Integrated Care Systems were created to deliver one of the most ambitious shifts in the history of the NHS. Their mission is to move the service from treating illness to promoting health, to knit together primary, secondary, community and social care, and to reduce inequalities across entire populations. These goals sit at the heart of the 10 Year Health Plan and are widely viewed as essential for a sustainable future. Yet the project is already straining under its own architecture. The accountability framework designed to support ICSs is so complex and so poorly understood by local leaders that it threatens to derail the transformation before it has begun. Instead of empowering systems to lead change, the framework risks turning the entire model into another bureaucratic reorganisation that diverts attention away from patients and toward process.
This tension was anticipated in the Hewitt Review. Patricia Hewitt argued convincingly that ICSs must be trusted with greater autonomy and given the freedom to lead on local priorities. But the reality that has emerged is a paradox. While national rhetoric has focused on light touch oversight, ICS leaders still face dense layers of reporting, performance monitoring and financial control from national and regional teams. The lines between local, regional and national responsibility remain blurred. Financial and operational targets, often set on short time horizons, continue to dominate the agenda, crowding out prevention, early intervention and the wider determinants of health. What was meant to be a permissive environment has instead become an increasingly prescriptive one.
This imbalance is exacerbated by the direction of accountability. Upward accountability to NHS England and the Department of Health and Social Care is extensive, frequent and tightly defined. Local accountability, by comparison, remains weak. Relationships with local authorities are still developing and patient involvement in governance is inconsistent, often symbolic rather than substantive. Without strong outward accountability to the communities they serve, ICSs cannot build legitimacy for the long term decisions they are expected to make. They are asked to lead complex reform but lack the authority structures that enable genuine leadership.
The consequence is a system misaligned with its own ambitions. The long term goals of the 10 Year Health Plan cannot be delivered through an audit culture that rewards compliance rather than creativity. Tackling inequalities, shifting investment into prevention and rebalancing resources toward community settings all require discretion, political support and the ability to make decisions that may not pay off within a single financial year. Local leaders cannot deliver this if they are pulled back into a cycle of weekly reporting, rapid turnarounds and centrally driven priorities that reset with every fiscal instruction.
What is needed now is simplification. The accountability framework must be clearer, smaller and more stable. National priorities should be limited to a focused set of long term outcomes, not activity metrics. Local scrutiny must be strengthened so that patients, communities and councils can hold ICSs to account in ways that reflect local needs and local nuance. And ICS leaders need the freedom to allocate resources in ways that match their population’s strategic priorities rather than the system’s short term imperatives.
The risk is not theoretical. Complexity is already demoralising local teams and constraining the innovation the ICS model was designed to unleash. Unless clarity replaces confusion, the opportunity for genuine transformation will slip away and ICSs will become another footnote in the long list of NHS restructures that promised renewal but delivered little change. To unlock the potential of the 10 Year Health Plan, the NHS must first restore the most basic condition for reform. It must create an accountability system that supports leadership instead of overwhelming it.
