Empowering ICBs: A blueprint for fixing the NHS

Executive Summary

The NHS in England is struggling. As Chapter One outlines, public satisfaction and patient outcomes have been falling, despite huge and growing government expenditure.

Meaningful reform to the NHS in England will be achieved by empowering Integrated Care Boards (ICBs), the prime focus of this report. Just as giving academy schools autonomy while holding them to exacting standards improved pupil outcomes in England in recent decades, the NHS must now empower its local leaders through ICBs to drive healthcare reform.

Focus of this report and methodology

This report examines in detail the current structure and outcomes of the English healthcare system, before going on to recommend policies to empower ICBs to improve the performance and efficiency of the NHS.

This report seeks to answer the following seven research questions:

Is the NHS in England underperforming, historically and internationally?
What are the leading problems facing the NHS in England?
What are the leading causes of the problems facing the NHS in England?
What are the healthcare policies and structures of other countries that have improved outcomes?
What is the history and role of ICBs in improving outcomes in the English healthcare system?
What are the barriers that are preventing ICBs from having greater impact?
Can new policies enable ICBs to improve outcomes in the NHS in England?

In order to answer these, we employed three research methods, as detailed in Chapter Two. First, we conducted an extensive literature review to examine the structure of and problems facing the NHS in England. Second, we interviewed a range of key decision-makers and thought leaders, such as CEOs of ICBs and NHS provider trusts. And third, we produced case studies of the healthcare systems of comparable countries to England, conducting reviews of their structures, inputs and outcomes.

Although international comparisons typically consider health inputs and outcomes across the whole of the UK, this report focuses on the structure of and policies for the healthcare system in England.

How the NHS in England compares internationally

Developed or OECD countries tend to have a ‘Beveridge system’ or ‘Social insurance system’ for healthcare. There is little evidence that one of these two types produces systematically better results than another.

As Chapter Three illustrates, Beveridge systems have the majority of their hospital beds in publicly owned and managed hospitals, and most of their healthcare funded directly by government. Beveridge systems, other than England, include Sweden, Denmark, Ireland, Spain, Italy and Finland in Europe, and Canada and New Zealand globally. Together, they are our ‘similar international peers’; this report prioritises comparing England with these throughout the report.

Social insurance systems include Germany and the Netherlands. They still provide near universal healthcare coverage, usually through state insurance for the very poorest, but most funding does not come from the government, and the state also does not necessarily own the hospitals.

The UK now spends a significantly higher percentage of GDP on healthcare (11.3%) than the OECD average (9.2%), as of 2021. The UK, however, spend slightly less per capita on health than the OECD average: $54,126 versus $58,956 Purchasing Power Parity (PPP), as of 2021.

Performing positively

As of 2021, compared to our similar international peers:

The UK performs very well when it comes to the proportion of people for whom cost is no barrier to accessing healthcare.
The UK performs well on efficiency when measured as share of total costs spent on administration, although it is not clear that this is an accurate indicator of efficiency.
The UK spends significantly less on drugs as a portion of its healthcare spending.
The UK has the highest rates of flu vaccination for the elderly in the OECD.
The UK has extremely high rates of statins utilisation in the over 40s.

Performing negatively

As of 2021, compared to our similar international peers and the OECD average:

The UK performs below average on life expectancy.
The UK is worse when it comes to quality of both prevention and treatment, since our mortality rates from treatable and preventable causes are higher – for example, the UK has more people dying from alcohol related diseases and certain cancers.
The UK has worse-than-average adverse events in hip and knee surgeries such as patients experiencing pulmonary embolism or deep vein thrombosis.
The UK performs relatively worse on mortality from circulatory disease and cancer.
The UK underinvests in health capital expenditure, even following the Autumn Budget 2024, so the UK has the fewest hospital beds and diagnostic scanners per person.
The UK has a below average number of doctors.

The UK’s peers tend to have a similar structure to England in that they have a national body, responsible for strategy and funding, but have regional bodies responsible for planning and delivering care. The key difference is these regional bodies are significantly more empowered than the bodies that exist in England – ICBs. Most appear to have greater authority, with some having some direct democratic legitimacy or having been in place longer. These regional bodies often do not manage all healthcare, usually focusing on secondary care while primary and social care are often taken care of by even more local government. As a result, even amongst Beveridge systems, England is one of the most centralised healthcare systems.

The leading causes of NHS underperformance in England

The six leading factors of NHS underperformance are described in detail in Chapter Four.

Lack of cooperation

The NHS in England has historically prevented cooperation between different bodies. This means that providers of the same type too often operate at too small a scale and providers of different types fail to collaborate, leading to patients – especially elderly patients – often ending up in inappropriate, costly and ineffective settings: primarily hospitals, specifically A&E.

Excessive centralisation in DHSC and NHSE

Since 2013-14, there has been an increase in capacity in the central bodies of the NHS such as NHS England (NHSE), the Department for Health and Social Care (DHSC) and others NHS regulators within England. This is coupled with a hollowing out of capacity elsewhere. Centralisation is why the funding given to ICBs is excessively short-term and over-specified.

A consultation system that blocks almost all change

ICBs are expected to design services to best meet the need of their population. During the development and consideration of proposals for change, some significant ones must be consulted on with the public. Theses consultation are excessively lengthy and the bar for sufficiency is unclear.

An excessive focus on hospitals at the expense of primary and community care

The NHS is too focused on hospitals, which experience funding growth at the expense of primary and community care and, as a result, at the expense of prevention and population health management. Since 1995, the number of GPs has grown at only 2% per year, while the number of provider trust doctors, who primarily work in hospitals, has grown by an average of 4% per year. There have been wider cuts to funding of services that support health but are not hospitals and not primary care. Overall, local authorities saw their funding fall by an average of 18% per person in real terms in the years 2010 to 2024.

Hospitals that are not capable of increasing treatment volumes

Hospitals are unable to increase treatment volumes despite the increased funding and staffing. This is largely a result of them being full. They have had insufficient capital investment in infrastructure such as beds, diagnostic and digital technology, and they are often an inappropriate setting to treat many of the patients who are in them: namely, older people with multiple conditions. Already slow healthcare productivity growth, 0.8% per year from 1995-2015, has gone into dramatic reverse. Since 2019, increases in government funding for hospitals have not come with increases in output. Despite a 20% increase in hospital staff numbers since 2019, the number of treatments delivered has remained roughly the same.

Short-term funding and priorities

Funding settlements for ICBs and hospitals are decided annually. This means that they cannot really plan over a longer than a 12-month horizon. Crucially, savings made in one year disappear from the budget for next year, as NHSE claims them back. Providers and ICBs struggle to plan service redesigns that will take more than a year, and it is exceedingly difficult to justify any investments, in systems or in people, which will take more than 12 months to pay off. Furthermore, the current NHSE operating planning guidance, the main annual document giving ICBs their marching orders, is overly focused on processes and is supplemented by endless ad hoc requests.

The history, role and benefits of ICBs

ICBs gained a formal statutory basis in the Health and Social Care Act 2022. They are regional bodies that manage most healthcare resources through arranging care for patients in their local areas: what is called commissioning.

They are responsible for commissioning hospital, community and mental health care for patients in their local areas and manage around 80% of NHSE’s resources. Therefore, they are predominantly focussed on commissioning secondary care. They also commission primary care, although annual contract negotiations are still handled by NHSE. As of 2023, they are also responsible for commissioning community pharmacy, general ophthalmic and dental services as well.

Each ICB is responsible for between 500,000 and three million people and includes, on average, around 150 GP surgeries and 12 hospitals. They are accountable for healthcare and financial performance within their geographical areas.

ICBs were established to integrate and join up services within the NHS in England. That means taking a collaborative, system-wide approach to treatment and is the key difference between them and Clinical Commissioning Groups (CCGs), their predecessor organisations, which encouraged competition between NHS bodies.

Chapter Five argues that the collaborative approach of ICBs can foster three key benefits:

More integration, meaning a healthcare service where constituent parts work together to deliver care where most appropriate, rather than where the patient shows up.
More prevention, meaning more care delivered earlier, and in the community, where it is more effective.
More consolidation, meaning services of the same type are rationalised and delivered at the most effective scale; often larger scale than today.

Main barriers to ICBs having greater impact

The evidence suggests there are four main barriers to ICBs achieving greater impact, as outlined in Chapter Six.

Limited strategic financial control

Even though ICBs are notionally in charge of around £120 billion of the NHS budget, as of 2022-23 the reality is that they have limited strategic control over the funding they do receive.

NHSE provides funding in ’penny packets,‘ which are very difficult to use strategically because they are split across many pots that are tightly targeted, short-term and come with extensive reporting requirements. ICBs are typically overcommitted on the money they do have and, so, they often spend the financial year trying to squeeze savings from their budget. Many ICBs are in deficit before each financial year starting in April begins.

ICBs are never on a longer than a 12-month financial horizon. This means that ICBs and provider trusts struggle to plan service redesigns, efficiency investments or anything else where the payoffs are going to take more than 12 months.

A lack of capacity

This is driven by three main reasons. First, repeated reorganisation: there is evidence that organisational stability is needed to support development of real relationships across different partners within and around the NHS.

Second, a lack of staff. Just after being created, ICBs were asked to reduce their running costs by 30% in two years, resulting in a vast decrease in the capacity to hire staff. Indeed, ICBs are outmatched when working with large provider trusts: they have 300 administrative staff per ICB.

Third, a lack of prestige, in some cases, restricting the quality of staff. Strong leadership remains primarily in hospital trusts and in NHSE, not in ICBs. The repeated reorganisations, and the perception that provider trusts were where change really happens, has made it difficult for ICBs, and CCGs before them, to attract high-quality staff, especially those with experience of working in provider trusts.

Weak formal influence

ICBs suffer from insufficient influence to drive the change they were designed to. This is as a result of excessive instructions from NHSE and DHSC. Also, NHSE holds 42 annual management meetings directly with provider trusts in attendance, despite, at least notionally, giving advanced ICBs the authority to manage their respective trusts themselves.

ICBs are also part of a complex web of different bodies within the NHS, within which their role and influence is unclear. Hospital trusts do not report formally to ICBs, and senior members of provider trusts are not appointed by ICBs, instead having their own hospital trust boards which usually appoint these roles. It is also not even necessary that ICBs are at all involved in the appointment of CEOs or chairs for their respective provider trusts, or are involved in the boards of their provider trusts, although this is often the case.

Onerous oversight

ICBs must comply with the NHSE Oversight Framework. While the original 2022-23 NHSE Oversight Framework included 63 individual measures, the 2024-25 Oversight Framework formally contained only 32. But the 2024-25 framework had 20 pages of instructions. What is more, in reducing the metrics in the 2024-25 Oversight Framework, NHSE chose to preserve those that were maximally intrusive. Not one of the remaining metrics was a true patient outcome metric, such as mortality, patient satisfaction, life expectancy or even stroke survival rates.

The NHSE also demand quarterly and annual reviews from ICBs, which take account of: the four main objectives of ICBs, six capability domains, key metrics in the NHSE Oversight Framework and a range of other statutory duties.

ICBs must also comply with the separate Care Quality Commission (CQC). The DHSC, too, has its NHS Outcomes Framework which contains yet more metrics that must be reported.

New policies

Chapter Seven makes 12 policy recommendations to strengthen ICBs. When formulating policy, we applied four key principles that our recommendations had to meet: prioritisation of the long-term; fiscal responsibility; no top-down structural reform; and greater autonomy and accountability, mirroring academisation in education policy.

Funding of ICBs

Recommendation one: Funding from NHSE in the areas where ICBs are responsible for commissioning should not go directly to provider trusts but to ICBs instead.

It is difficult to plan healthcare strategically if NHSE sends money for some schemes directly to hospitals, cutting ICBs out of the loop. If ICBs are to be committed to, they must be allowed to play their intended role rather than bypassed in favour of provider trusts. Thus, any new funding from NHSE should only go to ICBs rather than provider trusts.

Recommendation two: Reform NHSE funding to ICBS so a greater proportion is without specific conditions and at timescales of a minimum of three years.

Funding from NHSE should be given to ICBs with a real ability for them to strategically direct it as appropriate for the NHS to achieve a shift away from hospitals. This requires less hypothecation of the money awarded to ICBs and more long-term funding.

Recommendation three: The NHS should target a return of hospital funding back to 55% of the total NHS budget over the next five years.

Since 2016, overall spending on hospitals has grown from 55% to 59% of total NHS funding. This should be reversed over the next five years. It will be easiest to do this by directing much more of the growth in public funding into the NHS in coming years away from hospitals.

Recommendation four: Increase healthcare capital spending to 0.8% of GDP, administered by ICBs.

The UK currently spends 0.4% of GDP on health capital spending. Even following the increase in capital investment for health announced in the 2024 Autumn Budget, this is not set to increase beyond 0.5% of GDP. Given the capital spending deficit within the NHS, and the fact our similar international peers are all around the 0.8% of GDP level, a greater increase is a fiscally realistic ambition.

Performance measurement of ICBs

Recommendation five: Create a combined scorecard for all accountability frameworks for ICBs and provider trusts that focuses on long-term outcomes, integrating the demands of NHSE, DHSC and the CQC.

There ought to be a combined system scorecard against which both provider trusts and ICBs are measured, joining up the separate accountability frameworks that exist for ICBs from NHSE, DHSC and the CQC.

Recommendation six: The new scorecard for oversight frameworks should assess ICBs and provider trusts primarily on patient outcomes, especially life expectancy, preventable and treatable mortality, patient satisfaction, patients dying in their chosen setting and bed days per person.

The outcomes in the new scorecard that ICBs and provider trusts should primarily be assessed on long-term patient outcomes. Although this report understands that some short-term and financial outcomes are also likely to be included in the appendix also used by the oversight bodies.

Recommendation seven: All outcomes and metrics in the new scorecard and appendix for the accountability frameworks of ICBs and provider trusts should be updated and tracked using the Federated Data Platform (FDP).

The Federated Data Platform (FDP) is a software platform that is being built by Palantir for NHSE to sit across provider trusts and ICSs, enabling data to be brought together.

All outcomes and metrics that ICBs and provider trusts are being assessed on by the different accountability frameworks should be tracked in a live, single tracker, accessible by all the relevant parties built on the FDP. There should be formal requirements to keep the FDP up to date, which then automatically flow to parties that have the right to see the relevant data. These requirements should specify for each outcome how often it should be updated.

Governance of and involving ICBs

Recommendation eight: Mandate that provider trust appointment committees and boards contain at least one ICB-designated person.

Frequently, ICBs sit on provider trust-appoint panels for CEOs and senior staff. This should be mandated for all NHS provider trusts. Similarly, it is important that the boards of provider trusts, to which CEOs are ultimately responsible, should have ICB representation.

Recommendation nine: The NHSE should produce a standardised, streamlined consultation process for all NHS bodies for a maximum of six months.

NHSE should produce an outline for a standardised consultation process for all NHS bodies, and design it such that it is expected to last for no more than six months.

Recommendation ten: The Independent Reconfiguration Panel (IRP) should be able to advise ICBs and provider trusts on reconfiguration, and the Secretary of State for Health should accept any local reconfiguration the IRP supported.

The IRP is chaired by a former President of the Royal College of Surgeons and has a panel of up to 15 senior clinicians alongside managers and lay representatives. The IRP already advises the Secretary of State for Health on reconfigurations of healthcare services where the government requests this advice, typically in the case that a reconfiguration has been referred to or called in by the Secretary of State.

It would make sense to enable the IRP also to advise both providers trusts and ICBs on reconfigurations. This is because it makes sense to have a strong centre of expertise in NHSE concerned with the reconfiguration of local healthcare services. The Secretary of State for Health should commit to support any proposal where the proposed new standardised process for reconfiguration was followed, and the IRP is supportive.

Supporting ICBs that are ‘lighthouses’

Recommendation eleven: Designate high-performing ICBs as ‘lighthouses,’ which receive even more funding over up to five-year cycles without hypothecation.

The most high-performing ICBs, as established thorough the new scorecard outcomes proposed in this report, should be given more control than the new default proposed in this report over their money from NHSE. Their budgets, as much as possible, should be freely managed and given ideally five-year timescales.

There should be a commitment that as a default the lighthouse ICBs will be left out of new funding schemes from NHSE which require additional bidding or reporting – the ‘penny packets’ – and, instead, simply be given a portion of new funding from NHSE based on their population.

Recommendation twelve: Allow lighthouse ICBs to experiment with governance structures.

The pilot lighthouse ICBs should be allowed to adopt different governance structures. It is not yet clear what the right governance end-state of ICBs ought to be. But merging with the boards of provider trusts with an ICB has three key benefits. First, it drives provider trust collaboration and integration. Second, it streamlines governance. Third, it improves leadership quality. With that said, leadership consolidation comes with risks. This is why it is worth experimenting and evaluating this approach with some lighthouse ICBs.

Conclusion

The NHS in England is in trouble. It is underperforming, both historically and internationally. ICBs have an opportunity to improve the way the NHS in England operates.

A much more positive future awaits if ICBs are given the finances, outcomes and governance changes to realise their transformative potential: to build an NHS in England that is more locally driven, more long-term focused, more strategically planned and more focused on patients and care closer to home.

Chapter One: Introduction

The NHS is struggling. As shown in Chart 1.1 below, only 24% of the public is satisfied with the NHS, the lowest ever support level. Satisfaction with GPs has halved to 34% since 2019.¹ Voters are worried about the future of the NHS.²

This should not be surprising. As of 2024, only 74% of those attending A&E are discharged, admitted or transferred within four hours – a standard commonly used across the NHS to assess performance. In 2010, the target was for 95% of patients to be seen within this time. It has not been met nationally since 2013.³

In total, as of 2024, 6.3 million people are waiting on lists for care, with over seven million referrals left untreated as some people are waiting for multiple procedures.⁴

Patients, especially the elderly, are having increasing difficulty accessing social care as it is increasingly, informally, rationed.⁵ This is also true of primary, community and mental health care, where increasing difficulty contacting and booking services has reduced the access the public has to them.⁶

Long-term patient outcomes are suffering as well. Life expectancy has stagnated since 2014, and has still not recovered from its fall during the COVID-19 pandemic.⁷

This deteriorating performance is despite huge and growing government expenditure. The Department for Health and Social Care (DHSC) currently spends around £185 billion a year – around 30% of all UK government spending.⁸ Of this, NHS England (NHSE) – as described in Chapter Two – spends £160 billion, and, as of 2022-23, NHSE allocates around £120 billion of this money to Integrated Care Boards (ICBs), the focus of this report.⁹

What is more, total government spending on the NHS has been growing. As of the 2024 Autumn Budget, the NHS budget is set to increase by 2025-26 by £22.6 billion.¹⁰ As such, spending on the NHS is set to grow by 3.8% in real terms between 2023-24 and 2025-26, significantly outstripping the UK’s projected economic growth rate of 1.3% within the same period, taking spending to almost 13% of GDP.¹¹

Nonetheless, it is the case that the UK’s level of healthcare funding growth in recent years has been lower than the historic yearly 3.8% average growth in funding for the NHS from 1980 to 2020.¹² This growth in funding is judged by the Institute for Fiscal Studies (IFS) to be only about the rate needed just to maintain NHS provision at current levels, accounting for an increasing population, a higher proportion of elderly people with comorbidities and rising drug and wage costs. This means that, even without any complications, current fiscal circumstances are challenging for the NHS.

Focus of this report

This report examines in detail the current structure and outcomes of the English health system and compares this to international peers. It adds to the important work done by other organisations and the NHS itself in the pursuit of improving healthcare in England, but seeks to strengthen the case for reform, demonstrating that greater power and resources to ICBs in the coming years could improve both the performance and efficiency of the NHS.

This report seeks to answer the following seven research questions:

Is the NHS in England underperforming, historically and internationally?
What are the leading problems facing the NHS in England?
What are the leading causes of the problems facing the NHS in England?
What are the healthcare policies and structures of other countries that have improved outcomes?
What is the history and role of ICBs in improving outcomes in the English healthcare system?
What are the barriers that are preventing ICBs from having greater impact?
Can new policies enable ICBs to improve outcomes in the NHS in England?

The report is structured as follows:

Chapter Two describes the research methods employed, as well as outlining the definitions used in this report.
Chapter Three compares the UK’s healthcare inputs, outcomes and systems internationally.
Chapter Four explores the causes of underperformance within the NHS in England.
Chapter Five examines the role, history and benefits of ICBs, highlighting examples of ICBs achieving superior results for healthcare.
Chapter Six analyses the main barriers that prevent ICBs’ full potential from being fulfilled.
Chapter Seven recommends new policies to empower ICBs to improve outcomes in the healthcare system in England.

Chapter Two: Methodology

This report examines in detail the current structure and outcomes of the English healthcare system, before going on to recommend policies to empower Integrated Care Boards (ICBs) to improve the performance and efficiency of the NHS. This chapter outlines in detail the research methods employed and definitions used in this report.

Although international comparisons typically consider health inputs and outcomes across the whole of the UK, this report focuses on the structure of and policies for the healthcare system in England. Over 80% of the UK population lives in England and therefore we will assume that it is English trends driving what we see in the international performance data.¹³ We are focused on the NHS in England – that is all the organisations and people within England who are part of the public provision of healthcare. It is distinct from the NHS in Scotland, Wales and Northern Ireland, which are devolved and managed separately.

Research techniques

We employed three main research methods for this report.

