Drawing on research conducted throughout 2025, this report provides detailed insights into local leaders’ views as the national policy context rapidly evolved around them. Overall, leaders in the research supported the broad goals of Labour’s reforms – including the shift from hospital to community – but had varied interpretations of what they meant in practice and major concerns about delivery. Policy changes introduced throughout 2025, including scrapping NHS England, cutting ICB budgets, merging ICBs across larger geographical areas and redefining the role of ICSs, were also causing widespread disruption and distracting ICS leaders from delivering on the government’s three shifts. 

Standing back, reforms to ICSs should not undermine the cross-sector collaboration needed to tackle the major health challenges facing the nation. Better planning and communication of the government’s reforms are now needed to avoid further disruption and distraction at local level. Policymakers will also need to actively construct the ‘strategic commissioners’ that they want ICBs to become – developing skills and capabilities within local systems and backing them with broader policy changes that make the ambition to shift resources out of hospital a reality. 

Source: HSJ

The document sets out a blueprint for how ICBs can operate within a changing NHS landscape. It covers the following areas:

• purpose – why ICBs exist
• core functions – what they do
• enablers and capabilities – what needs to be in place to ensure success
• managing transition – supporting ICBs to manage this transition locally and the support and guidance that will be available.

1. Agree a ‘person first approach’: Where it does not exist, Integrated Care Boards (ICBs), Integrated Care Partnerships (ICPs) and local authorities should design a local approach that brings councils and health services together to look at how a person’s needs can be met first, with considerations of who is responsible and who pays coming an important second. This would create a structured ‘person first’ approach that puts people before organisational structures.
2. Use the existing tools effectively: Councils and NHS bodies must use the tools that exist effectively to support a holistic approach, such as local dispute resolution processes and the National Framework for children and young people’s continuing care. ICPs should monitor how effectively this is being done in their area.
3. Agree standard frameworks for communication: Where they do not already exist, councils and health bodies should put in place person-centred, standard frameworks for effective communication between organisations. These should focus on ensuring the professionals on the ground interact effectively and that discussions and decisions are properly recorded.

• It is now just over a year since the previous government’s formal response to Patricia Hewitt’s review of integrated care systems’ (ICS) autonomy and accountability. The proposals set out in the review are still overwhelmingly supported by ICS leaders and national partners as the right direction of travel to improve the population’s health, reduce health inequalities, improve patient care and get best value for money. Using integration, devolution, digitisation and shifting resources to prevent worsening ill health are essential to using resources more effectively and ensuring the long-term sustainability of the NHS.
• Only two years into statutory governance arrangements, it is still early days for ICSs. Changing the law does not immediately lead to the changes in services, behaviour and the ways of working that systems want to achieve. ICSs need time and structural stability to continue delivering reform.
• Some progress has been made towards aligning with the review’s principles and approach and in some cases implementing the review’s recommendations. For example, there has been some progress towards embedding accountability arrangements in system oversight, towards establishing a national ICP forum to support cross-government working and providing a baseline to shift resources towards preventative services.
• However, implementation needs to go further and faster. Short-term pressures and a short-termist political climate have impeded ICSs’ agency to drive change. Therefore, progress has been slow in implementing many important recommendations, such as streamlining and automating data collation; reducing the burden of top-down micro-management and reporting to enable a focus on longer-term improvement in health outcomes; and improving value for money by reducing use of small in-year funding pots.
• While the commitments made on the recommendations were under the previous government, following the UK general election ICS leaders believe the Hewitt review is still the right blueprint for the new Labour government to create the conditions ICSs need to reform public services and provide the best care for patients. 

Despite these signs of progress, some of the more transformative work planned by ICSs is proceeding at a slower pace than intended as a result of the extremely challenging circumstances in which ICSs have been introduced. There is widespread concern that ICSs may not achieve their full potential unless more is done to create an environment conducive to their success.

The behaviours of national, regional and local leaders will make or break ICSs. There is an urgent need to ensure that accountability arrangements drive behaviours that reinforce system working rather than undermine it. Success depends on supporting people at all levels to think, plan and act in ‘system-focused’ ways.

