‘Given the variation in integrated care system constitution and size, it was right that the government chose to be legislatively permissive. It was important to allow ICSs to create the architecture and governance … that enabled them best to serve their population. But as ICSs come towards the end of their first year as statutory entities, there is a valuable opportunity for them to learn from each other as well as from their own experience and adapt accordingly.’ The Hewitt review - an independent review of integrated care systems - April 2023
Integrated care boards (ICBs) are new organisations in the NHS in England, albeit with a long pre-history. ICBs are responsible for developing plans for meeting the health needs of the population, managing the NHS budget, and arranging for the provision of health services in their defined geographical area. As statutory bodies, many were built in a hurry during the Covid-19 pandemic and faced massive hurdles from the outset. In March 2023, NHS England challenged ICBs to reduce their running costs by at least 20% in 2024/25 and 30% by 2025/26.
ICBs must make these cost reductions at the same time as implementing the strategies they have recently developed and committed to delivering for their local populations. ICBs must also continue to focus on a demanding range of priorities and requirements, including recovering core services, delivering the key ambitions in the NHS long-term plan, and transforming the NHS for the future.
In this context, it is unsurprising that ICBs vary significantly in both size and structure.
Analysis of this variation provides useful insight and an opportunity for ICB leaders to learn from others, as they consider what more they can do to align their organisations behind their priorities – and as they look to reduce running costs. PA Consulting analysed the published organograms of all 42 ICBs to understand the composition, size, structure, and costs of ICB boards and executive-level roles. In the absence of an agreed best practice, this provides insights and learning from actual ICB data that ICB Leaders can use to optimise their own organisational shape and structure.
Variation in the size and costs of ICBs
The size in full-time equivalents (FTEs) in ICBs varies between 90 and 1,578. When we analysed the average FTE of an ICB adjusted for their population sizes we found there was significant variation across the country, with a median of 0.27 FTE per 1,000 population. One ICB has 0.14 FTE per 1,000 population and one has 0.76 FTE.
It is difficult to conclude on a definite driver for the variation, but it may suggest that some ICBs have already proactively done more work on their operating model and organisational structures than others, as they have brought together, merged, and de-duplicated constituent clinical commissioning groups’ (CCGs) headcount and functions. Making a further 30 percent cost reduction is likely to be a very significant challenge for these ICBs (and perhaps also an unfair one, if such cost-reduction rigor has already been applied before the blanket 30 percent was announced).
The variation in size among ICBs is mirrored in the reported running costs per FTE. The median running cost per FTE stands at £61,000, while the highest reported cost exceeds £85,000. When adjusted for population size, the costs per 1,000 population range from £8,320 to £32,000, with a median of £15,000. Although the exact driver for this variation remains inconclusive, based on publicly available data, it indicates that differences in ICB structures may play a role, such as variations in seniority or higher banding across different ICBs.
These cost differences highlight the need for further exploration into the factors influencing running costs within ICBs. It is possible that variations in organisational structures and the allocation of resources contribute to the range in reported costs. Understanding these factors and their impact on costs can help ICB leaders identify opportunities for optimisation, ensuring efficient resource allocation while delivering high-quality care to their respective populations.
Who sits around the ICB executive table?
There is significant variation on both the size of ICB executive teams and the range of roles these represent. The guidance on board compositions only mandates the finance, nursing, and medical roles at board level.
The number of executive directors on an ICB board ranges from five to 14 – nearly a three-fold difference – although 12 ICBs (29 percent) have 10 or more executive directors. There appears to be little relation between the size of the executive board and the population served – for example, the two largest ICBs by population size, have nine and seven executive directors respectively, far from the largest executive director team. This means that most ICB executive teams are at the upper end of – or above – commonly-cited figures for the optimal size of an effective executive team (which varies from around four to 10, including the chief executive). This is perhaps reflective of the wide range of roles and perspectives that ICBs are expected to incorporate – but is clearly a risk to the decision-making effectiveness of larger executive teams.
