The founding promise of Integrated Care Systems was bold. They were meant to replace fragmented commissioning with shared purpose, to bring local organisations together around population health, and to shift the NHS from reactive illness care to proactive prevention. Yet chief executives across the country are now signalling that the central body meant to anchor this vision, the Integrated Care Board, remains “opaque.” This lack of clarity is not a minor administrative flaw. It is driving the system back toward the transactional, contract-driven behaviours ICSs were explicitly created to move beyond. Unless NHS England provides immediate clarity and stability on the mandate of ICBs, the entire integration experiment risks collapsing into another bureaucratic structure that absorbs resources without delivering meaningful change for patients.
At the heart of the issue is the drift back to transactional relationships. When the role of the ICB is unclear, it defaults to the behaviours inherited from the old commissioner-provider model. That means focusing on financial balance, demanding cost reductions, managing risk at arm’s length and policing contractual compliance. Instead of shared accountability for population outcomes, Trusts find themselves once again negotiating activity levels and financial penalties. This recreates the adversarial dynamic ICSs were supposed to eliminate and distracts leaders from long-term system redesign.
The opacity also paralyses decision-making. CEOs do not know whether the ICB is meant to be a strategic partner, a regulator or simply a budget holder. Without clarity, Trusts hesitate to invest in new pathways, delay collaborative programmes and focus instead on short-term survival. Projects designed to improve prevention, community capacity or cross-organisational working stall because nobody can confidently predict how the ICB will interpret its role in funding, governance or oversight. This uncertainty creates inertia at a time when the system needs bold action.
Confusion over accountability makes this worse. The ICS model was supposed to decentralise power and place responsibility closer to populations, but vague lines of authority mean that leaders are unsure who is accountable when performance deteriorates. Is it the provider Trust, whose operational grip shapes day-to-day care? Is it the ICB, nominally responsible for system strategy? Or is it NHS England, which continues to exert pressure through performance targets and regulatory escalation? When responsibility is diffused, accountability weakens, and integration becomes little more than an aspiration rather than a functioning governance model.
The solution is not more structure but more clarity. NHS England must define a simple and durable mandate for ICBs. Their responsibilities should focus on strategic commissioning, population health improvement and long-term system planning. Provider Trusts must retain clear responsibility for operational delivery, workforce leadership and quality control. The metrics used to judge ICB performance must shift from activity-based indicators to outcome-based goals that measure genuine change in health, inequality and long-term sustainability. Without this, ICBs will remain trapped in a cycle of transactional oversight rather than becoming the collaborative leaders they were designed to be.
Trust between system leaders will be essential. Integration cannot flourish if financial pressure is used as a lever for dominance rather than as a shared challenge to be solved collectively. The opaqueness that currently defines the relationship must give way to transparent governance, open dialogue and joint ownership of both risk and ambition.
The warning from chief executives is unambiguous. Opacity breeds bureaucracy, and bureaucracy suffocates integration. The NHS cannot afford to let ICBs become complex, expensive replicas of the structures that preceded them. If the ICS model is to deliver on its promise, the government and NHS England must define the ICB’s role clearly, consistently and without further delay. The future of NHS reform depends on it.
