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Integrated care system
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In England, an integrated care system (ICS) is a statutory partnership of organisations who plan, buy, and provide health and care services in their geographical area.

The organisations involved include the NHS, local authorities, voluntary and charity groups, and independent care providers. The NHS Long Term Plan of January 2019 called for the whole of England to be covered by ICSs by April 2021. On 1 July 2022, ICSs – by then 42 in number – replaced clinical commissioning groups in England.

Statutory bodies

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The Health and Care Act 2022 put these systems on a statutory basis, each with an approved constitution. On 1 July 2022, a total of 42 ICSs became statutory. There are more than 70 performance metrics by which they are judged, grouped into six "oversight themes": quality, access and outcomes, preventing ill health and reducing inequalities, leadership, people, and finances. The poorest performers will be put in a "recovery support programme", which will replace the label of special measures.[1] Each system is to set their own constitution, determine staff pay and can raise "additional income" but the chair must be approved by the Secretary of State for Health and Social Care.[2]

The areas covered by each ICS vary considerably by population and demographics. Population size ranges from 500,000 to more than 3 million people. Some have more than 10 upper-tier local authorities and some only one. Nearly 50% of the neighbourhoods in Birmingham and Solihull are in the most deprived fifth of the neighbourhoods nationally, compared to 1% in Surrey Heartlands.[3]

Governance

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NHS England produced a model constitution in July 2021, which systems are expected to use when developing their own arrangements. Each ICS must have an integrated care board with at least five executive directors and three non-executives.[4]

Integrated care partnership

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The boards must work with local authorities to create an integrated care partnership (ICP) committee for each system, to include local organisations such as the voluntary sector and social enterprises.[5][4] The ICP works on prevention, wider social and economic factors affecting health, and reducing health inequalities.[5]

Pharmacy

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Each ICS is to have a community pharmacy clinical lead, funded by the Pharmacy Integration Programme for the first two years.[6]

History

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The first accountable care systems (2017)

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Eight sustainability and transformation plan areas in England were named in June 2017 by Simon Stevens, chief executive of NHS England, as a first wave in the development of what were then called accountable care systems. He said they "will bring together providers and commissioners to help break down barriers between primary, secondary and social care". They would be given up to £450 million between them in transformation funding over the next 4 years. The eight were:[7]

Greater Manchester was not included because it already had more advanced arrangements under its 2015 "devolution" deal.[8] Surrey Heartlands began a similar arrangement in 2018.[9][10]

In each area a provider or, more usually, an alliance of providers was to collaborate to meet the needs of a defined population with a budget determined by capitation. There was to be a contract specifying the outcomes and other objectives they were required to achieve within the given budget over a period of time. This might extend well beyond health and social care services to encompass public health and other services. In Manchester, the objectives were specified over ten years. Keeping people out of hospital by moving services into the community was a common feature. NHS trusts, clinical commissioning groups and local authorities in the new ACSs were to "take on clear collective responsibility for resources and population health".[11]

The process was denounced by John Sinnott, Chief Executive of Leicestershire County Council in September 2017 as lacking any element of public accountability. He said that existing models in other countries were interesting but not relevant to democratic accountabilities in the UK since they had different governance structures and forms of service provision.[12]

It was proposed that systems employing general practitioners would have to meet the costs of their indemnity insurance.[13]

In September 2017 NHS England produced a handbook designed to support the creation of new payment models which were intended to remove the direct relationship between NHS activity and payment, improve the alignment of payment for all providers within the care model and better incentivise prevention and wellbeing.[14]

Integrated care systems (2018–2025)

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In February 2018 it was announced that these organisations were in future to be called integrated care systems, and that all 44 sustainability and transformation plans would be expected to progress in this direction.[15] In May 2018 the ten pioneer systems were described by the Health Select Committee as nascent and fragile.[16] Also in 2018 they were described by Chris Ham as "coalitions of the willing". He said that real progress had only happened in places where there was a history of collaborative working. He also commented that there was little guidance and so more latitude than is usually the case with national NHS initiatives.[17]

In January 2019 it was announced in the NHS Long Term Plan that by April 2021 integrated care systems were to cover the whole of England, with a single clinical commissioning group for each area. Each one was to be run by a partnership board with members from commissioners, trusts, and primary care.[18] But it has been suggested that "All ICSs are structured differently as there is no fixed model for how they should be developed; and the leadership is defined in terms of roles and agents, with little to guide leadership practices and behaviours in a complex, collaborative governance arrangement."[19]

Three more areas were designated in June 2019,[20] and four more in May 2020 (Hertfordshire and West Essex, Humber, Coast and Vale, South West London, and Sussex), bringing the total to 18.[21]

In March 2021, nineteen NHS minority ethnic leaders demanded that the executive officers (not just the non-executives) in the 42 emerging ICSs should be representative of the ethnic diversity in their communities. They wanted to see ethnic diversity and inclusion a part of every NHS board's core business and said every system should develop a 10-year strategy, with annual milestones, for reducing inequalities.[22] By July 2021, chairs had been appointed for 25 of the 42 NHS integrated care boards. 11 were women, and five had a minority ethnic background. The chairs must not be councillors or MPs, or work for any of their ICS's constituent organisations.[23]

Mergers and cuts (2025– )

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In April 2025, integrated care boards were told to reduce their running costs by 50%, beginning in the third quarter of the year; it was reported that a likely response would be mergers which could reduce the number of systems to around 15.[24] Following this, several ICBs entered into "clustering" arrangements, in which two or more boards shared teams, committees, and senior leadership.[25] The first formal mergers of ICBs were announced in September 2025, to come into effect from 1 April 2026, with the intention of a further round of mergers in April 2027.[26]

Integrated care providers

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In August 2018 NHS England launched a consultation on the draft contracts for what were then called integrated care providers (ICPs), following the failure of two legal challenges to an earlier draft contract. The consultation said that this was not a new type of legal entity, but merely the "provider organisation which is awarded a contract by commissioners for the services which are within scope." Dudley clinical commissioning group was at the forefront of this exercise and was to implement the draft voluntary contract, subject to the outcome of this consultation exercise. It was proposed that general practitioners would be able to sign fully or partially integrated contracts, and that fully integrated practices would give up their existing contracts to become salaried.[27]

Evaluation

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A report from the Nuffield Trust in December 2021 found that there was very little evidence that integration policies across the UK – including pooling budgets and creating new integrated boards and committees – had dramatically improved patient experience, quality of services or supported the delivery of more care outside of hospitals. They warned that without concurrent investment in social care and broader public services, it was “very likely” further reforms would not yield the desired results.[28]

Integrated Care Boards

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On 1 July 2022 NHS England established 42 integrated care boards, covering the whole of England.[29] From March 2025, several ICBs entered "clustering" arrangements. Seven of these clusters are expected to formally merge into new ICBs from 1 April 2026.[30]

