A strong strategic MO function at ICB and system level is vital to maintaining control over both spend and outcomes and supporting the effective development of neighbourhood health services. Without this, there are serious risks to patient care, system performance and financial sustainability.

The long-awaited model ICB MO good practice guidance was released by NHSe a couple of weeks ago. It's an attempt to provide more detail to supplement the Model ICB blueprint that came out what feels like a lifetime ago.

That document stated that ICBs should retain a strategic MO function but 'transfer' delivery to other parts of the system. Clearly that is nowhere enough detail (particularly for a bunch of pharmacists) so much work has been done since to bring some of that to life and put meat on those bones.

Disclaimer – Under the leadership of the Chief Pharmaceutical Officer for England I was one of the authors of the Good Practice Guidance, working with colleagues from NHSe and others in the ICB chief pharmacist network. Overall that was an incredibly collaborative process that has helped to embed a level of mutual understanding between national and regional NHSe, ICBs and providers that I think stands us in good stead for the next stages of the process (more on that later).

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Each ICB should ensure it has expert system medicines leadership at senior level (Chief Pharmacist or equivalent) with sufficient resource to fulfil professional, statutory and organisational requirements in relation to strategic commissioning of medicines.

The document is in three parts:

1. Core functions that must be protected within the ICB, because they represent statutory responsibilities or essential system leadership roles.

2. Grow and retain functions, where we already have capability but need to focus on strengthening, scaling or embedding them in new ways.

3. Review and transfer functions, where the longer-term direction is to shift delivery into providers, regional or national structures, with the ICB retaining only strategic oversight.

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I think the 'core functions' are largely self-explanatory, and so I won't go into any detail about them, much more interesting are the sections on what can be reviewed and transferred in the short and medium term, and the functions that an ICB MO team should grow and adapt. I've picked out a few of the key ones here to discuss in more detail.

A general point across all of this is that in my view MO teams generally have not been good at describing what we do and how. We are often seen by ICB and system colleagues as 'clever people that keep us safe', as though we have some special sauce. That's true, but we do still work far too much in our own bubble with our functions not adequately integrated in many cases and the power of our work not impacting across the full breadth of strategic commissioning. Some of my colleagues will dispute that and it will vary from ICB to ICB, more influenced by history than current leadership, but I think we have to challenge ourselves as a discipline to be more vocal and visible.

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Functions to grow:

Population health management and epidemiology

• Our current capacity and capability in this is inadequate, but this is where the greatest opportunity lies. Growing this function at a time of significant running cost reductions will be challenging, but this is where we need to think smarter and let go of some of the lower value functions we currently provide, and those which providers should take on.

• We need to create the space in our teams to grow genuine population health management expertise. This will allow us to link prescribing data more effectively to outcomes and inequalities, transforming medicines optimisation from a technical oversight function into a driver of strategic commissioning. We need to work with our public health colleagues to better understand the 'causes of causes' (Marmot), join up data sets and better plan the role medicines can play in the health and wellbeing of our populations.

• Much of that will involve broadening our skill mix. How many MO teams have access to adequate data analyst and data scientist capacity to answer the questions of real clinical curiosity that will allow us to transform how medicines are used in a population context, rather than just measuring it?

System pharmacy professional and clinical leadership, including integration and system convening. Develop the medicines and pharmacy aspects of neighbourhood teams.

• Neighbourhood teams are aiming to become the new unit of currency for local multidisciplinary healthcare services, succeeding where PCNs have failed. For that to work it requires both community pharmacy to be valued and integrated in a way it never has been before (which will need a new national core contract) and a level of trust and openness between general practice and secondary care. Neither of these things are easy, and both will require mature and expert system leadership – a role my ICB chief pharmacist colleagues are well placed to provide.

Medicines and medicines value strategy to prioritise allocation of resources and ensure the ICB is acting as an intelligent healthcare payer.

• Intelligent healthcare payer and the concept of 'should cost' will transform commissioning. Linked to the point about market management, the emerging role of community pharmacy as independent prescribing services opens the door to a different type of conversation with providers – commissioners should be seeking to procure services with the best value for the taxpayers alongside the best quality and most accessible services for patients. That will require multiple different service provider models – it is no longer a binary choice between hospital and general practice. Neighbourhood contracting models should allow for the local design of services that better meet the needs of the communities they serve.

System readiness and impact assessment for disruptor technologies

• We need to strengthen our horizon scanning and impact assessment capability. This will allow us to prepare the system for the impact of disruptive medicines, both clinically and financially. The ICB chief pharmacist network is developing relationships with NHSe and NICE to support this. I am actually very optimistic that in the context of the life sciences plan, and the current challenging environment for the UK pharmaceutical industry we are making progress and will be in a better place soon to support the uptake and adoption of innovative therapies.

Strategic commissioning of community pharmacy

• This still worries me. It's not clear yet in the context of ICB transformation, NHSe region and OPICs (Offices of Pan ICB Commissioning) where community pharmacy will land. It is still baffling that the system manages community pharmacy (and optometry and dentistry) differently from general practice. It's hard to conclude that it's for any other reason than politics. In taking this approach we are underutilising one of our strongest and most undervalued neighbourhood providers, and I hope that in future ICBs are expected and mandated to lead this sector more effectively.