• NHS England has outlined plans to develop an improvement approach - NHS IMPACT - to support continuous improvement. There are also ambitions for integrated care systems (ICSs) to become ‘self-improving systems’.
• This report, written and researched by Sir Chris Ham and jointly commissioned by the NHS Confederation, the Health Foundation and the Q community, reviews the experience of a number of ICSs identified as being at the forefront of this work, focusing on the approaches they have taken and the results achieved.
• Around 40 leaders from across eight systems contributed interviews and data, resulting in eight case studies that illustrate the range of work underway and the results being achieved throughout England.
• System leaders have been resourceful in ‘going with the grain’ of existing improvement methods, creating improvement and learning communities of experienced staff, and sharing expertise with organisations and services that may lack capabilities.
• System leaders are ‘learning by doing’ as they seek to bring about improvement through influence and persuasion and build shared commitment to change.
• There are concerns that the legacy of top-down performance management in the NHS might create barriers to realising the ambitions behind NHS IMPACT. System leaders argue that the work of NHS IMPACT should focus on a small number of national programmes and leave scope for systems to work on local priorities.
• Leaders should recognise that spreading innovations requires adaptation and skills in taking something that works in one context and making it work in another.
• The National Improvement Board should use the findings of this report when shaping its strategy and should ensure that expertise in ICSs and other partners is used.

For Government

• The Department of Health and Social Care should publish guidance that requires patient representation on ICBs and the annual reporting of patient involvement and representation in ICB activity.
• The Care Quality Commission should be given more freedom to scrutinise the level of patient involvement being carried out by ICSs and ICBs. This should also take into consideration the structures for accountability and reporting on how patient feedback is considered.

For NHS England

• NHS England should better incentivise ICBs to involve patients within decision-making structures.
• NHS England should encourage ICS leaders to come together to discuss best practice for patient involvement.
• NHS England should support ICBs to implement their ‘Working with People and Communities Strategy’ and promote the sharing of best practice nationally.

For Integrated Care Systems

• ICBs should involve patient representatives on boards and on committees.
• ICBs should ensure that patient feedback loops are properly established and practiced allowing for patient input to formally contribute to the development of policy. Patient feedback should be anonymous and cover all forms of care.
• ICBs should ensure that there is a rolling patient satisfaction survey for patient treatments. These should be used as a management tool to improve services.
• ICBs should include a standing item on their Board meetings to review how effectively they consider the patient voice when making decisions regarding the delivery of care in their local area.
• ICSs and ICBs should first identify Voluntary, Community and Social Enterprises (VCSEs), review how they involve VCSEs, and emphasis should be placed on working collaboratively with community bodies. 

• England’s ten ambulance trusts occupy a unique position in serving large health populations, each spanning footprints of multiple integrated care systems. In the context of system working and place-based models of care, ambulance trusts are negotiating emerging systems within their geographic remit, adopting new ways of working to meet the needs of diverse systems across the populations they serve.
• With the move away from clinical commissioning groups to the new integrated care system framework, many want to see a rethink in how systems engage with their ambulance trusts to ensure co-design and co-production from their services as part of a holistic strategy for population health.
• To support this, NHS Confederation interviewed a range of NHS leaders from both integrated care boards and ambulance services to explore how they might evolve their relationship, and to examine the principles that underpin effective and practical collaboration.
• Interviewees identified four key priorities for effective collaboration: thinking creatively about the role of the ambulance service; focusing on data sharing; fostering cultures of collaborative planning; and nurturing relationships.
• By focusing on these four areas, system and ambulance service leaders can design arrangements and relationships that deliver vast improvements to their population’s health in the years ahead.
• Interviewees made practical recommendations for national and local partners about how this can be achieved. These include expediting the implementation of Provider Selection Regime; where appropriate, developing multi-ICB governance structures; and considering how ambulance service data can be used at neighbourhood, place, system, regional and national levels to maximise its impact.