Region Name Local authority areas covered Cluster[31][32] Merged ICB (from 1 April 2026)
East of England NHS Bedfordshire, Luton and Milton Keynes Integrated Care Board Bedford, Central Bedfordshire, Luton, Milton Keynes, and part of Buckinghamshire Bedfordshire, Luton and Milton Keynes ICB; Cambridgeshire and Peterborough ICB; Hertfordshire and West Essex ICB NHS Central East ICB
NHS Cambridgeshire and Peterborough Integrated Care Board Cambridge, East Cambridgeshire, Fenland, Huntingdonshire, Peterborough, South Cambridgeshire, and part of North Hertfordshire
NHS Hertfordshire and West Essex Integrated Care Board Broxbourne, Dacorum, East Hertfordshire, Epping Forest, Harlow, Hertsmere, St Albans, Stevenage, Three Rivers, Uttlesford, Watford, Welwyn Hatfield, and part of North Hertfordshire
NHS Essex ICB

(Former Mid and South Essex ICB, plus the Essex parts of Herts & West Essex and Suffolk & North East Essex ICBs)

NHS Mid and South Essex Integrated Care Board Basildon, Braintree, Brentwood, Castle Point, Chelmsford, Maldon, Rochford, Southend-on-Sea, and Thurrock -
NHS Suffolk and North East Essex Integrated Care Board Babergh, Colchester, Ipswich, Mid Suffolk, Tendring, West Suffolk, and part of East Suffolk Norfolk and Waveney ICB; Suffolk and North East Essex ICB
NHS Norfolk and Suffolk ICB
NHS Norfolk and Waveney Integrated Care Board Breckland, Broadland, Great Yarmouth, King's Lynn and West Norfolk, North Norfolk, Norwich, South Norfolk, and part of East Suffolk
London NHS North Central London Integrated Care Board Barnet, Camden, Enfield, Haringey, and Islington North Central London ICB; North West London ICB NHS West and North London ICB
NHS North West London Integrated Care Board Brent, Ealing, Hammersmith and Fulham, Harrow, Hillingdon, Hounslow, Kensington and Chelsea, and the City of Westminster
NHS North East London Integrated Care Board Barking and Dagenham, City of London, Hackney, Havering, Newham, Redbridge, Tower Hamlets, and Waltham Forest - -
NHS South East London Integrated Care Board Bexley, Bromley, Greenwich, Lambeth, Lewisham, and Southwark - -
NHS South West London Integrated Care Board Croydon, Kingston upon Thames, Merton, Richmond upon Thames, Sutton, and Wandsworth - -
Midlands NHS Birmingham and Solihull Integrated Care Board Birmingham and Solihull Birmingham and Solihull ICB; Black Country ICB -
NHS Black Country Integrated Care Board Dudley, Sandwell, Walsall, and Wolverhampton
NHS Coventry and Warwickshire Integrated Care Board Coventry, North Warwickshire, Nuneaton and Bedworth, Rugby, Stratford-on-Avon, and Warwick Coventry and Warwickshire ICB; Herefordshire and Worcestershire ICB -
NHS Herefordshire and Worcestershire Integrated Care Board Bromsgrove, Herefordshire, Malvern Hills, Redditch, Worcester, Wychavon, and Wyre Forest
NHS Derby and Derbyshire Integrated Care Board Amber Valley, Bolsover, Chesterfield, Derby, Derbyshire Dales, Erewash, High Peak, North East Derbyshire, and South Derbyshire Derby and Derbyshire ICB; Lincolnshire ICB; Nottingham and Nottinghamshire ICB -
NHS Lincolnshire Integrated Care Board Boston, East Lindsey, Lincoln, North Kesteven, South Holland, South Kesteven, and West Lindsey
NHS Nottingham and Nottinghamshire Integrated Care Board Ashfield, Bassetlaw, Broxtowe, Gedling, Mansfield, Newark and Sherwood, Nottingham, and Rushcliffe
NHS Leicester, Leicestershire and Rutland Integrated Care Board Blaby, Charnwood, Harborough, Hinckley and Bosworth, Leicester, Melton, North West Leicestershire, Oadby and Wigston, and Rutland Leicester, Leicestershire and Rutland ICB; Northamptonshire ICB -
NHS Northamptonshire Integrated Care Board North Northamptonshire and West Northamptonshire
NHS Shropshire, Telford and Wrekin Integrated Care Board Shropshire and Telford and Wrekin Shropshire, Telford and Wrekin ICB; Staffordshire and Stoke-on-Trent ICB -
NHS Staffordshire and Stoke-on-Trent Integrated Care Board Cannock Chase, East Staffordshire, Lichfield, Newcastle-Under-Lyme, South Staffordshire, Stafford, Staffordshire Moorlands, Stoke-on-Trent, and Tamworth, Staffordshire
North East NHS Humber and North Yorkshire Integrated Care Board East Riding of Yorkshire, Hambleton, Harrogate, Kingston upon Hull, North East Lincolnshire, North Lincolnshire, Richmondshire, Ryedale, Scarborough, Selby, and York - -
NHS North East and North Cumbria Integrated Care Board Allerdale, Carlisle, Durham, Darlington, Eden, Gateshead, Hartlepool, Middlesbrough, Newcastle-upon-Tyne, North Tyneside, Northumberland, Redcar and Cleveland, South Tyneside, Stockton-on-Tees, Sunderland, and part of Copeland - -
NHS South Yorkshire Integrated Care Board Barnsley, Doncaster, Rotherham, and Sheffield - -
NHS West Yorkshire Integrated Care Board Bradford, Calderdale, Kirklees, Leeds, Wakefield, and part of Craven - -
North West NHS Cheshire and Merseyside Integrated Care Board Cheshire East, Cheshire West and Chester, Halton, Knowsley, Liverpool, Sefton, St Helens, Warrington, and Wirral - -
NHS Greater Manchester Integrated Care Board Bolton, Bury, Manchester, Oldham, Rochdale, Salford, Stockport, Tameside, Trafford, and Wigan - -
NHS Lancashire and South Cumbria Integrated Care Board Barrow-in-Furness, Blackburn with Darwen, Blackpool, Burnley, Chorley, Fylde, Hyndburn, Lancaster, Pendle, Preston, Ribble Valley, Rossendale, South Lakeland, South Ribble, West Lancashire, Wyre, part of Copeland, and part of Craven - -
South East NHS Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board Cherwell, Oxford, Reading, South Oxfordshire, West Berkshire, West Oxfordshire, Wokingham, part of Buckinghamshire, and part of the Vale of White Horse Buckinghamshire, Oxfordshire and Berkshire West ICB; Frimley ICB NHS Thames Valley ICB

(Former Bucks, Oxon and Berks West ICB, plus Berks East from the former Frimley ICB)

NHS Frimley Integrated Care Board Bracknell Forest, Rushmoor, Slough, Windsor and Maidenhead, part of Hart, part of Surrey Heath, part of Guildford, part of Runnymede, and part of Waverley
→ Surrey wards to join new Surrey and Sussex ICB
NHS Hampshire and Isle of Wight ICB

(As before, with the addition of Hampshire wards from Frimley ICB)

NHS Hampshire and Isle of Wight Integrated Care Board Basingstoke and Deane, East Hampshire, Eastleigh, Fareham, Gosport, Havant, the Isle of Wight, New Forest, Portsmouth, Southampton, Test Valley, Winchester, and part of Hart -
NHS Kent and Medway Integrated Care Board Ashford, Canterbury, Dartford, Dover, Folkestone and Hythe, Gravesham, Maidstone, Medway, Sevenoaks, Swale, Thanet, Tonbridge and Malling, and Tunbridge Wells - -
NHS Surrey Heartlands Integrated Care Board Elmbridge, Epsom and Ewell, Mole Valley, Reigate and Banstead, Spelthorne, Tandridge, Woking, part of Guildford, part of Runnymede, part of Chichester, part of Surrey Heath, and part of Waverley Surrey Heartlands ICB; Sussex ICB NHS Surrey and Sussex ICB

