ICBs have been handed a familiar mandate. The history of commissioning suggests caution about the promises being made on their behalf.

In November 2025, NHS England published the Strategic Commissioning Framework, confirming that integrated care boards (ICBs) will, from April 2026, act as strategic commissioners for their populations.¹ The framework promises a move from transactional purchasing to genuine population stewardship, with outcomes, equity and long-term planning at the centre.

This is the fifth substantive attempt in three decades to make commissioning the engine of NHS reform. District Health Authorities, primary care groups, primary care trusts, clinical commissioning groups, and now ICBs. Each was launched with conviction. None delivered the structural shift that successive policymakers promised. The question is not whether strategic commissioning is a good idea. It is why we should expect it to succeed this time.

The international evidence is sobering, the most rigorous comparative analysis of strategic purchasing across ten European health systems found that none fully delivered against any established definition.² The follow up paper, Power and Purchasing: Why Strategic Purchasing Fails, argued the failure was structural rather than accidental.³ Purchasers everywhere face four asymmetries: information, market power, financial power, and political power. They know less than providers about what is actually happening in services. They lack the market leverage to shape supply. They have less financial flexibility than the organisations they buy from. They are politically weaker than the hospitals whose business models they must reshape.³ Each of these asymmetries applies directly to ICBs.

The evidence of failure is stark, Lord Darzi’s independent investigation, published in September 2024, made the consequences visible.⁴ Between 2006 and 2022, the proportion of the NHS budget spent on hospitals rose from 47 per cent to 58 per cent.⁴ This happened during a period in which every major policy document, every strategic plan, and every transformation programme claimed to be moving care into the community. Three decades of rhetoric. And the share of hospital spend went up. That is not a marginal failure. That is a structural defeat.

The new framework addresses some historical weaknesses. It puts population intelligence at the centre. It expects integrated needs assessment, segmentation, and inequalities mapping using linked data. It signals a shift toward year of care payments aligned with the 10 Year Health Plan.⁵ These are genuine improvements.

But better tools do not overcome structural asymmetries. Hospitals have always been more politically powerful than commissioners. Imison and colleagues, analysing 123 reconfiguration proposals reviewed by the National Clinical Advisory Team between 2007 and 2012, found that a significant proportion failed to be implemented as planned because of public and clinical opposition, despite the underlying clinical case.⁶

Decommissioning is the missing piece. If ICBs cannot decommission, they cannot strategically commission. The two are inseparable. Williams and colleagues’ NIHR study, the most comprehensive analysis of decommissioning in the NHS, found that 77 per cent of CCGs reported plans to decommission services, but that decommissioning had higher failure rates than any other form of service change.⁷ Their follow up sociological analysis showed that managers routinely avoid the language of decommissioning altogether, reframing reductions as redesign to manage opposition.⁸

The technical tools exist. Programme budgeting and marginal analysis (PBMA) and the socio-technical allocation of resources (STAR) framework provide structured, transparent methods for reallocation with public legitimacy. The barrier is not methodological. The system has rarely had the political cover, the analytical capacity, or the leadership confidence to use them at scale.

Three things matter most.

Focus ruthlessly. The framework asks more of commissioners than any can deliver well. The international evidence is clear that purchasers who pursue everything succeed at nothing.^2,3 ICBs should identify three or four population priorities, anchor them to measurable outcomes, and defend them from operational noise.

Build the methods that make difficult decisions defensible. PBMA and STAR are the practical infrastructure that allows decommissioning and reallocation to happen transparently and with clinical engagement.^7,8 A 2016 Nuffield Trust and King’s Fund survey found that only one in five GPs without a formal CCG role felt they could influence commissioning decisions.⁹ That gap will not close without serious investment in analytical and economic capability.

Be honest about the asymmetries. Pretending an ICB can outmanoeuvre a major acute provider through better contract management is to misunderstand thirty years of evidence. ICBs need national support to address financial and political asymmetries that they cannot solve alone.

The Strategic Commissioning Framework is the most thoughtful articulation of commissioning’s purpose the NHS has produced in some years. That is not the same as saying it will succeed. Every previous reform has failed not because the documents were poorly written, but because the structural conditions for commissioning to work were never seriously addressed.

ICBs deserve a fair test. They will only get one if national policymakers and system leaders confront the asymmetries that have defeated every previous attempt. Otherwise we will be writing this article again in 2031, about the next reorganisation, asking the same question.

References

1. NHS England. Strategic commissioning framework. Publication reference PRN01836. London: NHS England; 2025. Available from: https://www.england.nhs.uk/long-read/strategic-commissioning-framework/
2. Klasa K, Greer SL, van Ginneken E. Strategic purchasing in practice: comparing ten European countries. Health Policy. 2018;122(5):457–72. Available from: https://doi.org/10.1016/j.healthpol.2018.01.014
3. Greer SL, Klasa K, van Ginneken E. Power and purchasing: why strategic purchasing fails. Milbank Q. 2020;98(3):975–1020. Available from: https://doi.org/10.1111/1468-0009.12471
4. Darzi A. Independent investigation of the NHS in England. London: Department of Health and Social Care; 2024. Available from: https://www.gov.uk/government/publications/independent-investigation-of-the-nhs-in-england
5. Department of Health and Social Care. Fit for the future: 10 year health plan for England. London: Department of Health and Social Care; 2025. Available from: https://www.gov.uk/government/publications/10-year-health-plan-for-england-fit-for-the-future
6. Imison C, Sonola L, Honeyman M, Ross S, Edwards N. Insights from the clinical assurance of service reconfiguration in the NHS: the drivers of reconfiguration and the evidence that underpins it. A mixed methods study. Health Serv Deliv Res. 2015;3(9). Available from: https://doi.org/10.3310/hsdr03090
7. Williams I, Harlock J, Robert G, Mannion R, Brearley S, Hall K. Decommissioning health care: identifying best practice through primary and secondary research – a prospective mixed-methods study. Health Serv Deliv Res. 2017;5(22). Available from: https://doi.org/10.3310/hsdr05220
8. Williams I, Harlock J, Robert G, Kimberly J, Mannion R. Is the end in sight? A study of how and why services are decommissioned in the English National Health Service. Sociol Health Illn. 2021;43(2):441–58. Available from: https://doi.org/10.1111/1467-9566.13234
9. Holder H, Robertson R, Ross S, Bennett L, Gosling J, Curry N. Has clinical commissioning found its voice? GP perspectives on their CCGs. London: Nuffield Trust and The King’s Fund; 2016. Available from: https://www.nuffieldtrust.org.uk/research/has-clinical-commissioning-found-its-voice-gp-perspectives-on-their-ccgs

Author

Andi Orlowski

Andi is a health economist and Director of the NHS Health Economics Unit, a NHS consultancy team that supports health and care organisations locally, regionally, and nationally.

He is also a Senior Advisor for NHS England and the World Bank, providing expertise in population health management, non-communicable diseases, prevention, and data analytics.

Specialising in population health analytics, health inequalities, and strategic commissioning, Andi lectures and is pursuing a PhD at Imperial College London. 

He serves as Vice-Chair at the Healthcare Value Institute at the Healthcare Financial Management Association (HFMA) and Deputy Chair at Kaleidoscope Health and Care.

Outside of work, Andi plays rhythm guitar in an NHS covers band called the HEUristics and in a heavy metal band called the Black Museum.

Declarations of Interest
Andy is employee of the NHS Health Economics Unit. AO is a lecturer at Imperial College London, an advisor to the World Bank Group, Vice Chair of the HFMA’s Healthcare Value Institute and Deputy Chair of Kaleidoscope Health and Care.