The Big Beautiful Book

Is a single national formulary opportunity or over reach?

Nothing gets a pharmacist quite as excited as a formulary. We love a nice categoric list of increasingly complex names (most ending in -mab these days).

The NHS 10-Year Plan quietly but boldly proposes a single national formulary—a reform that could reshape how we prescribe, procure, and govern medicines across the health system. And it’s something the ICB Chief Pharmacist network proposed in our model ICB medicines optimisation blueprint

It’s the kind of idea that makes you sit up and take notice. In my view it’s potentially one of the biggest and most disruptive ideas in the plan. But is it achievable? Is it even desirable? Scotland have been trying for years and not made it happen - why would it be different in England? And what are the pitfalls?

Let me start with the positives. I love the ambition. For those of us in the medicines optimisation world, the idea of eliminating duplication across local systems is not just welcome—it’s long overdue. The potential to streamline governance, reduce variation, and support better digital integration is huge. It could save countless hours of local committee work and unlock greater consistency in prescribing and access.

But here’s what really caught my eye: the proposal appears in the life sciences section of the 10-Year Plan. That placement isn’t accidental. This isn’t being framed as a cost control measure or a local simplification tool. It’s being framed as a catalyst for pharmaceutical innovation, market access, and industry partnership. That changes the dynamic entirely. It suggests this isn’t just about making things tidier—it’s about setting the stage for faster adoption of new technologies and medicines across the NHS. And that’s crucial to understanding the ‘what’ and the ‘how’.

One of the biggest challenges is that no one quite agrees on what a formulary actually is—or what it’s for. To some, it’s a high-level list of approved medicines aligned with NICE guidance. To others, it’s a detailed, practical document that governs what product, dose, formulation, and route should be used on a day-to-day basis, and one that’s used as a cost control tool. That’s a significant gap in interpretation—and one that can have very real consequences in practice.

Does the formulary stop at the level of a drug class or chemical name? Or does it go deeper, specifying individual products—tablet versus capsule, generic versus brand, oral versus injectable? If a single national formulary is to replace dozens of local ones, clarity is needed on whether it sets therapeutic direction or operational control. For example, a national decision to approve “omeprazole” is very different from one that mandates a specific 20mg capsule from a particular manufacturer. One leaves local choice; the other has implications for procurement, supply chain resilience, and even patient experience.

Without a shared understanding of what level the formulary operates at—and who it’s designed to serve (clinicians, commissioners, industry or patients?)—we risk building a national asset that fails to meet the practical needs of the frontline. Getting this right isn’t a technicality; it’s foundational.

Another key piece of the puzzle is the role of NICE. They are going to change their outputs in a big way - both in retiring guidance that is outdated and considering how medicines should be sequenced—a tricky thing to do especially when multiple treatment options exist within a class. Attempting to sequence medicines strictly based on cost-effectiveness sounds logical in theory, but in practice it’s incredibly difficult to apply consistently across conditions and settings. It also risks destabilising the pharmaceutical market, particularly if manufacturers fear that their products will be deprioritised or effectively excluded due to shifting economic models. To be meaningful and sustainable, a national formulary must be dynamic and responsive—factoring in changes in drug pricing, new evidence, tendering outcomes, and market behaviours in real time. And don’t even get me started on cost concessions. If the national formulary doesn’t do this it risks becoming a blunt instrument rather than a strategic enabler and that work will then be done locally, defeating the purpose.

I’ve been involved in some of the early national discussions on how we might implement such a reform, and one thing is clear: implementation is everything. You can’t just drop a national formulary on top of a system with unresolved local commissioning and contractual tensions. Take shared care as an example. Many GPs argue that shared care prescribing falls outside their core GMS contract. So if a national formulary tries to standardise what's in shared care, that has direct implications for local commissioning. Unless we address those contractual issues—perhaps by changing the GP contract or scrapping shared care altogether—we risk policy clashing with reality.

And then there’s the medicines supply chain, which might be the biggest iceberg lurking under the surface. A national formulary may be good for standardisation—but what happens when it also concentrates demand and destabilises supply chains? The recent reporting on AstraZeneca’s potential exit from the London Stock Exchange is a red flag. CNBC’s piece makes clear just how fragile the relationship between government policy, pharmaceutical industry confidence, and market dynamics can be. A one-size-fits-all formulary could have unintended consequences here —limiting flexibility for manufacturers or disrupting smaller suppliers who currently rely on niche local agreements to stay viable. And it could risk pharma walking away from the NHS (which is a tiny market in a global sense). How would the public feel about innovative medicines not being launched in the UK?

There’s also the matter of influence. The pharmaceutical industry will—quite understandably—want a seat at the table. That introduces the potential for conflicts of interest at a national level. High reward meets high risk. We’ll need robust governance to ensure that commercial priorities don’t drown out clinical need or population health impact.

All of this might sound like I’m sceptical. I’m not. I’m optimistic. But I’m also realistic.

The success of a national formulary will hinge not on the idea itself—but on how we phase it, who we involve, and which enablers we put in place. That includes:

• Contractual alignment

• Robust supply chain modelling and horizon scanning

• Digital integration with clinical systems

• Meaningful stakeholder engagement, including patients, clinicians, and the pharmaceutical sector

• Strong and independent governance, to manage commercial influence

This is a reform with teeth. It deserves attention, caution, and above all—collaboration. The prize is worth chasing. But let’s not pretend it’s simple. And in the middle of all the other challenges just now?

Let me know your thoughts. This is the start of something big. Let’s make sure it’s also something better.