Literature review. We conducted an extensive literature review to examine the structure of and problems facing the NHS in England. We scrutinised and synthesised academic publications, government papers, statistics and studies and think-tank reports. When comparing UK health inputs and outcomes with international peers, it is worth noting that the most recent OECD data (2021) was used, which was disrupted by the COVID-19 pandemic. Conclusions were checked against 2019 data and were found to remain robust.
Expert stakeholder consultation. We conducted a number of informal, semi-structured interviews with a range of decision-makers and thought leaders, such as CEOs of ICBs and NHS trusts. These are listed in full below.
Case studies. We examined the healthcare systems of comparable countries to England, conducting reviews of their structures, inputs and outcomes. These are highlighted throughout the report.

Interviews

A number of interviewees are still involved in the English healthcare system and in order to give completely candid views and quotations some requested anonymity for their contributions either in whole or in part. So, throughout the report, interviewees and their quotations are occasionally anonymised.

Box 2.1. List of interviewees

Rosie Beacon, Head of Health at the think tank Reform.
Matthew Bryant, CEO of Dorset HealthCare and Dorset County Hospital.
Dr Claire Fuller, interviewed when CEO of Surrey Heartlands ICB, now National Primary Care Medical Director.
The Rt Hon Patricia Hewitt, Chair of the Norfolk and Waveney ICB, Deputy Chair of the Norfolk and Waveney ICP, former Secretary of State for Health (2005-2007).
Edward Jones, Senior Policy Advisor on ICB Networks at the NHS Confederation.
Dr Ben Horner, Managing Director and Partner at the Boston Consulting Group (BCG) and the Global Leader for Health Care Payers, Providers, Systems and Services.
Loy Lobo, Vice Chair of the Essex Partnership University NHS foundation trust and Non-Executive Director of the Northwest London Acute Provider Collaborative.
Professor Michael McCourt, former CEO of the Pennines community and mental health foundation trust and former interim Managing Director in acute trust in Cambridgeshire.
Paul Mears, Chief Executive of Cwm Taf Morgannwg Health Board (Wales) and the former Chief Executive of the Yeovil District Hospital (England).
William Pett, Head of Policy at Healthwatch England, former Head of Policy on Integration at the NHS Confederation and former Associate Director of Strategy at the Bath and Northeast Somerset, Swindon and Wiltshire Integrated Care Board.
Nicos Savva, a Professor at London Business School focusing on healthcare management, as well as external advisor to NHSE.
Sir David Sloman, a former NHSE COO and former CEO of multiple NHS Trusts.
Matthew Walker, the CEO of the National Association of Primary Care.
Anonymous, former Special Adviser to the Prime Minister on health.
Anonymous, former CEO of a community and mental health trust and former COO of a hospital trust.
Anonymous, CEO of an ICB.
Anonymous, CEO of an ICB.

The views in this paper are Bright Blue’s, and those listed in Box 2.1 do not necessarily endorse or agree with all the recommendations and statements in this report.

Definitions

The structure of the NHS differs in each of the four nations, so the below definitions are only a cursory description of how the NHS works in England. Chart 2.1, below,¹⁴ lays out a simplified view of the very complicated structure of the healthcare system in England. The flows of money are complex, and there are end destinations for funding not included on the chart for the sake of simplicity.

Department of Health and Social Care (DHSC)

The DHSC sets the overall health policy for the UK and the strategic direction for healthcare in England.¹⁵ The DHSC also funds and holds NHSE and the other arm-length bodies it is responsible for accountable for delivery. It does so with its budget of around £185 billion per year, as of 2022-23, though this is set to increase significantly in 2025-26 following the 2024 Autumn Budget. These other arm-length bodies include the National Institute for Health and Care Excellence, the Care Quality Commission (CQC) and the Health Research Authority.¹⁶

The DHSC is headed by the Secretary of State (SoS), the most senior minister in the Department, who is appointed by the Prime Minister.

National Health Service England (NHSE)

NHSE is the headquarters of the NHS in England and operationally oversees it. This involves overseeing the funding, planning and delivery of healthcare in England. It does so with its budget of £165 billion, as of 2022-23. NHSE also directly commissions some services, including secondary care for rare conditions and has some direct control over others such as primary care.¹⁷

Crucially, NHSE is not the NHS in England, as there are lots of bodies like provider trusts that are not part of NHSE but are part of the NHS in England.

NHSE uses its operational planning guidance and the included national NHS objectives to lay out its overall priorities and measures of success for the health system, including for ICBs and provider trusts.¹⁸

Integrated Care Systems (ICSs)

ICSs consist of all the organisations that have some impact on health within a geographic area. There are 42 of these geographic areas in England. They are contiguous and non-overlapping. The organisations include NHS bodies and other organisations with a responsibility for health and social care, including upper-tier local councils, the voluntary sector, social care providers and other partners.¹⁹

There is one ICB and Integrated Care Partnership (ICP) per each ICS. Each ICS covers a population of around 500,000 to 3,000,000 people. Within larger ICSs there are ‘places’ covering populations of around 250,000 to 500,000 people, within which a partnership of place-based health and care organisations may exist.²⁰

Integrated Care Boards (ICBs)

ICBs are responsible for commissioning and integrating care within their geographical areas. They were established in 2022 as legal entities to break with the past of competition within the NHS and instead promote collaboration, integration and consolidation.²¹

Their four key duties are to: improve outcomes in health; reduce inequalities; enhance productivity; and support broader social and economic development.²²

In theory, ICBs commission care strategically in line with the Integrated Care Strategy produced by the ICPs. They perform their role with their combined budget of around £120 billion per year as of 2022-23, although, as discussed later in this report, much of that funding is already pre-determined.

Integrated Care Partnerships (ICPs)

ICPs are statutory committees with the same four aims as ICBs: improve outcomes in health; reduce inequalities; enhance productivity; and support broader social and economic development.

ICPs are advisory bodies. They lack formal powers, which sit with ICBs. ICPs exist to bring local organisations together and encourage, but not force, collaboration.²³ The membership of these committees varies widely, but it must include ICB and local authority representatives.²⁴ They may also include representatives from voluntary organisations, NHS providers and others.

The sole statutory duty of the ICP is to produce an Integrated Care Strategy setting out how the ICB and the local authorities concerned will meet the health and wellbeing needs of its population.²⁵

NHS hospital/acute (foundation) trusts

Hospital trusts, also called acute trusts, are the bodies which deliver secondary care, excluding most mental health care, to patients. These bodies spend around £70 billion per year, as of 2022-23. NHS hospital foundation trusts perform the same role as NHS hospital trusts; in the 2000s, hospital foundation trusts were created to have more autonomy and local accountability, but the end outcome has been that they are treated very similarly by central government.²⁶ Given their similarity, and for the sake of simplicity, this report will refer to hospital trusts without clarifying whether they are foundation trusts or not.

Secondary care

Secondary care includes A&E, surgery and complex diagnostics and treatments such as childbirth, trauma surgery and urgent treatment for heart attacks and strokes.

Ambulance trusts

Nine ambulance trusts are responsible for providing ambulance services across England. They spend about £3 billion per year as of 2022-23, and their number means that each ambulance trust covers multiple ICBs.²⁷

Community trusts

Community trusts spend about £10 billion per year, as of 2022-23, and they provide community care.

Community care

Community care encompasses an incredibly diverse range of care. This care is most often provided to “children, older people, people living with frailty or with chronic, multiple and/or complex health needs, and/or people who are near the end of their life”.²⁸ These services include falls injury rehabilitation and prevention services, community nursing, palliative care and many others that can be provided within the patient’s local community.

Mental health trusts

Most secondary mental health care – that not delivered by General Practices or voluntary organisations – is provided by mental health trusts at a cost of around £10 billion per year as of 2022-23.²⁹ This care includes long- and short-term mental health wards and community mental health care.

Provider trusts

This is a term which covers hospital, community, ambulance and mental health trusts. A hospital or acute (foundation) trust, as described above, is a provider trust, as are community and mental health trusts. Therefore, not all provider trusts are hospital trusts.

Some provider trusts are combined, which means, for instance, that they are responsible for both mental and community health care.

Independent providers

Independent providers provide a wide range of services to the NHS at an estimated cost of £10 to £15 billion per year, as of 2022-23. First, around £2 billion, as of 2022-23, is spent each year to provide around 5% of all elective care paid for by NHSE. Notable examples include around a quarter of hip and knee replacements and around half of all cataract surgeries.³⁰ The rest of the spending can be opaque, but roughly half covers continuing care and community health services.³¹ These are services largely provided outside of hospitals by nurses and carers, including in care homes.³² The care might involve helping people with dressing and washing or providing occupational or speech therapy. Independent providers are tasked with the final 25% of expenditure to provide a range of services, including mental health, primary care and A&E.³³

Primary care

Primary care services provide the first point of contact in the healthcare system, acting as the ‘front door’ of the NHS.

Primary care includes general practice, community pharmacy, dental and optometry (eye health) services. Primary care undertakes a range of investigations, such as blood tests or physical examinations and offers onward referrals or treatments, such as prescriptions for antibiotics or statins.³⁴

General Practice

General Practices are generally people’s first point of contact with the NHS. Every person in England is generally registered with a practice, which allows them to book appointments and receive medical advice free of charge.³⁵

General Practices provide approximately one million appointments each day to identify and manage illnesses and refer to other NHS services where the general practice is not the most appropriate setting for care – usually for more complex and serious illnesses.³⁶ There are around 6,500 General Practices across England and they are usually small private businesses that receive all or a majority of their funding from the NHS.³⁷ They would typically include several General Practitioners (GPs), a practice manager, secretaries, nurses and further clinical staff, such as pharmacists.³⁸

Depending on how it is measured, General Practices receive between £10 and £15 billion of funding per year, as of 2022-23.

Primary Care Network

Every General Practice is typically a member of a Primary Care Network that generally joins together between three and six General Practices. These networks directly receive some funding and therefore directly hire some workforce. The idea is to encourage General Practices to operate at a greater scale. They can do this by hiring roles, such as physiotherapists and care coordinators, which there would not have been enough work for in a single practice. Expanding the primary care workforce with roles such as care coordinators also then makes integration with community, primary and hospital trusts more feasible.³⁹

Pharmacy, ophthalmic and dental services

All three of these services tend to be provided by private companies contracted by the NHS, but also can provide private services. Formerly commissioned directly by NHSE, from April 2023, ICBs have commissioned these three services.

Pharmacies, costing NHSE around £2.5 billion per year, as of 2022-23, are commissioned to dispense medicines, provide healthcare advice and can provide services such as some consultations and emergency medicines supply.⁴⁰

NHS dentistry, costing NHSE around £3 billion per year as of 2022-23, must provide treatment to keep mouths, teeth and gums healthy and free of pain.⁴¹

Ophthalmic services are those related to eyes. Opticians are paid by the NHS around half a billion pounds each year, as of 2022-23, to test peoples’ eyes and vision, give them prescriptions and refer them to secondary care if necessary.⁴²

Voluntary community and social enterprise organisations

A very diverse set of local and national organisations that typically have a social or charitable purpose to improve the health and lives of people. These organisations are typically not contracted to deliver services to the NHS and are thus distinct from the independent providers described earlier.

Examples relevant to the NHS include Age UK, Bernardo’s and the Suicide Prevention Consortium. They, for instance, provide companionship, advice and support to vulnerable people, old people, children or those contemplating suicide.⁴³

Social care providers

These organisations provide care, typically for older people, to allow them to stay healthy and independent in their community for longer. This care could include help with household tasks, like washing and cooking, or more medical services, such as rehabilitation. They provide care homes, retirement homes and in-home care.

Social care providers are essential to the NHS, as often elderly people are unable to be discharged from hospital without a care home spot or sufficient plans for in-home care, increasing the strain on hospital beds.⁴⁴

Local government

Local government in England is extremely diverse, including metro mayors controlling combined authorities, single-tier unitary councils, two-tier district and county councils, local town and parish councils and more.⁴⁵

Local government is usually responsible for social care, public health, some education, housing and planning, waste collection and more.⁴⁶ Most relevant for the NHS are their adult social care responsibilities: paying for some housing and care for the elderly and their public health role. Importantly for this report, local government receives about £3 billion a year, as of 2022-23, from the DHSC to provide drug and alcohol services and smoking cessation services, as well as miscellaneous related services.⁴⁷

Conclusion

The research methods and definitions detailed above enabled us to analyse how the NHS in England compares internationally (Chapter Three), the leading causes of NHS underperformance in England (Chapter Four), the history, role and potential of ICBs (Chapter Five) and the leading problems preventing ICBs from delivering (Chapter Six). This report concludes with policies to better empower ICBs and thus improve the NHS (Chapter Seven).

Chapter Three: How the NHS in England compares internationally

Having so far identified that the NHS in England is underperforming historically, we now zoom out to examine how our healthcare system compares internationally. This chapter compares the NHS in England with the performance and structure of healthcare systems in comparable countries. On performance, as mentioned in Chapter Two, international comparisons are made with the UK, rather than just England. Ultimately, the UK systematically outperforms developing countries in global rankings on leading performance inputs and outcomes,⁴⁸ but its performance against developed countries is much more mixed.

Similar healthcare systems to England

Excluding the US, developed countries tend to have universal healthcare coverage. They tend to do this in one of two ways.

They either have a model where the government pays for most healthcare via taxation, which we call ‘Beveridge systems’ – in that they are similar to what Sir William Beveridge called for in his 1942 report, which laid the foundations for the NHS in this country.

Otherwise, they tend to have a mandatory ‘social insurance system,’ similar to the German model first established by German Chancellor Otto von Bismarck in 1883, whereby all patients have to have insurance, but there are often multiple insurance funds and different levels of coverage. These funds, rather than the government, often have a large role in running the healthcare system.

There is little evidence that one of these two types produces systematically better results than another.⁴⁹ This report therefore concurs with the view of the King’s Fund that “there is little evidence that one particular ‘type’ of health care system or model of health care funding produces systematically better results than another. Countries predominantly try to achieve better health outcomes by improving their existing model of health care, rather than by adopting a radically different model”.⁵⁰

Box 3.1. The unusual US

This report will shy away from examining the national US healthcare system. It is an unusual outlier. The US spends more on healthcare in terms of both percentage of GDP and dollars than other developed countries, as shown further below in Chart 3.2 for worse outcomes both in life expectancy and avoidable mortality.⁵¹ It has the second highest proportion from among OECD countries of the population with no healthcare coverage,⁵² and over 50% of the US population rely on private healthcare – by far the highest proportion of any country in the OECD.⁵³

Some US healthcare organisations, however, are trying to break with this history and have experimented with a model similar to the ICB model, the Accountable Care Organisation (ACO) model. In fact, this model is arguably what the relatively new ICBs in the NHS are based on.⁵⁴

The goals of ACOs are to join up healthcare budgets for identified populations and join up leadership within their regions. They are paid based on outcomes rather than solely by activity. Key to this was limiting the number of outcomes measured. They differ from ICBs in that they cater for relatively small populations. Seventy percent have less than 100,000 beneficiaries and do not have a geographic monopoly on care.⁵⁵

Initial evidence has suggested quality and cost improvements, especially among the most medically complex patients. Also, as ACOs have evolved, they have generally been given a reduced number of indicators to focus on: only in the areas of patient experience, patient outcomes and prevention measures.⁵⁶

Some key findings are that the high-performing ACOs had the best data sharing and relationships with hospitals. Second, ACO beneficiaries had lower rates of the inappropriate use of services; for example, fewer women over the age of 75 going for breast cancer screening when they were unlikely to benefit. Third, ACOs facilitated better chronic condition management, such as through reduced admissions for chronic heart failure and pneumonia. Fourth, ACOS enabled better outcomes, including patients having fewer depressive symptoms and better physical health scores.

Beveridge systems include England, Sweden, Denmark, Ireland, Spain, Italy and Finland in Europe and Canada and New Zealand globally.⁵⁷ These countries have the majority of their hospital beds in publicly owned and managed hospitals, and most of their healthcare funded directly by government, as can be seen in Chart 3.1 below.⁵⁸

An international comparison of total public funding

It is worth highlighting before positive and negative international comparisons of leading health inputs and outcomes that the UK spends a significantly higher percentage of GDP on healthcare (11.3%) than the OECD average (9.2%), as of 2021 – and this proportion is set to increase following the announcements in the 2024 Autumn Budget. The 2021 spending is shown in Chart 3.2 below. The UK has spent a higher share of GDP on healthcare than the OECD average since 2016.⁵⁹

The UK, however, spend slightly less per capita on health than the OECD average: $54,126 versus $58,956 Purchasing Power Parity (PPP), as of 2021.⁶⁰ This can also be seen in Chart 3.2 above.

Higher public spending per capita does not necessarily correlate with better outcomes. Nevertheless, the Nordics overall demonstrates that spending significantly more per capita can be associated with better outcomes. However, it should be noted that Finland shows that these higher outcomes can be achieved with public spending per capita on health similar to that in the UK.

Box 3.2. Nordic healthcare systems

Finland’s health system used to be extremely decentralised, with over 300 municipalities responsible for organising care for their residents; almost the opposite of the UK system. Finland still remains much more decentralised than the UK. It now has 21 regions (wellbeing service counties) responsible for health and social care in their areas, each of which has a population of around 250,000.⁶¹ While the central government has a strong role in planning and steering, its influence is primarily through annual negotiations. The regions have significant local autonomy. They are officially “self-governing” and have county councils which oversee them and are directly elected.⁶²

In other ways, Finland is very similar to the UK. It spends roughly the same amount of money per capita on healthcare as the UK, but less as a proportion of its GDP. That spending is fairly centralised: around 65% of funding comes from government schemes, as compared to 78% in the UK, and 95% of hospital beds are public, as compared to 90% in the UK. Finland spends significantly more on healthcare capital relative to the UK, resulting in significantly more kit such as CT and MRI scanners. Finland also has more nurses and doctors per capita than the UK. Finland manages this at least in part by paying nurses less than the average worker’s wage.⁶³

The result of all of this is that Finland’s healthcare system performs better than the UK’s. It has longer life expectancy, but it performs about the same on avoidable hospital admissions for long-term conditions, has similar levels of avoidable mortality and lower levels of treatable mortality. It has slightly lower mortality after strokes and heart attacks than the UK.⁶⁴

Norway spends among the most per capita in the OECD on health and has one of the largest ratios of nurses and doctors to population. This is matched with a life expectancy 2.5 years longer than the UK’s.⁶⁵

Preventative and primary care is organised by local municipalities. The national government delivers specialist care through four regional health authorities which plan organise and manage activities with hospital trusts. Municipalities decide their own health and social care budgets – their funding is not hypothecated. Most hospitals are state-owned and are the responsibility of the regional health authorities.⁶⁶

Sweden is another example of a system which produces higher life expectancy and pays more for healthcare per capita as compared to the UK. Sweden spends a similar proportion of its of GDP on healthcare as the UK, but, due to Sweden’s larger GDP per capita, this works out at $5,500 at purchasing power parity per person per year in Sweden as opposed to $4,500 purchasing power parity per person per year in the UK.

Twenty percent of money in the Swedish healthcare system comes from the central Swedish government and can be performance-based. The central government sets overall health policy, and the 21 Swedish regions deliver and finance through local taxation 80% of healthcare services. They can and do decide to provide slightly different services.

Similarly to the UK, 290 municipalities provide social care for the elderly.⁶⁷

Sweden has very strong national policies to improve health, including on the restriction of alcohol, including only selling alcohol in government stores. The national government also publishes data down to the hospital level on waiting times. Regions are held to account primarily on only four core indicators, all about time to access care.

Denmark also pays about 20% more for healthcare per capita and has a longer life expectancy than the UK. National government collects taxes and allocates 80% of healthcare funding, with the remaining 20% being allocated by local authorities, and is in charge of general planning and setting eight key national quality targets. These targets are negotiated with the regions.

Regional funding in Denmark has in 2019 shifted from incentivising greater efficiency in hospitals to the coordination and integration of care. National bodies create standard treatment pathways and monitor performance against them and the performance of hospitals generally. Five regions, each with about a million people, have democratically elected councils which plan and deliver healthcare. Those regions own, manage and finance hospitals. Ninety-eight Danish municipalities handle social care and public health and are mandated to cooperate with the aforementioned regions on the provision of social care.⁶⁸

To see what England can learn, this chapter will prioritise – albeit not exclusively – comparisons of our performance with countries that have Beveridge systems with strong health outcomes but that do not have significantly higher healthcare expenditure per capita than the UK. As indicated in Chart 3.2 above, these countries are: Sweden, Denmark, Finland, Ireland, Spain, Italy, Canada and New Zealand. Together, they are our ‘similar international peers.’

This report could not compare all health inputs and outcomes between different countries, for time and data limitations; instead, it focuses on comparisons of what are considered the leading health inputs and outcomes.

How the UK compares positively with similar international peers

First, the UK performs very well (93%) when it comes to the proportion of people for whom cost is no barrier to accessing healthcare, as can be seen in Chart 3.3 below, likely in part because of the portion of healthcare expenditure that is covered by the state (83%).

Second, the UK also performs well on efficiency when measured as a share of total costs spent on administration, as can be seen in Chart 3.4 below – although, as we will discuss in Chapter Six, it is not clear that this is an accurate indicator of efficiency.

