Strategic planning (SP) is a widely-used practice within public sector organizations. However, SP does not only take place in strategy workshops and senior management levels. This article explores how medical managers of English hospitals ‘do’ SP in their clinical directorates. In doing so, the authors investigate the practices, the usage of strategy tools and the implications of medical managers’ strategizing. The article argues that what makes financial sense to medical managers strategizing in the local circumstances of their directorates does not always equate to value for patients, the hospital or for the public sector as a whole.