Responsibility for community pharmacy commissioning moved to ICSs/ICBs from 1 April. So how should pharmacy now work with ICBs, and are they friend or foe? By Saša Janković

Up to now, pharmacy funding has been the responsibility of central government, with the then option for clinical commissioning groups (CCGs), and local authorities, to commission services from pharmacies from their budgets.

However, the move to Integrated Care Systems (ICSs) and the dissolution of CCGs has led to a gradual switch of delegated commissioning responsibilities for pharmaceutical, general ophthalmic and dental (POD) services, with NHS England (NHSE) formally approving the delegation of these functions to all Integrated Care Boards (ICBs) from 1 April 2023.

NHSE welcomed the delegation of responsibility for commissioning pharmaceutical services to ICBs in a Primary Care Bulletin at the end of March, with Ali Sparke, director for dentistry, community pharmacy and optometry, and David Webb, the chief pharmaceutical officer for England, jointly stating: ‘This fulfils our long-term policy ambition of giving systems responsibility for managing local population health needs, tackling inequalities, and addressing fragmented pathways of care'.

While the change is broadly welcomed as a positive step, with so many developments – and a new stack of acronyms – in this part of the healthcare landscape it can feel difficult to keep pace with who is doing what, and where. Here is an overview, and some responses from within the pharmacy sector on what the changes may bring.

What is an ICS and an ICB?

Forty-two Integrated Care Systems (ICSs) were established with a statutory footing across England on 1 July 2022, serving individual geographical populations of between 500,000 and 3 million people. Born out of sustainability and transformation plans/partnerships (STPs) formed in 2016, ICSs bring together NHS organisations, local authorities and other service providers to improve population health, reduce inequalities, enhance productivity and value for money, and help the NHS to support broader social and economic development. They have two key parts:

  • Integrated care boards (ICBs): a unitary board responsible for allocating the NHS budget and commissioning services, with membership including (at a minimum) a chair, chief executive officer, and at least three other members from NHS trusts and foundation trusts, general practice and local authorities.
  • Integrated care partnerships (ICPs): a statutory joint committee of the ICB and local authorities to bring system partners together to develop an ‘integrated care strategy’ to address the wider health care, public health and social care needs of the population.

Each ICS has a chief pharmacist who leads on the safe and effective use of medicines to develop and deliver an integrated approach to medicines optimisation and pharmacy services. There are also other members of the team who may be pharmacists, including, in some ICSs, the chief executive.

What will ICBs commission relating to pharmacy?

ICBs hold budgetary responsibility with duties around service improvements, reducing inequalities, promoting innovation and patient choice, and took on delegated commissioning responsibilities for pharmaceutical, general ophthalmic and dental services from 1 April 2023.

However, note that ICBs will not negotiate the Community Pharmacy Contractual Framework (CPCF). James Wood, director of contractor and LPC Support at the Pharmaceutical Services Negotiating Committee (PSNC) explains that this will continue to be negotiated directly with NHSE and DHSC, saying: ‘NHS England retains the responsibility to identify national priorities, setting outcomes and negotiating national contractual frameworks, such as the Community Pharmacy Contractual Framework in the tripartite arrangements with DHSC and PSNC.’

What does the change mean?

‘Improved alignment’ of the delivery of nationally determined services within the primary care contracts with the work of other services providers in the health and care system could benefit community pharmacy, Mr Wood suggests.

The commissioning of primary care services through national contracting arrangements via local NHS bodies could potentially offer ‘an opportunity to ensure the value of community pharmacy services is better recognised and maximised to the benefit of patients and the NHS,’ believes Mr Wood.

In practical terms, he predicts the changes will mean:

  • NHSE is delegating the commissioning of Enhanced services to ICBs
  • ICBs must ensure all payments, including for Enhanced services, should be made using the recognised contractual mechanisms
  • And on the basis that NHSE delegates commissioning of Enhanced services to ICBs, the delegation under the pharmaceutical regulations will mean ICBs must consult with LPCs (in the area for which the service is provided) on the fee.

As functions change locally, it could be challenging for relationship-building between community pharmacy, LPCs and ICSs to keep pace, but there are plenty of good examples of pharmacy influence on, and representation within, these structures.

Pharmacy influence and representation

While the main drivers for community pharmacy have historically nationally been through the Community Pharmacy Contractual Framework (CPCF), the new commissioning arrangements could bring additional benefits locally from closer working relationships with ICSs and ICSs.

