Integrated Care Systems Face Growing Scrutiny Over Complex Accountability Structures

Integrated Care Systems were introduced to drive a fundamental change in the organisation of health and care in England. Their mandate includes coordinating primary, secondary, community and social care, reducing inequalities and shifting the NHS focus from treatment to prevention. These objectives underpin the 10 Year Health Plan and are seen as central to long term sustainability. However, concerns are emerging that the accountability arrangements designed to support ICSs are overly complex and difficult for local leaders to navigate, raising questions about whether the reforms can achieve their intended impact.

The Hewitt Review highlighted this challenge at an early stage, arguing that ICSs would only succeed if given meaningful autonomy and the discretion to prioritise local needs. Despite this, system leaders report a growing disconnect between national messaging and operational reality. While oversight was expected to become lighter and more strategic, ICSs remain subject to extensive reporting cycles, financial controls and performance monitoring from regional and national bodies. The division of responsibilities between local systems, NHS England and the Department of Health and Social Care continues to be unclear. Short term operational and financial requirements still dominate planning, limiting progress on prevention and wider population health goals.

This imbalance is reinforced by the direction of accountability. ICSs are required to provide detailed and frequent updates to national bodies, while local accountability mechanisms remain limited. Collaboration with local authorities varies between regions and public engagement in system governance is inconsistent. Analysts note that without stronger accountability to local communities, ICSs may struggle to build the legitimacy needed for long term reform. Leaders are expected to make decisions on major strategic issues without the authority structure typically required to support such decisions.

As a result, the system risks becoming misaligned with the core ambitions set out in national policy. The goals of reducing inequalities, expanding community services and increasing investment in prevention require stability, flexibility and the ability to plan beyond annual cycles. Local leaders caution that these conditions are difficult to meet while responding to frequent reporting requests and shifting national priorities. Stakeholders argue that the current approach favours compliance over innovation and limits progress on transformative work.

Observers and policy advisers have called for a streamlined accountability model. Proposals include narrowing national expectations to a small number of long term outcomes, strengthening local scrutiny through councils and community bodies and providing ICSs with greater flexibility over resource allocation. Advocates argue that simplifying oversight would help systems focus on population health rather than administrative process.

The concerns are already affecting implementation. Reports from several ICSs indicate that the administrative burden is affecting morale and limiting operational capacity. Without clearer governance and more stable expectations, commentators warn that ICSs could follow the trajectory of previous NHS reorganisations that struggled to translate structural change into measurable improvement. Analysts suggest that the next phase of reform will depend on whether the accountability framework can be redesigned to support leadership and encourage long term decision making.