3. Ensure clarity on national policy and principles for deciding new boundaries

Throughout 2025/26, ICBs experienced changing and sometimes inconsistent national policy around the implementation of their cost reductions. Most notably, this included prolonged uncertainty around national funding for ICB redundancies, which delayed the launch of their restructures. Changes to the initial direction on their functions set by the Model ICB Blueprint impacted the development of their operating model. 

Taken together, these factors exacerbated the complexity of creating new organisations, both in terms of organisational change and developing a strong vision for the new ICBs. The government should ensure the next wave of ICBs has clarity on their functions and responsibilities and that any national policy changes that would impact on their ability to progress the merger is communicated as effectively as possible. 

Support for merging ICBs was stood up at speed compared to previous reorganisations that had longer lead-in times due to legislative changes, such as the closing down of CCGs. Although ICBs clustered quickly, decision-making around statutory boundary changes is a lengthier process that requires input from national leadership. ICB leaders described being under considerable pressure to prepare for 1 April. In future, earlier decisions on boundaries would give ICBs as much time as possible to prepare, supporting a smoother and more effective transition. 

The government has also taken this opportunity to increase boundary alignment between ICBs and mayoral strategic authorities to align strategic planning and support a ‘health in all policies’ approach. It committed in the 10 Year Health Plan to ‘make ICBs coterminous with strategic authorities by the end of the [10 Year Health] Plan wherever feasibly possible.’ Decision-making around ICB mergers and boundary changes must consider this commitment, but this is made more challenging by the different timeline for devolution, variation in the establishment of mayoral strategic authorities and ongoing local government reform.

ICB leaders highlighted that, given the complexity and trade-offs in boundary decisions, co-production between both DHSC, MHCLG and ICBs, as well as engagement with local authorities and politicians, is essential. One leader reflected that, while their new geography now aligned with their local authority, a trust that was previously within a single ICB is now split across two, creating additional commissioning complexity. Making sure that all relevant partners are engaged and clear about the process for decision-making can mitigate some of the pitfalls of the political nature of these decisions. 

Form should follow function, with new boundaries supporting ICBs’ purpose as strategic commissioners and enhancing partnership working with local government and strategic authorities. The government should be clear on the rationale for boundary changes and how they will ultimately serve to integrate public services and improve people’s health and wellbeing.