Medicines optimisation teams need to showcase their value to withstand ICB funding cuts

As the dust settles on the high-profile announcements about the future structure and funding of the NHS, it is worth taking a breath and trying to understand what this all really means^​1​. Although there is an absence of detail for now, there is enough in the mood music and tea leaves to be able to predict some things about the future. 

It is worth bearing in mind the context for this; the country is in a pretty dire economic state and there is a perception — much of it justified — that there is too much duplication and ambiguity in the overly complicated NHS structure. Reducing ‘bureaucracy’ is appealing for a government at the best of times, but the opportunity to put £500m back into the Treasury coffers without reducing front-line services is clearly too tempting to resist^​2​.

The ‘abolition’ of NHS England is slightly misleading. In reality, it is a merger of functions with the Department of Health and Social Care (DHSC) with the previously announced 50% running cost reduction^​3​. Work will continue at both a regional and national footprint, with the DHSC responsible for performance management of NHS organisations, but there is a desire from the political centre to exert more control over that function and return NHS operations to ‘democratic control’^​4​.

More significant is the cut in running costs for integrated care boards (ICBs). Introduced in July 2022, these organisations have taken on the responsibilities of multiple clinical commissioning groups, as well as several functions delegated from NHS England — including commissioning of community pharmacy. They also have a responsibility to progress on regional integration, prevention and health inequality initiatives. Nevertheless, the core function of ICBs was never fully or adequately defined by NHS England, adding to the confusion and duplication that has been so frustrating for the government and many others in the system. 

The latest 50% reduction in ICB funding came off the back of a 30% reduction in 2024, meaning that they will soon have lost 65% of their resource^​5​. Given the significant variation in the size and running costs of ICBs — ranging from £20 to £49 per person^​6​ — it is not yet clear how or where these cuts will fall. This means people working in these organisations are dealing with a huge amount of uncertainty and anxiety, while being expected to continue providing an essential function.

We do have some idea of the direction of travel. In a nutshell, it is that greater autonomy and accountability will be given to systems and providers (i.e. NHS trusts) that have proven they can be trusted with it and a more direct performance management regime will be overseen by the DHSC. 

There has been strong messaging that ICBs are here to stay but with a slimmed down and better-defined remit of strategic commissioning for a population. A model ICB is being developed by NHS England and that will inform some of the decisions around how these cuts are implemented. 

Future of medicines optimisation

At the heart of this government decision is money, with staff and medicines being the NHS’s two largest expenditures. Medicines spend alone is hugely variable, volatile and increasing at a rate much higher than inflation^​7​. To manage these costs, ICBs employ medicines optimisation teams, which are largely led by pharmacy staff, to achieve the highest quality, safest, most efficient and most effective use of medicines across their populations. This involves several activities that vary from ICB to ICB.

Overall, delivering an increasing financial efficiency demand, while building a robust medicines governance system and maintaining a strong focus on quality and safety, is the three-card trick these teams play. As the medicines spend is so high, these teams are not cheap, but they are widely perceived as being excellent value for money.

So what will the ICB financial cuts mean for medicines optimisation teams? 

Despite there being a huge number of unknowns, there are a range of possible options:

• There is widespread acceptance that an investment in medicines optimisation pays for itself many times over. Some ICBs may decide that this function is valuable enough to perhaps not be left untouched, but to have a lighter cut than other areas;
• A strengthening of other levers to influence prescribing across a system, such as quality or performance incentive schemes, might mean that similar outcomes can be achieved with a smaller and more strategic medicines optimisation team;
• Another option is for ICBs to delegate some of this responsibility to their providers. Where there are strong foundation trusts in the system, this may be appealing — they may be asked to take accountability for the care of their local population. This will clearly not be an option for all trusts of course, as many grapple with their own financial, performance and operational challenges.

The biggest risk for both the system and the teams employed in ICBs is the professional tendency we have to undersell ourselves and to continue being quietly effective below the radar. Medicines optimisation is a very challenging and specialist role. It might appear to some as a distant, back office, ‘ivory tower-type’ function, but it is absolutely crucial to the functioning of NHS systems and to how patients access and use their medicines. 

The pace of change in this restructure is faster than we have experienced before and, if these teams do not ensure those making the decisions understand the value in what medicines optimisation teams provide, we may be written out of the future. Nevertheless, there is no point in resisting change — we need to embrace it and offer up a coherent and believable vision of how the vast investment in medicines in the NHS will be best served in the new world. 

For pharmacists and pharmacy technicians working in medicines optimisation teams — keep doing the fantastic job you already do and know that it is valued. For pharmacy leaders across the system — now is a time to be bold, be creative and be noisy.