CC: Wes Streeting MP, Secretary of State for Health and Social Care;
Duncan Burton, Chief Nursing Officer

Dear Sir James,

On behalf of the Royal College of Nursing (RCN), I am writing following your letter to NHS Trusts Foundation Trusts and Integrated Care Boards, and the subsequent publication of the Model Integrated Care Board (ICB) Blueprint guidance in early May. We are very concerned at the speed of change, and the timeframes expected for ICBs to produce their plans. While the RCN supports the need for transparency, consistency and value for money, and agree that we must ensure all roles contribute meaningfully to system priorities, we would like to highlight the significant and often overlooked value that these strategic nursing roles bring across NHSE and ICBs.

These roles are not administrative or corporate managers. They are essential roles often deeply embedded in safeguarding, quality improvement, workforce planning, and population health initiatives — all of which are essential to the successful delivery of healthcare services, the 10 Year Health Plan and the wider transformation agenda.

We are very concerned that the proposals around structural reform at a national and regional level have not been formally consulted on nor essential impact assessments completed. While we note that there has been some opportunity for ICB leaders across the country to feed into the Model Integrated Care Board (ICB) Blueprint document, we have not had assurance that there was a strong and visible enough nursing voice in shaping its content. We believe that the 30th of May is too soon to confidently ensure that all of these elements have been considered within ICB plans. 

Through recent RCN focus groups and engagement with nursing leaders within the system, several consistent themes have emerged:

• Nurses and nursing staff are a significant part of the workforce in NHS England and Integrated Care Boards, working in crucial nursing functions and clinical roles, as well as other parts of these organisations.

• Nursing leadership is critical to ensuring delivery of the objectives within the 10-year plan and therefore executive nurse leadership must be protected and maintained.


• Expert nursing knowledge and expertise is vital to the running of the health and social care system adding value across all areas including leadership, patient safety and quality, population health and commissioning.

• Nurses and nursing staff are concerned that their roles and functions and depth and breadth of their contribution are not fully understood or valued. They are also concerned that reductions in these organisations could not only lead to job losses in this vital workforce but dilute clinical and organisational memory, putting key programmes at risk.

RCN members are concerned that their expertise is not being heard in a process driven by financial imperatives rather than patient care, quality and safety requirements. Within this context, we note that ICBs are expected to develop and submit plans by 30 May and we do not believe this timeline allows for meaningful engagement and consultation with staff groups on the scale, direction, and implications of these changes. We are concerned that the speed of this process has not left time for vital safety and quality risk assessments to be undertaken.

Our specific reflections on the content of the Model ICB Blueprint include:

1. Nursing expertise: Many of the functions identified as being at risk of relocation, streamlining, or transfer are led by nurses with highly specialist knowledge. This includes system-level nursing leadership and expertise in infection prevention and control (IPC), safeguarding, special educational needs and disabilities (SEND), looked after children and care experienced young people, primary care nursing, and public health nursing. These roles provide essential clinical insight, multi-agency leadership, and assurance on safeguarding and equity. Nursing-led functions must be fully mapped, and their value understood to ensure that they will not be disproportionately impacted by these reforms, and that this critical expertise is retained in system structures.

2. Nursing leadership: The Blueprint includes the expectation that ICBs will "streamline Boards and reduce headcount at Board level." Chief Nursing Officer roles must be protected from this streamlining to ensure that nursing leadership is maintained at system level. It is vital that nursing continues to have a clear voice in system decision-making, including in commissioning, quality assurance, safeguarding, and population health.

3. Accountability: The Blueprint proposes a reduction in the contractual oversight functions of ICBs. In the context of an ongoing workforce crisis, we are concerned that this could weaken mechanisms for holding providers accountable for safe staffing, recruitment, retention, and working conditions. We maintain that accountability for workforce and service quality must be strengthened—not diminished—under these reforms.

4. Regulation: The Blueprint implicitly assumes providers can self-regulate within existing regulatory frameworks, without sufficient system-level safeguards. We therefore seek urgent clarification on where system-wide oversight of safety, quality, and professional standards will reside, and how the integrity of those functions will be maintained during and after the transition.

5. Staff consultation and engagement: It is vital that every ICB undertakes a meaningful consultation process with unions and affected staff groups, ensuring that they have the time and support to be fully involved in shaping and refining proposals, with clear mechanisms to raise concerns and contribute to the transition.

6. System-wide oversight of professional standards and patient safety: The Blueprint is unclear about where responsibility for maintaining professional standards and assuring patient safety will sit in the future system architecture. If ICBs are no longer responsible for direct oversight, and regional teams focus primarily on performance management, there is a risk that accountability for safety becomes fragmented and unclear.

7. Equity and diversity: To date there has been no sharing of any equality impact assessments (EqIAs), either in relation to the national proposals nor the organisation specific changes. EqIAs, when carried out meaningfully and transparently, provide an opportunity for NHS organisations to not only fulfil their legal obligation, but to effectively identify potential unanticipated consequences or otherwise, on groups of employees, as well as others, who have protected characteristics. We seek the urgent completion and publication of the EqIAs in relation to the proposals and ongoing NHS system changes.

In all aspects of this work, it is crucial that the value, impact and outcomes related to these functions and the roles associated with them is recognised, and a judgement is not made solely relating to their immediate cost.

Nursing leaders at all levels are committed to driving transformation, improving care quality, and restoring public confidence. These roles are vital to delivering the change we are collectively striving for. I would appreciate the opportunity to meet and discuss this, along with other relevant matters. Please feel free to contact my office at Patricia.Marquis@rcn.org.uk so we can arrange a suitable date.

Please note, we have cc-ed the Secretary of State for Health and Social Care, and the Chief Nursing Officer into this letter to bring our concerns to their attention, and will be publicly releasing this letter in the coming days.

Yours sincerely,

Patricia Marquis
Director, RCN England