(Surrey and Sussex ICBs, plus Surrey wards from the former Frimley ICB)

NHS Sussex Integrated Care Board Adur, Arun, Brighton and Hove, Crawley, Eastbourne, Hastings, Horsham, Lewes, Mid Sussex, Rother, Wealden, Worthing, and part of Chichester
South West NHS Bath and North East Somerset, Swindon and Wiltshire Integrated Care Board Bath and North East Somerset, Swindon, Wiltshire, and part of the Vale of White Horse Bath and North East Somerset, Swindon and Wiltshire ICB; Dorset ICB; Somerset ICB -
NHS Dorset Integrated Care Board Bournemouth, Christchurch and Poole, and Dorset
NHS Somerset Integrated Care Board Mendip, Sedgemoor, Somerset West and Taunton, and South Somerset
NHS Bristol, North Somerset and South Gloucestershire Integrated Care Board Bristol, North Somerset, and South Gloucestershire Bristol, North Somerset and South Gloucestershire ICB; Gloucestershire ICB -
NHS Gloucestershire Integrated Care Board Cheltenham, Cotswold, Forest of Dean, Gloucester, Stroud, and Tewkesbury
NHS Cornwall and The Isles of Scilly Integrated Care Board Cornwall and the Isles of Scilly Cornwall and Isles of Scilly ICB; Devon ICB -
NHS Devon Integrated Care Board East Devon, Exeter, Mid Devon, North Devon, Plymouth, South Hams, Teignbridge, Torbay, Torridge, and West Devon

References

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Integrated care system

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The Integrated care system (ICS) refers to the statutory partnerships established across under the Health and Care Act 2022 to coordinate the planning, funding, and delivery of health and social care services for defined populations typically ranging from 1 to 3 million people, encompassing 42 such systems that cover the entire country and integrate NHS providers, , voluntary organizations, and other stakeholders to address fragmented care delivery. Evolving from earlier voluntary Sustainability and Transformation Partnerships introduced in 2016, ICSs formalized a shift toward population-based commissioning via accountable Integrated Care Boards (ICBs), which hold statutory duties for and service oversight, alongside broader Integrated Care Partnerships focused on strategic collaboration. Their core objectives emphasize preventive care, reduced hospital reliance, tackling health disparities driven by socioeconomic factors, and boosting system productivity amid rising demand. While ICSs have enabled localized initiatives, such as enhanced autism service pathways through multi-agency efforts, empirical assessments indicate limited transformative impact to date, with persistent barriers including acute shortages, shortfalls exceeding £10 billion annually in some estimates, and structural tensions between national directives and local priorities. Controversies center on diminished democratic oversight, as ICBs operate with executive powers previously held by elected councils, alongside of intensified treatment protocols in response to resource constraints, potentially exacerbating wait times that reached record highs post-implementation. Systematic reviews of analogous integrated models predate full ICS rollout but reveal inconsistent gains in cost savings or outcomes, underscoring causal challenges in achieving seamless integration without addressing underlying fiscal and capacity deficits.

Definition and Objectives

Core Concept and Rationale

The integrated care system (ICS) in represents a statutory framework for collaborative partnerships across geographic areas, encompassing NHS trusts, primary care networks, local authorities, and third-sector providers to jointly plan, commission, and deliver health and social care services. Established under the Health and Care Act 2022, these 42 systems cover the entire of and emphasize management over fragmented, provider-centric models. The core concept shifts from competition-driven commissioning—prevalent since the 2012 Health and Social Care Act—to cooperative accountability, where partners share risks and resources to address complex needs like chronic conditions and . The rationale for ICSs stems from empirical evidence of inefficiencies in siloed services, including duplicated efforts, delayed discharges, and suboptimal preventive care, which contributed to rising NHS costs and health disparities documented in prior audits. Proponents argue that integration fosters causal links between upstream interventions—such as tackling or instability—and downstream outcomes like reduced hospital admissions, drawing from evaluations of earlier Sustainability and Transformation Partnerships (STPs) that showed modest gains in coordinated care pathways. Official objectives include improving outcomes, reducing inequalities in access and experience, enhancing productivity through value-based commissioning, and aligning health services with local economic priorities, as outlined in the 2019 NHS Long Term Plan. This model posits that localized , supported by shared and budgets, enables evidence-based over national mandates, with early indicators from 2022 statutory establishment suggesting potential for 5-10% efficiency savings in select areas through reduced avoidable admissions. However, the underlying assumption of partnership efficacy relies on robust to mitigate risks like uneven partner buy-in, as highlighted in National Audit Office assessments of pre-ICS pilots.

Stated Goals and Theoretical Foundations

The stated goals of Integrated Care Systems (ICSs) in , as articulated by , center on four principal aims: improving outcomes in and healthcare; tackling inequalities in outcomes, experience, and access; enhancing productivity and value for money; and supporting the NHS in contributing to broader social and . These objectives were formalized in the Health and Care Act 2022, which established ICSs as statutory bodies to foster collaborative planning and delivery of services across local health and care economies. The emphasis on outcomes prioritizes prevention and early intervention to reduce hospital admissions and manage chronic conditions more effectively, while the productivity goal targets elimination of service silos to optimize resource allocation amid fiscal constraints. Theoretically, ICSs build on established models of integrated care that advocate for coordinated service delivery to fragmentation in healthcare systems, drawing from frameworks such as person-focused and population-based care integration. This foundation posits that siloed organizations lead to inefficiencies, duplicated efforts, and suboptimal experiences, necessitating partnerships that align clinical, social, and resources under place-based . NHS 's rationale emphasizes causal links between local collaboration and improved equity, positing that devolved decision-making enables tailored responses to demographic pressures like aging populations and rising , rather than top-down mandates. Empirical underpinnings include prior experiments in accountable care, which demonstrated potential reductions in admissions through proactive care coordination, though remains debated due to variable local implementation.

Historical Development

Precursors and Early Experiments (Pre-2017)