Third, the UK also spends significantly less than most similar international peers on drugs as a portion of its healthcare spending, as seen below in Chart 3.5.⁶⁹

Again, it is unclear whether this is a pure good, as ”the UK has mixed performance on its level of access to new medicines” meaning that between 2017 and 2020 about 60% of the new drugs available in any EU country were available in the UK: higher than Spain at 53% but lower than Italy at 79%.⁷⁰

The UK also performs very well on some measures of prevention. For example it has the highest rates of flu vaccination for the elderly in the OECD and extremely high rates of statin uptake in the over 40s, as can be seen in Chart 3.6 below.⁷¹

But the UK’s performance in other measures of prevention have deteriorated. Our rate of diabetic foot amputations has gone from amongst the best in 2011 to below our similar international peers, such as Italy, Sweden, Norway and Finland, and, on a range of other preventative measures such as childhood vaccinations, mammogram and cervical cancer screening, we are at or below the average for our peer group.⁷²

The tentative takeaway here is that the UK with its highly centralised system is good at directing that certain specific health outcomes are achieved. It does so in the cases around prevention directly above by making highly specified payments to General Practices, through the NHS Quality and Outcomes Framework incentive programme, to deliver specified outcomes, including improved vaccine and statin uptake rates.⁷³ However, the wider determinants of health and wellbeing that are less easy to target through an incentive programme may be being more neglected, as we see below.

How the UK compares negatively with similar international peers

Most importantly, the UK performs below our similar international peers on life expectancy, even though we are slightly higher than the OECD average, as of 2021. This is seen in Chat 3.7 below.⁷⁴

The UK is also poorer than our similar international peers when it comes to quality of both prevention and treatment, since our mortality rates from treatable and preventable causes is higher than our similar international peers as of 2021, even though the rates are still lower than the OECD average. This is illustrated in Chart 3.8 below.

These suboptimal mortality rates from preventable and treatable causes are, at least in part, driven by the poor performance of hospitals, as shown in Chart 3.9 below, with those suffering from strokes and heart attacks dying in the UK more often than those in similar peer international countries, as of 2021.⁷⁵ In fact, our mortality rates from strokes are higher than the OECD average, although slightly lower for heart attacks, as shown in Chart 3.10.

The UK also has worse-than-average adverse events in hip and knee surgeries, with over 1% of patients experiencing pulmonary embolism or deep vein thrombosis; higher than all of our similar international peers, including Finland, Sweden, Spain and Italy, the last two of which have rates of 0.2% and 0.05% respectively.⁷⁶

Looking at mortality from the two biggest killers – circulatory disease and cancer, which accounted for around half of all deaths within the OECD in 2021 – underlines how the UK struggles relative to our similar international peers.⁷⁷

These relatively poor health outcomes might be associated with some relatively poor inputs, which can be observed in the data comparing different international healthcare systems. Most clearly, although Chart 3.2 earlier showed the UK having higher levels of public spending on health than the OECD average, the UK actually underinvests in physical infrastructure in health, as explained in length in the 2024 Darzi report. As Chart 3.11 below shows, the UK invested, as of 2023, below the average of similar international peers in health capital expenditure.

This seems to have severe consequences. The UK in 2021 had the fewest hospital beds and diagnostic scanners per person of any of its similar international peers, and fewer than the OECD average, as shown in Chart 3.12. Worryingly, the IFS reports there is a £2.5 billion high-risk backlog of maintenance where repairs are needed to avert potential major disruption to clinical services.⁷⁸

Important to note, however, is that, in the 2024 Autumn Budget, the Government announced that significant additional health capital expenditure will take place in 2025-26. This includes an extra £1.5 billion for the delivery of new beds, surgical hubs and diagnostic scanners; and £70 million to invest in new radiotherapy machines to improve cancer treatment. It also includes over £1 billion for clearing the backlog of maintenance and repairs across the NHS estate; an extra £2 billion for the delivery of NHS technology and digital; and £26 million for new mental health crisis centres. Overall expenditure on capital investment for health is set to increase by 10.9% in real terms by 2025-26.⁷⁹

The UK also performs poorly on human infrastructure, despite having an average level compared to the OECD of total employment in health and social care of 12.9% of the country’s workforce, as of 2021: above Italy and Spain, similar to Canada and Ireland, and well below Norway, Sweden, Denmark and Finland.⁸⁰

This is because the UK has a below average number of doctors than our similar international peers and the OECD average, as of 2021, as can be seen in Chart 3.13 below. This suggests that the UK health system has too few doctors, about the right number of nurses and probably too many of other, less qualified staff.

Compared to our similar international peers, the UK also seems to pay doctors over the odds, and nurses under, as of 2021, as can be seen in Chart 3.14 below.⁸¹

Box 3.3. Spanish healthcare

Spain spends less than on healthcare than the UK but achieves better life expectancy and performance on preventable and treatable deaths. It even has the highest life expectancy in the EU.⁸²

Spain is similar to the UK in that healthcare is mostly financed through taxation, and it has predominantly public hospitals. It is different in the autonomy it affords to its strong regional health authorities in charge of managing funding and “operational planning, resource allocation, purchasing and provision decisions”.⁸³ All 17 are represented by a regional minister of health and are responsible for around three million people each.

There are several qualitative lessons we can learn from our similar international peers which, generally, have better health inputs and outcomes than in England.

They do tend to have a similar structure to England, in that they have a national body, responsible for strategy and funding, but have regional bodies responsible for planning and delivering care.

The key difference is that these regional bodies are significantly more empowered than the bodies that exist in England – ICBs. Most appear to have greater authority, with some having some direct democratic legitimacy or having been in place longer. These regional bodies often do not manage all healthcare, usually focusing on secondary care while primary and social care are often taken care of by even more local government. As a result, even amongst Beveridge systems, England is one of the most centralised healthcare systems. The NHS Confederation has called it “arguably the most centralised … in the developed world”.⁸⁴

Most of the healthcare systems of our similar international peers involve more co-payments – that is, consumer payments for care – and have more private providers. Indeed, most of the UK’s peers have some public funding contingent in activity or quality as well as some block or capitated funding. Many healthcare systems among the UK’s peer countries are also moving towards greater public funding on prevention, unlike the NHS had been.

To move closer to our more successful peers, we need to empower ICBs with more real authority, which is the focus of later chapters in this report.

Conclusion

Overall, the UK does about average in the OECD when it comes to leading health inputs and outcomes, but it is generally behind the similar international peers that have Beveridge systems; namely Sweden, Denmark, Ireland, Spain, Italy, Finland, Canada and New Zealand.

We do spend more on health than many of our similar international peers and the OECD average, and the UK performs very well at access, meaning the UK offers universal healthcare coverage, and very few people in the UK find finances a barrier to treatment.

Nonetheless, our life expectancy and cancer mortality rates – and the quality of our prevention and treatment – is below that of our similar international peers.⁸⁵ Where the UK really stands out is in having fewer doctors and less capital investment than our similar international peers, resulting in significantly fewer hospital beds and diagnosis machines per person than them and the OECD average.⁸⁶

England also stands out relative to our similar international peers for its level of centralisation and the lack of power and autonomy that it gives the regional management layers of its healthcare system. Most of their regional bodies have greater authority in comparison to ICBs.

Having examined how the UK compares to its international peers, we now go on to explain the likely leading causes of the NHS’s underperformance.

Chapter Four: The leading causes of NHS underperformance in England

Having in earlier chapters demonstrated the underperformance of the NHS, historically and internationally, this chapter examines the six leading factors responsible for its underperformance. There are of course a variety of factors which explains the NHS’s underperformance; here we focus on what the evidence suggests are the leading ones.

The underperformance in the NHS in England is deep-rooted. The six leading factors are: lack of cooperation; excessive centralisation in the DHSC and NHSE; a consultation system that blocks almost all change; an excessive focus on hospitals at the expense of primary and community care; hospitals that are not capable of increasing treatment volumes; and short-term funding and priorities.

Lack of cooperation

The NHS in England has historically prevented cooperation between different bodies. This means that providers of the same type too often operate at too small a scale and providers of different types fail to collaborate, leading to patients often ending up in inappropriate, costly and ineffective settings: primarily hospitals, specifically A&E.

It was a constant concern of our interviewees that the way the NHS is funded and commissioned has been a blocker to collaboration. The Health and Social Care Act 2012 focused on autonomous NHS bodies delivering “their services,” as one interviewee said, and not worrying about the overall picture, making collaboration extremely difficult.

Organisational and budgetary boundaries make providing a joint service very difficult. Services were legally obliged by the Health and Social Care Act 2012 to be tendered for a competition to win them. The Competition and Markets Authority (CMA) also had the power to block collaborative arrangements, with the CMA assuming that choice over collaboration benefits patients.⁸⁷ Given the legal responsibilities that each NHS body had to provide direct accountability for results, collaborative relations often result in extensive bureaucracy, such as having to write full business cases, that dissuaded leaders from future collaborations.⁸⁸

Despite the legal changes introduced in the later Health and Care Act 2022, which aimed to ameliorate difficulty collaborating and thus removed some of the legal obligations to compete, interviewees told us that many people and bodies in the NHS were still struggling to cooperate given the legacy of behaviours and structures still in place.

The result of all this is NHS providers focused on their own services and not collaborating with other NHS providers. This has left NHS services with very few successful attempts at consolidation because providers of the same type have not collaborated to increase scale. This is despite compelling evidence, discussed later in the report in Chapter Five, that consolidation, especially between hospitals, improves care for patients and cuts costs.

It has also resulted in NHS providers of different types not collaborating to increase integration and ensure that patients are seen at the right place in the healthcare system. The lack of co-operation between different NHS providers has left care poorly designed for patients. This is especially true of older patients. Increasingly, “older people are too often left to fall between the cracks of disjointed services and professionals who don’t communicate well with each other,” according to Age UK.⁸⁹ When these elderly patients, often with multiple conditions, fall between the cracks of disjointed services, they often ultimately end up in an expensive and inappropriate setting: hospital, especially A&E.

This is undesirable, and not only because hospitals are much more expensive per incident of care than primary or community care. Even more so than for most patients, hospitals can be a risky place to be for old people, unless necessary. Their muscles can decondition due to lack of movement leading to functional decline; they can find it difficult to sleep, leading to delirium; and in an unfamiliar and often inappropriate environment they can fall, receive pressure injuries and become incontinent.⁹⁰ Hospitals are such a risky setting for patients over 65 that 44% of them will end up with “hospital-associated complications of older people” within an average seven-day stay.⁹¹

Even when these elderly patients do not end up in hospital, they bounce around primary care, secondary care and community care, taking up vast resources while often receiving poor quality care. East Surrey, one of the geographical areas within Surrey Heartlands – an ICS in Surrey – identified its neediest 0.25% of patients (600 people, of whom 80% were over 85) and discovered that, within the last 45 weeks, they had a total of 1,800 A&E attendances, 400 admissions to hospital and 450 outpatient appointments. Most shockingly, they had 54,000 GP contacts – that is an average of two a week.⁹²

Moreover, multiple teams and providers within the English healthcare system try to address the same problem, creating duplication of efforts. Matthew Walker of the National Association of Primary Care said that “in some systems you have four teams doing frailty and avoiding hospital admissions. These should be one team, be more proactive and not rely so much on hospitals as the default.”

Excessive centralisation in NHSE and DHSC

As an interviewee said, “when the money is as tight as it is, the temptation is always to centralise everything into NHSE, overriding the appetite for delegation … decision-making gets sucked to the centre, the big theme becomes grip and control.”

As the 2024 Independent investigation of the NHS in England produced by Lord Darzi, known as the Darzi report, showed, since 2013-14, the size of NHSE, DHSC and others NHS regulators within England has increased by 43%, despite a recent fall due to a 30% targeted headcount reduction within NHSE. This is illustrated in Chart 4.1 above.

The increase in capacity in the central bodies of the NHS is coupled with a hollowing out of capacity elsewhere, with 24% fewer managers per employee in the NHS since 2009 and a 30% cut in ICB staff requested, as discussed in Chapter Six later.⁹³

Centralisation is why the funding given to ICBs, for example, is excessively short-term and over-specified. NHSE or the DHSC come up with a specific activity of how to improve the NHS and give every ICB around the country a small amount of money for that purpose: “penny packets,” as interviewees called it. These must be used to do that specific activity, such as improving the digital infrastructure of hospitals in a specific way. This command to do a certain activity applies regardless of whether it is the most pressing priority in an ICB or not.

We heard repeatedly in our interviews that it was a drain on time and resources for ICBs and provider trusts to bid repeatedly for small, short-term pots of money. This prevented them from investing in ICB-specific opportunities which could save money or help patients, directing them to do less good value spending said. Edward Jones of the NHS Confederation said that “NHSE has disproportionate reporting requirements for small pots of money. This sucks oxygen, especially when their [ICBs’] budget has fallen by 30%. This stops them from being able to do strategic stuff and start building real relationships in the system.” A good example is a winter funding, discussed in more detail later in this chapter. Ed Jones went on to tell us: “Social care funding last winter came ring fenced for social care beds in care homes, not giving ICBs flexibility to take care of people in their own homes. In some cases, this resulted in people who should have been cared for at home sent to care homes at greater expense, less happy, and with poorer healthcare outcomes.” As winter funding is announced every year ICBs are also unable to plan for it and have to spend time bidding for it each year as if it is a one off.

A consultation system that blocks almost all change

There exists an excessive requirement for consultation to bring about changes in the NHS.

There is no specific trigger for a consultation process – in fact, consultation is not explicitly required by law – but, as per the National Health Service Act 2006, it is usually considered as necessary for the fulfilment by different bodies within the NHS of the statutory duty to involve the public in: the planning of the provision of health services; the development and consideration of proposals for changes in the way those services are provided; and in the decisions made by the health body affecting the operation of those services.

Regarding ICBs specifically, they are expected to design services to best meet the need of their population. During the development and consideration of proposals for change, some significant ones must be consulted on with the public.⁹⁴

We heard that, despite sounding benevolent, there were significant difficulties with this. An interviewee said that “people wherever possible avoid reconfigurations using the workarounds of temporary changes or urgent clinical need, because of the sheer difficulty of negotiating a consultation.” Leaders are “typically concerned with NHS services and beds being ‘axed’, ‘centralised’ and ‘closed’”.⁹⁵ An interviewee from a provider trust spoke of the potential in a London hospital to target high-intensity users who had mental health problems, or were frequent long-term stayers, and improve outcomes, but found it infeasible among other reasons because “doing so might close a number of wards.”

Indeed, the former Minister for National Health Services Delivery, Lord Norman Warner, described how “past attempts at service transfers have usually been slow and strongly opposed – often by local clinicians with a vested interest. At the end of lengthy and expensive processes, there has often been a failure of political will at the centre”.⁹⁶

An ICB CEO spoke to us about a scheme to open a new elective orthopaedics centre and reallocate elective activity from other hospitals to reduce the backlog. “We got very anxious about how to consult and engage. If we’d done a formal consultation, it would have added 18 months. The current process is not fit for purpose.”

An excessive focus on hospitals at the expense of primary and community care

The NHS is too focused on hospitals, which experience funding growth at the expense of primary and community care and, as a result, at the expense of prevention and population health management. This is regrettable, since the same money spent earlier on prevention and population health would generally have a far greater impact on improving people’s health than money spent providing more hospital care.

For example, controlling high blood pressure, or getting people to stop smoking or take anti-obesity drugs, is much better value-for-money than funding more expensive cancer, heart attack and stroke treatments. It is also almost four times more expensive to add a year of life in England by spending money on the hospital-focused NHS than on local government public health measures.⁹⁷ Nevertheless, historically, ever more funding and attention has flowed into hospitals over other parts of the healthcare system in England, as Chart 4.2 further below clearly shows.

There has been some acknowledgment of this in the 2024 Autumn Budget. The Budget document claims that one of the aims to be achieved by a £1.5 billion portion of the increase in capital funding for the NHS announced in the Budget is to “help shift more care into the community”.⁹⁸ The Budget likewise announced the oncoming publication of the 10 Year Health Plan which is set to outline “reforms [to] transform the NHS … more from model of sickness to prevention shift care from hospital to community.” However, as of the writing of this report, said Plan has not yet been published.⁹⁹

Especially for elderly patients with multiple long-term conditions, hospitals are often simply the wrong place for much treatment – as explained earlier – with many admissions ending up with avoidable long stays. Professor Michael McCourt, a former CEO of a community and mental health trust, said that “hospital trusts need to work in partnership with ICBs to solve the healthcare challenges we face. You cannot ultimately solve our healthcare problems in hospitals alone. Hospitals increasingly recognise the solution for their pressures’ rests with community stakeholders, including strong primary care and social care partners, if the pressures on hospitals are ever to reduce.”

Adding more GPs, too, reduces both A&E visits and long-term sickness. One extra GP reduces secondary care costs by around £80,000.¹⁰⁰ This finding is especially robust in an environment where people generally feel they have poor access to primary care, such as now.¹⁰¹ We would expect that longer-term effects of more primary care access, such as people receiving treatment at an earlier stage for cancer or having fewer strokes ten years after being prescribed statins, would make this case even more compelling.

This positive early intervention effect is also found for spending on community trusts, with a 31% return on investment found for ICBs that spend money through a reduction in secondary care demand. This effect is so large that ICBs that invested in community trusts more saw 15% lower non-elective admission rates.¹⁰² Indeed, each ICS, if a causal relationship were assumed regarding the above, could save an average of just under 1% of its budget if they invested more in community trusts.¹⁰³ This is because evidence suggests that the primary driver of health outcomes is not the quality of healthcare provided in hospitals but rather health behaviours and the social and economic environment that drive those behaviours.¹⁰⁴

The eating, drinking, smoking, physical activity and social behaviours of people are so important that they are estimated by government to account for up to 80% of differences in health outcomes.¹⁰⁵ Hospitals are far less well-placed to address these factors than primary, community and voluntary providers and other organisations.¹⁰⁶ Local government also plays a huge role, using its public health grant to spend more than £1 billion per year, as of 2022-23, on helping people to reduce obesity, smoking and alcohol and drug use.¹⁰⁷

Wigan local authority, for example, focused on wider determinants of health in part by investing in a community investment fund. This supported physical activity, addressed social isolation and loneliness and promoted positive mental health. As a result, Wigan added seven years to local healthy life expectancy in its most deprived wards as compared to 2013. This demonstrates the huge potential to improve health through early intervention, rather than through funding which went to hospitals.¹⁰⁸

As the King’s Fund has argued, there is theoretical alignment within government and NHSE that we should focus more on out-of-hospital care,¹⁰⁹ as demonstrated through “various policy documents and reports in the past decade”.¹¹⁰ But, despite this, primary and community care funding have been declining or holding steady as a proportion of the total NHS budget for the last 30 years.¹¹¹ A notable example was the 2006 Darzi white paper which called for more services to be delivered outside hospitals, which never materialised.¹¹²

More recently, in 2022, the Sunak Government-commissioned Fuller Stocktake strategy was published. Signed by all 42 ICB CEOs, it talked about integrating primary care with community, secondary and voluntary care to deliver more prevention and proactive care outside hospitals, as well as more joined-up care.¹¹³ Indeed, the Darzi 2024 report again called for more investment in primary and community care.¹¹⁴

General practice is currently funded with around 10% of the total NHS budget, as of 2022-23, while performing the majority of NHS activity.¹¹⁵ Chart 4.2 below shows that since 2016, the portion of spending on hospitals providing emergency care has been rising, while the proportion of spending on primary, community and population health has been falling.¹¹⁶

Going even further back, since 1995, the number of GPs has grown at only 2% per year, while the number of provider trust doctors, who primarily work in hospitals, has grown by an average of 4% per year, as can be seen in Chart 4.3 below.¹¹⁷

There is a reason for the trends seen in Charts 4.2 and 4.3 above. Hospital trusts have an outsized voice in the current system. The senior jobs in hospital trusts are considered “prestigious and exciting … [with] more respect than those in ICBs,” as one interviewee told us.

This is in part because hospitals are directly responsible for remaining targets that politicians are particularly politically pressured on, such as A&E wait times and elective care waiting lists.¹¹⁸ Problems in the NHS first become visible against these targets, even if one of the underlying causes has been the long-term underfunding of primary care. This is because a reduction in prevention and community care will not be visible for years until people grow sick and are seen in A&E. Politicians, on the other hand, are pressured to deliver results within the length of their parliamentary term. When too many people show up at A&E, a crisis is declared, but, instead of better funding prevention, money is pushed into hospitals to try to fix the problem immediately. “A&E consultants in hospitals have been very successfully able to use A&E waiting times to argue for more and more doctors in A&E, but this has not been able to solve the problem,” a former ICB CEO told us.

A national healthcare leader in a King’s Fund paper clearly laid out the cycle of crisis driving money to secondary care.¹¹⁹ “Hospitals know they’ll get growth money: [the commissioner] would say, ‘right, we’re going to give our hospital a budget that means they can afford a 2% growth in demand, and we’re going to invest the rest of the money in these wonderful community services, which is going to prevent hospital admissions.’ The hospital … knows that there won’t be 2% demand, there’ll be 4% growth in demand … and they know that the commissioner will end up paying them for that care.”

