A newly unveiled NHS Blueprint signals a significant organisational shake-up aimed at reducing operating costs and restructuring functions within local health systems in England. Tens of thousands of job losses will result to make way for the government’s new ambitions, but how will it help fix rising waiting lists and falling standards?
What is the ICB Blueprint?
Alongside the headlines about drastic staffing cuts at NHS England, there is a lesser-known demand for all 42 Integrated Care Boards, which control local health planning and spending, to reduce operating costs.
In what constitutes a substantial reorganisation, Integrated Care Boards will lose 18 functions to regional teams and local providers. Instead, they will focus on population health, strategy, and contract monitoring, and develop their “leadership” and “healthcare payer” roles. In light of these changes, ICBs will be expected to reduce their running costs by 50%.
Among the transferred responsibilities are workforce planning, primary care, and digital transformation; however, the Blueprint provides scant detail, leaving fundamental questions about how key health functions will be delivered and funded. More is expected in the government’s 10-year plan next month.
What is this change trying to achieve?
The Blueprint is rooted in the findings of the 2022 Darzi review, which highlighted the ongoing struggles of Integrated Care Boards (ICBs) to define their roles clearly, resulting in widely differing responses to the mounting pressures.
As consistently reported by the Lowdown, ICBs have faced relentless financial challenges, forcing them to compromise on service provision, make workforce cuts, and set unrealistic savings targets—decisions often obscured from public scrutiny.
However, it is clear that the Blueprint does not address the core financial and capacity difficulties within our local health systems and is preoccupied with the costs of managing the system. It promotes the idea that reshaping services can be transformational without additional investment. Based on what the Lowdown has observed about the scale of the challenges facing the NHS, this seems wildly optimistic.
The Darzi review also noted that, under the current structure of ICBs, funding continues to disproportionately favour acute hospitals over community providers. This contrasts with the government’s mission to shift services into community settings, believing it to be cost-effective and lessen the pressure on hospitals.
Previous governments have supported this idea since at least the 1990s, but none have followed through. With record numbers waiting and pressures everywhere in the system, to try now is even more ambitious. There is also virtually no detail as to how this might be achieved. Still, three major steps seem crucial: first, increase capacity in the community, make extra investment in people and buildings, and resolve the social care crisis.
With so little meat on the bone—about who will perform the transferred functions and how they will be organised and paid for—the ICB’s central preoccupation remains the savings they need to make. They are in a race to determine how to halve their running costs before the end of the month and then implement these changes by the end of the year.
The impact of cutting jobs and costs at pace is of genuine concern, Jon Restell, Chief Executive of Managers in Practice said:
“The Prime Minister says he’s fixing the Lansley mess, but he risks repeating the mistakes that held the NHS back for a decade. Destabilisation on this scale will affect delivery of government priorities and the public will feel that.
The government urgently needs to tell the country its plan to get the NHS back on its feet and how it will support managers to do that.
Duplication is a red herring. The NHS needs to know what will be done and what will not be done in the future, as a result of these changes.’
How are GPs and Primary Care affected?
Under the Blueprint, primary care responsibilities, including those for GPs, will transfer to neighbourhood teams; however, these teams have yet to be defined or established.
The Blueprint lays out the importance of ‘neighbourhoods’ in the government’s plans, but who will these neighbourhood providers be: GP organisations, NHS trusts, or some new body as yet undefined?
The potential for a disruptive structural change amid the current pressures is already raising concerns for some. Speaking to the Practice index, one ICB executive put it bluntly:
“There’s a lot of aspiration in the Blueprint. But neighbourhood teams don’t exist in the way this assumes. Building those teams takes time, money and leadership. Right now, the worry is we’re cutting before we’ve built.”
And a Practice Manager’s comments signal some of the likely objections.
“We’ve just got used to the current system and now we’re facing more structural change. If everything shifts to neighbourhood level, who do we go to when we need support? Who’s responsible for what?”
Who will take over ICB functions and how will they be accountable?
Some functions will be passed to NHS regions (see table), but provider collectives—including local health and care trusts—will likely take on the lion’s share. However, provider collectives are not public bodies, not required to meet in public, publish papers, or consult communities.
On the other hand, Integrated Care Boards (ICBs) have functions defined by legislation; which makes further legislative changes inevitable at some point.
With more powers being given to providers, what protections will be put in place?
Health unions can already testify to the potential dangers. Hundreds of non-clinical support staff are being forced out of NHS employment by the East Suffolk and North Essex NHS Foundation Trust, as their services are privatised to contracting giant Sodexo.
