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In Norse mythology…
… a wolf, Fenrir was repeatedly tricked and bound by the gods out of fear of his growing power.
We'd call them ICBs…
… either they are the fulcrum point of care, for the future…
… or, interlocutors for the DH+, regions, local government and their health system…
… or, caretakers until regions get organised and Trusts sort themselves out as Integrated Health Organisations, to take over local health economies.
For certain, they’re places where people are under threat of redundancy and managers under pressure deliver a complex and impenetrable strategic framework…
… uncertainty, part of the working day.
NHSE’s Strategic Commissioning Framework is meant to describe the future role of ICBs.
Read carefully, it does.
Read realistically, it exposes a widening gap between ambition and reality.
On paper, ICBs are the NHS’s strategic brains;
- population health stewards,
- pathway designers,
- payers,
- market shapers
- evaluators
In practice, they’re being told to halve their running costs, shed staff through voluntary redundancy, merge with neighbours, and…
… await the outcome of a wider NHS reorganisation that we know will see much of their influence absorbed by large provider Trusts.
That is not strategy; it is organisational purgatory.
The Framework sets a high bar.
Strategic commissioning is not clerical contracting. It requires deep population analytics, health economics, outcomes evaluation, sophisticated contracting, data shovelling and sifting and the confidence to shift resources.
It assumes skilled people, continuity of expertise and institutional memory, yet…
… many ICBs are now reducing headcount without any clear view of the minimum skills and capacity required to do the job.
We can agree, there are too many ICBs… obvious from the start.
Amalgamations are inevitable and sensible, but…
… mergers undertaken primarily to meet running-cost targets risk stripping-out precisely the strategic capability the Framework depends on.
Amalgamations, creating a bigger footprint do not automatically mean better commissioning. They often mean weaker local intelligence and slower decision-making.
At the same time, there’s a growing, barely acknowledged tension…
… if ICBs shrink too far, Trusts, already the dominant economic force in many systems… will naturally step into the vacuum…
… the risk is gravitational pull.
Providers with scale, data and management capacity will increasingly shape ‘the local health economy’, leaving the ICB as a thin oversight shell…
… blurring the crucial separation between payer and provider. We know how that ends, and...
... making a proper transfer of care into community settings, impossible. The necessary shift in tariff will never happen.
Running an ICB today. What matters most? I'd say five things...
1.Brutal clarity of purpose.
Strategic commissioning is the core. Everything else is secondary.
If a function doesn’t directly support population-health intelligence, pathway redesign, resource allocation or outcome evaluation, it’s a candidate for pooling, sharing or stopping.
Salami-slicing teams is the fastest way to destroy strategic capacity even though it appears fair.
2.Identify and protect the scarce skills that actually make commissioning work;
- Data analysts,
- health economists,
- contracting specialists,
- service designers
- performance evaluators…
… none are interchangeable with general management posts. Lose them and the ICB becomes a talking shop with a cheque book but no steering wheel.
Analysts? By 2030, the demand is projected to zoom from 13,000 to approximately 35,000. We’re not growing enough.
Before making VR decisions; who have you got, who do you need, who can you retrain?
3.Workforce design must assume fewer people, but not less capability.
That means federated analytics across ICBs, shared commissioning hubs, secondments with local authorities and providers and serious investment in digital and automation.
Reducing headcount without redesigning the work is not efficiency; it's wishful thinking.
4.Pick a path through the complexity.
There are three models emerging.
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A ‘lean strategic hub’; retaining a tight core. Relying heavily on shared services.
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A ‘networked commissioner’ model; pooling capability across neighbouring systems while preserving local insight.
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A ‘provider-lean’ model; where commissioning influence migrates to Trusts, with the ICB reduced to oversight and assurance.
Each has risks. The worst option is drifting into one by accident.
5.Leadership.
Honesty matters. Staff can cope with bad news; they struggle with ambiguity and silence.
Offering voluntary redundancy without a clear future operating model signals confusion, not confidence.
Strategic commissioning requires long-term thinking and we know leaders are being forced into short-term organisational firefighting.
Few NHS leaders have the experience to call on, to manage complication on this scale and those that do will very likely, take the money and run.
None will have managed through complexity, confusion and organisational chaos,
The Framework is not wrong, but…
… it is written as if time, stability and skills were plentiful.
They are not.
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