication between ICB leaders and national and regional teams will be crucial to releasing the savings needed and provide much-needed certainty to ICB staff. Regardless of what structures are developed, from retaining ICPs to working in partnership with health and wellbeing boards and strategic authorities, close collaboration between the NHS, local government and wider partners is at the heart of the mission of ICSs. 

On behalf of ICS leaders, we make the following recommendations to the DHSC and NHS England: 

1. Work with HM Treasury to clarify national funding and timeline for ICB redundancies to either allow ICBs to implement their restructures in 2025/26 or to allow what can be afforded to be delivering this year, with the remainder delivered in 2026/27.  
2. Deliver clear and regular communication with ICB leaders about timelines, process and expectations for the ICB change programme, equipping them to implement changes effectively and safely. This should include additional support for ICBs making greater reductions, clustering or merging.
3. Support and resource the development of ICBs’ strategic commissioning skills and capabilities, particular attention should be given to their functions as healthcare payers.
4. Appoint a senior commissioning lead in the future DHSC national structure, reporting into the director general for system development, with commissioning expertise to best support ICBs in the future.
5. Model collaboration with other government departments to promote integration between the NHS, local government and wider partners by aligning policy, guidance, legislation and the health and economic growth missions. 

6. Embed a more devolved, enabling operating model by:

   a.  Providing ICBs with the levers, autonomy and aircover they need to make difficult commissioning decisions to support new service models and shift resources from hospitals to communities. 

   b. Working with ICBs to co-produce the tools they need to effectively discharge their functions.

   c. Taking a ‘locally-led with national principles’ model to policy development, building on existing work and partnerships, in particular around neighbourhood health. 

Summary infographic