There have also been wider cuts to funding of services that support health but are not hospitals and not primary care. Overall, local authorities saw their funding fall by an average of 18% per person in real terms in the years 2010 to 2024.¹²⁰ These cuts had the strongest effect on non-statutory healthcare services, such as domiciliary care for old people in their own homes and Sure Start Children’s Centres, which give advice on child and family health, parenting, money, training and employment – but also restricted the growth of funding for adult social care. Adult social care is typically provided to the elderly in home or in a care home and could include help such as washing and dressing or with rehabilitation, either long term, or as an acute measure after an illness in hospital. These cuts might be expected to result in the long term in higher pressures on the NHS. An IFS report found that Sure Start was so effective in reducing hospitalisations of children after they had left them that that effect alone offset 31% of the cost of the programme.¹²¹

Adult social care has in particular has seen access increasingly restricted. Despite the number of those requesting social care increasing between 2016 and 2023, fewer people have been able to access adult social care in that period, as is visible in Chart 4.4 below.¹²²

Even in 2019, there were an estimated 1.5 million people over the age of 65 with an unmet need for elderly social care. As previously mentioned, this directly affects hospitals, which are then unable to discharge people who are otherwise well but need to be taken care of in the community through adult social care.¹²³

Hospitals that are not capable of increasing treatment volumes

Hospital productivity is falling. Already slow healthcare productivity growth, 0.8% per year from 1995-2015, has gone into dramatic reverse.¹²⁴ Since 2019, increases in government funding for hospitals have not come with increases in output.¹²⁵ Despite a 20% increase in hospital staff numbers since 2019, the number of treatments delivered has remained roughly the same. Admittedly, this increase in hospital staff without an increase in hospital activity is a problem that many nations in the western world are also experiencing.¹²⁶

The most important cause of this stagnating productivity in England seems to be the lack of the physical infrastructure to take care of patients in the NHS. Hospitals in England are operating at an average 94% capacity – 85% capacity is the aim, and 92% is the safe limit, according to the NHS itself.¹²⁷ Hospitals have not seen an increase in hospital beds to go with the increase in staff numbers, so an increase in the total number of patient bed-days – the total number of days stayed by all patients in hospital – is not possible. This is a problem especially as England has the fourth-lowest number of beds per person of any country in the OECD.¹²⁸

Other infrastructure deficiencies also exist. The UK currently has the sixth-fewest number of diagnostic scanners per person in the OECD.¹²⁹ The high-risk backlog of maintenance where repairs are needed to avert potential major disruption to clinical services has quintupled to a value of £2.5 billion within the last decade.¹³⁰

The Government has taken some steps to address this. In the 2024 Autumn Budget, the Chancellor announced that NHS capital expenditure will increase from 2025-26, including an extra £1.5 billion for the delivery of new beds, surgical hubs and diagnostic scanners and over £1 billion for clearing the backlog of maintenance and repairs across the NHS estate.¹³¹

Another cause of full hospitals is a rise in delayed discharges – a 30% increase in 2021-22 alone – caused by a lack of capacity in the social care system, meaning insufficient spaces in care homes and a lack of ability to provide intermediate care.¹³²

In a healthcare system that has focused more and more of its attention and money on hospitals, it is clearly undesirable when those hospitals are not capable of responding to increased funds and staff with increased treatment volumes.

Short-term funding and priorities

The NHS has extremely short funding cycles and constant new directives, making any long-term investment, planning or cooperation exceptionally difficult. The current NHSE operating planning guidance, the main annual document giving ICBs their marching orders, is overly focused on processes and is supplemented by endless ad hoc requests, as explained in more detail later in this chapter.

Our interviewees repeatedly said that the entire structure of the NHS in England promotes short-term thinking, making delivering significant improvements very difficult. More strongly, the King’s Fund argues that a typical health policy in England is “promising unachievable, unrealistically fast improvements without a long-term plan to address the underlying causes of the current crisis” and is thus ”doomed to failure”.¹³³

Funding settlements for ICBs and hospitals are decided annually. This means that they cannot really plan over a longer than a 12-month horizon.

Crucially, savings made in one year disappear from the budget for next year, as NHSE claims them back. An interviewee from a provider trust said that “you’d be unwise to target a 30% efficiency [improvement] in one year – you’d find a way to spread it out 5% per year over six years instead. You can’t reinvest savings made last year into transformation projects, and it creates the expectation of a similar scale of savings year-on-year.”

Furthermore, providers and ICBs struggle to plan service redesigns that will take more than a year, and it is exceedingly difficult to justify any investments, in systems or in people, which will take more than 12 months to pay off.

In practice, the funding horizon is even shorter than 12 months. Winter money is consistently announced every year, but since it is always unclear how much it will be, or what it will be for, it is impossible to plan for.¹³⁴ Some of our interviewees suggested that these mid-year announcements are because politicians like to be able to announce “eye-catching initiatives” rather than leave the English healthcare system to deliver.

With that said, winter money is a relatively small portion of total ICB funding, in 2023 worth only £200 million out of roughly £120 billion.¹³⁵ A bigger problem is that the overall budget is not agreed by NHSE and communicated with the ICBs until very late – sometimes not until right before the financial year starts in early April. This means that, instead of being able to plan even for the year ahead, often ICBs are in “a cycle of resubmitting, reviewing and editing plans during the year, which has drawn away time and capacity from delivering essential change,” according to the NHS Confederation.¹³⁶ An interviewee spoke of many ICBs “where four months into financial year budgets are still not signed off.”

Demands on ICBs and provider trusts regularly come down from the Secretary of State for the Health to respond to very specific concerns, such as problems with a specific A&E, and this absorbs management time and prevents proper longer term strategic planning. “The experience, cited in the 2023 Hewitt Review, [is] of one ICS receiving 97 ad hoc requests from DHSC and NHS England, in addition to the six key monthly, 11 weekly and three daily data returns in November 2022 [alone], remains common. Such requests continue to focus on outputs and activity, rather than health outcomes,” according to the NHS Confederation.¹³⁷

Professor Michael McCourt, a former CEO of a community and mental health trust, corroborated this, saying that “current metrics and scorecards don’t drive desired changes – they measure detailed process outcomes and not quality, cost or benefit outcomes. They measure unrelated pieces of the jigsaw rather than measuring progress towards the right picture of the common vision for a place.”

This approach results in a healthcare system in England that makes strategic mistakes, such as underinvesting in primary and community care, infrastructure and doctors. Currently, bodies in the healthcare system such as ICB are prevented from making and delivering longer term plans by short-term pressures and priorities.

Conclusion

We have identified and detailed the leading causes of the underperformance of the NHS in England. It is by no means an exhaustive list but is what the evidence suggests is the leading causes. We will now look at the history of commissioning within the NHS in England and the potential role that ICBs can have in ameliorating the NHS’s woes.

Chapter Five: The history, role and benefits of ICBs

Having identified the leading problems of the NHS in England in the previous chapter, this chapter turns to a body within the healthcare system which can be part of the solution: Integrated Care Boards (ICBs). This chapter will briefly outline the nature and history of ICBs as commissioners of care, before highlighting their benefits and unearthing examples of what ICBs can deliver.

The role of ICBs

ICSs and ICBs, as defined briefly in Chapter Two, were established to integrate and join up services within the NHS in England. That means taking a collaborative, system-wide approach to treatment and is the key difference between them and Clinical Commissioning Groups (CCGs), their predecessor organisations, which encouraged competition between NHS bodies.¹³⁸

The structure of the NHS over the last three decades has made collaboration between hospital trusts, primary care, community care and others NHS bodies very difficult. This is because each NHS body was incentivised very strongly to only think about their own budgets and focused on the outcomes of their own efforts rather than on the system-wide impact of their efforts. Having stronger ICBs in the middle of these bodies is intended to drive collaborative behaviour.

Theoretically, if primary, secondary, community, mental, social and voluntary care organisations cooperate, patients are more likely to end up where they can be best helped, and prevention can take place early to ease pressure on secondary care.

An interviewee told us that “an ICB’s key job is to strategically plan a local health system.” They do this as the “leader of the NHS system within its ICS”.¹³⁹

Each ICB is responsible for between 500,000 and three million people and includes, on average, around 150 GP surgeries and 12 hospitals.¹⁴⁰ They are accountable for healthcare and financial performance within their geographical areas.¹⁴¹

ICBs, when they function as intended, assess the care needs of their population and put in place what is necessary to deliver that care while meeting their four key goals:

Improving population health and healthcare
Tackling unequal outcomes and access
Enhancing productivity and value for money
Helping the NHS to support broader social and economic development¹⁴²

ICBs achieve these goals by managing most healthcare resources through arranging care for patients in their local areas: what is called commissioning.

They are responsible for commissioning hospital, community and mental health care for patients in their local areas and manage around 80% of NHSE’s resources.¹⁴³ Therefore, they are predominantly focussed on commissioning secondary care. They also commission primary care, although annual contract negotiations are still handled by NHSE.¹⁴⁴

As of 2023, they are also responsible for commissioning community pharmacy, general ophthalmic and dental services as well.¹⁴⁵

According to the Health and Care Act 2022, they are also supposed to integrate care delivered by the full range of healthcare providers within their geographic area, including those they do not commission.¹⁴⁶

ICBs are regional bodies, so they have convening, direction and funding power, but the actual healthcare is delivered by provider organisations, such as general practices and hospitals. As will be described below, ICBs are commissioners not providers of healthcare.

The history of ICBs

1991 to 2016

Before 1991, both the commissioning (purchasing) and provision of secondary care were provided by District Health Authorities (DHAs). DHAs directly managed hospitals in the way most organisations manage sub-divisions, with significant direct authority.¹⁴⁷

Chart 5.1 below shows the evolution of secondary care commissioning and provision since the late 1980s.¹⁴⁸

In 1991, the ‘purchaser-provider split’ happened. Since then, the NHS in England has delegated the majority of its budget to regional bodies, the primary purpose of which was to commission secondary care for their local populations while holding providers accountable.

Secondary care provision has been handled largely by hospital trusts, as defined in Chapter Two. These have their own boards that have independent responsibility for strategy, vision and monitoring resources. NHS provider trust chairs and non-executive directors are appointed by NHSE, while, in hospital foundation trusts, these are appointed in local processes.

On the commissioning side, there has been almost constant change in the organisation responsible. In 2022, ICBs took over their role from Clinical Commissioning Groups (CCGs), which themselves took over from Primary Care Trusts (PCTs) in 2013, which, in turn, took over from Primary Care Groups in 2002. Those took over from DHAs in 1999, which had been the first NHS commissioners.

Even this understates the level of change the NHS has seen, as the number of these organisations, their boundaries and their precise remits changed even within these periods. For example, parts of commissioning that GP fundholders handled and the fact that PCTs were subject to “frequent reorganisation”,¹⁴⁹ with the number of PCTs falling from 303 to 152 through reconfigurations and mergers.¹⁵⁰ There were then 211 CCGs in 2013, which shrunk to 106 by 2022.¹⁵¹

These groups have had differing structures and slightly different responsibilities. They have also had many formal obligations. PCTs, for instance, had over 60 statutory duties.¹⁵²

Other key changes over the 1991-2016 period include also the introduction of mandatory tendering in 2013, with CCGs intended to drive more competition within the NHS. This meant that, for all services that the CCG wanted to procure, including secondary care services, they had to put it to an open competition for both NHS and non-NHS providers.¹⁵³

The second was making commissioning clinician-led, as CCGs were run by GPs, unlike PCTs.

Both changes have been undone with ICBs. There is no mandatory tendering, as ICBs are intended to promote collaboration over competition. They are also not necessarily run by GPs, although ICBs may have GPs on their boards.

2016 onwards

ICBs initially began in 2016 as the informal Sustainability and Transformation Partnerships (STPs), which had to use relationships and soft power to increase cooperation, enact change and improve care. Their role increased in importance with the Conservative Government-commissioned 2019 Long Term Plan,¹⁵⁴ which focused on developing more integrated services between health and social care, amongst other changes.¹⁵⁵

ICBs finally became the centrepiece of a move away from competition over cooperation within the NHS, as envisioned in the Coalition Government reforms instituted by the Health and Social Care Act 2012. They gained a formal statutory basis with the 2022 Health and Social Care Act, which also abolished CCGs.¹⁵⁶

ICBs have since been left in something of a halfway house, where the provider-commissioner split has been weakened, but not abolished. This means that commissioners are no longer in a hard commercial relationship with providers. However, this has not been replaced with a management relationship, but, instead, with a collaboration-assurance relationship. This means that ICBs evaluate provider trusts’ work but are generally unable to direct changes within hospitals or redirect resources; for example, to direct some secondary care doctors to work with primary care to keep more frail people out of hospitals.¹⁵⁷

Commissioning is often seen as the less prestigious and impactful part of the healthcare system to work in, with hospital trusts generally regarded as most prestigious. Part of the reason for this has been the constant reorganisations of commissioning, which cost a great deal of money and damage productivity for years every time they occur.¹⁵⁸ As an interviewee, who is a former ICB CEO, said: “Every time you re-organise, you reset the clock. Hospitals are so formidable because they have had 30 years of organisational continuity.”

The Hewitt Review, commissioned by DHSC in 2022, was published a year later, with wide support from different NHS bodies.¹⁵⁹ The report examined the role of ICSs and produced with 36 recommendations. The core principles behind these were to grant ICSs, and their ICBs, greater autonomy; the intention behind this was to enable an increased focus on prevention, outcomes and long-term goals.¹⁶⁰ The Conservative Sunak Government of the time was broadly supportive of these recommendations, if non-committal.¹⁶¹

ICBs still have a window to demonstrate their worth and improve. There are already good examples of ICBs doing this, as will be described in the next section.

The benefits of ICBs

The collaborative approach of ICBs can foster the following three key benefits:

More integration, meaning a healthcare service where constituent parts work together to deliver care where most appropriate, rather than where the patient shows up.
More prevention, meaning more care delivered earlier and, in the community, where it is more effective.
More consolidation, meaning services of the same type are rationalised and delivered at the most effective scale; often larger scale than today.¹⁶²

Our report now goes on to explain each of these key benefits in more detail, with some examples of success in different parts of England.

More integration

Integration involves, especially for the most complex diseases and patient groups, setting up a single care pathway. This means joining up primary, secondary, community and voluntary care so that patients receive the same care no matter where they turn up. This is the opposite of what sometimes happens in the NHS, where patients get different and inappropriate treatment depending on where they access the healthcare system. Intentional patient care pathways lead to a greater focus on proactive prevention and shifting patients towards out-of-hospital care, even if they turn up at A&E or are currently in a ward, as it reduces the use of less effective and more expensive treatments and reduces unwarranted variation.

This integration is so crucial because of the increasing portion of the population who are older and have multiple comorbidities and conditions that cannot be fixed with a single intervention. Indeed, a staggering 70% of over 65s are set to have two or more long-term conditions by 2035.¹⁶³ These patients are especially poorly served by a healthcare system that tries to fix one problem at a time, as they are likely to need ongoing care for their multiple conditions from a combination of community, primary and secondary care providers.

Surrey high-need patient identification and management

One of the greatest opportunities of ICBs is that joined-up data and teams across health bodies can identify vulnerable patients who are currently being poorly served and are using lots of resources bouncing between lots of services.

Surrey Heartlands ICB has worked with healthcare providers in Guilford and Waverley to do exactly this work. They worked to identify 3,000 patients aged over 65 who were on four or more elective waiting lists. These patients were estimated to cost £19 million a year, which meant it was cost effective to offer them proactive care with a multidisciplinary team constructed with GPs from primary care and hospital geriatricians.¹⁶⁴

In East Surrey, one of the geographical areas within the Surrey Heartlands ICB, identified its neediest 0.25% of patients (600 people, of whom 80% were over 85) and discovered that, within the last 45 weeks, they had a total of 1,800 A&E attendances, 400 admissions to hospital and 450 outpatient appointments. Most shockingly, they had 54,000 GP contacts – that is an average of two a week.¹⁶⁵

In response, community frailty hubs were established in East Surrey which brought together secondary care geriatricians, primary care general practitioners, care coordinators, community services and voluntary services. These hubs proactively managed care for patients, such as by calling them to consolidate appointments and ask them what they really need, trying to prevent needless clinical visits, but also deliver better care to the patients.

The impact of this intervention in East Surrey was large: it managed to cut A&E attendances by 12% and GP contacts by around 25% for this cohort of 600 people.¹⁶⁶

Frailty services in Warwickshire

As previously mentioned, there are multiple ways in which old people are disadvantaged when staying at hospitals, as they are at risk of injuries, function decline and mental decline.¹⁶⁷

Interviewees for this report generally agreed that one of the highest-impact integrated services that a system could provide was a frailty service focused on keeping the elderly out of hospital. Of all demographics, the elderly are the most likely to end up in the wrong healthcare setting and are the most disadvantaged by this.

Therefore, the Warwickshire ICB worked to shift care away from hospitals with ambulances, community care and fire service keeping more elderly in their own home after falls, and after discharge from hospitals.¹⁶⁸

The result was that 50% of those patients in Warwickshire who had a fall that required the attendance of a paramedic ended up staying at home and there was an 80% reduction in re-admittances to hospital. Paramedics were given a ‘frailty phone,’ which allowed them to consult secondary care frailty consultants. They could promise ongoing support, as a nurse would phone every frail patient over 75 on the day after they were discharged and adult social care was coordinated with to ensure care packages restarted as soon as possible. The fire service was also used to carry out wellness checks, provide food and reduce trip hazards for patients being discharged.¹⁶⁹

Reducing musculoskeletal waiting lists in Sussex.

Tackling waiting lists is traditionally seen as something only hospitals can do. However, this need not be the case. The Sussex ICB managed to cut its musculoskeletal waiting list by five weeks by working with a community trust, charities such as Citizens Advice, mental health support and other community services to launch community appointment days.

People on the musculoskeletal waiting list were invited to attend these community appointment days, where they were able to access a range of non-medical interventions. This de-medicalised the approach to musculoskeletal issues. The solution for many people did not involve a clinical intervention directly related to musculoskeletal health.¹⁷⁰ Indeed, an interviewee told us that “lots of them did not need healthcare, they needed citizens advice, housing support. Not a healthcare problem, a societal problem.”

The five-week reduction in the waiting list was delivered because 50% of those who attended the community appointment day were taken off the waiting list for care, being discharged to self-manage their condition.¹⁷¹

Improving care for people with autism and learning difficulties in Leicester

The ICB in Leicester delivered better care to people with autism and learning difficulties by forming a joint virtual team between social workers from local authorities, themselves and provider trusts. This new team removed duplication of efforts between the local authorities and healthcare professionals.

The ICS in Leicester has gone from failing on care for these populations to being top quartile of ICSs across England, with 25% fewer people with learning disabilities in Leicester having long-term stays in hospital. In practice, this was achieved by delivering more proactive health checks and increasing the availability of local discharge options: simple when described, but difficult to execute in practice and only made possible by the existence and actions of the local ICB.¹⁷²

More prevention

A huge benefit of ICBs is the ability to focus more NHS resources on out-of-hospital care. By being better connected to different community organisations, ICBs are supposed to be better able to shift resources to focus on prevention of rather than the cures for diseases.

Given the lack of financial control afforded to ICBs, which we will describe in detail in Chapter Six, we in truth do not have examples of large-scale shifts of funding towards community and primary care to aid prevention. This is despite the 15% lower non-elective admission rates to hospitals in ICBs that spend more on community care, as found by an NHS Confederation study. The resultant cost saving would be than enough to fund the increase in community care and suggests a potential £26 million average net saving is available for each ICB.¹⁷³

Given the longer time horizons for better health outcomes to emerge as a result of prevention, it is fair to stress that the following examples from ICBs have not yet fully demonstrated efficacy, although there are encouraging indications.

Joining up system to focus on smoking prevention in the South Yorkshire and Bassetlaw system (SYB)

In Ottawa, Canada, the QUIT smoking prevention programme reduced deaths by 40% over two years and raised long term quit rates by over 10%.¹⁷⁴ So, the SYB ICS, where care is planned by the ICB, launched an analogous programme across NHS provider trusts, local authorities and local ‘stop smoking’ services. Every healthcare professional was asked to be aware of their patients’ smoking status and offer help to stop smoking. This meant hospitals and mental health institutions all must have support for smokers, such as through nicotine replacement, and that there must be continuation of treatment in the community by the community’s stop smoking service.¹⁷⁵

Since the start of the SYB programme three years ago over 200,000 patients have been screened and 17,000 treated, which are encouraging early signs of success. With an expected mortality of around 6% per year, the SYB programme should have already saved over 2,000 lives.¹⁷⁶

A holistic system approach to reduce cardiovascular disease in Manchester

The Manchester ICB decided in 2024 to put together a comprehensive plan for dealing with cardiovascular disease (CVD) and diabetes. Heart diseases alone are responsible for almost 20% of deaths in the UK, and diabetes and other weight-related complications contribute to other causes of death as well.¹⁷⁷

First, the ICB is working with non-NHS bodies to tackle the wider determinants of health; for example, coordinating with the local authority on the best start for children and young people, such as through the provision of Family Hubs.

Second, the ICB coordinates co-working between NHS and non-NHS bodies to tackle the behavioural drivers of CVD; for example working with the Greater Manchester local authority on increasing physical activity.