• As integrated care systems (ICSs) mark the first anniversary as formal partnerships, this report examines the progress that local systems have made, opportunities for further development and the areas where ICSs require action and commitment from national partners in order to ensure that they are able to effectively deliver for the population that they serve.
• The report shows that ICSs have got off to a strong start in a difficult operating environment – one that has been marked by one of the most challenging winters on record, rising demand for care, a cost-of-living crisis, ongoing industrial action, and reductions in the running costs of ICBs that materialised just seven months into their existence as statutory bodies.
• Nine in ten ICS leaders say that partners within their local systems are working collaboratively to set and deliver on their key priorities. Nine in ten ICS leaders also report that their ICB and ICP are working well together. ICS leaders do, however, highlight some of the challenges of partnership working and will look to build on this progress by strengthening collaboration and building capacity across all system partners.
• ICS leaders and their partner organisations are positive about the progress that local systems have made. These include coordinating the operational response to winter pressures, encompassing urgent and emergency care, discharge and elective recovery; developing and strengthening place-based arrangements and cross-system collaboratives; supporting and commissioning primary care; improving financial sustainability and productivity; enhancing engagement and co-production capabilities; and developing long-term, joint strategic plans.
• However, ICS leaders report a number of barriers that are impeding their progress and which require action from government and national bodies. The top three are: staff shortages and the lack of an equivalent long-term workforce plan for social care; a lack of funding for social care; and NHS finances, including unexpected cuts to ICB running costs and an ineffective capital regime.
• At the same time, ICBs have taken on greater responsibilities than when they went ‘live’, including the commissioning of primary pharmacy, optometry and dentistry services, and they have now been charged with implementing large elements of the NHS Long Term Workforce Plan. There is a clear danger that they are being asked to take on too much while their running costs are reduced by 30%. In particular, the further delegation of functions requires specialist capability which will now be in shorter supply.
• These barriers are compounded by a short-termist approach within government that is dragging ICSs into more immediate operational priorities over the long-term shift towards integration, equity and prevention that they have been tasked with delivering.
• While ICS leaders identify a number of areas where progress has been made, they also pinpoint areas where progress has been slower than hoped. These include their plans and commitment to supporting greater devolution. There are positive examples of devolved decision-making and provider collaboratives that ICSs will want to build on, but as place-based partnerships and provider collaboratives mature, ICS leaders recognise the need to devolve more decisions and functions to a more local level. That is their intention in the next period of their development.

On behalf of ICS leaders, and to best support ICSs in year two of their existence as formal partnerships, this report makes a number of recommendations to policymakers in government and national bodies:

1. Social care workforce plan: We welcome the NHS Long Term Workforce Plan and call on the government to demonstrate its commitment to supporting the social care sector by developing an equivalent plan for the social care workforce.
2. Capital spending review: We support the government’s commitment to reviewing the entire NHS capital regime in response to the Hewitt review. We call on the government to include in this review the amount of capital funding as well as the complex allocation process, which is resulting in delays in accessing funding that could be used to enhance productivity.
3. New commissioning functions: NHS England (NHSE) should work closely with ICBs to ensure that they have access to the data and the capacity they need to effectively discharge their new commissioning functions and responsibilities.
4. Devolve to evolve: We encourage the government and NHSE to commit to their intention to set a small number of core targets based on outcomes and to give ICSs the autonomy to innovate in how they deliver against these targets.
5. Co-production: We support a shift whereby co-production of national policy and guidance with ICSs becomes the norm, reflecting the planned changes to NHS England’s operating model. This should help to ensure that the support provided through NHSE’s regional and national teams is aligned with what ICSs need.

• Subvert the health and care system: ICSs present a unique opportunity to refocus and rebalance resources into health prevention, early intervention and reducing levels of health inequality.
• Strive for transformation: ICSs are grappling with unprecedented operational pressures and service demand that can, at times, distract from the ultimate goal of transforming health and care provision. These are not binary choices, as progress in one will advance the other.
• Be patient with public health and prevention: Initiatives to support public health will take time to bed in and prove their value and ICS strategy should account for this fact. Leadership has a role to play in ensuring that organisations are empowered to take localised action on prevention and health inequalities. Taking preventative action should not be considered a distraction from immediate challenges, but rather, the solution to manging demand in the long-term.
• Embed awareness of health inequality at all levels, and throughout every programme: Initiatives addressing health inequality cannot be addressed with siloed efforts, it must be a concept that underpins every level of leadership of an ICSs and be fundamental to the system culture.
• Partnership is essential to unlocking health inequalities and addressing unmet need: As ICSs mature, partnership-based programmes and initiatives are forming an increasing part of ICS strategy to tackle health inequalities and improve population health.
• Use information governance as an enabler of data sharing: ICSs can harness data governance to viability improve longevity of partnerships and provider collaboratives.
• Clarify points of entry across the system: Providers of various sizes, in both public and private sectors are experiencing difficulties in accessing the relevant functions of ICSs. Accordingly, ICSs need to provide greater clarity regarding points of entry into the system.
• Diversify leadership across every level: Diversity of perspectives and professional representation at ICB and ICP level will be crucial to the successful delivery of collaborative, integrated care.