ICBs can't afford to carry the leftovers

Simon Hall draws on his advisory work with multiple ICBs to identify what must move, what must stop — and why April 2026 is a leadership moment for ICBs, not an admin exercise

Integrated care boards are approaching April 2026 at a critical point in their evolution. While this date is often described as a technical milestone — mergers completed, operating models adjusted, running cost envelopes tightened — the work we are doing with ICBs across England suggests something much more fundamental is at stake.

This is not simply a restructuring exercise. It is a test of whether ICBs can become what national policy is now asking them to be: lean, strategic commissioners focused on outcomes, value and population health, rather than residual system operators carrying inherited functions that no longer fit.

Without deliberate leadership, ICBs risk becoming organisational ‘catch-alls’: absorbing responsibilities that regions, providers and national teams are not yet ready to take, while being expected to operate on shrinking budgets.

That trajectory is neither sustainable nor inevitable.

The direction of travel is clear — delivery now needs to catch up

The Model ICB Blueprint and emerging post-2026 guidance are consistent on one point: the 2022 ICS operating model is not viable in the medium term. ICBs are expected to narrow their focus and strengthen their strategic commissioning role.

In practical terms, that means prioritising:

• commissioning intent and investment decisions
• contract and market shaping
• pathway design through incentives and specifications
• outcomes, value and inequality reduction
• assurance through commissioning levers — not operational control.

Across many systems, however, ICBs are still carrying functions that sit uncomfortably with this future role. In most cases this happens quietly, through ‘temporary’ arrangements that gradually become permanent.

April 2026 is therefore less about completing a timetable and more about making deliberate choices.

What should move up — and stay there

Some functions are explicitly designed to migrate to regions and national infrastructure over time. These should not be quietly retained inside ICBs for convenience or continuity.

This includes:

• provider performance management and regulatory oversight
• system-level EPRR coordination and command centres
• strategic workforce planning and education infrastructure
• research, innovation and spread functions
• large-scale analytics and national data platforms.

ICBs should retain strong commissioning and contract management capability. Regional performance infrastructure, however, is not an ICB function in the new model.

There is also a financial dimension to this shift. These functions should sit outside the ICB running cost envelope. If they are absorbed locally ‘just to keep things moving’, the £19.40 per head allowance becomes unworkable before it has even had time to stabilise.

What must move down if neighbourhood delivery is to become real

At the delivery end of the system, the shift towards neighbourhood health models must translate into structural change, not just policy language.

Over time, ICBs should be stepping away from direct responsibility for:

• primary care operational management and transformation delivery
• medicines optimisation delivery
• pathway redesign programmes
• local workforce development activity
• green plan and sustainability delivery
• digital transformation delivery
• estates and infrastructure programme management
• place and neighbourhood partnership development.

The ICB role should become strategic: setting direction, shaping incentives and holding delivery partners to account.

Where ICBs continue to operate as programme delivery hubs because ‘the system is not ready yet’, neighbourhood models struggle to mature and strategic commissioning remains underdeveloped.

Do not wait for legislation to change behaviour

Some functions formally require legislation to move permanently. Operating models, however, do not need to wait for statute to evolve.

Across several systems there is growing scope to test lead-provider and delegated arrangements ahead of legislative change in areas such as:

• continuing healthcare
• safeguarding leadership
• infection prevention and control coordination
• SEND commissioning functions
• general practice IT support.

This approach is not about bypassing accountability. It is about preparing the operating model in a way that avoids another prolonged period of transitional arrangements quietly becoming business as usual.

The £19.40 question — and the grey-zone risk

Running cost envelopes will shape organisational behaviour whether leaders welcome them or not. What remains less clear nationally is how responsibilities are handled when regions are not operationally ready to absorb transferred functions.

This creates a growing grey zone risk, including:

• dual-badged performance staff
• EPRR coordination roles hosted locally
• workforce programme management teams
• temporary regional shadow arrangements.

If ICBs absorb these costs to avoid disruption, they undermine their own financial sustainability and strategic capacity.

Boards and executive teams therefore need to be more assertive. Where a function is regional in design, it must be funded regionally — even if interim hosting arrangements are required.

This is not about resisting change. It is about protecting the operating model that national policy itself is trying to establish.

What leadership looks like in the next phase

From our current work with multiple ICBs, one theme is emerging clearly: success in the next phase will not come from bigger structures or additional layers of governance.

It will come from leadership that is prepared to:

• draw firm boundaries around what the ICB will and will not carry
• design clear exit routes for transitional functions
• invest in commissioning capability rather than programme bureaucracy
• align assurance to outcomes and value, not activity volume
• hold the line on running cost discipline.

For non-executive directors in particular, this is a defining governance moment. The core question is not simply whether the organisation is coping with pressure. It is whether it is shrinking in the right places and strengthening in the right ones.

A closing challenge

Merging ICBs will create scale. Scale alone, however, does not create clarity.

April 2026 offers a rare opportunity to reset what ICBs are actually for. The greatest risk is not disruption. It is inertia.

If ICBs do not actively choose what to let go of, they will continue carrying responsibilities that no longer fit, on budgets that no longer support them, within a model that was never designed to work that way.

Strategic commissioning only works when ICBs are allowed to become genuinely strategic.

That requires deliberate choices, firm boundaries — and leadership prepared to say no.

About the author

Simon Hall is a principal consultant at GGi. He works with integrated care boards, NHS providers and system partners across England on governance design, operating models and board effectiveness.