Will the ‘model ICB’ strengthen or undermine system working?

No service is an island. That has been the driving logic of reforms to the English health and care system over the past decade. We cannot meet the needs of growing numbers of people living longer and with multiple, complex, long-term conditions, or tackle challenges such as widening health inequalities, through organisations working in isolation. Instead, we need close collaboration across boundaries with a shared focus on the needs of local people and an overarching structure designed to bind local partners together around this common purpose. This logic led to the creation of integrated care systems (ICSs) from 2017 onwards, formalised by the Health and Care Act in 2022. Integrated care boards (ICBs) are a central part of ICSs, responsible for planning and funding most NHS services across a system.

In the past few weeks, the requirement to make deep and rapid cuts to the running costs of ICBs has raised fundamental questions about their future shape and function. Those questions received a partial answer in the blueprint for a ‘model ICB’ shared recently with local systems. So what does this mean for the future of system working, and how will the model ICB relate to the other pieces of the complex health and care jigsaw?

ICBs have always had a dual purpose, balancing (often with difficulty) their role as ‘system conveners’ with being the holders of the NHS purse strings locally. The model ICB decisively tips the balance towards the latter, with a focus on commissioning effectively and much less emphasis on bringing together local partners and facilitating collaborative working. Under the model, ICBs will be expected to build up their ‘strategic commissioning’ capabilities, develop their use of population health management tools, and grow their capabilities to shape and commission new care pathways and services that support the key strategic shifts towards prevention, community-based provision and better use of technology.

Arguably, the conditions were never right for ICBs to perform their role as system convenors in the way originally envisaged, but it remains a function that needs to be performed. Through our work supporting local systems, we have seen repeatedly that the systems that have made most progress are those that have put sustained effort into building relationships across boundaries and establishing a shared understanding of how to improve the health and wellbeing of their local communities. System working, particularly with wider partners such as local government and the voluntary sector, is countercultural for much of the NHS, and organisations always have their own gravity pulling attention inwards. Without someone, or something, that actively counters this gravitational pull, integrated approaches capable of meeting people’s needs in a joined-up way struggle to take root.

If this convening role is no longer within the remit of ICBs, the question of how to hold local systems together and the structures needed to support this requires urgent attention. One option would be to have a boosted role for integrated care partnerships, for example based on the model already seen in Suffolk and North-East Essex. In some systems there could be other candidates, perhaps linked to devolution plans and mayoral authorities. Regardless of the model, the ability for organisations to come together to collectively improve outcomes for their local populations is essential to tackle the systemic issues facing health and care.

The changes signalled in the blueprint are not limited to ICBs. The document also lays a heavy load of responsibilities on providers, with a long list of functions currently performed by ICBs set to transfer to them ‘over time’. There has been a growing view among many policy-makers that as provider collaboratives develop and mature, some of the tasks performed by ICBs could be delegated to them. The current changes now cement that expectation and accelerate the process.

The question is, do NHS providers have the appetite or bandwidth to take on these responsibilities? For example, providers will be expected to support the development of neighbourhood models and place-based partnerships. Close partnership working at this local scale is needed now more than ever, particularly given the mergers expected in many parts of the country that will leave ICBs covering larger geographies with less of a direct link to local services and communities. But while providers have an important role in delivering integrated services at place and neighbourhood levels, place-based working isn’t solely about service delivery – as we have argued previously, it is also about understanding and working with local communities, agreeing shared priorities for the local population, and addressing social and economic factors that influence health and wellbeing. If providers are to lead on this, it will require a different outlook and skillset which they will need help to build.

The model ICB is just one part of a wider picture, much of which remains uncertain pending decisions on neighbourhood health, regional teams, local government reform, devolution and other issues. More will be known on some of this once the 10-year plan is published. Without that bigger picture, it is hard to draw firm conclusions on what the changes to ICBs will mean for ambitions around integrated care and improving population health. What is certain is that the nature of the challenges in health and care demand a systemic response. Going backwards on the commitment to system working simply isn’t a viable option.