Finally, there are a range of pathway specific targets, such as ensuring that 90% of those with CVD were treated with a lipid lowering therapy.¹⁷⁸

More consolidation

Consolidating services such that each hospital offers fewer different treatments but performs more of each of the treatments it does offer has been shown to increase quality and efficiency.¹⁷⁹

Consolidation has been shown to reduce costs in English hospitals – a 10% increase in volume of a given treatment leads to an up to 1.5% decrease in costs.¹⁸⁰ This can be because clinicians perform more of a given procedure each year, meaning patients get doctors who are better-practised, and also because larger services can invest in kit that smaller services could not – the standard economic benefits of specialisation. Indeed, it can lower wait times even without efficiencies by pooling demand and supply to reduce the amount of unutilised clinician time when patients are on a different waiting list.¹⁸¹

In 2010, for example, stroke care rationalisation in London – treating strokes at fewer sites, each of which was more specialised – improved care enough to save 100 lives a year and saved the NHS £800 per patient.¹⁸² This involved serious reorganisation; from 32 hospitals providing care, to eight hyper-acute stroke units. This was following evidence from the USA, Canada, the Netherlands, Denmark and Australia that centralisation of stroke care can increase access to specialist care and improve outcomes.¹⁸³

A merger between provider trusts allows the creation of specialised shared services and therefore drive greater overall capacity. This could involve, for example, having fewer individual A&Es or tertiary cardiac centres, but the remaining ones conducting a greater volume of work overall.

An important step is often to appoint the same person to the role of CEO or chair across the multiple provider trusts involved. In 2024 alone, this has happened in at least Leicester and Northamptonshire,¹⁸⁴ Hartlepool and Tees¹⁸⁵ and Lincolnshire,¹⁸⁶ which are publicly known about.

ICBs as strategic commissioners ought to assess procedures needed across a population and rationalise the provision of those procedures. Today, often several different hospital trusts provide the same range of services when it would be more effective to provide that service from a smaller number of providers or even from a smaller number of sites.

As Nicos Savva, a professor at the London Business School, put it, “With ICBs there is huge potential for pathways and departments within hospitals to be rationalised – group departments and functions together rather than running a bunch of sub-scale departments. There is clear evidence that scale increases quality and reduces costs.”

Beyond healthcare functions, ICBs could also unlock greater efficiency through increased purchasing power or scale in back-office functions. For example, increasing scale in the procurement of legal services and having fewer larger finance departments can maintain the same outputs with lower costs.¹⁸⁷

According to our interviewees, the advent of ICBs has prompted up to 15 groups of provider trusts to enter conversations regarding merging. But any reorganisation can take significant time, as the Kent and Medway reorganisation of stroke care shows. It was first discussed in 2014 and consulted on in 2018, and is now planned for 2025.¹⁸⁸ Currently, therefore, there is not yet any evidence that this report could find of an ICB-sponsored reorganisation, although Sommerset ICB is in the final approval process for a stroke care reorganisation.¹⁸⁹ But below are examples in England of consolidation involving ICBs’ predecessor organisations.

Manchester city-wide consolidation of cancer surgery

Manchester is now widely regarded as one of the most mature ICBs.¹⁹⁰ This is because a Greater Manchester Health and Social Care Partnership (GMHSCP) was devolved power over a wider range of care than CCGs were given, allowing it to be an “advanced testbed for the integration of care at scale” in 2016.¹⁹¹

GMHSCP used their consolidated organisation to drive through a consolidation of care delivery across Manchester by creating single shared services for certain acute and specialised activity. Specialist cancer surgery is one example.

There was a clear rationale to reconfigure and centralise but attempts to do so had failed for 15 years and the “history of competition between provider trusts” was identified as key to this failure. Finally, in 2018, a single Greater Manchester-wide specialist surgical centre was established to perform specialist cancer surgery and benign complex surgery, no longer performing these surgeries elsewhere.¹⁹²

This report could not find studies that demonstrated the clinical impact of this reorganisation. But given the strong evidence that in general consolidation saves money and lives, and that before the ‘ICB-like’ structure had come along, Manchester had been struggling and failing to consolidate due to competition between providers, this report concludes that the new ICB-like structure enabled a consolidation which likely saved lives. A stroke care rationalisation in Manchester that happened before 2016 was able to save around £500 per patient without a compromise in the quality of service.¹⁹³

Paediatric surgery consolidation in Bath and North-East Somerset, Swindon and Wiltshire

Back in November 2020, the NHS in the area of the Bath and North-East Somerset, Swindon and Wiltshire had over 1,200 children on the day surgery list.¹⁹⁴

A joint team, including staff from the ICB and three hospital trusts, launched a capacity-boosting all-weekend surgery service, which managed to reduce waiting lists by almost 50%.¹⁹⁵

The key here was using staff from all three trusts to launch an at-scale service in one location which could process more patients than the hospital trusts would have been able to on their own. This was complex because each hospital trust had to give up control and accept that there were costs to the joint enterprise that they would have to bear.

Conclusion

In this chapter, we discussed the benefits that ICBs have in improving the quality and efficiency of NHS care. In the next chapter, we discuss why their potential is not currently fully realised.

Chapter Six: Main barriers to ICBs having greater impact

Having discussed the role and benefits of IBCs, we now turn to look at the main barriers that stop ICBs from delivering positive change across the NHS more broadly.

The picture that emerged from our interviews is of ICBs not being able to deliver on their intended mission of strategically planning healthcare in their locality.

Either ICBs are acting only reactively; largely like CCGs, waiting for instructions to come down from NHSE so they could execute them. Or they find it almost impossible plan strategically. Their limited capacity is used up by too many demands from both the DHSC and NHSE. As an interviewee told us: “ICBs have largely failed to deliver on what they were setup to do – they are only focused on the short term and are not even succeeding there.”

Another interviewee summarised the state of affairs for ICBs: “[T]he ambition [for ICBs] is there to do the strategic long-term commissioning. The capacity is not there. What happens is there is duplication of performance management, NHSE, the CQC, and ICBs – there is a dynamic where the provider trusts are being asked the same questions by different partners and that is a frustration … If you were to talk to ICBs, they are not able to deliver on the vision. They are broadly so caught up in the day to day, capacity is a perennial concern, focus on wider determinants of health is being deprioritised to meet nearer term financial pressure.”

The evidence suggests there are four main barriers to ICBs achieving greater impact. First, limited strategic financial control. Second, lack of capacity. Third, weak formal influence. Fourth, onerous oversight.

Limited strategic financial control

Even though ICBs are notionally in charge of around £120 billion of the NHS budget, as of 2022-23 the reality is that they have limited strategic control over the funding they do receive.

Added to all of this, many ICBs are in deficit before each financial year starting in April begins. We heard repeatedly from our interviewees that ICBs are under immense, and sometimes unrealistic, financial pressure to balance budgets during the financial year. Almost all their capacity is often taken up trying to do this, and, consequently, they have almost no money and little management time to do anything else. “I had £3 billion I could spend however I wanted after I had paid £3.2 billion of bills,” said an interviewee who was a former ICB CEO.

ICBs are typically overcommitted on the money they do have and, so, they often spend the financial year trying to squeeze savings from their budget. This squeezing is not conducive to the collaborative approach they are meant to foster between different organisations in and around the NHS. The same former ICB CEO went on to say that “as soon as the budget tightened, the collaboration that we had established around elective surgery, with hospital trusts taking each other’s patients for load balancing and so on broke down.”

All this focus on in-year balancing of budgets precludes longer-term financial thinking. As discussed earlier in the report, this is an NHS-wide problem, but it does especially affect ICBs. As an interviewee said: “Long-term budgets have been needed for a long time. Short-term budgets are a huge impediment. You have bizarre scenarios where ICBs have identified ways to save money over several years but cannot do it because they either do not have enough up-front cash to invest and/or do not have clarity of funding for the upcoming years.”

As discussed earlier in Chapter Four, ICBs are never on a longer than a 12-month financial horizon. This means that ICBs and provider trusts struggle to plan service redesigns, efficiency investments or anything else where the payoffs are going to take more than 12 months.

Also, as argued in earlier chapters, the NHS in England spends too little on physical capital. This is in part because all budgets are so short-term and difficult to balance that people are loath to invest in long-term capital. Indeed, often already small capital budgets are raided to pay for day-to-day operational spending.¹⁹⁷

Box 6.1. The finances of the NHS are opaque and confusing

NHS finances are so opaque that it is often difficult to truly understand what is happening, even for NHS insiders.¹⁹⁸

Often, ICBs have core commissioning budgets, but there are significant inflows from outside this in the form of “central top ups … elective recovery, mid-year emergency budget supplements and employer pension contribution rate increases,” according to the Nuffield Trust.¹⁹⁹

There are also significant payments between different providers trusts within ICSs that make it difficult to work out where money ends up. Indeed, Wes Streeting MP, the then-Shadow Secretary of State for Health, was in 2023 forced to use a freedom of information request to ask how much the NHS in England is spending on hospital health services as compared to mental health and other services.²⁰⁰

For primary care, in 2023, NHSE put together a report of total spending on General Practices; it had 30 different funding streams which put total funding at £15 billion in the financial year 2021-22.²⁰¹ This calculation does not align with the £12.3 billion given in the response to Wes Streeting’s freedom of information request mentioned above, nor the £7.7 billion on the NHSE webpage ‘Payments to General Practice’,²⁰² nor the total of £10.5 billion given to all General Practices in an Excel sheet attached on the same page as the one giving the £7.7billion figure from NHSE.^203/sup>

The clarity of provider trust finances is no better. They are so inaccurate and out of date as to “obscure the underlying operational financial position of many hospitals,” according to the professional services network Grant Thornton.²⁰⁴ We heard from one ICB CEO that “even over all the years I was in post, I could not get my CFO to produce a version of the finances that I could understand.” An interviewee summed it up as that the “[financial] architecture of NHSE is really very random.” It has all been built layer upon layer over time, adding additional reporting requirements.
In practice, it is nearly impossible to come to an agreed view on the funding for any given area, which makes change exceptionally difficult. If you want to change a service, it is unclear what funding you may stop receiving and where any new funding could come from.

Funding is not just tight for ICBs, but across the whole of the NHS. This leads to NHSE seeking to exert greater control across the expenditure of different bodies within the NHS. One interviewee summarised it this way: “When the money is as tight as it is, the temptation is always to centralise everything into NHSE, overriding the appetite for delegation [to ICBs].”

This can be demonstrated through the ‘penny packets’ approach. When ICBs receive them, it happens because NHSE or the DHSC has a new idea or initiative and gives ICBs small, tightly specified pots of money with disproportionate reporting requirements. These ultimately distract management time and make ICBs more reactive and less likely to execute or come up with their own strategy.

Another key example of such control in secondary care is that the primary method of funding for acute elective care in England: a “national tariff Payment by Results (PbR) system” that pays providers based on the number of procedures they perform.²⁰⁵ This funding passes straight through ICBs and ICBs have virtually no control over it. This PbR system goes against prevention. It makes it impossible to justify efforts on prevention and public health if that would result in fewer elective procedures and therefore less funding. It also makes it impossible to shift that funding from secondary care to other parts of the NHS, which may provide greater results, such as community or primary care.

It should be noted, however, that PbR is a way to keep patient choice and private sector involvement. It has been shown to increase productivity and reduce lengths of stay and wating lists, equivalent to cutting costs by 3% when introduced in England and not in Scotland.²⁰⁶

Edward Jones from the NHS Confederation commented on how difficult PbR can be. “We don’t always want internal competition between [hospital trusts] to perform the most activity. [The idea behind] prevention [is to rather] try to get [hospital trusts] to do less. ICBs are supposed to strategically coordinate where we spend our resources …. PbR incentivises [hospital trusts] to do more of the expensive stuff [secondary care], rather than more of the effective stuff [prevention]. This is because if you do invest in primary and community care and it works, then you get less activity and therefore less money [for] your [hospital trusts].”

Similarly, Rosie Beacon, Head of Health at the think tank Reform, said that “[f]unding is really really critical – you need not just long-term settlements, but consolidation, no[t] hypothecation … If you group all budgets, then you are incentivised [towards] prevention. [It n]aturally incentivises much earlier intervention – [however] payment by activity disproportionately absorbs activity that should go upstream. No commissioner is rewarded for spending that on primary care.”

In primary care specifically, the problem is that ICBs have limited control over most of the funding for primary care, which is nationally negotiated by NHSE instead. ICBs are only in true control over Locally Enhanced Services (LESs): extra contracts ICBs can sign with General Practices, but these account for only about 5% of total NHS spending on primary care.²⁰⁷

All this specification reduces ICB control over finances and thus their ability to drive change. As an interviewee said, “ICBs could make funding contingent on changes, but they have little discretion over many pots of money; they basically have to just hand it over.”

A lack of capacity

ICBs suffer from a lack of capacity. This is driven by repeated reorganisation, a lack of staff and a lack of prestige, in some cases, restricting the quality of staff.

Repeated reorganisation

The constant reorganisation of ICBs’ predecessors, described in Chapter Five, has weakened them. A theme that emerged very strongly from our interviews is that change is hugely disruptive. It takes a very long time for commissioners to build relationships in their local health systems. Patricia Hewitt, the former Secretary of State for Health, said that “many of the most advanced ICBs have been building relationships within systems for years, sometimes decades, since they were PCTs.”

There is evidence that organisational stability is needed to support development of real relationships across different partners within and around the NHS.²⁰⁸ Indeed, as a former ICB CEO said, “[e]very time you re-organise, you reset the clock. Hospital trusts are so formidable because they have had 30 years of organisational continuity.”

A lack of staff

Another cause for ICBs’ inadequate capacity is their low staff numbers. Just after being created, ICBs were asked to reduce their running costs by 30% in two years, resulting in a vast decrease in the capacity to hire staff.²⁰⁹ Indeed, ICBs are outmatched when working with large provider trusts: they have 300 administrative staff per ICB and, between them, will have hundreds more staff in any single function. The vision for ICBs is that they have a much more expansive and strategic role than their predecessors, and yet they cannot afford to hire the staff to do so.²¹⁰

Box 6.2. Underinvestment in management

There is a pattern in the NHS of underinvesting in management as overall public spending rises; over the last 14 years, the number of managers has risen by only 3%, compared to a 40% increase in the number of doctors. Partially as a result, the NHS has just 3% of its workforce in management roles, which is less than one-third of the 11% seen in the general economy.²¹¹ The UK also spends less on administration as a portion of health spending than most comparable countries, as outlined in Chapter Three.²¹² As the 2024 Darzi report highlighted, this underinvestment in management been ongoing since at least 2009. Since then, the number of NHS managers per employee has fallen by 15% for senior managers and 24% for managers overall.²¹³

A lack of prestige

Strong leadership remains primarily in hospital trusts and in NHSE, not in ICBs. We heard that “some ICBs work really well and have excellent leadership” from an interviewee. But we also heard that there were “not enough strong leaders to fill all of the ICB crucial posts” from another interviewee. That the strength of ICB leadership was uneven was a trend across the interviews. We heard “the locus of control, skills, expertise and power is still in hospital trusts” from Paul Mears, a former chief executive of a district trust. Another interviewee concurred: “The difficulty is [that] ICBs, as currently constructed, cannot provide the leadership to run an accountable care organisation. The leadership [among] ICBs … is lighter than you would find in an acute community or mental health trust, alongside the fact that leaders are less likely to have had operational experience. Their relationships with system partners are varied and often not aligned to a common vision and goals.”

This report concludes that one of the key reasons for this is that hospitals have had more autonomy and potential for impact than ICBs. An interviewee summed it up as “exciting top jobs are seen to be in NHSE and trusts … [there is] more respect in those jobs because ICBs have been under-powered [and] under-considered.” This does not only have an effect on the leadership.

Overall, across our interviews, we heard that the repeated reorganisations, and the perception that provider trusts were where change really happens, has made it difficult for ICBs, and CCGs before them, to attract high-quality staff, especially those with experience of working in provider trusts.

Weak formal influence

ICBs suffer from insufficient influence to drive the change they were designed to. This is as a result of excessive instructions from NHSE and DHSC. As well as dealing with numerous ad hoc instructions from NHSE and the DHSC, they have to deliver their local system strategy, created by ICP, which is supposed to address local needs and opportunities for improvement, as described in Chapter Two.

NHSE is often under severe pressure from government ministers and from its own leadership who, in the words of one interviewee, “reach through the NHS, to use ICBs to implement micro-policy.” This, tied with the instinct for centralisation discussed in Chapter Four earlier, means that NHSE sometimes behaves in a way that undermines the influence of ICBs. Edward Jones of the NHS Confederation said that “NHSE still pulls central levers to get stuff done … [The] system often acts with the Secretary of State calling NHSE, who calls the regions, who calls the ICBs, who calls the trust.” This puts the ICB in a short-term performance management position, rather than in a position of providing strategic direction.

We also heard that, although NHSE and ministers are supportive of ICBs in general, they do not have a strong theory of how ICBs should go about driving change. Indeed, it is not clear if NHSE strongly supports the consolidation of services, shifting funding towards primary care or merging provider trust governance structures. Rather, the feeling among our interviewees is that ICBs are expected to not really change very much fundamentally but instead just get the providers in the system to talk to each other; the expectation is that then costs would go down and health outcomes would improve.

NHSE holds 42 annual management meetings directly with provider trusts in attendance, despite, at least notionally, giving advanced ICBs the authority to manage their respective trusts themselves. As Professor Michael McCourt, a former CEO of a community and mental health trust and consultant for integrated care, said: “There continues, in some parts of the NHS, to be doubt that integrated care works, despite the fact that there is absolutely evidence that it gives you a return on investment and better quality outcomes. The execution of integrated care remains partial, half-hearted, punctuated with systems not making the progress they would like to, with insufficient scale and insufficiently long-term delivery.”

This is recognised by the 2024 Darzi report: “The function and authority of ICBs remains unclear in some important respects. The 2023 Hewitt Review was unable to clearly define the relationship between providers and ICBs, and the ambiguity persists”.²¹⁴

As one interviewee told us, “it is clear that, legally, ICBs do not have regulatory powers over provider trusts.” Professor Nicos Savva put it this way: “There has been a confusion, that because ICBs should be collaborative with non-NHS actors (i.e. councils, voluntary organisations, and adult social care), they should have that same relationship with hospital trusts. This does not make sense given that the ICBs are accountable for health outcomes and improvements [and] for the money that flows through them. This relationship should be different to that of council to ICB – although some will disagree.” Indeed, Paul Mears, the equivalent of a joint ICB and trust CEO in Wales, pointed out that “there are currently too many lines of accountability, lots of boards, lots of accountable officers. In the end it obscures where control sits. In Wales, it is very clear that [for] anything that happens in my patch, the buck stops with me.”

Box 6.3. Welsh healthcare

The evidence suggests that, within the UK “there is little evidence that one country is consistently moving ahead of the others” in respect of healthcare performance.²¹⁵

Wales abolished the provider-commissioner split of the early 1990s for a more traditional structure.²¹⁶ Wales has local health boards, which are the equivalent of ICBs, and have even more services to integrate, with direct control of public health as well.²¹⁷ These local health boards directly employ doctors and nurses and are responsible for running hospitals, as contrasted with ICBs, which only commission them.²¹⁸

What we heard in interviews was that their struggles were down to the opposite of the English problem. “Not enough leadership and grip from the government,” said an anonymous interviewee. We also heard that this was because there was not comparable data due to the lack of performance-based payments.

What we did hear is that integration of healthcare in Wales is much easier than in England. Paul Mears, the CEO of a Welsh Health Board, told us that an initiative to launch a community rehabilitation team supported by general practice and secondary care clinicians was much easier to develop than it would have been in the UK; he simply had to approve it with the board of one body, rather than get formal approval from a wider range of stakeholders.

We heard that financial pressures, which are of a similar magnitude to those in England, have a similar pernicious effect. Single-year budgets which start in deficit make it very difficult to shift resources out of hospital as there is not a lot of spare money and it is hard to invest money in things that do not generate savings in the current year.

Interviewees were nearly unanimous that strong relationships were required to deliver change. This report views this as a criticism of the healthcare system ICBs operate in. Personality is required to overcome the fact that effective management is insufficient.

Collaboration is also sometimes difficult in the NHS due to the sheer “[n]umber of players on the pitch,” including all the ICB and provider trust chairs and CEOs, according to an interviewee. At least partially, these are limitations that were clear at the birth of ICBs in 2022, with one ICB worried that big providers, such as hospital trusts, “will be the cuckoo in the nest;” they will eject the ICB by refusing to cooperate with them.²¹⁹

All of the above is compounded by the need for consultation to introduce significant change within the NHS, as explained in Chapter Four. Although a problem across the NHS as a whole, as explained before, the problem is particularly acute for ICBs, which already suffer from great difficulty in driving change.

Onerous oversight

The formal oversight ICBs are subject to is excessively onerous. It is right that ICBs are held to account and that NHSE has a role in this. The problem is rather that oversight has often been redundant, focused on process over outcomes, focused on the short over the long term, and often disproportionate to the resources being distributed.

ICBs must comply with the NHSE Oversight Framework, which describes NHSE’s approach to the oversight of ICBs.²²⁰ While the original 2022-23 NHSE Oversight Framework included 63 individual measures, the 2024-25 Oversight Framework formally contained only 32. But, depending on how you measure it, “probably 120 instructions,” according to one interviewee. The 2024-25 framework had 20 pages of instructions which look suspiciously like metrics, such as “increasing adoption of new generics and biosimilars for priority molecules to a minimum of 80% within 6–12 months”.²²¹

What is more, in reducing the metrics in the 2024-25 Oversight Framework, NHSE chose to preserve those that were maximally intrusive. Not one of the remaining metrics was a true patient outcome metric, such as mortality, patient satisfaction, life expectancy or even stroke survival rates. Those that were there in the 2022-23 Oversight Framework, such as neonatal deaths per 1,000 total live births, were removed.

