Making commissioning strategic

The 10-year health plan for England aims to devolve decision-making power from the centre to places, providers and to patients. To achieve this, it outlines a new operating model for the NHS, and an important element of this is a reframed and refocused role for integrated care boards (ICBs).  

The idea of ICBs becoming “strategic commissioners” has been under development since late last year. As the 10-year health plan sets out, ICBs will be tasked with improving population health outcomes setting a long-term, evidence-informed strategy, and ensuring resources are allocated effectively. 

This shift signals a clear move away from a more transactional model of commissioning, where contracts for individual services are procured and performance-managed in isolation. Instead, it encourages a more holistic, outcomes-focused approach. Done well, this approach has the potential to transform how health and care services are planned and delivered. It may open opportunities to tackle longstanding challenges such as fragmented care, misaligned incentives and reactive service models. 

While NHS England’s (NHSE) Model ICB Blueprint begins to articulate the value of strategic commissioning and how this function fits alongside the broader responsibilities of ICBs, commissioning does not begin and end with ICBs. For it to succeed, providers will need to play a key role: their insight, collaboration, and transformation and delivery capability will be critical. Both the Model ICB Blueprint and the 10-year health plan also signal opportunities for trusts to take on some elements of commissioning themselves, particularly where it enables service transformation and better integration.  

This long read sets out how trusts and patients will benefit from a more strategic approach to commissioning, as well as how they are central to its success. 

Strategic commissioning will require a reset in how ICBs work with trusts. In many integrated care systems, trusts have already become active partners in setting, shaping and delivering system-wide priorities. This shift away from transactional commissioning depends on mutual trust, shared accountability, appropriate delegation, and joint leadership between commissioners and providers. 

To be effective, strategic commissioning needs three core functions — building a shared understanding of population need; commissioning services that meet that need and shaping the provider landscape to enable delivery. Trusts have a vital role in all three. 

Trusts bring vital clinical leadership, operational insight, and deep understanding of the communities they serve. This makes them essential partners in building a shared, system-wide view of population health needs.  

Robust data, shared intelligence and meaningful engagement with patients are the foundations of effective strategic commissioning. Trusts can immediately support ICBs with the rich nuanced data they hold, which gives insight into clinical outcomes and activity trends, patient experience, and local demand forecasts. Providers are also well placed to identify patterns of need, unmet demand, service gaps and health inequalities, and to shape strategies that reflect these. 

The diversity of provider organisations from acute, ambulance, community, mental health and specialist trusts means insights are generated at different scales — from neighbourhood to national. Each trust type brings a unique lens to understanding population health. For example, community and mental health providers often offer granular, place-based intelligence on vulnerable groups, specialist trusts can identify population-wide trends in rare or complex conditions. Ambulance trusts, with their real-time data on emergency response patterns and patient flows, can provide early signals of emerging health pressures across geographies. Strategic commissioning will be most effective when ICBs draw on this wide range of perspectives and capabilities to develop a comprehensive view of health needs across all levels of the system. 

While the 10-year health plan sets out the intention for the Federated Data Platform (FDP) to become the national default tool for population health insight, this transition will take time, especially in areas where data infrastructure is still developing. In the short term, by collaborating on analytics, modelling and risk stratification, providers can help ICBs plan services more effectively, monitor performance and make better-informed decisions to improve services and outcomes for patients and communities.  

Commissioning services that truly meet population need will require significant changes to how care is delivered and investing in improvement, rather than paying for activity. All of which requires clarity around what good care looks like, how it is best delivered, and embedding a continuous improvement approach. 

Trusts will be central to this work, by collaborating to design and deliver new models of care, particularly those that move services out of acute settings and closer to home. Providers bring a track record of leading transformation, piloting innovation, managing risk, and working across organisational boundaries to engage staff and system partners.  

Trusts are also well placed to take on delegated functions and budgets, where providers can lead. This builds on the success of provider collaboratives which have demonstrated the value of working at scale to pool resources, coordinate care, and deliver efficiencies across geographies and sectors.  

For example, ‘Reach Out’, the mental health provider collaborative in the West Midlands, holds the responsibility for arranging and transforming adult secure services on behalf of the system. Meanwhile the Cheshire and Merseyside provider collaborative, which manages and coordinates diagnostic and elective capacity across the system, has been able to reduce waiting times and balance demand. 

As strategic commissioning becomes more embedded, trusts can help build the capability needed to sustain it. This includes contributing expertise in pathway design, workforce planning, digital transformation, and service improvement. Through joint training, secondments, and leadership development, trusts can help grow the confidence and skills of commissioners and foster a shared culture around improvement and delivery. 

Trusts’ leadership will be critical to delivering change at scale and pace. Providers will also need to optimise how they work — going further and faster in reducing variation, adopting evidence-based clinical models, and making better use of their data and delivery capability to support decision-making. This must include a focus on productivity, pathway optimisation, and improvement at scale.  

