A credible commissioner adds value when it helps the system do what individual organisations often struggle to do alone: define a clear shared purpose, translate that purpose into delivery, make progress and variation visible, turn data into useful shared knowledge, reduce friction between organisations, and support honest conversations early enough for adaptation to happen. This article explains more.
ICBs need to become “gardener leaders”, with a focus on outcomes and value.
The meeting starts in a familiar way. Performance has slipped. Tension is rising. Eyes turn to the commissioner, as if the next move should come from the part of the system assumed to be in charge.
Peter Bullivant
That assumption is understandable. Commissioners have long been associated with mandate, oversight, assurance and resource allocation. So, when delivery becomes difficult, an old reflex quickly returns: more escalation, more updates, more pressure to show grip.
But in complex healthcare systems, especially where outcomes depend on multiple organisations working across boundaries, that is often the wrong test of commissioner credibility.
As we explored in our previous article, command-and-control rarely works well in complex systems. Pushing harder may create movement, but it can also create defensiveness, reduce candour and make adaptation harder. Donella Meadows’ work helps explain why. Systems change more effectively when we intervene in higher-leverage places: goals, rules, information flows and the wider conditions that shape behaviour over time.
That is the right lens for understanding commissioner value now. The question is not how far commissioners can control delivery, but what value they add so the system can perform better together.
This is a different kind of authority. It is rooted less in hierarchy and more in usefulness.
If the commissioner, or commissioning hub, is mainly experienced as the part of the system that sits above others and should therefore be obeyed, it may secure compliance. But compliance is not the same as collaboration or improvement. It may produce better slides and tighter performance management, but not earlier truth, stronger cross-boundary problem-solving or a deeper shared commitment to change.
In a complex system, commissioner credibility must be earned differently. A credible commissioner adds value when it helps the system do what individual organisations often struggle to do alone: define a clear shared purpose, translate that purpose into delivery, make progress and variation visible, turn data into useful shared knowledge, reduce friction between organisations, and support honest conversations early enough for adaptation to happen.
That is where credibility sits now. Not: how hard did you push? But: what changed because you were there?
Did priorities become clearer? Did organisations align around a small number of meaningful shared outcomes? Did data and operational insight create a more honest shared picture of reality? Were dependencies surfaced earlier? Did review become more useful?
Those are better questions.
One of the most important contributions a commissioner can make is strategic clarity. In many systems, people are working hard inside a fog of competing priorities and loosely connected plans. A valuable commissioner helps reduce that noise by helping the system orient around a small number of shared outcomes that matter to patients, to staff and clinicians, and to long-term sustainability and wellbeing. When that collective purpose is clearer, people can better understand what they are doing, why it matters and how their work connects across organisational boundaries. In Meadows’ terms, goals shape behaviour.
But clarity of purpose on its own is not enough. Strategy only becomes useful when it can be translated into delivery in a way that is visible, shared and reviewable.
Used well, outcomes, key results and stages (OKRs) help partners define the few shared objectives that really matter and the key results that show whether meaningful progress is being made. Used alongside logic modelling, they help make the mechanics of change more explicit: what we are trying to change, how change is expected to happen, what steps sit underneath delivery, and where assumptions, risks and dependencies lie across organisations.
Their value is not that they allow commissioners to communicate change at others. Their value is that they give partners a shared tool for understanding change together. They make interdependencies visible, prompt more open and objective review, and create a clearer basis for collective ownership of delivery. In that sense, OKRs and logic modelling are practical tools for shared clarity, engagement and coordinated action across a system.
Another source of commissioner value is the stewardship of data, variation and knowledge. In many systems, data is plentiful but shared understanding is weak. A valuable commissioner does more than ask for data. It adds value to it: creating a clearer shared picture across pathways, places and providers, highlighting meaningful variation, and combining quantitative data with operational and clinical insight to turn fragments into knowledge that can inform change. In Meadows’ terms, information flows are among the highest-leverage places to intervene in a system.
The next contribution is reducing friction across organisational boundaries. Many barriers to delivery sit in the spaces between organisations: unclear responsibilities, delayed decisions, hidden dependencies, weak information flows and unresolved tensions that nobody quite owns. A credible commissioner adds value when it helps unblock those spaces: convening the right people, clarifying roles, making trade-offs explicit and strengthening review so issues surface early enough to matter.
This is also why psychological safety matters so much. If the commissioner, or hub, is experienced primarily as the part of the system that judges, catches out or escalates, risk will surface late, challenge becomes personal, and information gets curated. If, however, the relationship is anchored in a shared and valued purpose, the conversation changes. Psychological safety does not remove challenge. It makes challenge more usable. It creates conditions in which people can raise issues, test assumptions and share uncertainty without unnecessary fear. In that environment, accountability is strengthened through transparency, earlier truth and better follow-through.
That is the real test. The future value of commissioning is not in policing delivery from above. It is in enabling collaboration that would otherwise remain too fragile, too unclear or too difficult to sustain.
So perhaps the most useful question for commissioners now is this: when performance slips, what do people experience when you arrive?
More fear? More reporting? More defensiveness?
Or more clarity? More useful challenge? Better use of data and knowledge? More practical help to remove barriers? More confidence that difficult truths can be raised in service of something shared and worthwhile.
In a complex healthcare system, that is where credibility sits. Not in being the part of the system that others must obey. But in being the part of the system that adds enough value to be wanted at the table.
To find out more join our workshop on 3 December 2026 “Strategic commissioning and integrated care delivery: Facilitative commissioning for system accountability”. You can book your place on https://www.pccevents.co.uk/pcc/3649
This workshop is one in a series of workshops on strategic commissioning and integrated care delivery you can find more details of these workshops at https://www.pccevents.co.uk/pcc/3648
We would be delighted to work with commissioners and their systems please contact enquiries@pcc-cic.org.uk to discuss.