As an interviewee put it, “There is not the willingness from NHSE, from ministers, to cede the control of the system. It is too great a risk … when you [lack] trust.” This is why the remaining metrics in the 2024-25 NHSE Oversight Framework are all process focused. A repeated theme in interviews was that everyone understood the need for central measurements and holding ICBs to account, and many of the metrics were deemed useful, but the overall takeaway was that measurements often focus on process and ticking boxes over actual outcomes for patients.

The NHSE also demand quarterly and annual reviews from ICBs, which take account of: the four main objectives of ICBs (as defined in Chapter Four), six capability domains, key metrics in the NHSE Oversight Framework and a range of other statutory duties, including promoting research and “the duty to obtain proper advice”.²²²

ICBs must also comply with the separate Care Quality Commission (CQC). The CQC will have another Strategic Oversight Framework coming out very soon, which will add to the ICBs’ oversight burden.

The DHSC, too, has its NHS Outcomes Framework which contains yet more metrics that must be reported, and all this is before ICBs start delivering the strategic plans, focused on addressing local circumstances, that are the key output of ICPs and respond to local circumstances and priorities.²²³

Conclusion

This chapter examined the main barriers to ICBs realising their potential and alleviating the leading problems facing the NHS in England. It found that their limited strategic control, capacity and formal influence, as well as onerous oversight, hamstrings them from achieving large-scale change. The next chapter will offer practical and original policy recommendations intended to help ICBs realise their potential.

Chapter Seven: New policies

Earlier chapters have identified the benefits of Integrated Care Boards (ICBs), but the barriers to achieving impact on a much greater scale. So, in this chapter, we detail new policy recommendations to ensure ICBs are given the resources and powers to realise their potential and mitigate some of the leading problems facing the NHS in England.

Policy approach

When formulating policy, we applied four key principles that our recommendations had to meet:

Prioritisation of the long-term. This report seeks to avoid short-termism. The following policies are not designed to fix immediate problems, but to make the NHS sustainable and efficient in the long-term.²²⁴
Fiscal responsibility. This report recognises the tight fiscal constraints the current Labour Government is under. Current public expenditure in the NHS is significant, as detailed in Chapters One and Three, and England is currently not receiving good enough healthcare provision for the money that is spent. Therefore, the policy ideas here will not generally be to spend significantly more public money.
No top-down structural reform. The current Secretary of State for Health, said that “[Labour’s plan] isn’t about changing structures and renaming Integrated Care Boards, or reconstituting trusts or changing the name of the Chief Executive of NHS England – What a waste of time those things would be”.²²⁵ Indeed, the number one ask from the NHS Confederation to the new Government is “no top-down structural reform” of the NHS.²²⁶ Edward Jones of the NHS Confederation agrees: “We have never had a structural change that has had as much support as the ICS change has had. The last thing anyone wants is another reorg, statutory change would not be improving care for patients.” There is huge amount of goodwill towards ICBs within this policy area: ICBs are supported across the political spectrum,²²⁷ within NHSE,²²⁸ provider organisations and to a large degree among clinicians.²²⁹ Our policy recommendations fit within this spirit.
Greater autonomy and accountability. The spirit of these policy recommendations mirrors principles which underlaid the successful academisation of state schools in England since the 2000s: autonomy twinned with high accountability over outcomes.²³⁰ Freeing academies from much central direction, but rigorously holding them to account for results produced notable improvements. This is not only evident in attainment data, but that England has seen significant improvements over the past decade to its position in PISA international rankings of reading, science and maths of 15-year-olds relative to the rest of the OECD.²³¹

This chapter offers 12 policies that would support ICB reform in this country, as well as enable the NHS to alleviate the problems it faces. These policies are obviously not exhaustive, and we would support other good ideas for NHS reform. But they would make for a significant step towards a more effective NHS.

This report makes policy recommendations to strengthen ICBs in four areas. First, the funding of ICBs. Second, performance measurement of ICBs. Third, governance of and involving ICBs. Fourth, supporting ICBs that are ‘lighthouses,’ as defined later in this chapter.

Funding of ICBs

Recommendation one: Funding from NHSE in the areas where ICBs are responsible for commissioning should not go directly to provider trusts but to ICBs instead.

Patricia Hewitt, current ICB CEO and former Secretary of State for Health, described how NHSE’s decision a few years ago only to consider capital bids that came from STPs (the precursors of ICBs) rather than individual provider trusts forced providers to work together, and to think and plan based on patient needs rather than organisational priorities.

Recommendation two: Reform NHSE funding to ICBS so a greater proportion is without specific conditions and at timescales of a minimum of three years.

First, funding ICBs without specification that it should be spent on any particular kind of care will mean much more of it can be focused on the most cost-effective measures. The best solutions will often require commissioning across a range of kinds of care. Long-term and unspecified funding will allow ICBs to develop capabilities and drive more collaborative working.

More discretionary funding gives a real mandate to ICBs to drive change rather than merely be a convener. When ICBs do not actually control budgets, they are merely performance managers, not the strategic planners of healthcare that they are supposed to be.

Second, the funding awarded to ICBs from NHSE should have a minimum three-year horizon if it is to drive transformative change. Current funding, typically of no longer than a year, prevents ICBs from investing in long-term programmes that could save money or help patients.

Recommendation three: The NHS should target a return of hospital funding back to 55% of the total NHS budget over the next five years.

Funding for primary care, community trusts and even local authority public health budgets is likely to have a much larger impact per pound on patient health than spending on hospital care. Such a shift in funding to these actors away from hospitals will lead to more prevention and proactive care. This is especially true as hospitals are currently at over capacity, as discussed earlier in Chapter Four, which means they are poorly placed to use new funding effectively without improvements in hospital infrastructure, especially if they are not given funding in conjunction with more cooperation with other NHS providers.

Recommendation four: Increase healthcare capital spending to 0.8% of GDP, administered by ICBs.

This report, in Chapters Three and Four, has identified a capital spending deficit as a likely cause of NHS productivity falls and of difficulty reducing the waiting list. The UK currently spends 0.4% of GDP on health capital spending. Even following the increase in capital investment for health announced in the 2024 Autumn Budget, this is not set to increase beyond 0.5% of GDP. Given the capital spending deficit within the NHS identified by this report, and the fact our similar international peers – as defined in Chapter Three, such as Sweden, Finland, Ireland, Canada – are all around the 0.8% of GDP level, a greater increase is a fiscally realistic ambition.

Ageing buildings and diagnostic machines at full capacity are unable to handle more patients and, without a sufficient capital budget, investing in new digital systems is hard. This report, therefore, recommends an increase in the level of capital funding for the NHS, given to ICBs as capital funding that is not used to plug holes in day-to-day operational budgets. This call for increased capital spending in the NHS is echoed by the NHS Confederation, which is calling for a near doubling of NHS capital spending, and by the 2024 Darzi report.²³²

This report maintains that capital spending should be prioritised over operational budget increases, especially if they are targeted at reducing the backlog. Nine in 10 NHS leaders responding to an NHS Confederation survey agreed that “reducing waiting lists is being hindered by a decade-long lack of investment”.²³³ As we have seen from the 20% rise in staffing since 2019 taking place at the same time as a stall in the number of treatments performed, the scope to increase output in hospitals without capital increases appears to have been exhausted.

Performance measurement of ICBs

Recommendation five: Create a combined scorecard for all accountability frameworks for ICBs and provider trusts that focuses on long-term outcomes, integrating the demands of NHSE, DHSC and the CQC.

This combined scorecard, which will be in a new NHSE Oversight Framework, the CQC Oversight Framework and the DHSC Outcomes Framework, must focus on long-term outcomes, cover the major demands from all major stakeholders and be committed to by said stakeholders. There should be a significant appendix in the scorecard to cover the inevitably large number of metrics requested. As Paul Mears, CEO of the Welsh equivalent of an ICB, said, “especially in a system like Wales where direct control from the centre diminishes you have to have clear incentives … and have a common currency which allows you to measure performance”.²³⁴

As explained in Chapter Six, the current oversight framework for ICBs is onerous and not fit for purpose. We heard repeatedly that effort duplication and redundant requests have sapped management time and morale. Especially with a new CQC framework for ICBs coming out soon, it is key that the different frameworks cover the demands of the NSHE, DHSC, and the CQC’s key needs. Currently, this does not happen.

It is better that the performance outcomes in the appendix be comprehensive, rather than requiring NHSE, DHSC and the CQC to interfere in-year to get more metrics beyond what is in the scorecard. But the key targets in and of themselves, and not just data in the appendix to show how the health system is running – should be kept limited.

Ben Horner, a Partner at BCG, said that “[w]hat is needed is smart simplicity, far fewer targets which people really focus on for a prolonged period.” New outcome metrics should be changed much less frequently than the current disease-specific measures.

The ICBs must only be held accountable using the proposed scorecard rather than continuing with the culture of constant ad hoc requests from the different oversight bodies. Where new funding is released for ICBs, as opposed to requiring specific activity, improvements in the outcomes in the scorecard or metrics in the appendix should be used to judge progress. This has the dual benefit of ensuring that new funding targets the pre-agreed objectives of the ICB and that there is no need for introducing additional measurements.

There are encouraging examples that this outcome targeting really can positively affect the incentives of the health system, such as Camden’s MSK service where 10% of the contract value was tied to outcomes. It managed to reduce spending on acute activity by 27% compared to a counterfactual.²³⁵

Recommendation six: The new scorecard for oversight frameworks should assess ICBs and provider trusts primarily on patient outcomes, especially life expectancy, preventable and treatable mortality, patient satisfaction, patients dying in their chosen setting and bed days per person.

This report suggests five patient outcomes to be included in the scorecard.

Life expectancy. This is the predicted lifespan of a hypothetical person assumed to be exposed, from birth through death, to the mortality rates observed in one calendar year.
Preventable and treatable mortality. Annual mortality from causes that should be treatable or preventable.
Patient satisfaction. Annual patient satisfaction, broken down by services accessed in a year. This could be measured initially by leveraging existing surveys such as the GP Patient survey, which tries to get a representative survey of the whole population, but currently focuses only on GP services. It could also be measured by the secondary care survey run by the CQC, the Cancer Patient Experience survey, and the VOICES survey on end-of-life care.²³⁶ The end goal should be to develop the GP Patient Survey into a survey which covers all health care provided by ICBs and attempts to randomly sample the population, alongside specific surveys that get additional data on patient groups that have smaller sample sizes, such as those being treated for cancer. Ultimately all significant NHS services should have a quantifiable patient satisfaction score by ICB, and each ICB should have an overall patient satisfaction score.
Patients dying in their chosen setting. Patients should be asked wherever possible where they wish to die (at home, in a care home or in hospital). Where they actually die should be measured and reported annually at least at the granularity of ICBs.
Bed days per person. The number of days spent in hospitals per person, known as ‘bed days’, should be recorded and reported by ICBs. This outcome should be further broken down by vulnerable populations, for example the elderly, children, those with learning difficulties, and those with severe mental health problems.

Some will be worried that these proposed patient outcomes are not within the full control of different NHS bodies, or even of just the NHS, but this is the entire point. As an ICB CEO said to us, “the beauty of the metrics you can’t accomplish on your own is that then you have to collaborate. You can’t move an outcome forward on your own – a whole range of partners is required. Metrics should force collaboration. “

Others will be concerned that outcomes broader than simply health are being included. But outcomes broader than patient health are important. Patients are the customers of the health system, and how they feel about the care that the NHS provides them is an important outcome in and of itself. Matthew Walker, the CEO of the National Association of Primary Care, said that “enabling people to spend their final weeks and days and die in their place of choice requires our teams to discuss what the patient actually wants, and enable it to happen.”

The final outcome also speaks to intractable problems within the NHS, the altering of which would indicate many smaller improvements. The CEO of an ICB, spoke of how “[l]iving in communities [with reduced bed days in hospital] is a great indicator of quality of patient treatment for all patients. This should be treated with great importance. It is even more important for vulnerable patient populations.”

Of course, the proposed appendix to the oversight frameworks should include many access and disease pathway metrics – such as the proportion of patients receiving diagnostic tests – so that the oversight bodies can understand in detail what is happening in the healthcare system. These should, however, be intended to inform discussions about why patient outcomes are moving in the right or wrong direction: not constitute ends in and of themselves. An interviewee said, “the appendix needs to be detailed enough to prove why a transformation in an outcome is happening, e.g., that the transfer of care is working, or that people with long-term conditions are having low admissions to hospital.”

Recommendation seven: All outcomes and metrics in the new scorecard and appendix for the accountability frameworks of ICBs and provider trusts should be updated and tracked using the Federated Data Platform (FDP).

All outcomes and metrics that ICBs and provider trusts are being assessed on by the different accountability frameworks should be tracked in a live, single tracker, accessible by all the relevant parties built on the Federated Data Platform (FDP). The relevant parties would be the CQC, NHSE, DHSC, and the involved ICBs and provider trusts.

There should be formal requirements to keep the FDP up to date, which then automatically flow to parties that have the right to see the relevant data. These requirements should specify for each outcome how often it should be updated.

This is more efficient than the production of spreadsheets which then have to be emailed to and manually consolidated among provider trusts, ICBs, NHSE, the DHSC and the CQC.

The FDP is a software platform that is being built by Palantir for NHSE to sit across provider trusts and ICSs, enabling data to be brought together.²³⁷ This ambition is clearly laid out in the FDP contract: “Inequalities will be visible and addressable, programmes of work tackling the backlog will be trackable, and ‘form filling and situational reports’ will be reduced. The ambition is that every Trust and [ICB] will have their own ‘federated’ platform which will work alongside their existing systems to enable consistent standards and bring information into one … [this] will allow NHS staff to understand in near real time how many patients are in hospital, how long patients are waiting for critical treatments, [and] where pressure points are”.²³⁸

Part of the duplication of requests to ICBs within the current healthcare system is because data produced for the CQC is done in offline spreadsheets and is not, as a default, available to other actors within the system, especially NHSE or ministers. Now is the perfect time, as the FDP is rolled out, to make sure that the FDP is used to consolidate formally all the outcomes ICBs and provider trusts are being managed against and that data is shared and kept available between the different actors within the English health system.

Governance of and involving ICBs

Recommendation eight: Mandate that provider trust appointment committees and boards contain at least one ICB-designated person.

Frequently, ICBs sit on provider trust-appoint panels for CEOs and senior staff. Where in place, this is helpful in ensuring that system-minded people are appointed to key NHS roles. It also eases subsequent collaboration. This should be mandated for all NHS provider trusts.

An ICB CEO commented that “[i]t is absolutely vital that ICBs can influence provider trust appointments. It can ruin a system if a CEO is appointed who is not system minded and just wants to grow the hospital.”

Similarly, it is important that the boards of provider trusts, to which CEOs are ultimately responsible, are system minded. It should be the case that ICBs have representation, especially on large provider trust boards. This ensures that provider trusts are judged not only on individual provider trust outcomes, but also on system-wide outcomes, for which ICBs are responsible.

Recommendation nine: The NHSE should produce a standardised, streamlined consultation process for all NHS bodies for a maximum of six months.

Service redesigns are assiduously avoided by provider trusts and ICBs because resultant consultations are so legally and politically difficult, as explained in Chapter Four. As an ICB CEO told us, “[f]ixing consultations is a no-brainer. So many go wrong because they are locally designed and don’t meet the guidelines. A standardised process would be so helpful … [it cannot be right that] consultation would have added 18 months, it is not fit for purpose.”

A CEO of a provider trust said that “[s]omething has to be done to cut through the consultation process. It is the equivalent of the planning system for the NHS. The NHS fears to tread – if you step through it you can do a lot, but the process is hard.” Another interviewee said, “consultation is essential, but there may be good reason to standardise to give assurance to patients to show what good due process looks like … [and also because] it is currently unclear to provider trusts and ICBs what is sufficient.”

NHSE should produce an outline for a standardised consultation process to be mandated nationally for all NHS bodies, and design it such that it is expected to last for no more than six months. This would be a significant improvement over the current vague statutory duty to involve the public in: the planning of the provision of health services and the development and consideration of proposals for changes in the way those services are provided. This is a view that former ministers for health have stated before.²³⁹

Recommendation ten: The Independent Reconfiguration Panel (IRP) should be able to advise ICBs and provider trusts on reconfiguration, and the Secretary of State for Health should accept any local reconfiguration the IRP supported.

There is significant scope to give additional support to ICBs with the reconfiguration of healthcare services by NHSE creating a standardised reconfiguration process.

It would make sense to enable the IRP also to advise both providers trusts and ICBs on reconfigurations.²⁴¹ This is because it makes sense to have a strong centre of expertise in NHSE concerned with the reconfiguration of local healthcare services. Opening and closing wards, changing where in the local NHS system people get treated for conditions and how the service is set up to treat them is clearly an expert activity. Each ICB will only reconfigure a service like stroke care rarely, but the IRP could collate practice to share nationally following each reconfiguration case.

The Secretary of State for Health currently has the power to call-in, or supersede, any decision taken locally on healthcare service reconfigurations. The Secretary of State should commit to support any proposal where the proposed new standardised process for reconfiguration was followed, and the IRP is supportive. Otherwise, the Secretary of State would find themselves in the unenviable position of defending each local decision to close or change a beloved local service rather than the principle that a better NHS is one that is flexible and able to change to meet the needs of its patients.

This principles-based approach would help the Secretary deal with reconfiguration requests already received.²⁴²

Supporting ICBs that are ‘lighthouses’

It will likely take around a decade for ICBs to mature and deliver fully on their mandate. To address this, as in previous stages of ICS evolution, and as in many other areas of the NHS, it would be beneficial to allow some ICBs to move further and faster and to experiment with how ICBs could evolve. These are called by many names: ‘pilots’, ‘lighthouses’, and ‘High Accountability and Responsibility Partnerships’ (by the Hewitt Review). This report will call them ‘lighthouses’, as the hope is that they light the safe way forward for other ICBs to follow.

Recommendation eleven: Designate high-performing ICBs as ‘lighthouses’, which receive even more funding over up to five-year cycles without hypothecation.

The value of proving the ICB model is immense and especially politically urgent, as ICBs are unlikely to be left unreformed for multiple years to show their worth.

We already have a healthcare system in England where ICBs that are higher performing formally have a lighter touch approach to oversight, such as by having fewer formal oversight meetings with NHSE.²⁴³ But, the reality is that all ICBs are subject to an extremely high level of direction from NHSE and DHSC, regardless of performance level.

While DHSC and NHSE understandably have a high level of anxiety about releasing their grip over the whole NHS, they should be less anxious about giving the highest performing ICBs more freedom. The most high-performing ICBs, as established thorough the new scorecard outcomes proposed in this report, should be given more control than the new default proposed in this report over their money from NHSE. Their budgets, as much as possible, should be freely managed and given ideally five-year timescales.

There should be a commitment that as a default the lighthouse ICBs will be left out of new funding schemes from NHSE which require additional bidding or reporting – the ‘penny packets’ described earlier in the report – and, instead, simply be given a portion of new funding from NHSE based on their population.

Recommendation twelve: Allow lighthouse ICBs to experiment with governance structures.

The pilot lighthouse ICBs should be allowed to adopt different governance structures. It is not yet clear what the right governance end-state of ICBs ought to be. One could involve merging the ICB board with multiple provider trust boards, as well as their CEO roles. One board, one CEO and one governance structure to oversee the integration of various, overlapping roles and services could be effective at aligning incentives and delivering improvements.

Merging with the boards of provider trusts with an ICB has three key benefits. First, it drives provider trust collaboration and integration, as leadership no longer have conflicting objectives. Second, it streamlines governance. It is much easier to push ICB cooperation with fewer stakeholders interfering. When we spoke to an interviewee, they told us that in London, there were 32 different CCGs and 36 separate provider trusts. “There were over 100 people with veto rights. They found cooperation easier as they systemically put in shared CEOs and chairs; and the quality of the leaders improved as they had to find fewer leaders.” The improved leadership quality is the third benefit.

There are further benefits of a more systemic move to joint leadership more broadly. Many of our interviewees, for example, felt that there was a lot of strong leadership among NHS providers, and that in a healthcare system where providers were divisions of an ICB rather than independent they would be much more likely to take ICB leadership roles.

What is more, all interviewees said that, if ICBs proposed such structures, ICBs should be allowed to try them. It is already starting to happen. Cornwall has just implemented a joint board comprised of its providers and ICB.²⁴⁴ However, the lack of formal support and legal complexity has meant that full integration of finance and performance, as opposed to pathway design, all of which had been planned had to be abandoned.

With that said, leadership consolidation comes with risks; in a healthcare system where leaders are likely to come from hospital providers, consolidated organisations might double down and focus even more on hospitals, ignoring community and primary care. This is why it is worth experimenting and evaluating this approach with some lighthouse ICBs.

Conclusion

The NHS in England is in trouble. It is underperforming, both historically and internationally. ICBs have an opportunity to improve the way the NHS in England operates.

The large structural change that created ICBs has already been done. Now is the chance for the new Labour Government to recognise some of the ICBs’ early successes, but also that ICBs have been asked to do a job without granting them sufficient resources and powers to do it.

Author

Conrad Bannister is an Associate Fellow at Bright Blue. He has extensive experience as a former member of Boston Consulting Group’s (BCG’s) Public Sector practice designing and implementing reforms in the UK public sector working across transport, housing and climate, notably COP26. In 2023 he helped write the £1.3 billion Primary Care Recovery Plan as part of a three-person team reporting to the Prime Minister’s Office. Prior to his tenure at BCG, Conrad briefly worked for the Competition and Markets Authority after completing his studies in Philosophy, Politics, and Economics (PPE) at the University of Oxford.

