Is now the time for The Insightful ICB Board?

Principal consultant Simon Hall says NHSE's 2024 document might just save integrated care

Integrated care boards (ICBs) were never going to have it easy. Conceived in the wake of a global pandemic, established amid financial constraint, and expected to drive transformation while the system around them faces deep structural pressures—these organisations have had a tough start in life.

Now, as they approach their third year, ICBs are being asked to do even more with less. The requirement for a 50% reduction in ICB running costs has accompanied the announcement of the abolition of NHS England and the changes that will inevitably mean to how ICBs will operate in the future.

This has prompted boards across the country to look again at their structures, their functions and, most of all, their core purpose. Against this backdrop, it would be easy to retreat into survival mode—focusing only on compliance, finance, and the immediate firefighting of performance issues. In my view, that would be a huge mistake.

Paradoxically, experience teaches us that it’s precisely at moments like this—when the pressure is greatest and the stakes are highest—that governance matters most. It’s therefore in this context that the November 2024 NHS England publication The Insightful ICB Board might now be most useful.

A timely framework for tough times

The Insightful ICB Board sets out a framework for assessing whether the information boards receive is sufficiently insightful to support good decision-making. In practice, however, it’s much more than that. The publication presents a maturity model for ICB governance—one that connects data, assurance and leadership culture to the actual outcomes ICBs are expected to deliver.

It organises this thinking around six domains: vision and purpose, strategy and planning, delivery, population health, governance, and leadership. Each is supported by structured lines of enquiry, intended not as a checklist but as a guide for boards to test their own effectiveness. Importantly, the guidance acknowledges the wide variation in scale, complexity and maturity across systems and invites adaptation rather than prescription.

At a time when some ICBs are being forced to make hard choices about which functions they can afford to keep, the framework provides a way to do that strategically. It can be used to help boards focus on what is essential, not just what is urgent.

Being bold: turning insight into impact

If the insightful board is to make a difference, though, it must be more than a document as a footnote. The ICBs that get the most from it will be those that use it to shape their operating model at this time of uncertainty, to be bold in redesigning governance structures, and build a culture of curiosity, challenge, and learning.

Over the past year, GGI has worked with several ICBs to translate the principles of the insightful board into practical tools. This has included committee redesigns that reduce duplication, clarify lines of accountability and align assurance with strategy. It has also involved redefining how programme management and system partnerships support board decision-making.

Some of the most effective approaches we’ve seen include:

• fewer, better-focused committees that distinguish clearly between assurance and transformation
• integrated programme oversight that draws on system partners, clinical leaders, and frontline insight
• stronger audit and risk functions, borrowing techniques from other sectors such as education
• board development plans that link member roles and performance to the domains of the insightful board.

This isn’t about bureaucracy, it’s about ensuring that boards of ICBs are properly equipped to meet the incredibly complex challenge of leading health and care systems.

The wider context: cuts, complexity, and clarity

Many observers of the health and care system have characterised the cost savings being imposed on ICBs as ‘a blow’ to integrated care. The scale of the cuts risks undermining the very system leadership capacity that ICBs were created to provide. There may be unintended consequences of ICBs being absorbed into provider collaboratives, being randomly merged to cover larger areas, or reverted into purely commissioning bodies by another name.

There is, though, huge opportunity at this time. There are important questions that need to be asked: what should ICBs actually do? What makes a good ICB, and how will we know? How might refreshed ICBs fit within a wider public sector that is also undergoing reform and reorganisation?

This is where the insightful board guidance helps. It doesn’t claim to provide all the answers, but it does give a clear articulation of what good looks like. It provides a compass to navigate the competing pressures of regulation, partnership, finance, and public accountability. Moreover, it encourages boards to be honest with themselves about where they are now and what they need to change.

A test of leadership

Ultimately, any value that The Insightful ICB Board can have will be determined not by how well it is understood but by how it is used.

Used well, it can help boards refocus on purpose and outcomes, even amid cuts and crises. It can support leaders to stay strategic in the face of operational pressures. And it can guide the simplification of committee structures, clarify the role of assurance, and reconnect the board to the voices of patients, staff, and partners.

However, this will take courage. Courage to simplify structures that are cluttered. Courage to invest in board development when budgets are tight. Courage to ask difficult questions – not just of others, but of the boards themselves.

In many ways, The Insightful ICB Board is less a checklist than a challenge. A challenge to ICBs to become the boards they were always meant to be: insightful, inclusive, and impact driven.

If ICBs can rise to that challenge, then perhaps the tough times ahead might just sharpen, rather than blunt, the promise of integrated care.