In the first two articles I talked about changing expectations, and changing levers of influence.

If both of those are shifting, then the next question feels more personal. Are medicines optimisation teams set up to operate in that world?

As I referenced in the last article, medicines optimisation teams have been built around stepping in when there’s a problem. We write guidance, we often implement it too. And very often we referee the difficult conversations between organisations. We are the ones people look to when they don't feel they can solve a problem themselves.

And to be fair a lot of the time we do it well. But it is not what we are tasked with doing in the new world. For good or for ill, the 'high heid yins' have decided that's not a valuable or affordable service any more. So we are being asked to become something different, and the only way we can do everything asked of us is by doing less stepping in and more standing back.

And so the role of market manager and intelligent payor requires us to approach things differently.

Take community pharmacy as one example. If it is goin g to become a legitimate, viable and competitive provider of clinical services, then it won’t be because medicines optimisation teams step in and make that happen operationally. It will be because we design the conditions in which it can succeed. There will hopefully be some national support for that in the form of a decent and progressive new core contract, but it's going to rely on local commissioning of clinical services. We are going to need to use a blend of contracts, incentives and provider management approaches.

The same applies more elsewhere in the system. if we no longer have the resource to “do” medicines optimisation for providers, then we have to ensure it happens in a different way. By designing it into contracts, setting expectations clearly, and importantly by holding providers to account for delivering it.

And then there is neighbourhoods. The new neighbourhood health framework was published recently. The principle sounds lovely. Care delivered closer to home, by multidisciplinary teams, with more local ownership and collaboration between parts of the system.

But from what I've seen the idea is largely built on goodwill. And goodwill is not a reliable operating model.

There will of course be some shining beacons of hope (there are places that have been doing exactly this for years), but in many places, goodwill doesn’t exist any more in the way the framework assumes it does. So ICB teams will still need to act as system conveners, but not in the way we have done historically.

Not as the helpful honest broker trying to keep everyone aligned, certainly not as the benevolent philanthropist who bank rolls change, but as the part of the system that makes the decision, sets the expectation, and holds everyone to account on the outcomes.

So for ICB teams who've worked so differently in the past the hardest part of this transition is not learning something new, it's unlearning a reflex.

When something goes wrong in the system just now, we step in. When someone asks for help we respond, by writing the guidance, commissioning the service, or finding the money.

That is what we have always done, and it's what the system has come to expect. But if we keep doing that, we will never be able to fulfil the new role the system has in mind for us.

We need to move away from refereeing the shared care interface, and into deciding what services need to exist in the first place. That will include much more decommissioning than we've done in the past.

We won't be writing searches for GP practices any more. We will be analysing data and evidence to understand how services need to change and how we get the best value from new technologies and models of care, not holding hands through implementation.

And that's going to create a significant gap. As we step back from some of the work we have traditionally done, there will be things that are not picked up immediately, and I don't think providers (in secondary or primary care) are ready for that, or indeed expecting it.

So I think in many cases, things may get worse before they get better, and that is difficult for us to see. Because most of us came into this profession to help people. Not stepping in feels uncomfortable and counter intuitive.

But if we don’t create that space, nothing changes. We don’t build the capability to act as strategic commissioners, we don’t develop the skills required to shape markets, design contracts, and influence the system upstream.

We will remain busy, helpful, and stuck. That is how ICBs will fail.

What does this mean for the ICB MO workforce?

Well, for those of us who are left........ Some people will thrive in this new role, some will not. Others may not want to.

And that is not failure. Part of the challenge is that the level of the system ICB medicines optimisation teams work at has never had a stable identity for long enough to develop a consistent capability framework. This layer of the NHS has been reorganised, renamed and reshaped so many times that there is no clear, established career path, consistent competency framework or shared understanding of what “good” looks like in these roles.

So people have come from a wide range of backgrounds, shaped by the needs of previous versions of the system. Which means some of them are now being asked to operate in a role that is fundamentally different from the one they trained for, applied for or expected, and not through any fault of their own.

It’s a bit like asking a goalkeeper to suddenly play as a striker (I do love a sporting analogy). Some will adapt and may even thrive (like the legendary Jose Luis Chilavert). But many won't want to, or won’t be able to.

It would be a mistake to assume that everyone will naturally evolve into this new model, or that we can continue to design teams around a set of capabilities that are becoming less relevant, and expect a different outcome.

So one of the biggest decisions facing medicines leaders over the next 12 months is this: What capabilities do we actually need in the new world, and how do we develop the workforce to meet them?

And crucially, will we be left alone long enough to do it?