The British National Health Service (NHS) has been involved in profound transformation to keep pace with; and shape; changes in our society. Innovation has been driven by the necessity to transform old hierarchical and paternalistic models into a modern health system; moving care closer to home; mobilizing and tailoring services to individual patients’ and their carers’ needs through the introduction of radically new services. This paper explores a particular element of ongoing NHS reform: Practice Based Commissioning (PBC). Based on first findings of a research project called ‚ÄúDesign in Practice. Change and Flexibility within Health Providers‚ÄĚ funded by the EPSRC research centre HACIRIC; the authors argue that PBC formally recognizes important forms of grassroots service design; but also introduces additional challenges. The project is based on case studies within the North West Strategic Health Area (UK); and the study of PBC frameworks and everyday PBC practices in this specific context is explored and contrasted with concurrent efforts to bring service design into the public sector; which are focusing on co-design and experience-based design methodologies. It is suggested that these have the potential to help NHS providers address NHS policy demands to use patient feedback in transforming services (DH; 2009); and the authors reflect on possibilities for potentiation through the application of Service Design methods in this context.