The Fourth Shift: Why Strategic Commissioning Must Become Community-Powered

Patrick Vernon reflects on his experience as a former Chair of an ICS, where one message has always been clear to him: the future of health and care cannot be delivered through structures alone. For commissioning to be truly strategic, he argues, it must evolve into a behavioural and relational transformation.

Chairing the Achieving Excellence in Strategic Commissioning session at the NHSConfed ICS Conference reinforced this belief. Every speaker echoed the same core message: people, culture and relationships not organisational charts will determine whether systems succeed.

What stood out was how closely these reflections aligned with what he describes as the Fourth Shift, a fundamental change he believes is missing from the current Ten-Year Plan.

A New Foundation for Strategic Commissioning

Alongside the well-established shifts toward prevention, integration and upstream care, Patrick argues for a fourth, equally essential shift:

A shift to coproduction, lived experience and community-led transformation.

In practice, this calls for:

Commissioning with communities rather than for them
Embedding community voices in governance
Recognising lived experience as genuine expertise
Leadership that listens, learns and shares power
A rebalancing of power across national bodies, systems, places and people

For Patrick, the Fourth Shift represents a permanent, structural change in how systems relate to the people they serve.

Insights from the Panel

The panel discussion strengthened his view:

Richard Watson highlighted the need to invest in people for collaboration to thrive.
Professor Patricia Miller OBE questioned whether ICBs truly have the freedom to deliver transformation.
Professor Sir Chris Ham emphasised that the centre must model enabling behaviours.
David Meates showcased what becomes possible when systems adopt community-based, trust-led models.

Together, their contributions underscored the same conclusion:
Strategic commissioning must be built on partnership, community insight and lived experience.

Patrick’s Reflections for ICS Leaders

Leadership matters especially leadership that shares power
Culture matters trust cannot be mandated
Capability matters people need support to work differently
Commissioning must be enabling, relational and place-driven
Lived experience must sit at the centre, not on the margins

Patrick believes ICSs are uniquely positioned to lead this transformation, but only if they embrace the Fourth Shift and adopt a commissioning model that is co-produced, community-powered and grounded in lived experience.