Efforts to integrate care within the UK's (NHS) predated the formal establishment of integrated care systems, tracing back to policy reviews and pilot programs aimed at bridging silos between primary, secondary, acute, and social care services. The 2008 NHS Next Stage Review, led by Lord Darzi and published on June 30, emphasized personalized, high-quality care through greater coordination across providers, highlighting fragmentation as a barrier to and patient outcomes. This review influenced subsequent initiatives by advocating for localized strategies to integrate services, though implementation relied on voluntary collaboration amid varying local capacities. Building on these recommendations, early experiments included the selection of 16 pilot sites in 2009 under programs designed to test care integration models, focusing on coordinating services for complex patients and reducing admissions through multidisciplinary teams. These pilots, launched following the framework, explored mechanisms like shared budgets and joint assessments but faced challenges in scaling due to organizational resistance and inconsistent funding. By 2013, the Integrated Care and Support Pioneers programme advanced this approach, designating 14 localities in November to innovate in coordinating around individual needs, such as through risk stratification and personalized care plans. Evaluations after one year indicated progress in multi-agency working but limited evidence of cost savings or widespread outcome improvements, underscoring the experimental nature amid resource constraints. The 2015 New Care Models programme marked a significant escalation, with selecting 50 vanguard sites in waves to prototype five integration archetypes, including Multispecialty Community Providers (MCPs), Primary and Acute Care Systems (PACS), and Enhanced Health in Care Homes (ECH). Financed with approximately £389 million through 2018, these experiments tested population-based commissioning and delegated budgets to shift care from hospitals to community settings, involving partnerships between clinical commissioning groups (CCGs), trusts, and local authorities. Initial findings from vanguards showed modest reductions in emergency admissions in some models, such as ECH, but overall impacts on utilization were small, with hurdles including data-sharing barriers and workforce silos. Preceding the 2017 designation of initial integrated care systems, Sustainability and Transformation Plans (STPs) emerged in 2016 as a broader precursor, requiring 44 geographic footprints—covering England's entire —to develop five-year strategies for sustainable, addressing £22 billion in efficiency gaps. STPs encouraged system-wide planning across NHS providers, CCGs, and , incorporating elements from vanguards like accountable care approaches, though they remained non-statutory and faced criticism for top-down imposition without sufficient stakeholder buy-in. These plans laid groundwork for later statutory frameworks by fostering collaborative footprints that evolved into integrated care systems, despite uneven progress in integration due to financial pressures and ambiguities.

Accountable Care Systems (2017–2018)

Accountable Care Systems (ACS) were introduced in 2017 by NHS England as a non-statutory model to foster collaboration among local commissioners, providers, and partners in managing population health and care budgets. Building on the 44 Sustainability and Transformation Partnerships (STPs) established earlier, ACS emphasized joint accountability for quality, activity levels, and financial sustainability across health and social care services. The framework sought to shift from siloed operations to integrated, place-based planning, with participating entities agreeing to shared governance structures and performance metrics. Key guidance appeared in NHS England's "Next Steps on the NHS Five Year Forward View," published on 21 March 2017, which positioned ACS as an evolution of STPs to enable commissioners—primarily clinical commissioning groups (CCGs)—to delegate responsibilities to provider-led partnerships. These systems incorporated risk- and reward-sharing arrangements, such as gain-share mechanisms for efficiencies and potential penalties for deficits, to incentivize preventive care and reduced hospital admissions. Initial focus areas included aligning , acute services, , and community provision, with an emphasis on data-driven strategies. In August 2017, issued a draft NHS Standard Contract for Accountable Care Models, outlining pathways for ACS to mature into Accountable Care Organisations (ACOs) with formal contracts for delegated commissioning and capitated budgets covering entire populations. Examples of early ACS development included the and Bassetlaw partnership, formalized in June 2017, which established memoranda of understanding for collective oversight of £1.8 billion in annual spending. By 2018, multiple STP areas had advanced towards ACS designation, though progress varied due to governance complexities and the need for regulatory amendments under the Act 2006. Implementation during 2017–2018 highlighted ACS as a transitional step toward broader system-wide integration, with supporting local plans through accelerated funding and technical assistance. However, the absence of statutory powers limited transfer initially, confining arrangements to voluntary agreements and prompting delays in ACO contract approvals until after February 2018. Evaluations noted early successes in joint but underscored ongoing barriers, including workforce silos and issues.

Statutory Formalization (2019–2022)

The NHS Long Term Plan, published on 7 January 2019, outlined the transition of all existing Sustainability and Transformation Partnership (STP) areas to integrated care systems (ICSs) by April 2021, emphasizing collaborative planning across health and care providers without initial statutory backing. This built on voluntary arrangements, with ICSs operating as non-statutory partnerships to integrate commissioning, provision, and population health management. In 2020, amid the , accelerated ICS development by designating 50 ICS geographies—later rationalized to 42—and granting delegated authority to select ICSs for managing portions of NHS budgets, including commissioning and some specialized services previously held by clinical commissioning groups (CCGs). These delegations, outlined in 's June 2021 design framework, enabled shadow ICSs to assume operational responsibilities for and service coordination, though lacking legal permanence and subject to revocation. The push for statutory formalization intensified with the government's white paper Integration and Innovation: working together to support patients in February 2021, which proposed to embed ICSs as legal entities. On 6 July 2021, the Health and Care Bill was introduced to , aiming to abolish CCGs, establish 42 integrated care boards (ICBs) as statutory NHS commissioners, and mandate integrated care partnerships (ICPs) for broader collaboration with local authorities. The Bill progressed through scrutiny, receiving amendments on governance, financial accountability, and reduced emphasis on competition, before gaining as the Health and Care Act 2022 on 28 April 2022. Effective 1 July 2022, the Act dissolved all CCGs, vesting their functions in ICBs and formalizing ICSs as accountable for planning and funding services across populations of 500,000 to 3 million, with duties to address inequalities and promote joint working under sections 19-35. This statutory shift marked the culmination of preparations, enabling ICSs to exercise powers like direct provider contracting and capital investment, previously constrained by non-statutory status.

Expansion and Maturation (2023–Present)

In the financial year 2023/24, marking the first full year of statutory operation for Integrated Care Boards (ICBs), England's 42 ICSs demonstrated progress in collaborative service delivery, with many achieving improvements in key performance indicators such as cancer 62-day waits and access standards, though outcomes varied by region. NHS England's annual assessment highlighted that while some ICBs advanced in management and prevention strategies, persistent challenges included financial deficits and shortages, with ICS leaders reporting strained resources amid rising demand. Independent analyses, such as those from the NHS Confederation, noted successes in shifting care to community settings and embedding preventive models, but emphasized barriers like fragmented systems and uneven engagement with local authorities. Financial maturation brought mixed results, as the combined 2024/25 budget for ICBs reached £6.2 billion, yet 18 of 31 analyzed boards faced cuts while 13 saw increases, reflecting tighter national fiscal controls and efforts to address inherited deficits totaling over £1 billion from prior clinical commissioning groups. guidance for 2024/25 prioritized enhanced data flows, in primary and community care, and integration of , with ICSs tasked to align strategies for sustainable economic growth and reduced hospital reliance. Reports from bodies like underscored advancements in workforce collaboration across ICS partners, including joint planning for recruitment and retention, though risks of centralization and insufficient persisted, potentially undermining local innovation. By mid-2025, the July announcement of the government's 10-Year Health Plan signaled further maturation, directing ICSs toward a reformed model emphasizing primary and community care expansion, digital interoperability, and for outcomes rather than activity volumes, without altering core structures but building on existing frameworks. Early implementation focused on aligning ICS strategies with national missions, such as tackling health inequalities through targeted interventions, though critiques from professional bodies like the BMA highlighted risks to ICB autonomy under heightened oversight. Overall, NHS England's 2023/24 accounts reported a 7% rise in appointments to 371 million, attributing gains partly to ICS-driven efficiencies, yet systemic pressures like post-pandemic backlogs continued to test maturation efforts.

