As we mark the second anniversary of the creation of ICBs, it's perhaps worth pausing to reflect on the progress they have made over the last couple of years and inevitably, the many challenges they are yet to overcome.

Let's be clear, it was a pretty tough baptism for the ICBs, launched as they were just as the sheer scale of the post-Covid demand recovery was becoming clear; they seem to have been clinging onto the coattails of events ever since.

Between 2020 and 2024, the number of people awaiting elective care ballooned from around 4m to over 7.5m and many of those people are now in the unacceptable position of having waited in excess of a year for their care.

Despite these huge challenges, it's always worth reflecting on what is being done as well as what isn't. The NHS still interacts with around 1.3m people every single day, it manages to run an operation with a budget that dwarfs that of many small countries and as we saw vividly during Covid, when it needs to step up, it generally does.

In terms of demand, however, the numbers are inexorable and they are only heading in one direction. The ability to continue to meet the scale and complexity of the demand facing the sector is impossibly beyond the capacity to meet it and ICBs were created, at least in part, to provide a strategic vehicle to begin to address this challenge.

Given that only 20% of an individual's health prospects are determined by clinical factors, it makes perfect sense to create a governing structure, that through working together, can identify and proactively address the social, economic and environmental factors that so heavily influence health outcomes.

To have leadership from public and voluntary sector organisations dealing with housing, communities, education, troubled families and many other interventions sat around the same table offers the prospect of tailoring interventions; getting ahead of the curve and – in time - guiding people away from the ever growing queue for acute care.

So, if the model is right, what's wrong?

The fundamental challenge still facing ICBs and the care systems they exist in, is the relative maturity of the senior-level relationships between the organisations that lead them. Put bluntly, even where these relationships are more developed, they can hardly be described as high maturity, and where they are bad, they are basically dysfunctional.

This should not be a surprise. Anyone who has attempted to work across multiple organisations knows full well that just because you call something a ‘system' does not axiomatically lead to seamless integration.

The relationships that underpin ICBs are complex and at times ambiguous. These relationships also exist within - and are subject to - the effects of a volatile and ever more challenging operational environment.

The inadvertent creation of a SINO (system in name only) is a very real danger for community leaders and policymakers alike; a structure that may hit the basic expectation of joint working, but sadly miss the point of creating lasting impact.

Further structural fiddling is not the answer either. The basic principle of integrated responsibility and accountability is the right one for better outcomes. Achieving the maturity of relationships to realise an effective system is a considerable challenge and one that will require resources, commitment and political patience to fully realise.

Aidan Rave, principal consultant at Good Governance Improvement and acting deputy chair, Buckinghamshire, Oxfordshire and Berkshire West (BOB) ICB.