In terms of the roles represented on ICB executive teams, there is also significant variation, other than in the three mandated roles (finance, medical, nursing). The top 10 functional groups represented in ICBs are:
- people/ workforce: 83% of ICBs have this role
- operations/ delivery/ performance: 79%
- strategy: 64%
- transformation: 45%
- place: 40%
- digital/ data/ intelligence: 38%
- corporate affairs: 31%
- communications and engagement: 29%
- partnerships: 26%
- primary care: 26%
Observations and conclusions
Of course, board structures and job titles only provide very basic indications of how ICBs are operating, and of their relative priorities. Nonetheless, this analysis does allow us to draw some initial, broad conclusions about ICBs and how they might work, including:
ICBs are taking the NHS’ people and workforce challenges seriously
More than 80 percent of ICBs have a board-level position dedicated to workforce.
‘Places’ lack a specific, board-level voice in most areas
Just four in 10 ICBs have place directors at the board table. This is despite the consistent and widely articulated desire for place to be the ‘engine room’ of change. This suggests that there is a risk of place and place-level priorities being marginalised in many areas unless there are strong mechanisms for place voices to be present at board level. The risk that places will be marginalised is exacerbated by cost reduction, and by the unwillingness in many areas to establish the financial governance arrangements necessary to sustain meaningful delegation (seen by some as ‘re-creating CCGs’).
Confusion about strategy and transformation
More than half of ICBs (24 out of 42) have either an executive director of strategy or executive director of transformation. A further 11 ICBs (26 percent) have both, and the remaining seven (17 percent) have neither. This suggests a difference in view on both the importance and the definition of the roles, which will be critical in ensuring that ICBs can focus their time and resources on long-term improvements as well as operational priorities.
In most areas, digital and data are not being prioritised at board level
Around four in 10 ICBs (38 percent) have an executive director focusing on digital, data or intelligence. Digital transformation will feature prominently on all ICBs’ agendas – but there is a clear difference of view about whether it is significant enough to warrant its own executive position, or whether it can be picked up as part of a larger portfolio. This, therefore, provides an opportunity to assess the extent to which progress on an important, but tricky agenda can be influenced by executive structures.
A natural experiment on innovation
Five ICBs (12 percent) have a dedicated ‘innovation’ role at board level. This provides an opportunity to develop the NHS’s thinking in relation to a famously difficult question – how best to drive innovation (and the adoption of innovation) within health and care systems. We can consider whether senior appointments focused on innovation can really make systems more innovative and, if so, what kinds of actions innovation leaders end up taking to drive this change.
Some ICBs are using structures to signal particular priorities
A small minority of ICBs have board-level posts focusing on equality, diversity and inclusion, adult social care and children and young people, presumably reflective of key strategic priority areas. Again, time will tell if executive level appointments outdo establishing transformation programmes to drive improvements in these areas. There is an opportunity to focus and represent at board level the key objectives for the ICB and the entire system.
Opportunities from emerging ICB structures
ICB size and executive team composition vary significantly across the country. Some of this variation may be entirely appropriate, given the differing populations and priorities that ICBs are serving. However, it is likely much of it reflects each area’s local perspective about how best to use the levers of organisational structure to pursue objectives that are relatively consistent across the country.
These structures cannot all be equally effective. In time, a preferred, more standardised version of an ICB structure will emerge.
Within such a complex and changing system landscape, identifying the right lessons will be challenging, and learning from them even more so. Nevertheless, we see an important window of opportunity to use the current variation in the way that ICBs are set up to advance our understanding about what works. In this window, ICB leaders can learn from each other about which structures and roles are most effective, including what changes could be made to cut running costs by at least 20 percent in 2024/25 and 30 percent by 2025/26.
More details at NHS | PA Consulting
Michael West, PA healthcare expert Connect
Gareth Fitzgerald, PA healthcare expert Connect
Matthias Winker, PA healthcare operating model expert Connect
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