Many more staff at trusts up and down the country, currently Dorset and Newcastle, face being transferred against their will out of the NHS into “subcos”, companies wholly owned by the trusts, which aim to reduce costs through developing a 2-tier workforce with new employees on inferior terms and conditions, and dodging VAT payments.
The Lowdown has charted how previous NHS reorganisations have already weakened NHS accountability regarding public scrutiny. Our researchers have needed to dig deeper to bring crucial news about the implications of ICB situations to the wider public.
It has always been very difficult for staff to speak out. Despite facing the toughest of challenges, there are clearly strong disincentives for managers to publicly discuss the risks to services and standards. A more accountable system would take the onus from the individual and place it onto the organisation.
Providers already have a duty of candour around the care of individual patients. Greater openness should exist with key policy decisions. It is surely right for the public to see how their local NHS leaders are managing the evident consequences of underinvestment, to see the compromises. In this reorganisation, provider collectives should not be allowed to develop without substantial checks and balances, as accountability is already weak.
Local authorities?
The mission of integrated care was always to encourage partnership, especially after the Lansley competition era. But where does the Blueprint leave key players like local authorities? Again, there is uncertainty – will they have more power in the neighbourhood structure?
A report by the county council network highlights some of the problems
Across England, only nine out of 91 ICB members were councillors, suggesting that this underrepresentation limits the influence local authorities have within these systems. They also say that although more time is spent on partnership, the distraction of immediate pressures has undermined the original goals of integration.
“Local authorities are ‘very cautious’ about pooling further resources with the NHS at a time when finances are stretched, particularly as the NHS is felt to have less focus on living within budgets than councils. Nationally, county authorities have pooled £13.43 per-head from their budgets into the Better Care Fund (BCF) this year; down from £15.56 per capita in 2017-18”
More outsourcing?
The Blueprint says services should be delivered by “the most capable provider”—not necessarily an NHS trust. This opens the door to deeper private sector involvement in collaborative pathways, especially in diagnostics and elective surgery.
Campaigners forced the government to amend its draft NHS legislation as recently as 2021, allowing any individual or organisation to be appointed to ICBs. Therefore, any shift to allow providers more freedom to procure would require additional provisions to protect against privateers influencing the new structures.
The independent provider’s view?
However, the Independent Healthcare Provider Network is not confident that Blueprint changes will give the private sector more opportunities.
“it is vital that on one hand, the transfer of some responsibilities to NHS trusts doesn’t lead to some of the siloed behaviours that ICSs have sought to move away from, while on the other that the development of neighbourhood health teams, and the role of lead providers, creates opportunity for providers of all types to exercise leadership and help shape the healthcare in their areas based on their understanding and expertise.”
They also envisage that ICBs will take a closer look at contracts – confirming the current lack of oversight of outsourced contracts from the NHS side.
“ICBs will be responsible for evaluating impact and outcomes. In practical terms, providers are likely to see more active contract management than has previously been the case”
Will any savings be made?
The FT reported that the government anticipates savings of £750 million per year from changes to ICBs; however, the estimated cost of redundancies of at least £1 billion will not only wipe out those savings but could also leave NHS trusts in even greater debt, unless the government yields to pressure to secure additional funding for the NHS, as called for by the NHS Confederation and others.
So, savings in year one are unlikely, but can they be expected in subsequent years? Well, despite the existence of a short-term transformation fund, we still don’t know how the organisations taking on the work previously done by the ICBs will cover this cost. It’s not guaranteed that all of the work currently being done will still be carried out after the changes have been enforced. If gaps are created in one or more ICBs, whose responsibility is it to highlight these issues and take action to fill them? Both the providers’ collectives and the NHS regional teams, who will take on the lion’s share of these functions, will need extra staff and could significantly reduce these anticipated savings.
Incomplete plans
With many questions outstanding, the 10-Year Health Plan, which should arrive in June, needs to shed far more light on how the new era of neighbourhood-driven health will work.
It is almost certain to require more funding, as current NHS spending, although higher than planned by the Tory government, still falls well short of what is necessary. The 2025–26 NHS budget is projected to increase by only 1.5% in real terms, which is less than half the long-term average growth rate.
Labour should not make the same mistake as other governments by believing that structural changes and efficiencies can compensate for this lack of investment.
To say the NHS is weary of change is an understatement. The gains from the supposed “integration” era that followed Lansley’s disruptive marketisation experiment are unclear. The next moves have to be the right ones.
With hospitals in disrepair and the workforce too small to handle the waiting lists (now growing again), the Blueprint presents a plan with inherent problems. It does not address the system’s lack of capacity or consider how to prevent more disease in the future, and the 10-year plan cannot repeat these flaws.
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