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Review and transfer in the short term:

Transfer MO delivery functions to suitable providers

• An ICB as a strategic commissioner shouldn't be providing services. Its role is to set priorities, commission outcomes, and hold providers to account — not to manage the day-to-day delivery of services like practice pharmacy teams. If an ICB directly provides care, it blurs the line between commissioner and provider, creates conflicts of interest, and risks duplication with existing GP, PCN, or community pharmacy teams. It also ties the ICB down with fixed workforce and HR responsibilities, limiting flexibility to shift resources where population health needs are greatest. Providers are better placed to deliver operational services and hold the associated workforce risks.

• But here's the rub – ICBs are hugely dependent on the financial efficiencies often delivered by these teams. So moving away from that model presents a level of risk that many organisations may find intolerable, certainly in the short term. This gets to the heart of much of medicines optimisation – it is a function that overlays a dysfunctional system. If we had better core contracts with GPs and community pharmacy and ICBs were acting as true strategic commissioners then much of what practice and care home pharmacy teams would happen as a matter of course.

• In my ICB we moved away from employed provider functions at the last reorganisation and are managing the activity of our providers through a mixture of better utilisation of existing contractual levers and local commissioned services. It represents a more mature relationship with our providers where we make our strategic expectations clear in terms of outcomes and impact, but leave it to them to decide how best to achieve that.

Consolidate MO functions across clustered ICBs to reduce duplication

• This is an obvious one, although as someone working in an ICB made up of 8 former CCGs I can say with confidence that the inherited history weighs heavily. Getting the balance of economies of scale whilst maintaining the good work done previously and the confidence of local relationships is a hard balancing act.

Review and transfer in the medium term:

Delegate prescribing budget responsibility to willing/competent providers

• This one is the biggie for providers. I've written about it before (here) While this may offer alignment with wider provider responsibilities, it carries significant risk if budgets are handed over in isolation. Medicines spend is volatile and closely linked to outcomes and inequalities. Any delegation must be carefully planned, with guardrails and strong professional leadership, or it risks destabilising providers, driving unwarranted variation and limiting access. In the medium term we will engage actively in national discussions, stress-testing local readiness, and making the case for delegation only where incentives, outcomes and system financial strategy are properly aligned.

Develop and implement single national formulary

• Another one I've written about before. The single national formulary has major potential benefits in reducing unwarranted variation, cutting duplication, and streamlining adoption of new medicines. We do need to be realistic about our expectations of this though – I expect further communications to the system about this soon.

Consolidate standards, tools and protocols to improve MO; rationalise investment in prescribing support tools; and develop standardised datasets and dashboards

• We have a healthy market of prescribing support systems and data sources, but there is no doubt some of this could be rationalised. There are a number of systems and providers that operate on a subscription basis, which may be more robust and economical if commissioned once nationally. And if there is a collaborative and concerted effort to develop more meaningful measures (to replace ASTRO-PU for example) then we could revolutionise our understanding of the impact of medicines use on outcomes and population health.

Provider performance, infrastructure and delivery risks and collaboration opportunities, including aseptic services and radio-pharmacy

• Something that should be clarified by working through the model NHS region. An ICB MO team's responsibility will be to ensure that medicines are explicitly factored into provider assurance frameworks and contractual expectations. I expect some of this to be further clarified as we develop the Offices of Pan ICB Commissioning (OPICs).

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Along with all of this we have had the model region document. It's important in the context of system architecture, and as the meat gets put on those particular bones I'll do a follow up to this article (covering important things like strategic workforce planning and statutory functions like controlled drugs), but for me the biggest challenge when the dust settles is going to be the changing demands on providers. Jim Mackey and other FT CEOs are clearly up for the challenge of greater autonomy, and I think that's a great thing. It is high risk and high reward, but ICBs have been caught betwixt and between for the last couple of years and I welcome a move to a clearer system. It is going to mean a very different way of working for providers; the answer to a problem will not be to submit another business case to the commissioner – it will mean internal transformation and making difficult decisions about the use of it's own resources, but a more free hand to make those decisions will be helpful.

And non-hospital providers must be supported by the right contractual and financial frameworks to do what is expected of them, but the move towards more collaborative ways of wrapping around local populations is a step in the right direction.

Of course with more autonomy at provider level comes greater accountability and greater variation. I hope we design a system that allows that to happen where it is informed by genuinely understanding our populations.

For my colleagues working in ICBs, NHSe and other parts of the system – it really is worth taking a step back from the day job when you can to try and look at this from a whole system perspective. And for many people doing so might help to clarify which part of the system you most want to inhabit. For me, strategic commissioning feels like the right place to be, but that will be too remote from service provision for some.

So there you have it. Much work to be done, but the clouds are starting to lift and a vision is starting to emerge. The role of leadership now is to make this a reality and take our teams and systems with us; which will be no mean feat in the current environment.

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