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The first 100 days for Integrated Care Boards

26 January 2023
Gerard Hanratty

This article was first published by LaingBuisson on the 21st December 2022

We have now gone through the 100 day mark, it passed on 8th October 2022, which was just before I delivered a session at the Brown Jacobson Health and Care Conference in Nottingham with Ed Jones from the ICS Network. During our session we looked at the issues which ICBs have faced in being established, what had been some of the main issues in the first 100 days and then what would the face going forward. Given the uncertain political and economic times we live in then there were a wide range of issues to consider.

Establishing ICBs

Rarely has primary legislation that fundamentally changes the legal architecture for a public service gone through Parliament quite as quickly as the Health and Care Bill. Certainly, there has been emergency legislation rushed through, such as the Coronavirus Act 2020, but that is normally to deal with a developing emergency on which a government needs to establish grip. The Health and Care Bill, however, was a planned change to move the public health system away from a competitive system of autonomous bodies to a collaborative system of shared decision making for the benefit of patients and wider local communities which integrated the provision of health and social care. That meant not only a change to the system architecture but also a fundamental shift in culture. Moving at such pace has inevitably led to the need for a bedding in period and gaps in terms of policy for the new integrated approach, these are matters that will need to be addressed during the current financial year.

The speed of change also gave the CCGs, tasked by legislation to support the establishment of ICBs, a challenge in establishing the shadow ICBs, getting their governance and commissioning polices in place, and supporting the appointment of a new board for each ICB. The short delay from an original start date of 1 April 2022 to an actual start date of 1 July 2022, provided a little breathing space but many ICBs are still completing their appointment processes and starting on leadership development for what is a new statutory body. During this period the CCGs also had to undertake their own due diligence exercise for the transfer of their property, rights and liabilities to the new ICBs, with their functions being transferred under the Health and Care Act 2022 and its amendments to the NHS Act 2006.

Overall, this meant the whole system, which was just starting the process of recovery from dealing with the coronavirus pandemic, was stretched further to establish new statutory bodies and still undertake business as usual. It should also be remembered that NHS England were also completing their merger with NHS Improvement at this time, prior to embarking on mergers with Health Education England and NHS Digital, as well as being the statutory body that had to approve and establish the new 42 ICBs.

It is quite remarkable that the new system was in place by 1 July 2022, given that the Health and Care Bill only had its first reading in the House of Commons on 6 July 2021. 

The First 100 Days

During the first 100 days the ICBs have had some significant issues to deal with, such as:

  • Governance – Given the time available to establish the ICBs it was inevitable there would be gaps in governance processes and ICBs have been working hard since 1 July to fill those gaps. This has meant looking at the committee structure and terms of reference they have put in place, as well as the overall map of where functions will be exercised. Getting the structures right is essential for ICBs to meet their commissioning duties and look at how they can integrate service provision with social care.
  • Backlog and Ambulances – The need to reduce the backlog in patient treatment which built up during the pandemic and reduce ambulance waiting times, is clearly important, and does add to the pressure on systems. It has also come at the same time as new legislation is embedded and new structures bed in, increasing the need for ICBs deliver new governance processes.
  • Culture – As mentioned above the new legislation not only introduced a new legal framework but also a cultural change from competition to collaboration. During the response to the pandemic the health and care system built up many good relationships and those have been hugely important to support the change to integrated working with partners.
  • Transformation – It became apparent during the response to the pandemic that how services were delivered needed to change and some temporary measures that were put in place to give capacity are not being developed into permanent changes. There is also a need to meet the timelines that come with the NEW Hospital Programme and so a number of ICBs are now reinvigorating service change programmes that had been effectively suspended due to dealing with the pandemic.
  • Politics and the Economy – The current turbulence has also impacted on the NHS, with a lack of clarity on policy and what capital is available, as well as funding for the system overall. Whilst there is now a move towards some stability the reality is that each ICB will need to look carefully at financial management and policy direction.
  • Workforce – The challenges in maintaining a stable workforce have been apparent since the decision to leave the EU and are increasing as it becomes more difficult to fill posts in health and social care. Whilst the majority of the issues fall on to providers, ICBs need to work in their systems to support solutions to maintain services to the public.

During the first 100 days following the establishment of ICBs, it has become apparent that they and their system partners face a number of pressures to maintain services. Adding in the need to recover and restore following the pandemic, as well as the uncertain political and economic landscape has created a more pressurised environment for these new statutory bodies to grow and function within.

The Future

In moving forward it seems apparent that there will need to be focus on the treatment backlog, ambulance waiting times and workforce pressures. Getting grip on these issues is fundamental to enabling and improving performance across all systems. To achieve that there will need to be greater autonomy given to ICBs and their system partners as they develop so they can create local solutions and implement them quickly. That will also mean clarity needs to be provided on what money is available to the system, will current levels be maintained and increase with inflation or will plans for service transformation through improving estate and embracing digital technology need to be reviewed for a less radical approach.

All public services are under pressure as we enter a recession and face needing to develop innovative workforce solutions. ICBs will be central to working with partners in ICSs to deliver solutions and need to be given the freedom to try new ways of working. However, in the midst of future pressures and uncertainty, it does seem only right to applaud the NHS and their social care partners for delivering and establishing a new way of working. Much remains to be done on changing culture and relationships remain a key part of enabling the new system, but achieving a fundamental change in how the system works whilst dealing with a host of other pressures, including a global pandemic, shows the resilience and ability which these public bodies have to achieve change.



Gerard Hanratty


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