Background to the report

Integrated Care Boards (ICBs) are responsible for planning and funding health services in England to improve population health and reduce health inequalities in their area. ICBs receive funding from NHS England (NHSE) for commissioning NHS services in their area and are accountable for delivering value for money from their NHS budget. They work in partnership with NHS trusts, primary care providers (such as GPs) and local authorities to address the wider determinants of health and decide what local healthcare services should be provided to meet the health needs of the population they cover. Working through NHSE, the Department of
Health & Social Care (DHSC) has overall responsibility for oversight and strategic direction of ICBs.

The 2024 Darzi review of the NHS concluded that the role of ICBs needed to be clearer and that there were opportunities to reduce duplication with other bodies. In response, DHSC and NHSE announced plans to restructure ICBs so they could focus more on commissioning services. The restructuring also aimed to reduce ICB running costs by half by eliminating duplication and achieving economies of scale.

At the beginning of 2025-26, there were 42 ICBs across England, responsible for total expenditure of £171 billion. They spent £2.2 billion on their running costs in 2025-26 and the remainder on commissioning health services for their local populations. NHSE estimates that reducing running costs will require ICBs to cut staff numbers by around a third, equivalent to around 8,000 posts in total. To help them achieve the running cost reduction, some ICBs have merged or formed clusters. By September 2026, there were 25 ICBs or clusters of ICBs. Current ICB boundaries do not always match local or strategic authority boundaries. In July 2026, the government announced further devolution plans, including a commitment to align ICB and strategic authority boundaries by the end of the current Parliament.

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Scope of the report

This report examines the reforms to ICBs, including progress in changing their size, role and functions, the progress and impact of ICB consolidation and staff reductions, and DHSC’s oversight of whether the objectives of the ICB reforms are being met. The report covers:

  • DHSC’s objectives for the reforms to ICBs;
  • progress in preparing reformed ICBs to be strategic commissioners of local NHS services; and
  • progress in establishing new operating models, making savings, and managing
    associated risks.

Alongside the reforms to ICBs, the government is also proceeding with wider plans to merge NHSE into DHSC by March 2027 and plans for further devolution. These wider changes are not the subject of this report. We do not audit ICBs, so have not evaluated their individual plans or the relative progress they have made. We have examined the direction DHSC and NHSE have provided to ICBs and the assurance they have sought about action ICBs have taken.

Conclusions

ICBs are implementing significant restructures, with the dual objectives of strengthening their role as strategic commissioners and reducing running costs by 43% from previous levels of around £2 billion. To support the changes, NHSE has provided guidance and support on strategic commissioning, organisational restructuring, and redundancy arrangements, and ICBs have responded at pace. Most ICBs have developed new operating models and have substantial workforce reductions underway. Many ICBs have clustered or merged to achieve efficiencies, and some newly formed ICBs are already making progress with plans to improve health in their neighbourhoods.

The reforms have progressed faster than some of the arrangements that are needed to support them. Key aspects of ICBs’ future role, and their relationships with NHSE regional teams and local government, have continued to evolve during implementation. While DHSC and NHSE have closely monitored progress towards reducing running costs, they have less assurance about whether ICBs will retain the skills and capacity needed to deliver effective strategic commissioning. Arrangements for assessing the performance of the reformed ICBs are still developing, which may make it difficult to track how the reforms influence population health outcomes. Closer alignment with local government could bring significant benefits in terms of operational efficiency, prevention services and care in the community. Getting there will be challenging and will require proactive management at all levels of the health service, particularly in the context of wider government reforms. DHSC and NHSE now need to provide greater clarity on the future model for ICBs, strengthen assurance over capability and workforce risks, and establish clear measures of success if they are to demonstrate that reforms deliver sustainable improvements and value for money.

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Press release

View press release (4 Nov 2026)

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