Acknowledgments

I would like to thank Bartek Staniszewski and Ryan Shorthouse for their editing, feedback and tireless support on this report. As the first think-tank report I have written, it has been immeasurably improved by their intervention.

I would also like to repeat my sincere thanks to the interviewees who took time out of their busy schedules to help improve the system they work in.

Any mistakes in this report of course remain my own.

Finally, thank you to all of those in the health system, who through their herculean efforts make it a system that over a million people can use every day to improve their health and lives.

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55 Ibid.
56 Ibid.
57 Siva Anandaciva, “How does the NHS compare to the health care systems of other countries?”, https://www.kingsfund.org.uk/insight-and-analysis/reports/nhs-compare-health-care-systems-other-countries (2023).
58 The Commonwealth Fund, “International Health Care System Profiles: Denmark”, https://www.commonwealthfund.org/international-health-policy-center/countries/denmark (2020); this chart, and also subsequent charts, highlight the UK’s peer countries, the choice of which is explicated later on in this report.
59 OECD “Health at a Glance 2017”, https://www.oecd-ilibrary.org/docserver/health_glance-2017-en.pdf?expires=1722646243&id=id&accname=guest&checksum=B42B4F1BDC3F8028884921209E087A4D (2017); OECD “Health at a Glance 2015”, https://www.oecd-ilibrary.org/docserver/health_glance-2015-en.pdf (2015)
60 OECD, “Health at a Glance 2023”, https://www.oecd-ilibrary.org/docserver/857d9cb0-en.pdf (2023).
61 European Commission, “State of Health in the EU, Finland, Country Health Profile 2021”, https://health.ec.europa.eu/system/files/2021-12/2021_chp_fi_english.pdf (2021); European Observatory on Health Systems and Policies; “Finland; Health system summary”, https://iris.who.int/bitstream/handle/10665/366710/9789289059398-eng.pdf?sequence=1 (2023).
62 Ministry of Social Affairs and Health (Finland), “Wellbeing services counties will be responsible for organising health, social and rescue services”, https://stm.fi/en/wellbeing-services-counties (2023).
63 Dominic Montagu, “The Provision of Private Healthcare Services in European Countries: Recent Data and Lessons for Universal Health Coverage in Other Settings”, https://www.frontiersin.org/journals/public-health/articles/10.3389/fpubh.2021.636750/full (2021).
64 Siva Anandaciva, “How does the NHS compare to the health care systems of other countries?”, https://www.kingsfund.org.uk/insight-and-analysis/reports/nhs-compare-health-care-systems-other-countries (2023).
65 Roosa Tikkanen et al., “International Health Care System Profiles: Norway”, https://www.commonwealthfund.org/international-health-policy-center/countries/norway (2020).
66 OECD, “Norway: Country Health Profile 2023”, https://www.oecd.org/en/publications/2023/12/norway-country-health-profile-2023_8febbd22.html (2023).
67 Anna H. Glenngård, “International Health Care System Profiles: Sweden”, https://www.commonwealthfund.org/international-health-policy-center/countries/sweden (2020); OECD, “Sweden: Country Health Profile 2023”, https://www.oecd.org/en/publications/2023/12/sweden-country-health-profile-2023_1f0c8967.html (2023).
68 The Commonwealth Fund, “Internation Health Care System Profiles: Denmark”, https://www.commonwealthfund.org/international-health-policy-center/countries/denmark (2020).
69 Siva Anandaciva, “How does the NHS compare to the health care systems of other countries?” https://assets.kingsfund.org.uk/f/256914/x/7cdf5ad1de/how_nhs_compares_other_countries_abpi_2023.pdf (2023).
70 Azeem Majeed et al., “Healthcare outcomes and quality in the NHS: how do we compare and how might the NHS improve?”, https://www.bmj.com/content/362/bmj.k3036.full or https://spiral.imperial.ac.uk/handle/10044/1/62285 (2018).
71 Guadamuz, Shooshtari, and Qato, “Global, regional and national trends in statin utilisation in high-income and low/middle-income countries, 2015–2020”, https://bmjopen.bmj.com/content/bmjopen/12/9/e061350.full.pdf#page=4&zoom=100,53,564 (2022); OECD “Health at a Glance 2023”, https://www.oecd-ilibrary.org/docserver/857d9cb0-en.pdf (2023).
72 “Health at a Glance 2023”, https://www.oecd-ilibrary.org/docserver/857d9cb0-en.pdf (2023). .
73 NHSE, “Quality and Outcomes Framework guidance for 2024/25”, https://www.england.nhs.uk/wp-content/uploads/2024/03/PRN01104-Quality-and-outcomes-framework-guidance-for-2024-25.pdf (2024).
74 OECD, “Health at a Glance 2023”, https://www.oecd-ilibrary.org/docserver/857d9cb0-en.pdf (2023).
75 OECD, “Health at a Glance 2023”, https://www.oecd-ilibrary.org/docserver/857d9cb0-en.pdf (2023).
76 OECD, “Health at a Glance 2023”, https://www.oecd-ilibrary.org/docserver/857d9cb0-en.pdf (2023); Siva Anandaciva, “How does the NHS compare to the health care systems of other countries?” https://assets.kingsfund.org.uk/f/256914/x/7cdf5ad1de/how_nhs_compares_other_countries_abpi_2023.pdf (2023).
77 OECD, “Health at a Glance 2023”, https://www.oecd-ilibrary.org/docserver/857d9cb0-en.pdf (2023).
78 George Stoye et al., “The past and future of UK health spending”, https://ifs.org.uk/publications/past-and-future-uk-health-spending (2024).
79 HM Treasury, “Autumn Budget 2024”, https://assets.publishing.service.gov.uk/media/672232d010b0d582ee8c4905/Autumn_Budget_2024__web_accessible_.pdf (2024).
80 OECD, “Health at a Glance 2023”, https://www.oecd-ilibrary.org/docserver/857d9cb0-en.pdf (2023).
81 Dr Billy Palmer, Lucina Rolewicz and Emma Dodsworth, “Exploring the earnings of NHS doctors in England”, https://www.nuffieldtrust.org.uk/resource/exploring-the-earnings-of-nhs-doctors-in-england (2023).
82 EU Commission, “State of Health in the EU: Spain Country Health Profile 2023”, https://eurohealthobservatory.who.int/publications/m/spain-country-health-profile-2023 (2023)
83 Ibid.
84 David Oliver, “Is England’s NHS too “top down””, https://www.bmj.com/content/377/bmj.o1550 (2022).
85 Azeem Majeed et al., “Healthcare outcomes and quality in the NHS: how do we compare and how might the NHS improve?”, https://www.bmj.com/content/362/bmj.k3036.full (2018).
86 Dayan et al, “How good is the NHS?”, https://www.nuffieldtrust.org.uk/sites/default/files/2018-06/the-nhs-at-70-how-good-is-the-nhs.pdf (2018).
87 Bob Hudson, “Competition and Collaboration in the ‘New NHS’”, https://chpi.org.uk/wp-content/uploads/2013/06/Bob-Hudson-Competition-and-collaboration-in-the-new-NHS.pdf (2013).
88 Justin Aunger et al., “Collaboration over competition? Regulatory reform and inter-organisational relations in the NHS amidst the COVID-19 pandemic: a qualitative study”, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9099284/ (2022).
89 Age UK, “The crisis in the NHS is largely a crisis in older people’s preventive care, and if we’re to avoid another catastrophic winter in nine months’ time we need to act now to fix it”, https://www.ageuk.org.uk/latest-press/articles/2023/the-crisis-in-the-nhs-is-largely-a-crisis-in-older-peoples-preventive-care-and-if-were-to-avoid-another-catastrophic-winter-in-nine-months-time-we-need-to-act-now-to-fix-it-warns-age-uk/ (2023).
90 Dr Ruth Law, “Avoiding hospital associated harm for older people this winter”, https://www.bgs.org.uk/blog/avoiding-hospital-associated-harm-for-older-people-this-winter (2022).
91 Alison M Mudge et al., “Hospital-associated complications of older people: a proposed multi-component outcome for acute care”, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6367036/ (2019).
92 Claire Fuller et al., “Integrating primary care: an inside perspective on the Fuller Stocktake”, https://www.sciencedirect.com/science/article/pii/S2514664524003291 (2023).
93 Lord Darzi, “Independent Investigation of the National Health Service in England”, https://assets.publishing.service.gov.uk/media/66e1b49e3b0c9e88544a0049/Lord-Darzi-Independent-Investigation-of-the-National-Health-Service-in-England.pdf (2024).
94 Alex Bate, “Reconfiguration of NHS services (England)”, https://researchbriefings.files.parliament.uk/documents/CBP-8105/CBP-8105.pdf (2017).
95 Alex Bate, “Reconfiguration of NHS services (England)”, https://researchbriefings.files.parliament.uk/documents/CBP-8105/CBP-8105.pdf (2017).
96 Lord Norman Warner, “The NHS: Decline and fall, or resurrection?”, https://www.smf.co.uk/wp-content/uploads/2022/07/The-NHS-Decline-and-fall-or-resurrection-July-2022.pdf (2022).
97 Stephen Martin et al., “Is an ounce of prevention worth a pound of cure? A cross-sectional study of the impact of English public health grant on mortality and morbidity”, https://bmjopen.bmj.com/content/10/10/e036411 (2020).
98 HM Treasury, “Autumn Budget 2024”, https://assets.publishing.service.gov.uk/media/672232d010b0d582ee8c4905/Autumn_Budget_2024__web_accessible_.pdf (2024), 52.
99 Ibid., 58.
100 Michael Wood, “From safety net to springboard: putting health at the heart of economic growth”, https://www.nhsconfed.org/publications/safety-net-springboard (2022).
101 Thomas Cowling et al., “Access to Primary Care and Visits to Emergency Departments in England: A Cross-Sectional, Population-Based Study”, (2013).
102 Bridget Gorham and Michael Wood, “Unlocking the power of health beyond the hospital: supporting communities to prosper”, https://www.nhsconfed.org/publications/unlocking-power-health-beyond-hospital (2023).
103 Ibid.
104 Samantha Artiga and Elizabeth Hinton, “Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity”, https://www.kff.org/racial-equity-and-health-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/ (2018).
105 DHSC, “New office for health promotion to drive improvement of nation’s health”, https://www.gov.uk/government/news/new-office-for-health-promotion-to-drive-improvement-of-nations-health (2021).
106 Michael Marmot et al., “Health Equity In England: The Marmot Review 10 Years On Executive Summary”, https://www.instituteofhealthequity.org/resources-reports/marmot-review-10-years-on/the-marmot-review-10-years-on-executive-summary.pdf (2020).
107 David Finch, “Investing in the public health grant”, https://www.health.org.uk/news-and-comment/charts-and-infographics/public-health-grant-what-it-is-and-why-greater-investment-is-needed (2024).
108 Donna Hall, “The Hewitt Review”, https://assets.publishing.service.gov.uk/media/642b07d87de82b00123134fa/the-hewitt-review.pdf (2023).
109 NHS England, “The NHS Long Term Plan”, https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf (2019).
110 Chris Ham, “The rise and decline of the NHS in England 2000–20”, https://assets.kingsfund.org.uk/f/256914/x/0ab966500b/rise_decline_nhs_england_2000-20_2023.pdf (2023).
111 Beccy Baird et al., “Making care closer to home a reality”, https://assets.kingsfund.org.uk/f/256914/x/ab65341d7a/making_care_closer_home_reality_report_2024.pdf
112 Max Thilo, “What the NHS can and cannot learn from the Singaporean health care system”, https://www.smf.co.uk/wp-content/uploads/2024/03/Lessons-from-Singapore-for-NHS-primary-care-March-2024.pdf (2024).
113 Claire Fuller, “Next steps for integrating primary care: Fuller Stocktake report”, https://www.england.nhs.uk/wp-content/uploads/2022/05/next-steps-for-integrating-primary-care-fuller-stocktake-report.pdf (2022); Allen et al., “Letter from the 42 Integrated Care System CEO-designates to CEO NHS England”, https://www.england.nhs.uk/wp-content/uploads/2022/05/fuller-stocktake-ics-ceo-letter.pdf (2022).
114 Lord Darzi, “Summary letter from Lord Darzi to the Secretary of State for Health and Social Care”, https://www.gov.uk/government/publications/independent-investigation-of-the-nhs-in-england/summary-letter-from-lord-darzi-to-the-secretary-of-state-for-health-and-social-care (2024).
115 Nuffield Trust, “Where does the NHS money go?”, https://www.nuffieldtrust.org.uk/resource/where-does-the-nhs-money-go (2024); Beccy Baird et al., “Making care closer to home a reality”, https://assets.kingsfund.org.uk/f/256914/x/ab65341d7a/making_care_closer_home_reality_report_2024.pdf (2024).
116 Nuffield Trust, “Where does the NHS money go?”, https://www.nuffieldtrust.org.uk/resource/where-does-the-nhs-money-go (2024).
117 NHSE, “General and Personal Medical Services, England – 1995-2005”, https://digital.nhs.uk/data-and-information/publications/statistical/general-and-personal-medical-services/1995-2005 (2006); NHSE, “General Practice Workforce, 31 May 2024”, https://digital.nhs.uk/data-and-information/publications/statistical/general-and-personal-medical-services/31-may-2024 (2024); . The King’s Fund, “Key facts and figures about the NHS”, https://www.kingsfund.org.uk/insight-and-analysis/data-and-charts/key-facts-figures-nhs (2024); Statista, “Number of doctors in the NHS Hospitals and Community Health Service (HCHS) workforce England from 1995 to 2023”, https://www.statista.com/statistics/679968/number-of-doctors-nhs-hchs-workforce-england/ (2024).
118 The latest A&E target was 76% seen within 4 hours set for March 2024, and the 18-week referral to treatment standard is a right in the NHS constitution. Nuffield Trust, “A&E waiting times”, https://www.nuffieldtrust.org.uk/resource/a-e-waiting-times (2024); Kathryn Marszalek et al., “The NHS waiting list: when will it peak?”, https://www.health.org.uk/news-and-comment/charts-and-infographics/waiting-list (2023).
119 Beccy Baird et al., “Making care closer to home a reality”, https://assets.kingsfund.org.uk/f/256914/x/ab65341d7a/making_care_closer_home_reality_report_2024.pdf (2024).
120 Kate Ogden and David Phillips, “How have English councils’ funding and spending changed? 2010 to 2024”, https://ifs.org.uk/publications/how-have-english-councils-funding-and-spending-changed-2010-2024 (2024).
121 Sarah Cattan et al., “The health impacts of Sure Start”, https://ifs.org.uk/publications/health-impacts-sure-start (2021).
122 The King’s Fund, “Key facts and figures about adult social care”, https://www.kingsfund.org.uk/insight-and-analysis/data-and-charts/key-facts-figures-adult-social-care (2024); Simon Bottery and Saoirse Mallorie, “Social care 360”, https://www.kingsfund.org.uk/insight-and-analysis/long-reads/social-care-360 (2024).
123 Age UK, “Age UK: General Election Manifesto 2019”, https://www.ageuk.org.uk/globalassets/age-uk/documents/campaigns/ge-2019/age-uk-general-election-manifesto-2019.pdf (2019).
124 Anita Charlesworth and Paul Johnson et al., “Securing the future: funding health and social care to the 2030s”, https://ifs.org.uk/sites/default/files/output_url_files/R-143-new.pdf (2018).
125 Max Warner and Ben Zaranko, “Is there really an NHS productivity crisis?”,
https://ifs.org.uk/articles/there-really-nhs-productivity-crisis (2023); Sam Freedman and Rachel Wolf, “The NHS productivity puzzle: Why has hospital activity not increased in line with funding and staffing?”, https://www.instituteforgovernment.org.uk/sites/default/files/2023-06/nhs-productivity-puzzle_0.pdf (2023).; Stephen Sutherland, Ben Horner, and Cassandra Yong, “Getting to grips with the workforce conundrum: A practical approach”, https://www.hsj.co.uk/workforce/getting-to-grips-with-the-workforce-conundrum-a-practical-approach/7036613.article (2024); Institute for Government, “Performance Tracker 2023: Hospitals”,
https://www.instituteforgovernment.org.uk/publication/performance-tracker-2023/hospitals (2023); Sam Freedman and Rachel Wolf, “The NHS productivity puzzle: Why has hospital activity not increased in line with funding and staffing?”, https://www.instituteforgovernment.org.uk/sites/default/files/2023-06/nhs-productivity-puzzle_0.pdf (2023).
126 Stephen Sutherland, Ben Horner, and Cassandra Yong, “Getting to grips with the workforce conundrum: A practical approach”, https://www.hsj.co.uk/workforce/getting-to-grips-with-the-workforce-conundrum-a-practical-approach/7036613.article (2024).
127 Sam Freedman and Rachel Wolf, “The NHS productivity puzzle: Why has hospital activity not increased in line with funding and staffing?”, https://www.instituteforgovernment.org.uk/sites/default/files/2023-06/nhs-productivity-puzzle_0.pdf (2023).
128 OECD “Health at a Glance 2023”, https://www.oecd-ilibrary.org/docserver/857d9cb0-en.pdf (2023).
129 OECD, “Health at a Glance 2023: OECD Indicators: Diagnostic technologies”, https://www.oecd-ilibrary.org/docserver/857d9cb0-en.pdf (2023). Diagnostic scanners is defined here as CT, PET and MRI scanners (computed tomography, positron emission tomography and magnetic resonance imaging).
130 George Stoye et al., “The past and future of UK health spending”, https://ifs.org.uk/publications/past-and-future-uk-health-spending (2024).
131 HM Treasury, “Autumn Budget 2024”, https://assets.publishing.service.gov.uk/media/672232d010b0d582ee8c4905/Autumn_Budget_2024__web_accessible_.pdf (2024).
132 David Foster, “Delayed hospital discharges and adult social care”, https://commonslibrary.parliament.uk/delayed-hospital-discharges-and-adult-social-care/ (2023).
133 The King’s Fund, “‘Addiction to short-termism’ put NHS future at risk, warn think tanks”, https://www.kingsfund.org.uk/insight-and-analysis/press-releases/short-termism-nhs-future-at-risk (2023).
134 Siva Anandaciva, “A short history of NHS winter funding”, https://www.kingsfund.org.uk/insight-and-analysis/blogs/short-history-nhs-winter-funding (2018).
135 DHSC, “£200 million to boost NHS resilience and care this winter”, https://www.gov.uk/government/news/200-million-to-boost-nhs-resilience-and-care-this-winter (2023).
136 Annie Bliss and Edward Jones, “The Hewitt review: where are we one year on?”, https://www.nhsconfed.org/long-reads/hewitt-review-where-are-we-one-year (2024).
137 Annie Bliss and Edward Jones, “The Hewitt review: where are we one year on?”, https://www.nhsconfed.org/long-reads/hewitt-review-where-are-we-one-year (2024).
138 NHSE “What are integrated care systems?” https://www.england.nhs.uk/integratedcare/what-is-integrated-care/ (2024).
139 NHSE, “NHS Oversight Framework”, https://www.england.nhs.uk/nhs-oversight-framework/ (2024).
140 NHSE, “NHS in numbers today”,
https://www.england.nhs.uk/nhsbirthday/about-the-nhs-birthday/nhs-in-numbers-today/ (2023).
141 Lillie Wenzel, Ruth Robertson, and Charlotte Wickens, “What is commissioning and how is it changing?”
https://www.kingsfund.org.uk/insight-and-analysis/long-reads/what-commissioning-and-how-it-changing (2023); Phoebe Dunn et al., “Integrated care systems: what do they look like?” https://www.health.org.uk/publications/long-reads/integrated-care-systems-what-do-they-look-like (2022); Phoebe Dunn et al., “Integrated care systems: what do they look like?” https://www.health.org.uk/publications/long-reads/integrated-care-systems-what-do-they-look-like?gad_source=1&gclid=CjwKCAjwxLKxBhA7EiwAXO0R0LluuoTd6vRuTPY5iFc5qPGL0aeMR-SM9J2kkGBEXaZKBVRB7vjRnxoCTxAQAvD_BwE (2022).
142 NHSE, “Integrating care”, “https://www.england.nhs.uk/wp-content/uploads/2021/01/integrating-care-next-steps-to-building-strong-and-effective-integrated-care-systems.pdf” (2020).
143 Julian Kelly (CFO NHSE), “Financial performance update”,
https://www.england.nhs.uk/long-read/financial-performance-update-1-feb-24/ (2024); Lillie Wenzel, Ruth Robertson and Charlotte Wickens, “What is commissioning and how is it changing?”, https://www.kingsfund.org.uk/insight-and-analysis/long-reads/what-commissioning-and-how-it-changing (2023).
144 NHSE, “Supporting general practice, primary care networks and their teams through winter and beyond”, https://www.england.nhs.uk/long-read/supporting-general-practice-primary-care-networks-and-their-teams-through-winter-and-beyond/ (2022); NHSE, “Arrangements for the GP contract in 2024/25”, https://www.england.nhs.uk/long-read/arrangements-for-the-gp-contract-in-2024-25/ (2024).
145 Julian Kelly, Davd Sloman and Mark Cubbon, “Direct commissioning delegation”, https://www.england.nhs.uk/long-read/direct-commissioning-delegation/ (2023).
146 Health and Care Act 2022, “General duties of integrated care boards”, https://www.legislation.gov.uk/ukpga/2022/31/section/25
147 The Health Foundation “NHS Reorganisation Act 1973” https://navigator.health.org.uk/theme/nhs-reorganisation-act-1973
