Change is needed in the NHS: the case for investing in dedicated system-wide teams to deliver

The NHS is one of the largest organisations of its kind in the world. It is estimated to be the sixth largest employer globally with access to substantial resources, but faces multiple long-term, structural challenges as demand for services increases continuously.  

The need for change and improvement has been recognised by successive governments and various NHS institutions have responded with recommendations and plans for reform but, for pragmatic reasons, the experience of staff on the ground often remains focused on delivering ‘business as usual’ (BAU), doing their best with stretched budgets and limited capacity. 

Implementing meaningful change across the NHS is a mammoth feat. It requires the buy-in of a vast workforce spread across a multitude of organisations, often operating with distinct contractual arrangements, and an array of other internal and external stakeholders^​1​. 

In March 2025, a newsletter published by Roy Lilley, a health policy analyst, writer and broadcaster, proved to be an interesting read^​2​. In it, he listed out how the recent ask from health secretary Wes Streeting is not entirely new:

• Shift care out of hospital into primary care;
• Analogue to digital;
• Stop people getting sick in the first place.

Successive governments have made similar recommendations since the 1960s. We know what needs to happen, but the scale change needed can feel overwhelming. Saying all of this, the NHS has made progress, but change has been glacial in speed. For example, most clinicians now routinely use digital systems when delivering care but maximising these digital tools and digital interconnectivity still has so much further to go. 

Along a similar vein, the ‘NHS England medicines optimisation opportunities 2024/2025’ guidance, published in July 2023, contained few surprises, because many of these have been priorities for years, sometimes even decades^​3​.

The hard part is making change with speed and embedding the change so that it becomes the new BAU. We all know that changes being asked of the system are important, but each ‘big ask’ requires dedicated capacity with the relevant skills and influence to work at scale, which costs. And, if the change requires long-term funding in a cash-constrained system (e.g. analogue to digital switch), it adds another layer of difficulty. 

Introducing the ‘North central London medicines efficiency programme’ team

In response to the ‘NHS five-year forward view’ (published in 2014), which the ‘NHS long-term plan’ (published in 2019) built on, north central London (NCL) partners collectively funded a central dedicated medicines efficiency programme (MEP) team to support the system to deliver on the NCL 2018/2019 medicines optimisation priorities^​4,5​.

One of the first projects the team had to deliver was a switch from Humira originator to adalimumab biosimilar at pace. This is because a previous attempt to switch to 90% etanercept biosimilars was not met within 12 months. 

With project management support from the MEP team, NCL achieved a 89% switch within three months. The cumulative savings released during the fourth quarter of 2018/2019 was £5m. NCL maintained ongoing 90% biosimilar prescribing and performed well when compared to the two other north London integrated care systems (ICSs) one year later, which had achieved rates of 81% and 72%, respectively.

The transition to integrate pharmacy and medicines optimisation

In advance of NHS England being divided into ICSs in July 2022, it published guidance on how ICSs should integrate pharmacy and medicines optimisation and asked for the local systems and ICS footprints to agree their integration plans by the ICS go-live date^​6​.

The ‘Integrating NHS pharmacy and medicines optimisation’ (IPMO) programme describes the collaboration between organisations to build pharmacy services of the future and the creation of a system-based, pharmacy professional network with joined-up working across the different parts of the system. The MEP team was in a good position to support system leaders with this plan. Domains (similar to working groups) were established to focus on delivering ICS medicines optimisation priorities around workforce, medicines value and safety.

Following the success of delivering the adalimumab switch and support with other NCL priorities, the MEP team was renamed the ‘IPMO programme team’. 

Our team continue to support the system with cost-saving programmes, but the savings we supported to release allowed us to also work on quality and safety projects including:  

• Reducing carbon from inhalers: consistently met annual NHS England targets (approximately 6-7% reduction per year);
• Discharge medicines service launched in seven out of nine NCL trusts; 
• A 9.2% reduction in high-risk prescribing based on the ‘PINCER’ indicators by embedding focused reviews in 93% of NCL practice;
• Better understanding of the pharmacy workforce through a landscaping exercise.

