Strategic commissioning is misunderstood by NHS leaders

This article first appeared in Healthcare Leader on 12 October 2026.

Strong strategic commissioning is critical to an effective and sustainable health and care system, but the skills and role are often misunderstood or sidelined. The changing focus for ICBs set out by the government, from performance management to commissioning for outcomes, is welcome, but this alone will not bring about the desired change.

We need to see a real support for the NHS 10 Year Health Plan’s three shifts across the system, with clarity of roles and responsibilities and baked-in expectation that resources will move to communities, safely and sensibly, over time.

In a recent survey of ICB leaders, less than half of respondents said they believe that NHS England has a good understanding of the role of ICBs as strategic commissioners and more than a third think that their understanding is poor.

Both local, regional and national partners are getting to grips with what it means but a lack of shared understanding of how commissioning is changing, alongside uncertainty around the operating model, will undermine effective implementation.

The case for change in the NHS has never been stronger. Healthy life expectancy is falling, health inequalities are stark and more people are out of work due to ill health than ever before. We continue to fund more acute activity at the expense of care in the community and upstream intervention. People are struggling to access the care that they need.
Many ICBs have carried out modelling of future capacity and demand, which demonstrates that our current healthcare model is not fit for purpose. To change this, we need the data, insight and understanding of our populations to pull the system towards a north star, to manage the provider landscape and align its incentives, and commission services differently to improve patient outcomes and experience. ICBs are uniquely placed to do this.

We hold over £160 billion of public money. If we understand what our populations need, then we can move towards a value-based approach to care, where every pound spent results in better, more sustainable.
We have the power to change how we commission services to support people at each stage of their life, not just when they’re in crisis: from starting well at birth and supporting our children to ensuring everyone can approach end of life with choice and dignity.

Our biggest opportunity is how we commission a neighbourhood health service. Working with partners in local government and the voluntary sector, it should wrap care around the person and support them to access preventive care in the community – only turning to acute and specialist care when absolutely needed.

ICB leaders know we have work to do, but we are making progress. We have massively improved data collection and analysis and are reimagining how we embed the public and patient voice in commissioning. Linked data sets and population management systems across the country are already supporting proactive interventions for people with frailty and reducing non-elective admissions.

This is not just about the NHS. It’s about joint commissioning with local government and working with strategic authorities to address the wider determinants of health. Collaborative approaches on the work and health agenda demonstrate that when we work together, we can deliver more with less.

I saw this for myself in deprived areas in Lincolnshire recently: local people working in their communities with leisure centres, schools, GPs and many others, to provide services tackling obesity, frailty and loneliness.

As ICBs, we cannot deliver on this vision of strategic commissioning alone. We need to build a stronger common understanding of what it means for all system partners.

This means a more devolved approach from the DHSC and NHS England. But also building commissioning capability among providers as new models emerge and they take on more responsibility for pathway redesign. By embracing the government’s devolution agenda, we can also work towards stronger place-based delivery while aligning strategic priorities at a regional level.

The target operating model should support this approach. ICBs must focus their capabilities and resources on improving population health through planning, purchasing, monitoring and evaluating services, rather than lead day-to-day operational management. If they continue to do both, immediate priorities of winter planning or hitting elective care targets will continue to crowd out long-term change.

Alongside this, we need to be measuring and be held to account for the right metrics. We want to improve healthy life expectancy and reduce the years people spend in ill-health. Are we improving vaccination rates? Are we preventing avoidable deterioration for those who are frail? Each ICB will be assessing progress against its local priorities, but getting the national oversight framework right is key.

Looking ahead, the next NHS planning cycle is a test for how, as a system, we can do things differently. As we face tough decisions and trade-offs about how we move money from acute hospitals to the community and what we prioritise for investment, we need support from national and regional partners to take risks.

We face huge challenges. Commissioning will be key to success, but that will only happen if we commit, together, to making it work.

Kathy McLean, ICB Network chair at the NHS Alliance.