Organizational Framework

Integrated Care Boards

Integrated Care Boards (ICBs) are statutory bodies within the (NHS) in , established on 1 July 2022 under the Health and Care Act 2022 to replace the 191 clinical commissioning groups (CCGs). There are 42 ICBs, each aligned with one integrated care system (ICS) and covering the entire population of , with collective annual resources exceeding £100 billion for health and care services. ICBs hold primary responsibility for commissioning the majority of NHS-funded services, including primary medical services, hospital care, , , and most elective and urgent care, while also managing workforce planning and strategies within their areas. They receive direct allocations from , totaling £129.8 billion for core and primary medical services in the 2025/26 fiscal year, and are required to collaborate with integrated care partnerships (ICPs), authorities, and providers to align commissioning with broader social care and needs. Unlike CCGs, which operated on a more fragmented, GP-led basis, ICBs integrate commissioning with system-level planning to reduce silos, assuming some direct commissioning functions previously held by , such as specialized services. Each ICB operates under a unitary board structure, comprising executive members (including a chair, chief executive, and finance lead), non-executive directors, and partner representatives from providers and local government, with all members jointly accountable for organizational performance and statutory duties like reducing inequalities. Constitutions, approved by NHS England, mandate statutory clinical commissioning committees to ensure clinical input in decisions, alongside requirements for transparency in procurement and financial management. ICBs must publish annual plans detailing service improvements, budget use, and progress against national targets, subject to oversight by NHS England on financial sustainability and quality metrics. As of October 2025, the 42 ICBs continue to face operational challenges, including staff redundancies—up to 12,500 positions targeted by year-end amid efficiency drives—and proposals for clustering or mergers to streamline , such as reducing to 28 entities by 2026, though no statutory changes have been enacted. This evolution reflects ongoing efforts to balance local autonomy with national accountability, building on the Act's intent for place-based integration over the CCG model's narrower focus.

Integrated Care Partnerships

Integrated Care Partnerships (ICPs) form the collaborative arm of Integrated Care Systems (ICSs) in , serving as statutory committees that unite the Integrated Care Board (ICB), local authorities, healthcare providers, and wider stakeholders to address needs beyond clinical commissioning. Established under the Health and Care Act 2022, ICPs were required to be operational by July 1, 2022, across all 42 ICSs, with statutory membership limited to the ICB and upper-tier local authorities, while inviting broader participation from voluntary organizations, trade unions, and community representatives. Unlike ICBs, which hold legal responsibility for NHS budgeting, service commissioning, and performance accountability as independent statutory bodies, ICPs lack status and instead emphasize joint strategy development without direct financial or operational control. Their primary statutory duty involves producing an integrated care strategy every five years—or sooner if significant changes occur—outlining shared priorities for improvement, prevention, and tackling social determinants such as housing and employment, which interim strategies addressed by December 2022 and full versions by June 2023. ICPs facilitate system-wide alignment by promoting widespread engagement, including with adult social care providers and unpaid carers, to ensure strategies reflect local needs and foster collaborative across sectors. Guidance emphasizes their role in oversight and , such as reviewing ICB against objectives, though practical varies due to differing local models and constraints. Effective ICPs exhibit characteristics like strong alliances, data-driven planning, and mechanisms for addressing inequalities, as evidenced in joint reports from and NHS bodies.

Governance Mechanisms

Integrated Care Boards (ICBs), the statutory NHS bodies within each of England's 42 Integrated Care Systems (ICSs), are governed through constitutions that outline their , functions, and arrangements, as mandated by the Health and Care Act 2022 and statutory guidance from . These constitutions, which must be approved by , specify requirements for board composition, including a chair appointed by , a chief executive, executive directors responsible for key functions like finance and , non-executive directors comprising at least half the board to ensure independence, and partner members such as local authority representatives to facilitate joint working. ICB boards operate under principles of , with delegated powers to committees for areas like , , and oversight, while managing conflicts of interest through standing orders and transparency protocols. Decision-making mechanisms emphasize collaborative planning, requiring ICBs to develop five-year joint forward plans in partnership with Integrated Care Partnerships (ICPs), which integrate input from local authorities, providers, and the on needs. ICPs, as non-statutory entities, rely on partnership forums and agreements to support system-wide strategy without formal commissioning powers, fostering shared accountability through memoranda of understanding rather than hierarchical control. ICBs exercise statutory commissioning for most NHS services, subject to national standards, with mechanisms like place-based boards at sub-ICS levels allowing localized on resource allocation while aligning to system priorities. Accountability flows upward from ICBs to , which applies the annual NHS Oversight Framework to evaluate performance across segments including quality of care, financial sustainability, operational delivery, and strategic change, using metrics such as elective recovery trajectories, indicators, and integrated care expenditure. Oversight categorizes ICBs into levels—such as targeted support for standard performance or mandated interventions for those in special measures—based on data-driven assessments, with escalation to the Secretary of State for where national interests are at risk. Local democratic accountability is embedded via ICP involvement of elected councillors and on plans, complemented by mandatory reporting on inequalities reduction and financial probity, though critics note potential tensions between system-level and granular oversight.

Roles of Providers and Pharmacy Integration

In Integrated Care Systems (ICSs), healthcare providers encompass a range of NHS organizations, including acute trusts, trusts, services, community providers, and networks (PCNs) comprising general practitioners (GPs). These providers are responsible for the direct delivery of clinical services, operational management of quality, and participation in system-wide planning to achieve integrated care pathways that address needs. For instance, acute and community providers collaborate within provider collaboratives—formal groupings of NHS trusts and foundation trusts—to specialize in elective care, manage waiting lists, and optimize resource allocation across the ICS, as established under the Health and Care Act 2022. providers, such as PCNs, focus on proactive care coordination, managing long-term conditions, and referring patients to appropriate secondary services to reduce admissions, with roles expanded to include initial for minor illnesses. Provider responsibilities extend to contributing evidence-based input on service commissioning through Integrated Care Partnerships (ICPs), where they align with local authorities and third-sector organizations to develop joint forward plans covering prevention, acute care, and social services integration. Medical and clinical leaders among providers facilitate this by promoting dialogue, trust-building, and shared accountability for outcomes like reduced inequalities and improved care efficiency, as ICSs were statutorily mandated in July 2022 to coordinate such efforts. Providers also bear duties in quality assurance, including operational oversight of safety, effectiveness, and patient experience, often through place-based partnerships that devolve decision-making to local levels within the ICS footprint. Pharmacy integration within ICSs emphasizes medicines optimisation and expanded clinical roles for pharmacists to support seamless care across sectors. Community pharmacies, numbering over 11,000 in , are commissioned directly by Integrated Care Boards (ICBs) since April 1, 2023, enabling pathway-wide services such as minor ailment management, long-term condition support, and vaccination delivery, which integrate with GP and hospital workflows to reduce fragmentation. The NHS England's Pharmacy Integration Programme, building on earlier Sustainability and Transformation Partnership (STP) frameworks from 2018, funds workforce development, advanced clinical training, and independent prescribing capabilities for pharmacists, aiming to embed them in multidisciplinary teams for proactive medicines management and deprescribing to mitigate risks like . This integration addresses sector challenges, including workforce shortages, by leveraging ICS structures for recruitment, retention, and cross-sector deployment, as highlighted in a 2023 review noting opportunities for regional coordination. Pharmacists contribute to strategies by optimizing prescribing data and supporting digital tools for shared records, with Royal Pharmaceutical Society recommendations urging ICSs to prioritize pharmacy in roles and allocations for enhanced networking and clinical impact. Overall, pharmacy roles evolve from dispensing-focused to consultative, aligning with ICS goals of cost-effective, patient-centered care, though implementation varies by local ICB priorities.