How does IPMO work?

For significant integration and collaboration of pharmacy and medicines optimisation to happen across an ICS, the creation of a dedicated team was essential to deliver at pace in NCL. System leaders can trust the IPMO team to deliver because they have dedicated time to develop a strategy, identify data-driven priorities (beneficial to the ICS as a whole rather than individual organisations), set standards and develop governance, deliver project management and create the necessary documentation and resources (e.g. standardised project frameworks). 

Having an empowered ICS leadership that champions the IPMO programme has been essential. The NCL ICS pharmacy leadership meet regularly with the aim of agreeing a strategy, collaborating on medicines optimisation projects and opportunities within the system. The IPMO programme feeds into the group by identifying and reporting on delivery of agreed priorities, escalating barriers when encountered. The group includes pharmacy leaders from all sectors of the ICS (such as ICS chief pharmacist, trust chief pharmacists, ICB head of medicines management and local pharmaceutical committee leaders).

It is important to ensure that priorities focus on new ways of collaborating or enhance business as usual activities and need to be beneficial to the ICS as a whole, rather than individual organisations. 

Reflections and learnings

At North Central London ICS, we are now six years into this journey and at a point where it is valuable to reflect on progress made so far and identify lessons learned that can feed into the ongoing development of IPMO and ICS-level collaboration.

It takes time for the system partners to get used to new ways of collaborative working and many of the stakeholders may not know their ICS colleagues. Fostering a new way of working across NCL ICS was challenging and required significant facilitation during the adjustment period. Remember that trusts and boroughs may have historical (sometimes competitive) ways of working that have been in place for many years. Some crucial observations include:

• We have found that it is better to focus on a few priority areas (no more 3-4) each year and do them well rather than spreading resources more thinly across large numbers of initiatives;
• For individual projects, it is important to have clear governance (including a senior responsible owner and escalation process);
• Owing to stakeholder capacity, it may be difficult to always get good attendance and membership of project groups or domains may need to be refreshed on a regular basis;
• Access to data is vital. Some ICSs may not have the right information governance in place to allow for this sharing. It is important from the outset to get high-level access to data, where possible (e.g. ePACT, DEFINE, EMIS/SystmOne). Data are important for identifying priorities, potential impact and also for monitoring change;
• The importance of universal buy-in at all levels and decisive action cannot be overstated. The ICS chief pharmacist needs to provide support with this through engagement with leaders across the system;
• ICS level collaboration provides a real opportunity for team-led projects which can deliver impressive results and also provides rich opportunities for professional development;
• Change teams moving beyond their professional silos and identifying and working with other change teams on common goals, leads to sharing of best practice;
• Have clear project plans and delivery timelines from the start. Provide sufficient time for more complex projects;
• Quick wins with high returns should be prioritised;
• Lack of funds in the system have been a consistent issue with gathering momentum (incentives, digital platforms);
• Measuring return on investment (ROI) and publishing annual reports are important components of governance. NCL IPMOP team have delivered a consistent ROI of 4:1 (usually 2:1 is considered good and we consistently deliver above that);
• Some benefits of the IPMO team are difficult to quantify but still valuable (e.g. offering project management support and facilitating strategic thinking).

Medicines remain the most common therapeutic intervention in the NHS[6] and the pharmacy workforce carries the potential to improve patient therapeutic care and efficiency at the same time. 

That said, the scale of change required is huge. In addition to this, a whole raft of major financial cuts has been announced. ICBs are being asked to make 50% cuts to running costs and NHS England is to be abolished. As a result, the attention of many leaders will be focused on delivering these organisational changes or adjusting to them. Clinical teams will need to adapt to new roles and responsibilities and NHS staff on the ground — many of whom are already struggling under the pressure of their BAU work — will be feeling vulnerable. Having a stable system-wide team, dedicated to driving the delivery of NHS priorities during this period of transition and change will continue to be highly valuable.

Shahid Gani, lead pharmacist, IPMO programme team (NCL ICS)