Strategic commissioning and neighbourhood working are being developed largely in parallel. A focus on unwarranted variation might be what brings them genuinely together.
Bec Richmond
Senior Specialist Advisor · International Perspectives & Facilitation
System pressure is rising on every front. Organisations across health and care are being asked to improve outcomes, manage demand, satisfy tighter budgets, and navigate increasing regulatory scrutiny — often simultaneously, and often without the capacity to do any of them well.
Meanwhile, new national frameworks arrive faster than systems can absorb them, not always aligned with each other or with the realities on the ground. Three pressures, in particular, make this moment distinctive.
1. Structural complexity
Aging demographics and long-term conditions increase clinical and operational burden without a proportional increase in funding or capacity.
2. Intensifying oversight
External measurement regimes make variation and underperformance more visible — increasing accountability pressure across organisational boundaries.
3. Financial constraint
Neighbourhood teams are expected not just to maintain services but to innovate. With budgets flat or declining, that requires finding what to stop, not just what to start.
These pressures are real. And I don’t think we’re yet using all the tools available to us to address them. One of those tools — one I keep returning to — is a sustained, system-wide focus on unwarranted variation.
Strategic commissioners must create the conditions for neighbourhood teams to agree on what good looks like — rather than using metrics as blunt instruments.
What do we mean by unwarranted variation?
Definitions matter here, so let me be clear about mine. Unwarranted variation refers to practice differences not justified by illness severity, evidence, or patient preference — differences that produce wasted resource, inconsistent outcomes, and inequity. That last word is crucial. When large, unjustifiable differences deprive people of beneficial care, the system fails on both performance and fairness grounds. That is what separates legitimate personalisation from avoidable inconsistency.
Atlases of variation across multiple countries and health systems have made these differences visible, comparable, and increasingly difficult to defend as “local nuance.” The evidence base is substantial. What interests me more is how a focus on variation could simultaneously advance two things the NHS is working on — often in isolation — at the same time.
The case for bringing them together
If systems genuinely ran at tackling unwarranted variation, could that simultaneously support sustainable neighbourhood working and provide a meaningful organising focus for ICB commissioning functions? I think it could. The potential gains include better integration of services, more consistent care quality, improved person-centred outcomes where variation is driven by preference and not postcode, and more engaged staff because consistent approaches make collaborative working easier.
When I first explored unwarranted variation in depth, the lens was predominantly clinical — theatre efficiency, discharge processes, treatment decisions. Neighbourhood working is inherently broader. Reducing variation in a whole-person care context requires significantly higher and broader ownership, and we have not yet built reliable ways to enable that.
True, data-driven strategic commissioning could change that. It could enable collaborative process development, support shared decision-making through population health management data, and flow resource to where the evidence says it is most needed — for and with citizens and patients.
The human dimension
But — and I always come back to this — it is not just about process and data. Standard-setting is as much a social challenge as an operational one. Strategic commissioning, if it is to support neighbourhood working, must invest consistently in human enablement. Three things matter most.
1. Inter-agency training and development
If neighbourhood working is about whole-person care across organisational boundaries, why is training still largely delivered in silos? Joint training is not a nice-to-have; it is infrastructure.
2. Tracking adoption — with the right tone
When agreed standards are not followed in practice, we need to understand why. Not to put people on the naughty step — but because non-adoption is often a signal of a better approach, or a barrier worth removing. The conversation must shift from compliance to professional excellence.
3. Creating space for ongoing learning
Checklists and standards are not silver bullets. Long-term variation resolution depends on an environment that supports continuous learning, together, across neighbourhood teams.
A shift in tone, not just in method
What I am proposing, ultimately, is a shift in how we frame the targeting of unwarranted variation. Not as the imposition of external standards, but as an expression of professional responsibility and collaborative accountability — one that establishes collective commitment to quality, uses data to compare and improve, prioritises citizen and patient impact, and recognises that shared culture matters as much as shared process.
Strategic commissioners have a specific role in this: creating the conditions for neighbourhood teams to agree on what good looks like, removing barriers, funding infrastructure, and enabling adoption at scale. Not controlling the outcome — but making the right outcome possible. We should be talking about this more.