Janet Finucane discusses commissioning specialist services while maintaining strong local links. She provides examples of how a prison commissions health services for its population, developing telemedicine, new dental/drug services, and links to local pathways. She questions whether relationships with local services will remain strong after a transfer, and whether the local health system can take on bariatric surgery given budget/pathway constraints and user need. Commissioning requires understanding problems, affordability, processes and user views.