According to Fiona Garnett, associate director medicines optimisation at Bedfordshire, Luton and Milton Keynes Integrated Care Board (BLMK ICB), delegated commissioning enables an ICB to ‘proactively support the integration of community pharmacy as a system partner’.

BLMK ICB has also been proactive about getting pharmacists on the inside of its organisation, recruiting a chief pharmacist into the medical directorate, appointing a community pharmacist as a Primary Medical Services Providers Partner Member to ensure the voice of community pharmacy is heard, and with a chief executive, Felicity Cox, who is also a pharmacist.

Adam Irvine, chief executive officer at Community Pharmacy Cheshire & Wirral (CPCW), says his organisation has a good relationship with its ICB, although he acknowledges that this will ‘vary wildly’ across the country.

‘In Cheshire & Merseyside the ICB has really valued all of its provider disciplines within primary care’, he says. ‘It’s why I have been able to be appointed as a primary care partner Board member of Cheshire & Merseyside ICB and appear regularly at the Health & Care Partnership Board also.

Mr Irvine says there are also several ways community pharmacy is championed within the ICS: ‘From my role on the board, the LPCs showcasing what they are doing at place level with the relationships they hold there, and the Clinical Lead for Community Pharmacy Integration which are appointed or being appointed in every ICB footprint.’

The collaborative picture looks bright in Greater Manchester too, where community pharmacy, general practice, dentistry and optometry are working collaboratively within the GM Integrated Care System through the establishment of a GM Primary Care Provider Board which represent their respective disciplines, and collectively within the GM ICS governance boards.

It also has a Community Pharmacy Provider Board (CPPB) – a sub-discipline board of the GM PC board with members drawn from Bolton LPC, Greater Manchester LPC and the provider company CPGM Healthcare Ltd to create a distributed leadership model of representation.

As a result, Luvjit Kandula – director of pharmacy transformation at Greater Manchester Local Pharmaceutical Committee – says community pharmacy is ‘championed by GM LPC representatives and members of the Community Pharmacy Provider Board across many areas such as population health, CVD, digital, Primary Care Boards, IPMO workstreams and urgent care.’

GM LPC has also been consulted on the development of the ICB governance and the chairs of the Primary Care discipline boards now have a place on the GM integrated Care Partnership Board.

Strong working relationships

With 162 community pharmacy contractors within BLMK providing essential and enhanced services, BLMK ICB has some good examples of strong relationships with the sector

‘The Covid vaccination programme has been one of the more recent successes for community pharmacy in BLMK’, says Ms Garnett.

She says: ‘Community pharmacy providers were engaged to deliver at the very start of the vaccination programme with the first providers going live in January 2021 in large scale vaccination sites.

‘In June 2021, BLMK were the pilot site to test the proof of concept for the role out of smaller scale delivery by community pharmacy from existing premises [and] the role of community pharmacy in the programme has continued to increase, with community pharmacy delivering over 60% of the Covid vaccinations in phase 5, and for the Spring 23 booster programme, community pharmacy will be the main provider for the vaccinations.’

But with room for improvement?

Nonetheless, since it’s relatively early days, it’s not surprising that there are still some barriers that community pharmacy is finds itself up against.

‘I personally have some really good relationships across the two ICBs I work in’, says Nick Hunter, chief officer for Doncaster, Rotherham and Nottingham LPCs. ‘However, they are organisationally in their infancy and even though I can speak with people in the ICB who understand the issues we face and the opportunities, they themselves are often at a loss as to where to take the opportunities and issues.

‘The main issues for community pharmacy are the same as described nationally by PSNC: lack of core reliable funding to encourage investment – some longstanding services are being decommissioned – like the Nottinghamshire Pharmacy First and local Emergency Supply Schemes – and no new opportunities even in the pipeline.’

The Pharmacist spoke to Mr Hunter in March about the decommissioning of Nottinghamshire’s long-standing Pharmacy First scheme.

A further significant issue is around the support of workforce development and retention, required for the implementation and future development of pharmacy services, and which would be supported through smarter commissioning, and a commitment to services commissioning.

‘If we want contractors to train their staff further, there has to be a purpose to that’, argues Mr Hunter.

‘Commissioners need to reinstate confidence such that contractors can at least stand a chance of getting a return on investment - whereas at the moment it feels like you are training someone to make them more poachable.’

