We’re on the verge of the biggest operational change in the NHS since its inception. Reform (pardon the unfortunate pun) in the past has generally involved tweaking, abolishing, creating or renaming one part of the system at a time. The system getting bigger, and then smaller, before it inevitably gets bigger again. 

What we are seeing now is more like rewiring an entire house while all the circuits are still live.

For those of us in the medicines world we have the additional complications of the UK/US trade deal, NICE changing its constitution and cost-effectiveness threshold, an avalanche of disruptive treatments, and the opportunities and threats of AI. Throw in a fragile medicines supply chain and there’s no end of work to be done.

Despite that, ICBs and NHS England are vastly reducing the resource available to steward this environment. We can’t keep doing what we’ve always done. Fundamental philosophical and operational change is required.

I predict that the way we make decisions in this environment over the next 12 months will lay the foundations for a step change in how we use medicines. If we do it well, we can expect to see and be able to demonstrate/understand the genuine impact of medicines as a population health intervention - an important factor in reversing healthy life expectancy decline.

If we do it badly, we’ll end up in a world of increasing rationing and restricted access. Eventually the political pendulum will swing away from widespread public support for the NHS and open the door for the next political guardians of the system to downgrade it into something closer to an explicit two-tier model.

No pressure then?

So what are the big and difficult decisions we in the medicines leadership world are going to have to make in the next 12 months, and how can we make them well?

I’ve split them into four themes, and over the next few weeks will be exploring what’s going on and how we can navigate this complexity and challenge well.

1. Changing expectations

2. Changing levers of influence

3. Changing capability requirements

4. Changing operating environment

Changing expectations

Medicines policy has never been closer to being the centre of the political story.

• Politicians have made contradictory promises to industry and the public. They have promised pharma (and Donald Trump) that spend on medicines will increasing from 10% of NHS spend to 12%. That’s going to cost between £1-3 billion/year (depending on who you believe). That’s a lot of efficiency to find from elsewhere, at a time when the government are only seemingly concerned about waiting lists, RTT, stop clocks and all the other headline metrics of ‘NHS productivity’. Medicines are now being seen as a strategic economic asset. Government discussions about life sciences growth, industrial strategy and global competitiveness now sit alongside, and often counter to, traditional NHS affordability conversations. 

• The public expect that when new groundbreaking/disrupter/gamechanging medicines are developed, that they can be accessed on the NHS universally and with no geographic variation. That’s not achievable in the current model and environment. The single national formulary is being framed in the context of reducing geographic variation, as much as a promise to pharma as it is to the public.

• Contract negotiations with primary care providers (predominantly general practice and community pharmacy) are tense. This spills over to local service commissioning and contracting. Avoiding difficult discussions at a national level, particularly around expectations within core contracts, pushes those tensions down into local systems. They then reappear in discussions about shared care, enhanced services and clinical responsibility. Those negotiations consume enormous amounts of time and energy locally. Time that could otherwise be spent improving pathways or doing the population health work the system needs.

So how does someone working in this environment remain composed, controlled and professionally effective? My thoughts on how to navigate these issues:

• Remember you are a steward not a saviour

You cannot reconcile a political promise to increase medicines spend with a simultaneous demand for rapid waiting list reduction. You cannot personally deliver universal access to every breakthrough therapy overnight. Your job is stewardship: bringing a system together to make defensible decisions about sequencing, affordability, and safety within finite capacity. 

• Accept that the tension in the system is structural and not personal

GPs have a new contract offer, which the BMA is rejecting. Community pharmacy is about to begin negotiations which are destined to be extremely tough. Foundation Trusts are under enormous pressure to address the most politically sensitive metrics. Alongside that, every time the NHS reorganises itself the debate about where the locus of power sits begins again.  That national tension will mean that local negotiations will be more fraught than ever. It would be easy to see this all as a local ‘fight’ between commissioner and provider. And if we allow ourselves to be dragged into that mindset we will lose perspective, composure and influence.

• Own the medicines agenda

As medicines become more politically visible, decisions about them will increasingly be made publicly. We’ll see more ministerial announcements and headlines about “breakthrough treatments” and “postcode lotteries”.

For many years the medicines world in the NHS has operated largely through technical processes: NICE appraisals, commissioning policies, formulary decisions, prescribing optimisation. Those are still essential, but they will be done differently (more on this in a future article). But as medicines are now tied to economic growth and the political story of the NHS, our expertise needs to become more visible.

Not in a combative or self-promoting way, but in a confident and calm way. The current ICB and NHS England change process has been professionally challenging, after all why would you need a team of expensive pharmacists and technicians when you’ve got to cut the wage bill by 50%? Are we an expensive luxury? The simple answer is that other than staffing, medicines is the highest spend in the NHS, and it’s increasingly one of the most volatile and politically sensitive areas.

We need to shape that agenda, rather than observing it. If we continue to position ourselves as ‘pharmacy’ rather than ‘medicines’, then we’ll be on the outside of the room where the big decisions are being made. 

It’s time for us to step forward and own this agenda. 

The next article in this series will consider how we use the changing levers we have to drive change in the system, and to ensure we can be most impactful in the new world.