Editorial: Systems of care – what will the future hold?

Integrated Care Boards (ICBs) in England are undergoing a major restructure – arguably the most significant NHS transformation in over a decade. At its core, this overhaul fundamentally shifts the NHS operating model, moving care delivery closer to home while placing strategic commissioning at a greater distance from the front line. How might this affect diabetes care? Could this serve as a cautionary tale for the other devolved nations?

Radical reform

ICBs in England have been directed to halve their running costs, aligning with broader public sector reforms such as the dissolution of NHS England into the Department of Health and Social Care. This leaves ICBs with around £19 per head of population to act as strategic commissioners, transferring many of their current responsibilities to provider organisations. To remain viable, smaller ICBs will likely be forced to merge.

Given the workforce challenges faced by provider organisations over the past year, including widespread vacancy freezes, adding extra responsibilities without guaranteed additional resources is likely to worsen issues already present in diabetes and obesity care. Key members of multidisciplinary teams and those with portfolio roles may be lost in the upheaval.

Clinical leadership is under threat, particularly for roles employed through ICBs. These roles are crucial for system integration and effective commissioning. This is especially evident in the evolving field of obesity care, where the rapid introduction of new medications and management strategies demands coordinated, collaborative clinical leadership. The recent SURMOUNT-5 trial, which demonstrated the superior efficacy of tirzepatide over semaglutide for weight loss, signals a transformative shift in obesity management and highlights the need for expert clinical oversight as new therapies emerge. As these changes accelerate, questions arise: will provider collaboratives step in to address the gap left by diminishing clinical leadership? How can the divide between strategic commissioners and clinical expertise be bridged to ensure optimal patient outcomes?

Rapid reform

NHS England has released its “Model Blueprint”, a template for ICBs to use in planning their restructuring (NHS England, 2025a). Local plans are expected to be published, arriving in September at the latest, and this will mark the start of a 45-day consultation period.

The speed of this process is already disrupting the commissioning and oversight of diabetes services. Much non-essential ICB activity has been paused to focus on the restructure, despite ICBs’ crucial role in connecting primary, secondary and community care providers.

Shifting boundaries: Opportunities and risks in healthcare restructuring

A central government initiative is the creation of Integrated Neighbourhood Teams, designed to deliver seamless, proactive and holistic care to local populations (Edwards, 2024; NHS Confederation, 2025). This move to holistic care is welcomed; we have reflected in this issue of the journal on the power of combining interventions in a sustainable way. The SPAN study, for example, shows us that small changes in multiple risk factors – sleep, physical activity and nutrition – can have a large impact on all-cause mortality.

These Integrated Neighbourhood Teams will conduct holistic assessments and case reviews that consider medical, social and personal needs, with ongoing input from multidisciplinary teams drawing on primary and secondary care, social services and the voluntary sector. Naturally, not everyone can be included, so the focus will be on those with the highest healthcare utilisation, aiming to manage them proactively and keep them out of acute care. The vision is for streamlined access, improved patient experience, prevention and early intervention, and a reduction in health inequalities through tailored, local solutions. For people with diabetes, this may involve, for example, proactive management of cardiovascular risk, including, as David Morris covers in this issue, antiplatelet therapy.

Now is perhaps the time to revisit the DiaST model of diabetes care (Ali et al, 2021). This restructure could provide the funding and focus needed to develop such evidence-based approaches, allowing people with diabetes to access the most appropriate care setting. Achieving this will depend on expanding virtual care, delivering services closer to home and increasing support for self-directed learning. However, if funding fails to follow, innovative approaches risk being deprioritised. Such a trend is already visible, for example, in the reduction of diabetes remission programme places this year, even as investment in obesity prevention increases. Strong leadership to champion investment in diabetes care will be essential to keep it on commissioners’ agendas, and provider collaboratives may help amplify these messages.

Digital solutions will play a pivotal role, and diabetes care is already leading the way in this arena. We can harness digital diabetes education, continuous glucose monitoring and streamlined “one front door” models that enable prompt access to specialist advice. The true strength of these systems lies in delivering person-centred, informed care. For example, even a simple measure like HbA_1c can be transformed into a meaningful conversation, helping individuals understand what the test is, what their results signify and why their agreed target is important. You can refresh your own knowledge on this with Jane Diggle’s in-depth review!

If managed well, and if ICBs focus on their core role as strategic commissioners (NHS England, 2025b), these reforms could ultimately deliver more efficient, locally responsive and integrated care. However, evidence from previous NHS reorganisations suggests improved patient outcomes are not guaranteed, and much will depend on the quality of implementation and support (Arnold et al, 2025). Experience shows that cost-cutting can stretch ICB leadership and hinder collaboration, risking progress towards integrated care.

Political interference as a social determinant of health

The government’s “triple aim” is to shift care from treatment to prevention, analogue to digital, and hospital to community (NHS England, 2025c). However, diabetes prevention, whilst a national priority, is likely to struggle if budgets are squeezed and innovation capacity is lost.

ICBs have been instrumental in overseeing and driving work to address health inequalities; for example, through CORE20PLUS5 (NHS England, 2023). They play a strategic role in population health management, which requires maintaining and expanding the involvement of Local Authorities and voluntary and community sectors. Reallocating resources to those most in need will become more difficult as ICBs lose power and funding.

The scale of this change is likely to hit already struggling ICBs hardest, potentially increasing regional inequalities in service provision. Careful management will be required to avoid fragmentation but, at this pace, it’s hard to see how this will be achieved.

The key takeaways for our devolved nations would be to avoid blunt, centrally imposed cost-cutting, as this damages partnerships and grinds many important functions to a halt. Where restructuring is needed, have clear communication and prioritise stability, avoiding transfer of responsibilities to places where there is a mismatch of resources, support and skill. Growing strategic capacity is important, and this needs to be thought about carefully within a restructure. To be successful in the long term, the team needs to challenge the status quo and be more than wolves dressed in strategic sheep’s clothing.

Also in this issue

Our Prescribing pearls series turns to finerenone, a relatively new non-steroidal selective mineralocorticoid receptor antagonist used for treating chronic kidney disease in adults with type 2 diabetes. Pharmacists Suhrab Sayfi and Nadia Malik outline the practicalities of prescribing for us.

This issue’s interactive case study covers fatty liver disease, including its causes, diagnosis and management. Finally, Diabetes Distilled reveals an association between maternal diabetes and increased risk of neurodevelopment disorders in the offspring. Yet more reasons to encourage optimal glycaemia and weight management pre-conception.