Ms Kandula’s wish is that the ICS will support harmonisation and standardisation of commissioned services. ‘This is currently a challenge as we have variation in commissioning of services across 10 localities’, she says, ‘so working towards a GM standardised specifications for common services will help develop a core offer which will reduce variation, improve access and support a reduction in inequalities.’

Creating connections

Michael Lennox, chief officer at Somerset LPC and local integration lead at the National Pharmacy Association, has some characteristically proactive advice for LPCs looking to increase their visibility.

‘There could well be the occasional LPC out there which might not have positioned itself as a system partner and player and is finding itself trapped in a lower echelon downstream of medicines management, plus if you had a narrow band of relationships in a CCG you might find as the ICS formed you don’t have any natural allies within it’, he says.

‘The question to ask yourself is are you in a position where you can pick up the phone to the system exec team? If not, there’s no need to panic but you will need to get these bridges built fairly quickly and have the confidence, commitment, competency and the capacity to invest in these connections.

‘Yes, it’s time consuming,’ he says, ‘But in order to make a withdrawal from the ‘emotional bank account’ of these relationships you first need to keep turning up and bring ideas and energy to real problems, so they get to think of you as a systems player.’

Unseen support

Building these channels of communication will also give LPCs – and contractors – insight into the work going on behind the scenes in ICBs in relation to community pharmacies.

Ms Garnett says that BLMK ICB has been working collaboratively with the regional NHSE (East) regional team to plan and prepare for the transfer of community pharmacy services ‘to provide the ICB with assurance and for the ICB to provide the region with assurance’.

As part of this, the ICB has created a dedicated team – including a community pharmacy integration lead pharmacist – which will be reaching out to community pharmacy providers to on-board them as members of the ICB integrated system partners.

Ms Garnett says the priority is ‘stability of the current services’ but, at the same time, the team is currently working with key stakeholders to develop plans for wider integration with the system utilising the opportunities with the pharmacy contract regulatory framework to enhance community pharmacy services.

The LPC view

Mr Hunter thinks that LPCs are ‘very ready for the changes – even new LPCs like the one forming in South Yorkshire by merging the four existing LPCs’, and he’s not alone.

Ms Kandula says Greater Manchester ‘has been building these relationships and structures for some time due to the devolution model’, and Mr Irvine says CPCW has also ‘spent a lot of time over the last two years learning about the upcoming changes’.

Of course, no one is under any illusion that the hard work will have to continue. ‘There is no doubt that there will be more joint meetings to attend and this time and effort is not necessarily funded’, says Ms Kandula.

‘The concern is whether the investment in time building relationships and collaborating with other system partners will bring tangible outcomes for contractors, so it’s important to balance the needs of the system and ensure we are working to support contractors and Pharmacy teams at the same time.

‘The good news is we have already seen some positive engagement and outcomes and we hope we can build on this by supporting integrated working within the ICS.’

Guidance on ICBs and pharmacy commissioning

On 31 March, Ali Sparke, director for dentistry, community pharmacy and optometry, NHS England, and Chief Pharmaceutical Officer for England, David Webb said

'On 1 April, NHS England will be delegating the responsibility for commissioning pharmaceutical services, general ophthalmic and dental services to local Integrated Care Boards. This fulfils our long-term policy ambition of giving systems responsibility for managing local population health needs, tackling inequalities, and addressing fragmented pathways of care.

A key enabler to realising this ambition is the delegation of direct commissioning functions to ICBs. By giving ICBs responsibility for a broader range of functions, they will be able to design services and pathways of care that better meet local priorities.

They will also have greater flexibility to integrate services across care pathways, ensuring continuity for patients and Improved health outcomes for the local population. Their joined-up structure helps them to meet the challenges facing the whole health and care system, like supporting people to stay active and well in their local community and out of hospital.

This means the NHS, local government, the voluntary sector, and wider public services can create joined up services that rethink how to deliver care that meet the needs of local people.

Nine ICBs already took on responsibility for one or more of these functions in July last year. Learning from those systems about how they have implemented delegation effectively will be published soon.

To provide an overview of potential collaborative working arrangements between NHS organisations and local government, guidance published on 27 March for ICBs and trusts details the legislative changes set out in the Health and Care Act 2022, how to implement new legislative options available to delegate and jointly exercise those functions, and outlines expectations on the use of these powers.'