It is clear that diverse approaches are emerging across systems to reimagine the relationship between commissioners and providers. It is equally clear however that most of these developments are at an early stage and that there is no blueprint to work from.

Contributors to this report were unanimous in their view that the single most important driver of change was investing the time required to build strong relationships which would then underpin a tailored approach that works for their local population.

While there is no single best approach to deliver place-based commissioning, there are some key changes at the national level which could further enable providers and commissioners to collaborate more freely as system partners, in a way that supports the planning and delivery of care to best meet the needs of the populations they serve. These changes include:

  • Aligning national policy expectations with developments on the ground
    National regulation, financial incentives and assurance processes should align with the expectation that local organisations work collaboratively in systems.
  • Ensuring national behaviours mirror the expectations of local partnerships.
    As CCGs and providers look to develop closer partnerships, colleagues in the national bodies should consistently adopt a similar approach in their day-to-day dealings with local bodies, offering constructive support to balance a focus on immediate challenges and the longer term direction of travel for the system.
  • Offering national guidance and support to help systems navigate the new landscape 
    Given the early stages of developing system working, some key areas of challenge have been identified, where both commissioners and providers would benefit from greater support or guidance. NHSCC and NHS Providers similarly recognise their role in offering additional support in these areas. Three key areas where national support is needed were highlighted:
    • Leadership support to develop collaborative and clinical leadership. New skills are required to effectively lead across a system, in particular to manage the challenges associated with working in pressured systems. Leadership programmes should emphasise the importance of clinical engagement across system and place.
    • Support to manage risk, accountability and governance. Many local systems would welcome support to develop robust governance arrangements that assist collaborative working, in line with their legal obligations. This support should reflect the varied needs of local contexts, including challenged systems.
  • Continuing to create opportunities to share innovative practice.
    As it emerges across the sector, good practice examples of system working should be shared to enable learning.


Contributors to this report were unanimous in their view that the single most important driver of change was investing the time required to build strong relationships which would then underpin a tailored approach that works for their local population.


Alongside our call for national support, this report highlights key areas for systems looking to drive forward system working.


Table 1: Supporting system working


Early success factors Challenges to navigate

Strong collaborative and clinical leadership

Leadership must be capable of transcending traditional organisational boundaries and must remain clinically driven.


Contractual mechanisms

Balancing system financial risk and the financial requirements placed on organisations remains a key barrier to collaborative working, particularly within challenged . Perverse incentives in the payment system also remain, though some areas are working to navigate this.

Establishing one version of the truth

Having ‘one version of the truth’ - both in terms of the financial position and a shared evidence base is a key enabler of collaborative working. This can be facilitated through shared data sources and open-book accounting.

Governance and accountability

Partners within systems need to ensure that robust governance mechanisms underpin collaborative working, with clear lines of accountability to the public for delivery.


Supporting the workforce  

There is a need to work with local staff over time to develop the flexibilities needed to support integrated working, for example through pooling resources or appointing joint posts.  



Commissioners and providers have to fulfil the regulatory requirements of national bodies, which can often prove time-consuming and shift focus away from collaborative working. While areas of local progress are being made, national policy that is aligned to support new relationships between CCGs and providers would be welcomed.

Involving all system partners

While this report focuses on relationships between clinical commissioners and providers, successfully integrated system working requires engagement of all system partners, including local authorities and the voluntary and independent sectors.

Previous system failures

Deep seated challenges within a local system and previous organisational failures can lead to a retreat from system thinking, with attention focusing on individual organisational performance.



What is striking is the appetite for change right across the NHS. Both commissioners and providers recognise the need to do things differently to make best use of their collective resource, and to deliver the best possible outcomes for their patients and populations in the face of significant performance, financial and operational challenges. A pragmatic approach is emerging in many localities that is allowing commissioners and providers to find creative ways of working more collaboratively across system, place and neighbourhood footprints.