Operational Functions

Service Planning and Commissioning

Integrated Care Boards (ICBs), established under the Health and Care Act 2022, hold primary responsibility for service planning and commissioning within each of England's 42 integrated care systems (ICSs), effective from 1 July 2022. ICBs succeeded clinical commissioning groups (CCGs), absorbing their functions to centralize NHS planning at the ICS level while emphasizing population-based and resource allocation. This shift aims to align commissioning with broader ICS goals of integrating , though ICBs retain statutory duties focused on NHS-funded services. The commissioning process involves assessing local health needs, prioritizing services, procuring contracts with providers, and monitoring performance to achieve optimal outcomes. ICBs commission the majority of NHS services, including secondary care, , ambulance services, most , and provision, controlling budgets equivalent to approximately 85-90% of local NHS expenditure. Some specialized commissioning functions, previously managed nationally by , have been delegated to ICBs, such as certain elective and cancer services, enabling more tailored local planning. ICBs must publish annual forward plans detailing service strategies, , and financial projections, developed in collaboration with Integrated Care Partnerships (ICPs) to incorporate wider determinants of like social care and . ICBs exercise flexibility in delivery models, opting for contracts with providers or delegating budgets to Integrated Care Providers (ICPs) for place-based management, particularly in primary and community care. This delegation supports integrated pathways but requires safeguards against underperformance, with ICBs retaining oversight and accountability for statutory functions. As of 1 April 2025, ICBs assumed commissioning for all vaccination services and most screening programs, previously handled by NHS England, to enhance local responsiveness amid rising demand. Commissioning decisions prioritize evidence-based needs, with ICBs required to reduce health inequalities and promote prevention, though implementation varies by ICS due to differing local demographics and provider capacities.

Population Health and Prevention Strategies

Integrated care systems (ICSs) in emphasize management (PHM) as a foundational approach to enhance overall health outcomes through data-driven, proactive interventions rather than reactive treatment. PHM involves segmenting populations by risk levels, using analytics to identify individuals most vulnerable to poor health, and coordinating services across providers to address needs early. This strategy aligns with the statutory duties of integrated care boards (ICBs) under the Health and Care Act 2022, which require them to commission services that improve and reduce inequalities. Prevention strategies within ICSs prioritize upstream actions targeting , such as housing instability, employment barriers, and lifestyle factors, often through collaborations with local authorities and voluntary sectors via integrated care partnerships (ICPs). For instance, ICPs develop five-year joint forward plans that embed prevention, including initiatives like enhanced networks (PCNs) for targeted screenings and community-based programs to mitigate chronic disease progression. Data platforms enable predictive modeling; one reported application reduced hospital admissions by improving coordination between and housing services, demonstrating causal links between integrated prevention and lower utilization. Empirical implementation varies across the 42 ICSs, with national guidance from promoting standardized PHM tools, such as the Population Health Management Academy, to build system-wide capacity. In 2023/24 assessments, several ICBs reported progress in prevention boards overseeing health inequalities, though challenges persist in data interoperability and for non-clinical interventions. Secondary prevention efforts, focusing on post-event reduction like cardiovascular , have shown promise in pilot areas, with data analytics informing targeted outreach that lowered readmission rates by up to 15% in select systems. Overall, these strategies aim to shift expenditure from hospitals to prevention, supported by efficiency targets exceeding £7 billion in 2023/24 through reform.

Resource Allocation and Financial Management

NHS England allocates financial resources to the 42 Integrated Care Boards (ICBs) using a needs-based statistical formula that accounts for population size, demographics, morbidity, and geographic factors to ensure equitable distribution across . These allocations, which constitute the majority of NHS spending, cover core services, medical services, and running costs, with detailed figures for 2025/26 published on January 30, 2025. For the 2024/25 financial year, distributed over £120 billion in public funding to ICBs, emphasizing accountability in local spending to align with national priorities. Within each Integrated Care System (ICS), ICBs hold statutory responsibility for budgeting, commissioning, and distributing resources to providers, including hospitals, general practices, and community services, replacing the prior functions of clinical commissioning groups. ICBs collaborate with ICS partners—such as local authorities and providers—on system-wide financial planning, which integrates activity forecasts, workforce needs, and expenditure to support joint decisions on resource flows. To enable localized control, ICBs may delegate portions of their NHS allocation to place-based partnerships, allowing sub-system entities to make spending decisions tailored to specific geographic or population needs while maintaining overall system accountability. Financial management in ICSs emphasizes pooled resources and outcome-linked allocation to promote preventive care and , though mechanisms like the Better Care Fund facilitate integration by blending NHS and local authority budgets for 2023–2025. ICBs must adhere to NHS financial frameworks, including business rules for apportioning costs and managing deficits, with oversight from to enforce sustainability plans. Despite these structures, faces significant challenges, with ICSs collectively overspending by £1.4 billion in 2023/24—more than double the prior year's deficit—driven by rising , , and deferred investments. Many ICBs report ongoing deficits and reliance on non-recurrent funding, undermining long-term , as highlighted in NHS 's 2023/24 assessments of individual boards. The National Audit Office has critiqued systemic issues, including short-term fixes that exacerbate volatility and fail to address underlying pressures like workforce shortages and backlogs, recommending a shift toward comprehensive financial restructuring over ad-hoc support.

Implementation Across England

Establishment of the 42 Systems

The establishment of the 42 Integrated Care Systems (ICSs) in marked the culmination of a multi-year evolution from non-statutory partnerships to statutory entities under the (NHS). Initially developed as Sustainability and Transformation Partnerships (STPs) in 2016 and rebranded as ICSs in the NHS Long Term Plan of 2019, these systems aimed to integrate health and care services across local geographies. By March 2021, the NHS had designated all areas of as ICSs, covering the entire population through 29 mature systems and 13 emerging ones, fulfilling a key commitment to nationwide rollout. The Health and Care Act 2022 provided the legislative framework for statutory status, abolishing the 191 Clinical Commissioning Groups (CCGs) and empowering to create Integrated Care Boards (ICBs) as the core commissioning bodies within each ICS. The Act, which received on 28 April 2022, amended the National Health Service Act 2006 to define ICSs as partnerships comprising an ICB and an Integrated Care Partnership (ICP), with responsibilities for planning, commissioning, and delivering joined-up services. On 1 July 2022, the Integrated Care Boards (Establishment) Order 2022 legally established the ICBs, operationalizing the ICSs as statutory bodies across and assuming CCG functions such as budgeting and service commissioning. This transition aligned ICS boundaries with local authority areas, serving populations ranging from approximately 500,000 to 3 million people per system, to facilitate place-based planning and resource allocation. Each ICB was required to collaborate with local authorities, providers, and voluntary sectors through ICPs to address needs, though implementation varied due to pre-existing regional differences in maturity.

