If you've been a GP for more than five years, you've now lived through at least two complete reorganisations of the commissioning structure. PCTs became CCGs in 2013. CCGs became ICBs in 2022. The buildings changed, the logos changed, and the people mostly stayed the same. But the structure through which decisions about your services are made did change — and most GPs lost track of it during the transition.
This matters because the decisions that affect your daily working life — what services are commissioned, how referral pathways work, what targets you're expected to hit, and how your practice gets funded for enhanced services — are all made within this structure. If you don't understand it, you can't influence it.
The current structure (as of 2026)
Integrated Care Systems (ICSs) are the overarching partnerships covering large geographic areas (typically populations of 500,000–3,000,000). There are 42 ICSs in England, each containing:
The Integrated Care Board (ICB) — this is the statutory NHS body that controls the budget and makes commissioning decisions. The ICB replaced the CCG. It decides which services to fund, which providers to contract with, and how money flows through the system. The ICB board includes a chair, CEO, medical director, nursing director, and representatives from NHS trusts, local authorities, and (in theory) primary care.
The Integrated Care Partnership (ICP) — a broader partnership that includes the ICB plus local authorities, voluntary sector, public health, and other partners. The ICP sets the overarching health and care strategy. In practice, its influence on day-to-day GP operations is limited.
Place-based teams — the operational layer within each ICB, covering smaller populations (typically 100,000–500,000). "Place" is where most decisions that directly affect GP practices are made: commissioning of local enhanced services, community service specifications, and interface with secondary care. Your Place Director or Place Lead is probably the most important person you've never met.
Primary Care Networks (PCNs) — the practice-level grouping (30,000–50,000 patients), sitting within Place. The PCN Clinical Director is the link between your practice and the commissioning structure above.
Where GP decisions actually get made
In theory, decisions flow strategically from ICS/ICB level down through Place to PCNs and practices. In reality, the decision that matters to you on Monday morning — whether the dermatology referral pathway changed, whether your enhanced service funding is being renewed, whether the GP access target just shifted — was probably made at Place level, by a small group of commissioning managers, often with limited GP input.
This is both the problem and the opportunity. The problem: GPs feel decisions are imposed on them. The opportunity: Place-level decision-making involves far fewer people than you'd expect. A GP who turns up consistently, speaks clearly, and understands the commissioning language can have disproportionate influence.
How to actually influence decisions
Know your PCN Clinical Director and what they're working on. They're your representative in the commissioning structure. If they're effective, work through them. If they're overwhelmed or disengaged, consider whether you should be doing that role yourself.
Attend Place-level meetings. Most ICBs have primary care committees or forums where commissioning decisions are discussed. These meetings are often poorly attended by GPs because everyone is too busy. The GPs who do attend tend to have outsized influence simply because they're the only clinical voice in the room.
Speak the commissioning language. Commissioners respond to: cost-effectiveness data, activity numbers, patient outcomes, and system risk. "We're too busy" doesn't move policy. "Our practice saw 4,200 same-day presentations last quarter, 30% of which could have been managed by [specific service], saving an estimated £X in secondary care referrals" does.
Build relationships with commissioning managers. These are the people who write the service specifications and hold the budgets. They're usually not clinicians and they genuinely value clinical input when it's constructive rather than adversarial.
Engage with LMC processes. Your Local Medical Committee represents GP interests in negotiations with the ICB. LMCs vary in effectiveness, but they have formal standing in commissioning discussions that individual GPs don't.
Is it worth the effort?
Honestly — it depends on your personality and career stage. If you're a salaried GP focused on clinical work, the commissioning structure is largely somebody else's problem. If you're a partner or CD whose practice income depends on commissioned services, understanding the structure is a professional necessity. If you're interested in leadership, commissioning engagement is the entry point to a career path that leads to CD, ICB clinical lead, Medical Director, or national policy roles.
The GPs who describe themselves as "powerless" in the system are usually GPs who've never engaged with it. The structure is bureaucratic and frustrating, but it's also responsive to persistent, informed clinical voices — because it has very few of them.
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