With the new role of ICBs as strategic commissioner, alongside tighter budgets, targets and the three shifts to achieve, it’s likely that effective decommissioning will become more important across the system.
Decommissioning, which is the planned process of removing, reducing or replacing a service, is not new. Many ICBs already had a policy for this before the unveiling of the changes to the NHS last year, including North East and North Cumbria ICB whose first version of their policy was released in April 2023.
However, decommissioning has been explicitly called for by NHS England in this new phase of organisation of the NHS.
In the strategic commissioning framework, published in November 2025, NHS England said while ICBs were already carrying out the four stages of strategic commissioning, ‘now is the time for a more comprehensive and consistent approach across all ICBs.
‘This requires commissioners to be bold and rearrange and, potentially, decommission services to secure the best possible health outcomes, quality of services and value for the taxpayer, while ensuring they continue to reduce healthcare inequalities,’ it added.
Sarah Walter, deputy chief executive and director of the ICB Network at NHS Alliance, says: ‘Every ICB is likely to be exploring options for decommissioning’.
However, with ICBs in varying states of maturity given the clustering and merging that has been happening over the past year, they are at different levels of reaching that ideal strategic commissioner role. They are also facing different levels of cuts to their budgets and therefore different levels of decommissioning.
‘Our members have identified that decommissioning is a key element of their strategic commissioning approach,’ says Ms Walter. ‘This will include a focus on quality, patient safety and experience as well as making sure the kind of services they commission are delivering for their populations both now and in the future.
‘There’s also the question of ICBs needing to look at how they can secure maximum value within limited financial constraints. To do that they may need to change how services are delivered; this might include a decommissioning element as service delivery is shifted into the community.’
So, given these factors, what are ICBs actually cutting and how are they making those tough decisions?
Deciding what to cut
ICBs have faced calls to be ‘bold’ in their decommissioning, but the reasons behind it will look similar to before, whether that’s factors around value for money, clinical priorities or the quality of the service.
It is the definitions of those factors that have changed. For example, value for money might now mean something different to before the funding envelope was squeezed. Services may also no longer be a clinical priority following the three shifts and focus on neighbourhood health.
But, while there has been a steer as to what principles need to be followed regarding strategic commissioning, with the framework calling for commissioning to ‘secure the best possible health outcomes, quality of services and value for the taxpayer, while ensuring they continue to reduce healthcare inequalities’. Ms Walter says it could be clearer on decommissioning.
‘There’s been a clear steer nationally around the approach to strategic commissioning, but less so nationally around decommissioning,’ she says.
‘It’s hard to get a national picture of what’s been decommissioned, because it’s not something that’s being measured,’ adds Ms Walter.
It’s also relatively early in the restructuring process, with changes to ICB footprints only going live in April.
What decommissioning looks like is likely to vary across ICBs, with different areas needing different levels of cuts.
‘Decommissioning could be relatively small-scale contracts or ‘low value’ service provision or could involve really significant service reconfiguration. So, there’s quite a big range in terms of what decommissioning looks like,’ says Ms Walter.
Some of the more common ones are around reducing rounds of IVF and gluten free prescribing, Healthcare Leader understands.
For example, a spokesperson for South Yorkshire ICB says: ‘The most recent areas considered by the ICB board were gluten-free prescribing and IVF cycles.’
In South East London (SEL) ICB, the areas of Bexley and Greenwich recently decommissioned a long Covid rehab service, according to the ICB.
A spokesperson says: ‘They still provide the warfarin services, but ‘long Covid rehab’ patients from this borough are now referred to the services provided by Guy’s and St Thomas’ NHS Foundation Trust and King’s College Hospital NHS Foundation Trust.’
They add: ‘SEL ICB is accountable for creating the best value for our population from our allocated budget. Fulfilling this remit could involve decommissioning services in the future, to ensure that we are improving population health, reducing health inequalities and ensuring our population has access to equitable and consistently high-quality healthcare.’
Humber and North Yorkshire ICB says that the recent changes to the NHS will be informing its decisions.
A spokesperson for the ICB says: ‘Clearly the direction set out in the 10 Year Plan and the ‘three shifts’ will require NHS commissioners to change the model of our provision and this will require decommissioning.’
However, it did not state what it would be decommissioning.
The newly created Thames Valley ICB meanwhile is looking at places where there are ‘significant imbalances’, according to a recent document from Oxford University Hospitals NHS Foundation Trust Board, which discussed an overview of ICB commissioning intentions.
This document referenced the ICB’s strategic intentions, saying they had a decommissioning programme to ‘decommission where there is a significant imbalance of resource investment for marginal outcome improvement’. However, the ICB did not respond to Healthcare Leader’s questions on this programme.
Ms Walter highlights that some newer ICBs in particular might face some complex decommissioning decisions.
‘Some of the newer ICBs are also inheriting a new patch as a result of ICB mergers or clustering, which often involves complex contracting arrangements – for example over 1,000 contracts in one geography – which could be very difficult to manage,’ says Ms Walter.