Integrated Care Providers and Partnerships

Integrated Care Providers in England's 42 Integrated Care Systems (ICSs) encompass NHS foundation trusts, NHS trusts (including acute, , , and community services), primary care networks, and contracted independent sector organizations responsible for direct service delivery. These providers operate under the oversight of Integrated Care Boards (ICBs) while contributing to system-wide planning through collaborative arrangements. Provider collaboratives form a key partnership mechanism, uniting at least two NHS trusts to coordinate planning, resource sharing, and service transformation across ICS boundaries or within them. Established as mandatory for acute and trusts from July 2022, these collaboratives focus on achieving in areas such as , , digital infrastructure, and specialized care pathways, thereby addressing service fragmentation and enhancing . For instance, collaboratives enable joint delivery of or crisis response, with governance determined locally in consultation with ICS leaders and regions. Primary care provider collaboratives, emerging since 2023, further integrate general practices and federations into ICS decision-making, amplifying their voice in strategic objectives like preventive care and . Broader partnerships involve providers aligning with local authorities and entities via Integrated Care Partnerships (ICPs), which develop non-statutory integrated care strategies emphasizing and joint commissioning. This includes formal engagement protocols for adult social care providers to ensure seamless transitions between health and social services. In select ICSs, Integrated Care Provider (ICP) contracts devolve comprehensive responsibility for primary, secondary, , and social care to a single accountable entity or collaborative, often under 10- to 15-year agreements valued in billions of pounds, to incentivize long-term integration over siloed commissioning. Such models, piloted pre-2022, prioritize outcome-based payments but require robust risk-sharing and performance metrics to mitigate financial exposures for providers. These arrangements shift from competitive tendering toward , with providers influencing ICB budgets—allocated at £3.2 billion per ICS on average in 2023/24—through delegated authorities for elective recovery and urgent care. However, variability in collaborative maturity across ICSs, with some achieving integrated back-office functions while others face hurdles, underscores ongoing challenges.

Coverage and Population Scope

Integrated care systems (ICSs) encompass the entirety of , divided into 42 distinct systems that collectively serve the nation's approximately 56.5 million residents as of mid-2023. Established statutorily on 1 July 2022 under the Health and Care Act 2022, these systems replaced earlier sustainability and transformation partnerships (STPs) and ensure comprehensive geographic coverage without overlaps or exclusions, aligning with NHS 's mandate for nationwide integration of health and care services. Each ICS delineates a specific geographic footprint, typically corresponding to sub-regional clusters of local authorities, with boundaries designed to facilitate coordinated service delivery across , hospitals, providers, community services, and social care. Population sizes served by individual ICSs vary significantly, ranging from approximately 500,000 to 3.5 million people, reflecting differences in urban density and regional demographics; for instance, densely populated areas like cover over 2.8 million, while rural systems such as those in and the serve around 580,000. The average ICS population stands at about 1.46 million, enabling tailored planning that accounts for local health needs, deprivation levels, and inequalities. The population scope of ICSs extends to all residents within their boundaries, encompassing not only NHS-funded healthcare but also integration with non-NHS elements such as , voluntary sectors, and , with a statutory to reduce disparities and promote prevention across the full demographic spectrum. This includes targeted efforts for vulnerable subgroups—such as the elderly, those with chronic conditions, and underserved communities—but operates without explicit exclusions, prioritizing evidence-based distribution over selective enrollment. Boundary adjustments, such as those approved in to enhance alignment with upper-tier authorities (achieving coterminosity in about 70% of cases), underscore ongoing refinements to optimize coverage efficacy amid evolving like migration and aging.

Empirical Evaluation

Measured Achievements and Outcomes

Integrated care systems (ICSs) in , statutorily established in July 2022, have recorded initial progress in enhancing collaboration across providers. A 2024 King's Fund analysis found that ICSs facilitated more coordinated workforce strategies, with 80 percent of surveyed systems reporting advancements in joint recruitment and training initiatives, contributing to stabilized in acute and settings during periods of national shortages. This collaborative approach has supported localized responses to labor demands, reducing reliance on agency staff in select ICSs by up to 10 percent in pilot programs. Service integration efforts have yielded measurable gains in preventive and management. The NHS Confederation's 2023/24 survey of ICS leaders identified successful resource reallocation in multiple systems, such as one ICS achieving a 15 percent increase in community-based interventions, correlating with reduced admissions for ambulatory care-sensitive conditions by 5-7 percent in targeted populations. NHS England's 2023/24 annual assessment of integrated care boards (ICBs) documented improvements in joint commissioning, with 25 of 42 ICBs meeting or exceeding targets for integrated primary and secondary care pathways, leading to shorter average referral-to-treatment times in elective specialties by 2-4 weeks in high-performing areas. Longer-term outcome data, though preliminary, aligns with prior evidence on integrated models. A 2018 systematic review of integrated care initiatives reported reductions in patient waiting times by 20-30 percent and outpatient appointments by 10-15 percent where coordination was prioritized, patterns echoed in early ICS evaluations for , where 70 percent of systems reported higher fulfillment of patient preferences through multidisciplinary teams. These achievements, however, vary by ICS maturity and local , with quantitative gains most evident in systems emphasizing data-driven .

Identified Shortcomings and Failures

Despite the objectives of enhancing and integration, Integrated Care Systems (ICSs) have encountered substantial financial shortfalls. In 2023-24, NHS systems, including ICSs, recorded an overspend of £1.4 billion, more than double the previous year's deficit, reflecting persistent budgetary pressures. For 2024-25, nearly three-quarters of Integrated Care Boards (ICBs, the statutory bodies of ICSs) submitted deficit plans totaling £2.2 billion in projected overspend, indicating widespread to achieve balanced budgets amid rising costs and inadequate productivity gains. By March 2025, the year-to-date system position showed a £62 million overspend, with nine ICSs accounting for 80% of the variance, prompting to withhold deficit support from five systems for failing to deliver required savings. Draft financial plans for 2025-26 implied a £6.6 billion deficit across ICSs, underscoring systemic inefficiencies in despite central mandates for financial recovery. Empirical assessments reveal limited progress in core outcome metrics under ICS oversight. Precursor integration models, such as Sustainability and Transformation Partnerships, yielded only mixed results with minimal reductions in unplanned hospital admissions, a key target for ICSs. Early ICS evaluations similarly show no compelling evidence of sustainable improvements in emergency admissions or overall care quality, as staffing shortages and funding constraints hinder preventive strategies. NHS waiting lists, managed through ICS planning, reached record highs post-implementation and continued rising into 2025, with hospitals failing to treat patients at a rate sufficient to reduce backlogs, exacerbating access delays. Productivity metrics, including activity levels per staff input, remain below pre-pandemic benchmarks despite workforce expansions, attributing stagnation to integration barriers rather than enhanced coordination. Implementation challenges have compounded these issues, with nascent ICSs struggling to foster genuine amid extreme operational pressures. Staff reports indicate support for integration principles but highlight measurement gaps and cultural resistance, leading to risks of systems "going off track" under intense scrutiny and service demands. Barriers such as fragmented systems and regulatory hurdles persist, limiting empirical demonstration of integration benefits and contributing to uneven performance across the systems established in July 2022. These shortcomings reflect a disconnect between ambitions and on-ground realities, where causal factors like chronic underfunding and gaps undermine purported efficiencies.

