Who holds the pen?
The Illusion of Control in Managing Prescribing Budgets
What’s your job? Mine is….erm…..eh…..difficult to explain. Simplest way to do so is to say that I’m responsible for ensuring the NHS gets the best value from the money it spends on medicines. There is a lot of stuff that sits underneath that, and it’s an oversimplification, but the bit that always gets people’s attention is the number. In my patch of the NHS we spend £1.3 billion on medicines each year.
But I don’t write a single prescription. So why not give control of that money to the people who do?
When you’ve worked around medicines budgets long enough, you learn a humbling truth: control is mostly fiction. Prescribing isn’t centrally orchestrated — it’s an accumulation of thousands of individual clinical decisions, made daily by people juggling competing priorities, time pressures, differential evidence bases, patient needs, and sometimes, gut instinct.
And yet, across the NHS, we keep trying to “grip” it. Rationalise it. Control it.
The NHS England ICB Blueprint lists medicines optimisation as a function that may be delegated (interestingly it doesn’t say who to). Whilst I’m involved in some excellent work nationally to try and put some meat on these bones, some have interpreted the blueprint wording as a green light to delegate prescribing budgets to providers — a seemingly neat solution to messy accountability. But we risk mistaking clarity for capability. Or worse: passing the parcel without checking if what’s inside is about to explode.
“Prescribing is more like food shopping…”
In one of the most insightful posts I’ve read recently, Laura Angus nailed it:
“Prescribing is more like food shopping than we like to admit... it is not always perfectly rational. It is human. Messy. Complicated.”
Laura Angus, LinkedIn – Prescribing and food shopping
This is the uncomfortable truth. Budget holders and policymakers often yearn for predictability — but medicines spend behaves more like a chaotic trolley dash than a neat procurement plan. Choices are made in context, in conversation, and under pressure. And delegation doesn’t simplify that — it just changes whose headache it is.
There’s growing interest in giving prescribing budgets to providers — Foundation Trusts, Integrated Health Organisations, even neighbourhood teams. The logic goes: “If they deliver care, they should hold the cost.”
But medicines spend is inherently volatile. Concessions fluctuate. Uptake of new medicines spikes. Single patient cohorts can drive six-figure shifts. Delegating this financial risk — particularly in isolation from broader system budgets — can destabilise providers, incentivise restrictive behaviours, or push high-cost patients out of scope.
Take cost concessions for example - these cost the NHS an extra £170m/year. What would happen if we delegated that down to GP practice level? That would be a £30k pressure on each GP practice in England, and it’s hugely volatile.
From the ICB perspective, retaining the budget preserves grip, alignment with national incentives, and the ability to benchmark across providers. But it can feel remote. Bureaucratic. Detached from front-line care. And it means the prescriber holding the pen doesn’t always feel the same sense of accountability to the tax payer that they should.
Each model comes with trade-offs. But pretending that delegation solves structural weaknesses in prescribing governance is wishful thinking. And we potentially undermine and risk the viability of other parts of the system
Not a “no” — but a “not yet, not like this”
Let’s be clear: this isn’t to say that delegation can’t or shouldn’t happen.
But the way it’s implemented matters. It must be intentional, phased, and fully cognisant of the risks. Without that, we risk repeating mistakes of the past.
We’ve been here before. GP fundholding in the 1990s was, in theory, a way to localise decision-making and encourage efficient use of resources. But in practice, it often led to fragmentation, inequity, and a deeply uncomfortable shift in the clinician–patient relationship. History doesn’t always repeat, but it tends to rhyme.
Delegation only works when the receiving provider is willing, able, and genuinely capable of absorbing the responsibility. That means understanding commissioning and having the expertise and capacity to manage it, having the right governance, access to real-time data, and the operational maturity to hold financial and clinical risk in balance.
This becomes even more important when we consider the wider picture — because the entire medicines policy landscape is in flux. The outcome of the ongoing VPAG negotiations could fundamentally reshape pricing, access, and affordability. The rules of the game might change mid-play. If that happens, those holding a delegated prescribing budget may find themselves committed to a level of financial risk they weren’t designed to carry.
That’s why the work underway on a single national formulary — which I reflected on in The Big Beautiful Book — is so important. It’s an attempt to standardise the what and the why of prescribing, so that we can eventually evolve the who and how in a safe, consistent, and scalable way. Without that, delegation risks amplifying variation, not resolving it.
Misaligned incentives, fragmented systems
Without careful alignment of risk, incentives, and accountability, delegation creates distortion:
Neighbourhood teams and providers exposed to cost volatility they’re not equipped to manage
Providers incentivised (consciously or not) to avoid expensive prescribing
Local formularies diverging. Access to NICE-approved treatments becoming increasingly postcode dependent
Frontline clinicians caught between clinical duty and fiscal pressure
And let’s not forget the wider ecosystem. Our success in squeezing acquisition costs has been both our superpower and our Achilles’ heel. Missteps here risk eroding pharma confidence in the UK market — undermining access, investment and innovation.
It’s a theme I explored in Access Denied — where I argued that we risk blocking the very innovation the life sciences sector is trying to bring us, by building systems that can’t afford to welcome it in.
So what’s the alternative?
We don’t fix this by moving money around like counters on a chessboard and saying ‘tig, you’re it’. We fix it by building the scaffolding to support system-wide, shared accountability and understanding the problem we are trying to fix:
Embed strong pharmacy leadership at ICB, provider and neighbourhood levels
Align contracts to incentivise optimal prescribing — not just the cheapest option
Co-design governance that allows delegation of delivery, while retaining strategic oversight and a shared pursuit of strategic objectives
Create financial models that share risk and gain — so no one part of the system carries all the volatility and that clinicians holding the pen are making genuinely balanced decisions about the costs and benefits of their interventions
Final thought: delegation ≠ abdication
We talk a lot about empowering local systems. But true empowerment requires capability, infrastructure, and shared ownership. Delegating the prescribing budget without those things isn’t transformation — it’s abdication.
And in a system already this complex, we can’t afford oversimplification.
Delegation might look like progress. But without the right plan all we’ve done is move the mess into someone else’s in-tray and called it innovation. And we’ll have to put the genie back in the bottle at the next reorganisation.