Integrated Care Boards were created to do more than manage day-to-day pressures. They were meant to shape the future of healthcare in their areas, shifting resources towards prevention, strengthening primary care, and improving services for groups with specific needs such as people with learning disabilities. Yet new figures show that ICBs across England have underspent by more than £100 million in funds set aside for these very purposes.
The money was ringfenced for transformation, the type of investment that aims to reduce future demand on acute services by keeping people healthier for longer and addressing inequalities in access and outcomes. Instead, significant portions of it have gone unused. That is a missed opportunity for both patients and the health system.
The underspend is spread across three priority areas. Prevention funding could have supported initiatives to reduce smoking, tackle obesity, improve vaccination uptake, or expand community health programmes. Investment in learning disabilities could have strengthened specialist support, made services more accessible, and addressed long-standing gaps in provision. Primary care funding could have bolstered GP capacity, expanded multidisciplinary teams, or improved digital access to routine care.
The reasons for the underspend are not fully detailed, but the possibilities are familiar. Delivering transformation requires not just funding but the capacity to plan, implement, and sustain new services. In a system where leaders are focused on meeting immediate targets and managing financial pressures, long-term change often slips down the priority list. Staffing shortages, delayed decision-making, and competing operational demands can all slow progress.
Some ICBs may also have been cautious about committing to programmes without certainty over future budgets. If funding streams are short-term, there is a risk of creating services that cannot be maintained once the initial money runs out. That caution may be understandable, but it undermines the very purpose of transformation funding.
This underspend comes against a backdrop of wider concerns about NHS finances and transparency. Recent warnings from think tanks about ministers presenting a “misleading” view of waiting list reductions highlight the tension between headline achievements and the underlying reality. ICBs are under pressure to meet tight financial targets, often in-year, and that pressure can drive decision-making towards the immediate and measurable, rather than the strategic and long-term.
Failing to spend transformation funds has consequences. It delays progress in prevention, which could help reduce the burden on urgent and emergency care. It slows improvements in primary care, which plays a crucial role in managing chronic conditions and keeping hospital admissions down. And it leaves people with learning disabilities waiting longer for the changes they have been promised.
If the NHS is to move beyond firefighting, transformation funding must be treated as essential, not optional. That means giving ICBs the support and flexibility to deliver programmes, ensuring multi-year commitments so services are sustainable, and holding boards accountable when ringfenced funds are not used for their intended purpose.
The aim of the integrated care model is to create systems that prevent illness, tackle inequalities, and join up services around the needs of communities. Underspending in these areas suggests that vision is still some way from being realised. The challenge for NHS England and the government is to ensure that when money is allocated for transformation, it is both spent and spent well.
Transformation funding is not just another budget line. It is the investment that determines whether the NHS will be better equipped to meet future demand. Allowing it to go unused is not only a missed opportunity, it is a step backwards.