Methodological Challenges in Assessment

Assessing the effectiveness of Integrated Care Systems (ICSs) in faces significant methodological hurdles due to their systemic scale, complexity, and recent statutory implementation in July 2022. Evaluations often struggle with attribution, as outcomes are influenced by concurrent national policies, the , and local variations across the 42 ICSs, making it difficult to isolate ICS-specific impacts. Additionally, the absence of non-ICS comparator areas—given full geographic coverage—precludes straightforward control groups, complicating quasi-experimental designs. A primary challenge is the heterogeneity of interventions within and across ICSs, which encompass diverse partnerships, service redesigns, and strategies, rendering standardized outcome measurement elusive. Peer-reviewed analyses highlight a paucity of robust empirical studies, with many evaluations relying on descriptive or self-reported data rather than rigorous methods. For instance, prospective quasi-experimental assessments of precursor programs like the Pioneer initiative encountered recruitment failures and delays in data linkage, as routine datasets (e.g., Hospital Episode Statistics) were not readily accessible for matched comparisons. This heterogeneity also undermines cost-effectiveness analyses, lacking agreed-upon methodologies to determine whether integration yields net savings or merely redistributes expenditures. Data integration poses further barriers, as ICSs require linking disparate , social care, and primary datasets, but persist due to restrictions and incomplete digital . Ethical and regulatory processes exacerbate delays; approvals from bodies like the Health Research Authority can take over 20 months, hindering timely prospective evaluations. Moreover, short observation windows limit detection of long-term effects, such as reduced admissions or improved chronic management, which may emerge years post-implementation amid fiscal pressures and shortages. Finally, defining success metrics remains contentious, with tensions between process indicators (e.g., formation) and hard outcomes (e.g., mortality rates or equity gains), often leading to overemphasis on quantifiable but proximal measures that fail to capture holistic integration benefits. Early ICS assessments, such as NHS England's 2023/24 reviews, acknowledge these limitations, noting reliance on interim performance data amid ongoing performance shortfalls in areas like urgent care. Without addressing these issues—through better pre-implementation designs or advanced econometric techniques like synthetic controls—evaluations risk producing inconclusive or biased results, impeding evidence-based refinements.

Controversies and Critiques

Bureaucratic Overreach and Centralization

The establishment of Integrated Care Systems (ICSs) through the Health and Care Act 2022 consolidated commissioning responsibilities from 191 local Clinical Commissioning Groups (CCGs) into 42 larger regional entities, a restructuring critics argue fosters centralization by concentrating decision-making authority in Integrated Care Boards (ICBs), which function as statutory NHS bodies primarily accountable to rather than local elected representatives. This shift has been linked to reduced local autonomy, as ICBs must adhere to national performance mandates and operational directives from , potentially overriding place-based priorities in favor of standardized targets. For instance, a 2023 parliamentary inquiry highlighted risks of ICSs becoming overly NHS-centric, sidelining social care partners and input in . Bureaucratic overreach manifests in heightened administrative burdens, including frequent data reporting and compliance demands from that divert resources from patient care. A 2023 NHS assessment noted persistent "last-minute requests for data and too much unnecessary bureaucracy," with ICS leaders reporting that such processes hinder collaborative working across systems. Similarly, the 2024 survey found only 40 percent of ICS leaders viewing accountabilities between ICBs and NHS England's national team as clearly defined, underscoring tensions where central oversight is perceived as micromanaging local operations. These issues echo broader critiques of the Act's implementation, where policy guidance is described as "overly bureaucratic, time-consuming, and out of touch" with frontline realities. The Hewitt Review, an independent 2023 evaluation, acknowledged these dynamics by recommending enhanced ICS autonomy through devolved budgets and reduced central prescription, while emphasizing the need for robust national accountability to ensure financial probity and performance standards. However, ongoing concerns persist regarding democratic deficits, as ICBs lack direct public elections and prioritize hierarchies, potentially enabling top-down interventions that limit clinician-led innovation and local responsiveness. Empirical indicators include stalled progress on integration goals, with some ICSs reporting governance structures overwhelmed by compliance rather than service delivery, as evidenced in early post-2022 implementation analyses.

Financial Pressures and Cost Inefficiencies

The aggregated deficit for NHS integrated care systems (ICSs) doubled from £517 million in 2022/23 to £1.4 billion in 2023/24, despite the providing £4.5 billion in additional support to cover shortfalls. In 2023/24, ICSs planned for a combined deficit of £720 million but exceeded this due to persistent overspending, with 14 ICSs forecasting an additional £650 million shortfall. Projections indicate further deterioration, with a £6.6 billion deficit anticipated for ICSs and trusts in 2025/26, driven by staffing costs comprising 49% of budgets, adding £1.4 billion in 2023/24, and reallocation of £900 million from capital to revenue spending. These pressures have prompted measures such as 1% reductions in cost bases and targets for 4% productivity gains, alongside service rationalizations like consolidating community and delaying supplier payments to manage . By April 2025, integrated care boards (ICBs)—the statutory bodies leading ICSs—faced mandates for 50% cuts to running and programme costs, affecting administrative functions and potentially exacerbating frontline strains. Of 23 surveyed ICBs, 18 ended 2023/24 in deficit, with 10 projecting larger gaps for 2024/25, often attributed to unmet efficiency targets and reliance on agency staff. Cost inefficiencies stem partly from expanded bureaucratic layers post-ICS establishment in 2022, including increased regulatory burdens reported by 72% of ICS leaders and "double-running" of parallel systems during transitions. ICB running costs per staff varied widely, with medians at £61,000 and per 1,000 ranging from £8,320 to £32,000, reflecting uneven overhead absorption without commensurate integration savings. Despite aims to deliver systemic efficiencies through , many ICSs have failed to meet savings goals, as evidenced by persistent deficits and dependence on temporary funding mechanisms like elective recovery funds to offset shortfalls. This has led to critiques that added tiers have not yielded anticipated cost reductions, instead amplifying administrative demands amid workforce shortages.

Ideological and Policy Debates

The establishment of Integrated Care Systems (ICSs) under the Health and Care Act 2022 has elicited policy debates regarding the tension between centralized national directives and decentralized local decision-making. Critics argue that persistent top-down control by limits ICS flexibility, with the 2023 Hewitt Review recommending a fundamental shift toward bottom-up accountability to better align services with regional demographics and needs, such as varying urban-rural healthcare demands. This perspective highlights how statutory bodies, while intended to foster collaboration among NHS trusts, local authorities, and providers, often replicate prior bureaucratic structures, potentially exacerbating delays in service reconfiguration reported in early evaluations. Ideologically, ICSs embody a collectivist framework prioritizing population-level over market-driven , yet this has drawn scrutiny for sidelining individual patient choice and incentives inherent in selective contracting. analyses note that while ICSs aim to reduce inequalities through cross-sector partnerships—targeting a 10-15% improvement in preventive care access by 2024—empirical shortfalls in social care integration risk entrenching an NHS-dominant model, neglecting broader determinants like and . Opponents from efficiency-focused viewpoints contend this approach conflicts with evidence-based trade-offs, where equity mandates can inflate costs without proportional outcome gains, as seen in historical NHS reforms balancing universal access against . Further contention arises over accountability mechanisms, with parliamentary inquiries emphasizing opaque in ICSs that obscures oversight of multimillion-pound budgets, such as the £3.5 billion allocated for 2023/24 system-wide transformations. While frames ICSs as enablers of holistic care, skeptics highlight implementation barriers, including fragmented initiatives that may inadvertently centralize power in integrated care partnerships (ICPs) at the expense of voluntary and sectors, undermining causal links between integration rhetoric and tangible reductions in admissions. These debates underscore broader ideological divides: state-orchestrated coordination versus devolved, outcome-verified autonomy, with recent reports urging legislative tweaks to enhance transparency without reverting to pre-ICS silos.

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