The third core element of strategic commissioning is managing the provider market — shaping and nurturing a provider landscape that is well set up to deliver on system priorities, with the right capability, configurations and collaborations in place. This involves making deliberate decisions about service scale, the support and development offered to providers, and the design of system architecture. Effective strategic commissioning should ensure that the right services are delivered in the right place, by providers with the capacity and expertise to do so. This includes determining when services are best delivered locally, at place, or across wider system or regional footprints, particularly for ambulance and specialist services which operate at scales across multiple footprints. 

For this to work well, it must be done with trusts, not to them — trusts have a critical role in shaping this landscape. As established system leaders and collaborators, they are well placed to lead at-scale service transformation, coordinate care across organisational boundaries, reduce duplication and improve efficiency. Trusts also bring significant insight into the structural barriers to better joined-up care, as well as what is working well already that should be preserved and built on. Trusts have been building collaborations for many years, to improve services, and make best use of resources.  

The experience and leadership trusts bring makes them key partners for ICBs in shaping a landscape that aligns incentives, reduces duplication, and delivers care at the right scale and geographical footprint. In many systems, providers are already leading service reconfiguration or coordinating functions across organisational boundaries. For example, through elective recovery programmes, shared diagnostic capacity, integrated urgent and emergency care, or provider collaboratives delivering mental health or community care across geographies. 

In this context, ICBs can add value by drawing on learning from across the country, identifying variation in outcomes and productivity and supporting consistent evidence-based models of care. This includes supporting and strengthening smaller or fragile services and using commissioning levers such as contracts, payment models and performance frameworks to support delivery. This strategic support should create the conditions for trusts to deliver high quality services. 

Trusts are broadly optimistic about the renewed emphasis on commissioning as a core function of ICBs as it brings clarity and aligns responsibilities and expectations with the underpinning legal framework. Beyond this, the intended shift from transactional contracting to strategic commissioning offers an opportunity to address persistent and longstanding challenges such as variation in care, inefficiency, and fragmentation in a way that is more integrated and sustainable for the long term. 

Strategic commissioning could fix problems trusts struggle to resolve alone such as entrenched variation, duplication or spreading the adoption of solutions across a system. Strategic commissioning should therefore create the conditions for system-wide improvement which in turn should enable providers to focus on delivering high-quality care, reducing inequalities and improving outcomes. 

Strengthening the interface with primary care 

Disjointed communication, delayed referrals, and patients feeling ‘bounced’ between services are longstanding frustrations at the interface between primary and secondary care that affect patient experience, outcomes, and efficiency. This is a key element in the 10-year health plan neighbourhood agenda. 

Some systems have made tangible progress. For example, the London shared care record has been made accessible to both GPs and hospitals, improving clinical handovers and reducing duplication in diagnostic testing. This means patients are less likely to undergo the same tests multiple times or fall through the gaps when moving between services.  

Sandwell and West Birmingham Hospitals NHS Trust has also worked closely with Modality Partnership, a GP ‘super practice’, to expand outpatient provision in the community. And, Surrey Downs Health and Care, a partnership formed between Epsom and St Helier University Hospitals NHS Trust, Surrey County Council, and the three GP federations, is joining up services to ensure people receive holistic, joined up care close to home. This gives patients easier access to services in their local area and reduces unnecessary hospital visits. However, progress remains patchy.  

The 10-year health plan sets a ‘new era for general practice’, focused on ensuring the NHS feels like a ‘single, coordinated, patient-orientated service’. ICBs will be key to making this a reality if they are able to improve communication and coordination, get incentives for primary and secondary care pulling in the same direction, and work with providers to integrate pathways of care that feel seamless to patients. Trusts also see a role for ICBs in coordinating relationships with general practice at system level, and empowering trusts and GPs to collaborate more effectively at scale.  

Deepening partnership with local government

A sustainable health and care system that delivers improved health and better outcomes for its population will depend on strong relationships between strategic NHS commissioners and local government. This has always been a key aim for system working. Joint commissioning provides a formal mechanism to align planning and investment across NHS and local government partners. It is particularly valuable for delivering integrated services for people with long term and complex needs, wrapping services around the person regardless of organisational boundaries.  

Greater Manchester, under its 2015 devolution deal, became the first region to formalise pooled health and social care budgets. This has supported the establishing and scaling of integrated neighbourhood teams, which support hospital discharge and manage demand in the community. This has enabled patients to leave hospital sooner and receive coordinated support at home, reducing avoidable readmissions. Similar approaches have been taken elsewhere, but there is more to do to embed co-commissioning models, particularly for services which support people with complex needs. 

However, there are risks. The consolidation of ICBs, driven primarily by cuts to their running costs, is being conducted in the context of a parallel local government reorganisation, including the creation of new large-scale strategic authorities. While the 10-year health plan sets a long-term goal for ICBs to match strategic authority boundaries, it is possible the two reorganisations will lead to increasingly complex local relationships.  

