The NHS is undergoing one of its most significant structural shifts in a decade. Integrated care board (ICB) mergers – some of which are set to take effect from April 2026 – and clustering for other ICBs (remaining separate organisations but working together across larger footprints) are reshaping how care is planned, funded, and delivered across England. While these changes are mostly driven by cost reduction imperatives, they also present an opportunity to modernise commissioning and design more integrated, outcome focused pathways across regional systems.
For organisations like Feedback Medical, which work at the intersection of technology, workflow redesign, and clinical behaviour change, the new environment opens meaningful doors to support systems in delivering simpler, more consistent patient care.
The reduction of ICBs from 42 to around 26 is intended to streamline governance and clarify accountability. Newly merged boards will take on a strengthened role as strategic commissioners, overseeing long‑term planning, resource allocation, performance evaluation, and pathway redesign across larger and more diverse populations.
This transformation is supported by NHS England’s new strategic commissioning framework, which places ICBs at the centre of planning. It sets out the requirement for a four‑stage commissioning cycle grounded in high‑quality data, strong partnerships, and population insight.
Strategic commissioning: A bigger arena for better outcomes
So why the focus on strategic commissioning? The government sees this as necessary for the NHS to better manage rising demand without the need for an ever-increasing share of government spending. It is also intended to help drive the three shifts in the NHS 10 Year Health Plan: from hospital to community, sickness to prevention and analogue to digital.
For ICBs to shape these reforms, commissioning needs to evolve from transactional contracting with individual providers to better management of a resident population’s needs, particularly in the delivery of neighbourhood health models.
NHS Confederation’s vision of strategic commissioning defines it as: “The pursuit of the best possible health outcomes for a given population and experience for patients through the planning, purchasing, evaluation, integration and transformation of services, promotion of self-care and exercising system leadership to that end.”
Shifting to larger footprints
The shift to larger ICB footprints positions commissioning teams to address population health needs on a broader scale. This matters because strategic commissioning relies on three things: scale, consistency, and connected data.
Larger ICBs aim to bring all three:
- Scale enables commissioners to take a whole‑system view – aligning investment across acute, community, diagnostic, and prevention services rather than designing isolated interventions. For example, the Model ICB Blueprint emphasises the need for ICBs to become expert at commissioning entire end‑to‑end pathways, including risk management, neighbourhood health, and long‑term condition management.
- Consistency becomes achievable when previously fragmented systems merge. Variation in referral policies, digital maturity, governance processes, and quality measures currently creates postcode‑dependent experiences for patients. Mergers allow commissioners to standardise pathways, unify quality standards, and adopt a single commissioning strategy aligned to shared population outcomes.
- Connected data is the foundation for evidence‑based commissioning. The new framework requires ICBs to use joined‑up data, patient feedback, and partner insights to identify inequalities, analyse unmet needs, and evaluate what works. Larger merged organisations will have broader access to datasets across health, social care, and community services – offering richer visibility of population risk and demand patterns.
For Feedback Medical, this environment amplifies the value we bring. To overcome the issues that the NHS has it needs to deliver care at scale and realise the full impact that technology can have. A whole system approach can optimise capacity and clinicians can be deployed in the areas that need them most. Standardised pathways can save money and speed up and improve patient outcomes with less clinical variation.
By working with systems to streamline pathways we can reduce avoidable variation and embed technology where it accelerates clinical decision making rather than complicating it.
Operational realities: Challenges on the road to integration
As highlighted in the Nuffield Trust’s review of the last 30 years of commissioning it has been the most reorganised part of the health service and lessons need to be learned to avoid the pitfalls of previous models – “creating the conditions for innovation rather than attempting to design every detail themselves.”
Structural change at this scale will not be barrier‑free.
- Operational disruption is expected as systems reconfigure codes, boundaries, reporting structures, and IT infrastructure. The Organisation Data Service (ODS) reconfiguration process provides toolkits and assurance steps, but local teams will need disciplined programme management to protect care continuity.
- Cultural alignment may be even harder. Each ICB brings its own commissioning philosophy, risk appetite, and leadership style. The Model ICB Blueprint offers a shared vision, but implementation will depend on genuine engagement across clinicians, managers, and partner organisations.
- Financial pressures also loom large. ICBs are implementing a mandated 50% reduction in running costs, meaning they must transform structures and processes while continuing to meet population needs. Clear priorities, outcome‑based contracting, and digital solutions that genuinely reduce workload – not simply generate new interfaces – will be essential.
The Nuffield Trust review recommends that providers should be responsible for pathway redesign and innovation as they have the clinical expertise, information and operational control for this to succeed. But providers will continue to need drivers to work collaboratively across a region to redesign pathways for the greater benefit of patients. Commissioners need to create the financial frameworks and incentives to support the transformation, not drive or micromanage it themselves.
The changes also mean that, in many cases, a large proportion of a highly experienced workforce with institutional and regional knowledge are being decimated due to the scale of the cuts required.
Delivering on digital commitments
Recent reporting in the Health Service Journal highlights that several ICBs are removing digital and workforce directors from their top teams, driven by overhead‑reduction pressures. This may not bode well for accelerated delivery of the digital commitments in the government’s 10 Year Health Plan. The guidance is that digital delivery should transfer to providers but progress is likely to falter during the transition.
“As ICBs reshape their structures and remove senior digital roles, we risk losing the very leadership required to deliver the NHS’s digital and productivity ambitions. Digital transformation doesn’t happen by accident – it needs strategic direction, system‑wide coordination, and a champion at the top table.
“Without that, we’re likely to see fragmentation, slower progress on interoperability, and a widening gap in digital maturity between healthcare organisations. At precisely the moment when the NHS needs to accelerate digital‑first pathways, these changes could unintentionally put the brakes on progress.”
Director of External Affairs of Feedback Medical
It will be important for regions to retain as much expertise as possible, particularly in terms of digital capabilities, when rationalising the workforce during the transition.
Looking forward
ICB mergers mark a decisive moment for NHS commissioning. By aligning systems around shared outcomes, unified data, and standardised pathways, the NHS can create a commissioning environment that is simpler for staff, more predictable for providers, and more seamless for patients.
However, there is also a risk that the mergers – and particularly losing digital leadership roles – will slow progress on digital transformation and pathway redesign. This creates a vacuum in digital leadership at precisely the moment when systems are expected to deliver interoperable records, coherent data strategies, and digitally enabled pathways.
Leaders warn that shifting digital leadership to providers could result in fragmented digital experiences, reduced economies of scale, and weakened oversight of system‑wide digital programmes. These will ultimately delay the very improvements mergers aim to unlock.
Feedback Medical’s focus on pathway redesign, workflow optimisation, and behaviour change positions us to support systems through this transformation – with the ability to turn structural reform into measurable improvements in care.