148 UK Parliament Health Committee “Commissioning 1948-2010”, https://publications.parliament.uk/pa/cm200910/cmselect/cmhealth/268/26805.htm (2010); Ruth Robertson et al., “Clinical commissioning: GPs in charge?”, https://www.kingsfund.org.uk/insight-and-analysis/reports/clinical-commissioning-gps-in-charge (2016), Department of Health, “A Short Guide to NHS Foundation Trusts”, https://www.nuffieldtrust.org.uk/sites/default/files/2019-11/foundation.pdf (2003); NHS Confederation, “The legacy of primary care trusts”, https://nhsconfed.org/system/files/2021-07/The_legacy_of_PCTs.pdf (2011); NHSE, “Code of governance for NHS provider trusts”, https://www.england.nhs.uk/long-read/code-of-governance-for-nhs-provider-trusts/ (2023); The Health Foundation, “Primary Care Groups”, https://navigator.health.org.uk/theme/primary-care-groups (2001); David Wilkin et al., “Tackling organisational change in the new NHS”, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC32310/ (2001); NIH “The abolition of the GP fundholding scheme: a lesson in evidence-based policy making.”, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314221/ (2002).
149 NHS Confederation, “The legacy of primary care trusts”, https://nhsconfed.org/system/files/2021-07/The_legacy_of_PCTs.pdf (2011).
150 Ibid.
151 Hett Insights, “What are Clinical Commissioning Groups (CCG’s)?”, https://blog.hettshow.co.uk/what-is-a-clinical-commissioning-group (2024); BMA, “Focus-on: CCG mergers”, https://www.bma.org.uk/media/1983/bma-ccg-merger-guidance-jan-2020.pdf (2019).
152 Functions of primary care trusts. PCT Network, September 2010
153 NHS Confederation “Clinical commissioning groups: transferring the legacy into learning”, https://www.nhsconfed.org/publications/clinical-commissioning-groups (2022)
154 Anna Charles, “Integrated care systems explained”,
https://www.kingsfund.org.uk/insight-and-analysis/long-reads/integrated-care-systems-explained (2022).
155 BMJ, “Will a new NHS structure in England help recovery from the pandemic?”,
https://www.bmj.com/content/372/bmj.n248
156 The Health Foundation “District health authorities (DHAs)” https://navigator.health.org.uk/theme/district-health-authorities-dhas (2024).
157 The Health Foundation, “A review of the effectiveness of primary care-led commissioning and its place in the NHS”, https://www.health.org.uk/sites/default/files/ReviewEffectivenessPrimaryCareLedCommissioningPlaceNHS_summary.pdf (2004).
158 NHS Confederation, “Triumph of hope over experience”,
https://www.nhsconfed.org/system/files/2021-05/Triumph-of-hope-over-experience.pdf (2021).
159 NHS Confederation, “ICS Network’s support for the Hewitt review’s proposals”, https://www.nhsconfed.org/publications/ics-networks-support-hewitt-review-proposals (2023).
160 Annie Bliss and Edward Jones, “The Hewitt review: where are we one year on?”, https://www.nhsconfed.org/long-reads/hewitt-review-where-are-we-one-year (2024).
161 DHSC, “Government response to the HSCC report and the Hewitt Review on integrated care systems”, https://www.gov.uk/government/publications/government-response-to-the-hscc-report-and-the-hewitt-review-on-integrated-care-systems (2023).
162 Edward Jones, Skeena Williamson and Jonathan Barron, “Unlocking reform and financial sustainability: NHS payment mechanisms for the integrated care age”, https://www.nhsconfed.org/publications/unlocking-reform-and-financial-sustainability (2024), NHS Confederation, “Case studies; How local organisations are working in partnership to tackle the biggest challenges facing health and care.”, https://www.nhsconfed.org/topic/campaigns/integration-action/case-studies (2024).
163 National Institute for Health and Care Research, “Multi-Morbidity Predicted to Increase in the UK
over the next 20 Years”, https://evidence.nihr.ac.uk/alert/multi-morbidity-predicted-to-increase-in-the-uk-over-the-next-20-years/ (2018).
164 NHSE, “Surrey partners identify thousands on four or more waiting lists”, https://www.england.nhs.uk/integratedcare/resources/case-studies/surrey-partners-identify-thousands-on-four-or-more-waiting-lists/ (2024).
165 Claire Fuller et al., “Integrating primary care: an inside perspective on the Fuller Stocktake”, https://www.sciencedirect.com/science/article/pii/S2514664524003291 (2023).
166 Claire Fuller et al., “Integrating primary care: an inside perspective on the Fuller Stocktake”, https://www.sciencedirect.com/science/article/pii/S2514664524003291 (2023).
167 These conditions will affect 44% of them in an average seven-day stay; Alison M Mudge et al., “Hospital-associated complications of older people: a proposed multi-component outcome for acute care”, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6367036/ (2019).
168 NHSE, “Warwickshire frailty service keeps half of patients at home after falls”, https://www.england.nhs.uk/integratedcare/resources/case-studies/warwickshire-frailty-service-keeps-half-of-patients-at-home-after-falls/ (2024).
169 Ibid.
170 NHS Confederation, “A community-centred approach to musculoskeletal care”, https://www.nhsconfed.org/case-studies/community-centred-approach-musculoskeletal-care (2023).
171 Ibid.
172 NHSE, “Case study: Collaborative working transforms the lives of people with a learning disability, autism or both in Leicester, Leicestershire and Rutland Integrated Care System” https://www.england.nhs.uk/long-read/case-study-collaborative-working-transforms-the-lives-of-people-with-a-learning-disability-autism-or-both-in-leicester-leicestershire-and-rutland-integrated-care-system/ (2023).
173 Bridget Gorham and Michael Wood, “Unlocking the power of health beyond the hospital: supporting communities to prosper”, https://www.nhsconfed.org/publications/unlocking-power-health-beyond-hospital (2023).
174 SYB QUIT, “Evidence base”, https://sybics-quit.co.uk/healthcare-professionals/evidence-base (2024).
175 SYB Quit, “Latest News”, https://sybics-quit.co.uk/latest-news (2021).
176 SY ICS, “Stop smoking programme helps thousands QUIT in South Yorkshire Hospitals”, https://syics.co.uk/news/latest/stop-smoking-programme-helps-thousands-quit-south-yorkshire-hospitals (2024); SYB QUIT, “Evidence base”, https://sybics-quit.co.uk/healthcare-professionals/evidence-base (2024).
177 ONS, “Total deaths in the UK in 2020 and deaths from heart attacks, heart disease, cancer, and Alzheimer’s and dementia, 2016 to 2020”, https://www.ons.gov.uk/aboutus/transparencyandgovernance/freedomofinformationfoi/totaldeathsintheukin2020anddeathsfromheartattacksheartdiseasecancerandalzheimersanddementia2016to2020 (2021).
178 NHS Greater Manchester, Operational Plan – Draft 2024-2025”, https://democracy.greatermanchester-ca.gov.uk/documents/s31606/Implementing (2024).
179 Nicos Savva, Michael Freeman and Stefan Scholtes Management Science “Economies of Scale and Scope in Hospitals: An Empirical Study of Volume Spillovers” https://pubsonline.informs.org/doi/epdf/10.1287/mnsc.2019.3572 (2019).
180 Nicos Savva, Michael Freeman and Stefan Scholtes Management Science “Economies of Scale and Scope in Hospitals: An Empirical Study of Volume Spillovers” https://pubsonline.informs.org/doi/epdf/10.1287/mnsc.2019.3572 (2019).
181 Management Science “Economies of Scale and Scope in Hospitals: An Empirical Study of Volume Spillovers” https://pubsonline.informs.org/doi/epdf/10.1287/mnsc.2019.3572 (2019).
182 Fulop NJ et al., “Health Services and Delivery Research No. 7.7: Chapter 5; Cost-effectiveness of centralisations of acute stroke care in London and Greater Manchester”, https://www.ncbi.nlm.nih.gov/books/NBK537635/ (2019); Denis Campbell, “NHS needs to close wards and hospitals to centralise care, says doctors’ leader”, https://www.theguardian.com/society/2012/jul/24/nhs-hospitals-need-to-close (2012); UCL, “Centralising acute stroke services has saved more than 400 lives since 2010”, https://www.ucl.ac.uk/ion/news/2013/aug/centralising-acute-stroke-services-has-saved-more-400-lives-2010 (2013).
183 Ibid.
184 UHL, “Trusts appoint new Group Chair”, https://www.leicestershospitals.nhs.uk/aboutus/our-news/press-release-centre/2024/trusts-appoint-new-group-chair/ (2024).
185 North Tees and Hartlepool NHS Foundation Trust, “Group chief executive officer appointed to hospital group”, https://www.nth.nhs.uk/news/single-chief-executive-officer-appointed/ (2024).
186 Unlited Lincolnshire Hospitals NHS Trust, “Appointment of Group chair for two Lincolnshire NHS Trusts”, https://www.ulh.nhs.uk/news/appointment-of-group-chair-for-two-lincolnshire-nhs-trusts/ (2024).
187 Ibid.
188 Kathy Bailes, “Concerns raised following update on hyper acute stroke units in Kent and Medway”, https://theisleofthanetnews.com/2023/10/14/concerns-raised-following-update-on-hyper-acute-stroke-units-in-kent-and-medway/ (2023).
189 NHS Somerset, “Somerset Acute Hospital-Based Stroke Services Reconfiguration – Decision Making Business Case”, https://nhssomerset.nhs.uk/wp-content/uploads/sites/2/Enc-C-Somerset-Acute-Hospital-Based-Stroke-Services-Reconfiguration-%E2%80%93-Decision-Making-Business-Case.pdf (2024).
190 Karl Williams “Is Manchester Greater?”, https://cps.org.uk/wp-content/uploads/2021/09/CPS_IS_MANCHESTER_GREATER.pdf (2021).
191 Competition and Markets Authority, “Press release: Manchester hospitals merger cleared by CMA”, https://www.gov.uk/government/news/manchester-hospitals-merger-cleared-by-cma (2017).
192 Catherine Perry et al., ““Attending to History” in Major System Change in Healthcare in England: Specialist Cancer Surgery Service Reconfiguration”, https://www.ijhpm.com/article_4226.html (2022).
193 Fulop NJ et al., “Health Services and Delivery Research No. 7.7: Chapter 5; Cost-effectiveness of centralisations of acute stroke care in London and Greater Manchester”, https://www.ncbi.nlm.nih.gov/books/NBK537635/ (2019)
194 Victoria Binks “Reducing paediatric surgery waiting lists”, https://www.nhsconfed.org/case-studies/reducing-paediatric-surgery-waiting-lists (2022).
195 Ibid.
196 Rt Hon Patricia Hewitt, “The Hewitt Review”, https://assets.publishing.service.gov.uk/media/642b07d87de82b00123134fa/the-hewitt-review.pdf (2023).
197 Henry Anderson, “Exclusive: £1bn raid on capital budget to cover pay rises and strike costs”, https://www.hsj.co.uk/finance-and-efficiency/exclusive-1bn-raid-on-capital-budget-to-cover-pay-rises-and-strike-costs/7036668.article (2024).
198 Nuffield Trust, “Where does the NHS money go?”, https://www.nuffieldtrust.org.uk/resource/where-does-the-nhs-money-go (2024).
199 Nuffield Trust, “Where does the NHS money go?”, https://www.nuffieldtrust.org.uk/resource/where-does-the-nhs-money-go (2024).
200 Wes Streeting, “NHS: Expenditure; Question for Department of Health and Social Care”, https://questions-statements.parliament.uk/written-questions/detail/2023-11-17/2419 (2023).
201 NHSE, “Investment in General Practice in England, 2017/18 to 2021/22”, https://www.england.nhs.uk/publication/investment-in-general-practice-in-england-17-18-to-21-22/ (2023).
202 NHSE, “NHS Payments to General Practice, England 2022/23”, https://digital.nhs.uk/data-and-information/publications/statistical/nhs-payments-to-general-practice/england-2022-23 (2024).
203 NHSE, “NHS Payments to General Practice, England 2022/23”, https://digital.nhs.uk/data-and-information/publications/statistical/nhs-payments-to-general-practice/england-2022-23 (2023).
204 Grant Thornton, “NHS hospital finances – the increasing challenges”, https://www.grantthornton.co.uk/insights/nhs-hospital-finances–the-increasing-challenges/ (2023).
205 BMA, “Models for paying providers of NHS services”, https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/funding/models-for-paying-providers-of-nhs-services (2024).
206 John Appleby et al., “Payment by Results How can payment systems help to deliver better care?”, https://assets.kingsfund.org.uk/f/256914/x/a024b91a9b/payment_by_results_report_november_2012.pdf (2012).
207 BMA, “Enhanced services GP practices can seek funding for”, https://www.bma.org.uk/advice-and-support/gp-practices/gp-service-provision/enhanced-services-gp-practices-can-seek-funding-for (2024); NHSE, “Investment in General Practice in England, 2017/18 to 2021/22”, https://www.england.nhs.uk/publication/investment-in-general-practice-in-england-17-18-to-21-22/ (2023).
208 Helen Parker, “Making the Shift: A Review of NHS Experience”, https://web.archive.org/web/20070721042308/http://www.hsmc.bham.ac.uk/news/MakingtheShift6881.pdf (2006).
209 NHSE “Health Education England and NHS England Complete Merger” https://www.england.nhs.uk/2023/04/health-education-england-and-nhs-england-complete-merger/ (2023).
210 Healthcare Leader, “Exclusive: More than 1,250 people quit ICB job since July”, https://healthcareleadernews.com/news/exclusive-more-than-1250-people-quit-icb-job-since-july/ (2023).
211 IfG, “Performance Tracker 2023: Hospitals” https://www.instituteforgovernment.org.uk/sites/default/files/2024-01/performance-tracker-2023.pdf (2024); NHS Confederation, “Is the NHS overmanaged?”, https://www.nhsconfed.org/long-reads/nhs-overmanaged (2022).
212 Siva Anandaciva, “How does the NHS compare to the health care systems of other countries?”, https://www.kingsfund.org.uk/insight-and-analysis/reports/nhs-compare-health-care-systems-other-countries (2023).
213 Lord Darzi, “Independent Investigation of the National Health Service in England: Technical Annex”, “https://assets.publishing.service.gov.uk/media/66e1b517dd4e6b59f0cb2553/Independent-Investigation-of-the-National-Health-Service-in-England-Technical-Annex.pdf”
214 Lord Darzi, “Independent Investigation of the National Health Service in England”, https://assets.publishing.service.gov.uk/media/66f42ae630536cb92748271f/Lord-Darzi-Independent-Investigation-of-the-National-Health-Service-in-England-Updated-25-September.pdf (2024).
215 Bevan et al., “The four health systems of the United Kingdom: how do they compare”, https://www.nuffieldtrust.org.uk/sites/default/files/2017-01/4-countries-report-web-final.pdf (2014).
216 Institute for Government, “Devolution and the NHS”, https://www.instituteforgovernment.org.uk/explainer/devolution-and-nhs (2020); Judith Smith et al., “A review of the effectiveness of primary care-led commissioning and its place in the NHS”, https://www.health.org.uk/sites/default/files/ReviewEffectivenessPrimaryCareLedCommissioningPlaceNHS_summary.pdf (2004).
217 Welsh Government, “NHS Wales health boards and trusts”, https://www.gov.wales/nhs-wales-health-boards-and-trusts (2023)
218 Aneurin Bevan University Health Board, “The Health Board”, https://abuhb.nhs.wales/about-us/the-health-board/ (2024).
219 Kings Fund, “The first days of statutory integrated care systems”
https://www.kingsfund.org.uk/insight-and-analysis/long-reads/first-days-statutory-integrated-care-systems
220 NHSE, “NHS Oversight Framework”, https://www.england.nhs.uk/nhs-oversight-framework/ (2024); NHSE, “NHS Oversight Framework”, https://www.england.nhs.uk/wp-content/uploads/2022/06/B1378_NHS-System-Oversight-Framework-22-23_260722.pdf (2022).
221 Ibid.
222 NHSE, “NHS Oversight Framework”, https://www.england.nhs.uk/nhs-oversight-framework/ (2024); NHSE, “Priorities and operational planning guidance 2024/25”, https://www.england.nhs.uk/publication/priorities-and-operational-planning-guidance-2024-25/ (2024).
223 NHSE, “NHS Outcomes Framework Indicators, April 2024 release”, https://digital.nhs.uk/data-and-information/publications/statistical/nhs-outcomes-framework/april-2024 (2024); Rachel Cooper, “New and improved, or is it? – The CQC’s Single Assessment Framework”, https://cms-lawnow.com/en/ealerts/2024/04/new-and-improved-or-is-it-the-cqc-s-single-assessment-framework (2024).
224 NHS Confederation, “Streeting should empower ICSs, not undermine them”, https://www.nhsconfed.org/articles/streeting-should-empower-icss-not-undermine-them (2024).
225 Wes Streeting SoS Health and Social Care, “Speech to Future of Britain conference 09-07-2024”, https://www.youtube.com/watch?v=Jpxc0ZMoy8E&ab_channel=GuardianNews (2024).
226 NHS Confederation, “Building the health of the nation: priorities for a new government”, https://www.nhsconfed.org/publications/building-health-nation-priorities-new-government (2024).
227 UK government, “Health and Social Care Act 2022”, https://www.legislation.gov.uk/ukpga/2022/31/contents (2022); Helathcare Leader, “ICBs to lead Labour’s primary care reform”, https://healthcareleadernews.com/integrated-care-boards/icbs-to-lead-labours-primary-care-reform/ (2023).
228 NHS England, “The NHS Long Term Plan”, https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf (2019).
229 https://healthcareleadernews.com/integrated-care-boards/icbs-to-lead-labours-primary-care-reform/ NHS Confederation, “Streeting should empower ICSs, not undermine them”, https://www.nhsconfed.org/articles/streeting-should-empower-icss-not-undermine-them (2024).
230 DfE, “Written evidence submitted by the Department for Education”, https://committees.parliament.uk/writtenevidence/47509/html/ (2013).
231 Simon Burgess, “What can the UK learn from the latest global data on pupil performance?”, https://www.economicsobservatory.com/what-can-the-uk-learn-from-the-latest-global-data-on-pupil-performance#:~:text=The%20UK’s%20position%20remains%20strong,reading%20and%20stable%20in%20maths. (2023); Andrew Eyles & Stephen Machin, “The Introduction of Academy Schools to England’s Education”, https://academic.oup.com/jeea/article/17/4/1107/5049125#140501184 (2019).
232 NHS Confederation, “Building the health of the nation: priorities for a new government”, https://www.nhsconfed.org/publications/building-health-nation-priorities-new-government (2024).
233 NHS Confederation, “Lack of capital funding risking patient safety and waiting list recovery”, https://www.nhsconfed.org/news/lack-capital-funding-risking-patient-safety-and-waiting-list-recovery (2024).
234 Beccy Baird et al., “Making care closer to home a reality”, https://assets.kingsfund.org.uk/f/256914/x/ab65341d7a/making_care_closer_home_reality_report_2024.pdf (2024)
235 Edward Jones, Skeena Williamson and Jonathan Barron, “Unlocking reform and financial sustainability: NHS payment mechanisms for the integrated care age”, https://www.nhsconfed.org/publications/unlocking-reform-and-financial-sustainability (2024).
236 NHSE, “National Patient and Staff Surveys”, https://www.england.nhs.uk/statistics/statistical-work-areas/patient-surveys/ (2024).
237 NHSE, “Data platform frequently asked questions”, https://www.england.nhs.uk/digitaltechnology/nhs-federated-data-platform/fdp-faqs/#can-a-patient-access-their-own-data (2024).
238 Sam Trendall, “NHS signs £10m deal to support rollout of Palantir data platform”, https://www.publictechnology.net/2024/04/15/health-and-social-care/nhs-signs-10m-deal-to-support-rollout-of-palantir-data-platform/ (2024).
239 Norman Warner, “The NHS: Decline and fall, or resurrection?”, https://www.smf.co.uk/wp-content/uploads/2022/07/The-NHS-Decline-and-fall-or-resurrection-July-2022.pdf (2022).
240 DHSC, “Independent Reconfiguration Panel: Frequently asked questions”, https://www.gov.uk/government/publications/independent-reconfiguration-panel-frequently-asked-questions/independent-reconfiguration-panel-frequently-asked-questions (2024).
241 DHSC, “Reconfiguring NHS services – ministerial intervention powers”, https://www.gov.uk/government/publications/reconfiguring-nhs-services-ministerial-intervention-powers/reconfiguring-nhs-services-ministerial-intervention-powers#fn:2 (2024).
242 Hayley Kirton, “Ministers sitting on 26 requests to intervene in service reconfigurations”, https://www.hsj.co.uk/service-redesign/ministers-sitting-on-26-requests-to-intervene-in-service-reconfigurations/7037366.article (2024).
243 NHSE, “NHS Oversight Framework”, https://www.england.nhs.uk/nhs-oversight-framework/ (2024).
244 Nick Carding, “Joint ICB/trust committee given binding powers to improve system’s care quality”, https://www.hsj.co.uk/policy-and-regulation/joint-icb/trust-committee-given-binding-powers-to-improve-systems-care-quality/7037077.article (2024).