Integrated care boards (ICBs) are currently navigating swingeing cuts, as teams across England implement the government’s instruction last year to slash their workforce by 50%. Just this week, a new report from The Health Foundation found the cuts to have left staff ‘on their knees’ and resulted in ‘terrible, terrible morale’. Reporter Fiona McDonald spoke to health policy expert, Nigel Edwards about what it all means
NHS policy specialist Nigel Edwards is no stranger to NHS reorganisations, having seen successive governments bring in a range of different structures including health authorities, primary care trusts, clinical commissioning groups and then in July 2022 integrated care boards. Less than three years later, these latest cuts were called for in March 2025.
He says that when the 50% cuts were announced, ‘it looked like it was slightly politically performative,’ adding that ‘50% is a funny number to just come up with out of nowhere.’
He said there is a ‘slightly illogicality of this’ all and that if the government is about devolving care down to place level, ‘you might cut 50% at the top’ and then 25% lower down, ‘you don’t cut 50% right the way down your system…it should be on a gradient’.
The former chief executive at the Nuffield Trust continued: ‘I think, to be honest, the headcount reduction was made before any thinking was done about what the role of the ICB is. [It is] being done in a completely disconnected way.’
Allow providers to do more heavy lifting
Elaborating on this, he said: ‘I suspect that they are struggling now to try and work out how they can do all these things that they’re required to do because it wasn’t thought about, because the plan wasn’t done before the announcement.’
He pointed to ‘a whole list of things’ which ICBs have to do by law, with duties or responsibilities that need to be discharged, such as continuing healthcare commissioning and the commissioning of primary care.
He continued: ‘I think there is something to be said for commissioning being more about strategy, holding systems to [be] accountable for outcomes, than it is about trying to micromanage the way that healthcare is delivered via contracting and procurement.
‘The headcount reduction almost necessitates them being strategic, because they may not have the resource to do anything else,’ adding that ICBs, will need to ‘devolve and delegate’ and allow providers to do ‘more of the heavy lifting’.
Loss of expertise
Mr Edwards said the result of so much reorganisation ‘is a continued loss of expertise and knowledge’.
‘Every time you do one of these organisations’, he said, ‘you burn up at least a year or so of management time thinking about reorganisation, and then another six to nine months working out what to do with the new organisation.
‘So, you lose a good 18 months, if not two years of forward momentum.’
He added: I think, [what] one would say is that people are making the best of what has not been a brilliantly thought through exchange process.’
The Health Foundation’s report, published after this interview took place, is a result of interviews with NHS senior leaders, local government and organisations in four ICSs in England, that pointed to the ‘human impact’ of the government’s cuts on the staff delivering the services.
Primary care must maintain relationships
As for where primary care figures in these changes, Mr Edwards urges them to maintain existing relationships as ‘historically, the commissioning of primary care has been done almost like a separate activity.
He continued: ‘There’s a lot of technical knowledge you’ve got to have to be able to do that commissioning…It’s not so easy to just bundle it in with all of the rest of commissioning.’
He said that successive rounds of changes risk ‘disrupting’ expertise and relationships in primary care.
‘I think people in people working in primary care, need to be really watching about who is going to be doing what, and trying to make sure that some of those relationships are maintained.’
