To achieve the vision of the 10-year plan and the government’s "three shifts", it is vital that those expected to deliver these ambitions are clear about the part they should play. And Lord Darzi was right when he wrote that more needs to be done to clarify the role and responsibilities of integrated care boards.
There has been a specific issue around how ICBs have been asked to focus on immediate operational and financial pressures — indeed, NHS England's 2022 operating framework has encouraged them in that direction. But this has made it harder for systems to focus on longer-term transformation.
Encouragingly, there are now clear signs that these issues are being understood and acted upon by national leaders.
Yesterday, Amanda Pritchard outlined how ICBs would be tasked with leading on strategic commissioning in their systems, with NHSE providing targeted support and appropriate regulatory oversight and performance management. And this morning, Wes Streeting reinforced that point with a clear direction for ICBs to focus on developing neighbourhood health services.
In line with this, NHSE's new Insightful ICB Board guidance, published yesterday, reframes ICBs’ role to emphasise strategic leadership focused on achieving the four core aims of ICSs: improving population health, tackling inequalities, enhancing financial sustainability, and contributing to their local economies. ICBs' ability to focus on longer-term aims is vital to shifting care closer to home and towards a prevention-focused model — two of the government’s three "big shifts".
If the national and system architecture is to support rather than hinder progress, NHSE's forthcoming oversight and assessment framework should then build on this approach.
Trust leaders — our members — have told us consistently about the challenges that have been caused by placing ICBs in a quasi-regulatory performance management role. They say that conversations with ICBs are too often focused on short-term issues, and our 2024 regulation and oversight survey found 62 per cent of trust leaders thought that ICBs' activity duplicated that of NHSE. The consequence of giving them responsibility for overseeing individual trusts' performance has been a tendency to focus on day-to-day operational and financial performance, which has not always left room for the strategic leadership role.
The immediate performance challenges are very real, of course, but we know that continuing to work in the same way won't deliver the change required to see sustainable improvement. We need the added value ICBs can bring if given the space to convene partners to collaboratively plan, problem-solve, and join up services across the NHS and with social care. This is the system leadership role that was envisaged for them in the Health and Care Act 2022.
A shift in this direction will remove duplication, which in turn will free up trust boards to focus on doing their part to deliver for the communities they serve and work with partners in their systems to create the sustainable NHS that we all want to see. Re-empowering trust boards to govern their own organisations and allowing ICBs to strategically commission in the interests of their communities could also begin to create the conditions for the "self-improving" systems envisaged by Patricia Hewitt in her review last year.
We now need this change in direction to be followed through in NHSE's revised oversight and assessment framework. This is crucial as it will create the context that either nurtures, or hinders, the trusting relationships and collegiate behaviours necessary for effective system working.
Next, the 10-year plan should tackle the other barriers to successful system working and integration, including financial flows and incentives, annual planning cycles, and lack of capital investment.
But the new emphasis on ICBs' strategic role is a hugely welcome first step to reducing duplication, freeing ICB and trust staff from non-value-adding activity, and beginning to create the conditions for greater system autonomy and self-improvement. We hope this shift in focus will enable systems to concentrate on their four core strategic purposes. Trust leaders are ready to help make it work.
This article was first published in the Health Service Journal.
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