Conclusion

The way the NHS plans and manages the use of public money – commissioning – needs to adapt to meet the health challenges of today. A more proactive model of care, which puts more effort in keeping people well and preventing worsening ill health, will require a substantial shift in resources away from hospitals towards the community and prevention. Strategic commissioners’ role is to do this. 

While the structures introduced by the Health and Care Act 2022 are the right ones, delivering change requires more than an act of parliament. This report has set out six shifts in the approach to commissioning, both by ICBs and lead providers: 

1. From reactive to proactive.
   
   
2. From downstream to upstream.
   
   
3. From competition to collaboration.
   
   
4. From transactional to transformational.
   
   
5. From cost to value.
   
   
6. From compliance to leadership.

Commissioning will become more strategic when it moves from transactional relationships with individual providers of episodes of care to commissioning whole pathways of care, requiring providers to collaborate towards the shared goal of improved health. Given the increased population scale and new or forthcoming delegated commissioning responsibilities that unite budgets for whole pathways of care, ICBs are uniquely placed to do this.

Delivering strategic commissioning will require some practical steps. The DHSC, working with NHS England through its transition period, needs to support the further development of system-level workforce skills, data analysis, diplomatic skills, system leadership, contract management expertise and estate management capability through training and ICB recruitment. ICBs can then harness these competencies to take a population cohort segmenting approach, designing services and pathways with partners around the needs of these patient cohorts, including earlier intervention. The 50 per cent reduction in running cost allowance for ICBs will need to be managed carefully or it risks bringing to a standstill any efforts by ICBs and their partners to deliver on strategic commissioning and the government’s plans for NHS reform. 

To support this service transformation and reallocation of resource, ICBs could use outcomes-based contracting for these populations across pathways. Vertical provider models and collaboratives should take on more responsibility and accountability for patient outcomes, to help integrate service delivery and align incentives in often fragmented provider landscape. 

Finally, NHS the future oversight regime needs to support and incentivise this change, better balancing management of performance today with oversight of the delivery of this reform for tomorrow. Within systems, ICBs must maintain oversight of providers’ delivery of outcomes - an essential lever to drive the government’s reform agenda. Alongside this, a smaller number of national priorities and targets that focused on ends not means could liberate local leaders to lead, innovate and drive change tailored to the needs of their populations. Aligning these steps to mobilise change and achieve more than the sum of their parts puts the ‘strategic’ into ‘strategic commissioning’. 

This vision of change is based on engagement with and the views of local system leaders. We hope it may make a constructive contribution to NHS England’s upcoming strategic commissioning framework and how to mobilise change through the ten-year health plan.