Strategic commissioning in transition: the role of ICBs in navigating change

As we edge closer to the publication of the long-anticipated 10-Year Health Plan, it’s becoming increasingly clear that Integrated Care Boards (ICBs) are not just transitional constructs – they are the engine rooms for future transformation. With their strategic commissioning role firmly at the centre of reform, ICBs are being positioned as pivotal agents in shaping a more sustainable, high-quality, and population-focused NHS.

However, alongside this renewed purpose comes a significant challenge: the requirement to reduce ICB running costs by 50%. This is not a minor adjustment – it represents a fundamental shift in how the system operates, and one which must be handled with care if we’re to avoid undermining the very ambition we are seeking to realise.

It’s a delicate balance. On the one hand, there is urgency – we must act quickly to retain talent, maintain morale, and seize the window of opportunity for ICBs to evolve into leaner, smarter commissioning bodies. On the other, we must avoid knee-jerk reductions that strip away core capabilities or destabilise the foundations we’re trying to strengthen.

Maintaining core functions during transition will be essential. Commissioning for continuing healthcare and newly delegated services must remain intact in the short term, even as we explore more efficient delivery models. At the same time, investment in critical enablers such as finance, contracting, analytics, strategy and market management is not a luxury – it’s a necessity if ICBs are to truly deliver on their strategic promise.

The move towards a more rules-based operating model, with earned autonomy and incentives for good performance, is a welcome development. It brings clarity, direction, and much-needed alignment with quality – an area that Penny Dash’s leadership has rightly brought back into focus.

What remains to be seen is how this transformation will be funded and implemented in practice. Regional Directors will be working closely with ICB Chief Executives to define what functions can be streamlined – or even merged – without compromising statutory duties. Areas such as safeguarding, infection control, performance management and communications are already duplicated across providers, regions and local authorities. Careful rationalisation here may unlock meaningful savings.

But cuts alone won’t deliver transformation.

Sir Jim Mackey’s recent reflections point to a more hopeful horizon: using savings from reduced ICB staffing costs to seed a ‘neighbourhood development fund’ or similar vehicles focused on prevention, urgent and emergency care, or frailty. If realised, this could finally tip the balance towards the long-promised ‘left shift’ – a rebalancing of resource and focus towards out-of-hospital care. None of this can be achieved without strategic commissioning activities.

Let’s remind ourselves of what commissioning actually is. With person-centred outcomes at the heart, good commissioning is the continual process of collaborating with providers and the public to design, plan, agree and monitor services.

Commissioning is not one action but many, ranging from:

• Health and care needs assessment for a population

• Clinically based design of patient pathways

• Design of new models of care and service specifications

• Contract negotiation • Procurement (using the provider selection regime)

• Continuous quality assessment

There is no single geography across which all services should be commissioned: some local services can be designed and secured for a population of a few thousand, while for rare disorders, services need to be considered and secured nationally.

It’s encouraging to hear that NHS England recognises the need for transitional support. Allowing in-year savings to be reinvested locally on a non-recurrent basis offers ICBs flexibility to manage risk and protect delivery. But the true test will come in 2026, when any recurrent changes begin to bite.

There’s no hiding from the scale of the task. With continuing healthcare (CHC) costs remaining a persistent pressure – and suggestions emerging that other partners, such as trusts or local authorities, might take on commissioning and delivery roles under formal partnership models – it’s clear that new ways of working will be required.

Strategic commissioning doesn’t mean doing more with less. It means doing the right things, in the right way, at the right level of the system. For neighbourhood health to flourish, ICBs must focus on enabling, collaborating, guiding and investing at a local level, whilst recognising that one size does not fit all, what will be right for one area may not be right for another.

The ambition is bold, the pathway complex. But with the right support, shared learning, and careful navigation, ICBs have a real opportunity to shape a system that is not only more efficient, but more equitable, responsive and sustainable.

The question now is not whether this is possible – but how we make it work.

Recognising that the challenge is great, if you would like to find out more about our thoughts on how we can work in partnership with you to support shaping commissioning for the future, please get in touch .