Social care commissioning remains with county and borough councils, meaning ICBs will be co-commissioning with several councils. The 10-year health plan introduces a new contact point between the NHS and local government, as the mayors of new strategic authorities will have a seat on ICBs. While NHS commissioners will be used to working with multiple partners, the potential for conflicting mandates between councils and strategic authorities sitting over them, with a seat on the ICB, is new. ICBs will need to adopt flexible ways of working with multiple local authorities, ensuring public health and social care remain central to commissioning decisions.  

Realising the benefits of specialised commissioning reform 

The delegation of some specialised commissioning responsibilities from NHSE to ICBs offers a chance to better align specialised and locally delivered services. Some providers see opportunities for pathway redesign in areas such as renal or cancer care, where closer integration with community and primary care can improve access and outcomes. Bradford Teaching Hospitals NHS Foundation Trust, for example, has expanded home dialysis through integrated renal pathways, giving patients with kidney disease the option to manage their condition from home, improving comfort and flexibility. Meanwhile, Manchester University NHS Foundation Trust has brought cancer services closer to community diagnostics to support earlier detection. This means more people are diagnosed sooner, when treatment is more effective. 

However, these benefits of delegating to ICBs are balanced by some risks which will need careful mitigation. While the integration of specialised and local services may well improve many pathways, some providers are concerned that replacing a single national commissioner with several more local ones could lead to a more fragmented approach. This could unintentionally undermine services that have been built on close links to academic centres of research, and which are provided on a national or multi-region footprint. In addition, specialised commissioning often requires specialist expertise, and this is why it is typically conducted at national or regional levels.  

Some elements of specialised commissioning will need capabilities, such as skillsets or a knowledge base, which ICBs have not previously held. Providers have raised concerns around ICBs’ capacity and capability in this area, particularly in the context of headcount reductions and abolition of NHSE. The consolidation of 42 ICBs to 26 may mitigate some risks, but challenges remain, especially around maintaining specialist expertise and avoiding the fragmentation of services best delivered at scale. Realising the benefits of reform will depend on continued collaboration between ICBs, NHSE, regional teams, and providers to ensure commissioning models support quality, consistency, and integration. 

Supporting longer-term thinking and transformation 

To fully realise the benefits of strategic commissioning, a new multi-year approach to financial and operational planning is needed. If strategic commissioning is to succeed, it cannot only be about commissioning at scale —it must create the conditions for long-term transformation. At present, short-term incentives often work against sustainable change, pushing systems to prioritise in-year savings over longer-term improvements. The 10-year health plan includes the aspiration to set out a new financial foundation supporting longer term improvements in the model of care, this will need to become a reality to support the aims of strategic commissioning.  

Three essential changes are needed — a financial framework that encourages longer-term planning, a payment system that supports commissioners and providers to invest in community-based and prevention-focused models of care and mechanisms that enable financial risk to be shared appropriately between commissioners, acute providers, and community or primary care providers.  

Combined, these could support a shift in the model of care that supports more people, particularly those with long term conditions, closer to home. For example, multi-year agreements could give community providers confidence to invest in expanding services that reduce urgent care demand through proactive management of long-term conditions. For patients, this could mean better access to proactive, ongoing care in their community, helping to manage their condition and avoid emergency hospital visits. 

ICBs cannot do this alone. The 10-year health plan proposes a range of new financial mechanisms including incentives, new currencies, and contracts to support integrated community and neighbourhood care. As these are developed and implemented, care must be taken to carefully manage and share financial risk, deal with stranded costs associated with closing services that are no longer needed and deliver change at a sustainable pace. ICBs will need a national framework that balances transformation with delivering on immediate priorities. Commissioners and providers will need to build community and preventative services at the same time as cutting waiting lists and driving productivity in acute services.  

In addition, approaches such as the proposed year-of-care payments, as outlined in the 10-year health plan , reflect a move towards more integrated, person-centred commissioning models that support full local population budgets. Strategic commissioning offers a way to reorient the system around shared outcomes.  

Some systems are already testing this approach, for example, in Oxfordshire, the joint commissioning team hosted by Oxfordshire County Council recently awarded a long-term contract for mental health building on the outcomes-based contract that was in-place for some time. As strategic commissioners, ICBs should work with providers to design outcome-focused contracts that incentivise integration, continuity and improved patient experience, helping to realise longstanding ambitions for a more joined-up NHS. 

If implemented well, these changes would allow providers to invest in the present, reducing waiting times and improving performance, while laying the groundwork for a transition to a more preventative, community-oriented health system. Ultimately, patients stand to gain from faster treatment, fewer avoidable hospital stays, and care that is better coordinated around their individual needs. 

A more strategic form of commissioning presents a real opportunity to improve outcomes for patients and tackle longstanding system challenges. Providers are hopeful about what a more strategic, long-term approach to commissioning can achieve, particularly in enabling more integrated, preventative models of care. Success will depend on strong partnership working. 

 NHS trusts are ready to play their part by co-producing strategies, sharing intelligence, and aligning their efforts with system priorities to help realise the ambitions of the 10-year health plan and make meaningful change for the populations they serve.