ICBs across England are undergoing a significant structural evolution. Aiming to streamline commissioning and achieve cost efficiencies, clustered ICBs increasingly adopt shared executive teams, chairs, and board members. Health leaders say this consolidation signifies a strategic transition towards larger operational footprints, even though the bodies retain their current legal separation.
NHS England launched a national directive earlier in 2025. That directive mandated Integrated Care Boards (ICBs) to achieve substantial cost-reduction targets, specifically requiring a 50 per cent cut in both running and programme costs. Given their existing population sizes, most ICBs found it unfeasible to meet this significant financial pressure independently. Consequently, clustering, which often leads to eventual mergers, emerged as the primary strategy for achieving necessary economies of scale. As a result, clusters across the Midlands, South West, and East of England now serve large populations and feature more tightly aligned commissioning functions across adjacent geographic areas.
Clustering means multiple Integrated Care Boards (ICBs) keep separate legal status but agree to share senior leadership and governance structures to eliminate redundancy. This differs from a formal merger. Boards increasingly hold joint meetings, establish combined committees, and align their terms of reference to facilitate collective decision-making across the cluster area. Additionally, some boards jointly appoint non-executive directors to enhance shared strategic oversight.
Integrated Care Boards (ICBs) across England adopt diverse, shared governance models to achieve strategic leadership continuity and cost efficiencies while maintaining statutory independence. For example, Birmingham and Solihull and Black Country ICBs share a group of non-executive directors and system partners, retaining their statutory independence while broadening strategic commissioning and delivering cost savings. The Derbyshire, Lincolnshire, and Nottingham Cluster aligns governance through joint appointments and Boards that meet in common, allowing a shared process while each fulfils separate statutory duties. Furthermore, Surrey Heartlands and Sussex began aligning governance in October 2025 with a joint chair and chief executive, preparing their systems for a planned merger in 2026.
A broader 2025 policy drives the shift towards clustering Integrated Care Boards (ICBs), moving ICBs from operational management to strategic commissioning. This aims to eliminate duplication and strengthen capacity to address severe NHS financial strain and efficiency mandates from NHS England. While supporters view this shared governance model as a pragmatic interim solution anticipating further consolidation in April 2026 and April 2027, critics caution that the approach introduces complex challenges by risking the dilution of local focus and confusing lines of accountability, despite potential cost savings. Statutory obligations, however, remain fragmented across individual boards, thereby impacting local accountability and community engagement.
ICB clustering with shared boards introduces one of the most substantial organisational shifts in the NHS since the advent of integrated care systems (ICSs). This change will redefine how organisations execute commissioning, resource allocation, and population health planning for millions of patients throughout England. In the coming months, we will see whether shared governance reinforces strategic commissioning or creates new governance complexities for local leaders and communities.