‘Systems will be looking through these inherited arrangements and exploring how they can make their contracting approach more efficient.’
However, recently merged West and North London ICB says it has no plans for decommissioning at this time.
‘As strategic commissioner and ICB we regularly review services to ensure we are meeting needs of local people across our 13 boroughs, and adapt to the changing health of our population, it is important we do this in order to get the best value for taxpayers money,’ a spokesperson says.
How are the cuts happening?
In the places where decommissioning is taking place, the process varies depending on the programme and circumstances.
‘In some areas decommissioning will be the end of a contract which you don’t renew. Or that you do something different, in which case it would naturally close down what was being delivered,’ says Ms Walter.
‘If it’s more of a planned, proactive approach, it’s likely to involve looking at the service area, doing an impact assessment and building your case for change. It will include engaging with stakeholders, patients and the public, and reviewing potential options, then getting to the formal decision-making process and implementation. In some areas you may have to do more of a formal consultation, but that will depend on the legal context for the change.’
NHS England also highlighted in its strategic commissioning framework that decommissioning will need to happen on the grounds of poor quality contracts, via ‘rapid quality reviews and quality improvement groups’.
So, while some contracts could wind up quite quickly, there could also be lengthy evaluation processes in order to decommission other services.
However, South Yorkshire says decommissioning is already ingrained in their work as a board, with ‘reviewing contracts and services [being] a continuous cycle’, while North and West London ICB adds it ‘regularly reviews services’.
Humber and North Yorkshire is also reviewing its approach.
‘The ICB is currently considering its decommissioning approach making sure we take account of our statutory duties for example those set out in the ‘triple aim’ of ICBs, and including public sector equality duties as well as consultation and engagement with patients and public,’ says a spokesperson for Humber and North Yorkshire.
Other ICBs have already developed policies around this area.
‘There are a number of ICBs who have developed decommissioning or disinvestment policies, or commissioning for value policies. This is to ensure they have clear principles and a process for taking these decisions,’ says Ms Walter.
‘It’ll be part of their wider strategy, trying to see how they can create better sustainability of the system, based on their understanding of their population and some of the key challenges they’re facing.’
Gerard Hanratty, health and life sciences partner at law firm Browne Jacobson, who helped advise Cornwall and the Isles of Scilly ICB on its decommissioning policy a couple of years ago, says the statutory changes that are coming in will play a role in how decommissioning plays out.
‘The process for decommissioning is within the statutory framework, so it needs to align with the overall view that’s indicated between health organisations and the local authority, and the movement now towards having mayoral involvement,’ says Mr Hanratty.
‘Some bits of decommissioning will be relatively straightforward, perhaps there’s a new treatment in,’ he adds. ‘But other bits will take a bit more in terms of understanding what’s happening and when you’re in that place as well you have to think about how you’re going to involve the public, as there’s a specific duty on that.’
Mr Hanratty adds that the health bill is also bringing in the ‘ability for the secretary of state to issue regulations which will allow individuals to effectively appeal individually the decision of an ICB on commissioning’.
‘It’s an interesting move,’ he says. ‘I guess it’s an attempt to reduce the ability for people to go to judicial review and to go straight to litigation.
‘How well that is going to work is open to interpretation, because ICBs could get overwhelmed. If you look at CHC [continuing healthcare] and the number of times that is challenged, if you think about that potentially across all commissioning decisions – that could be quite significant.’
However, he adds that that the impact of this remains unknown until it’s put in place.
Challenge of evidence
ICBs are also facing calls to ensure any decommissioning decisions are ‘evidence-based’.
However, Ms Walter highlights that this can be difficult as the data is not always there.
‘Ideally, it should be an evidence-based process, but we don’t always have the right evidence or data. Shifting care upstream and into the community is a priority area for ICBs, but it can be quite hard, as we know, to demonstrate the cost saving and improved patient outcomes of moving a service from one setting to the other,’ she says.
‘So that could be a real barrier to actually decommissioning the service in one area and commissioning somewhere else, because until you move the service, it can be hard to demonstrate that it’ll have that cost saving and will improve outcomes.’
She adds that some of the ‘biggest areas of opportunity’ will be ‘within those more challenging areas of change such as large-scale reconfiguration, rather than decommissioning decisions made at a smaller scale’.
There is also the challenge of patients and other stakeholders. There will always be patients, clinicians and politicians pushing for certain services, which may not align with each other.
A 2015 study that looked at 123 National Clinical Advisory Team reconfiguration proposals for hospital services, published between 2007 and 2012, suggested that ‘despite significant pressures to reconfigure services, many proposals fail to be implemented owing to public and/or clinical opposition’.
‘Stakeholder engagement and collaboration that includes clinical leadership is really important,’ adds Ms Walter. ‘Lack of effective engagement can make the decommissioning process more challenging.
‘Building a positive case for change and having honest conversations with stakeholders about what they’re doing and why, can help make decommissioning a smoother and more effective process.’
