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When the government published the new NHS ten-year plan in July 2025, one of its stated aims was to move to a single national formulary (SNF) for medicines by 2027. This would replace local lists of approved medicines in what it said was a bid to remove the “postcode lottery” of access to medicines, and “provide a core standard of high-quality care to everyone”.
Local versus national
Currently, formularies are locally maintained documents that list medicines deemed suitable for prescribing within the local area. Drawn up by locally constituted groups of clinicians — representing both secondary and primary care, with occasional commissioner or patient input — the formulary setting committees operate under good practice guidance published by the National Institute for Health and Care Excellence (NICE).
An SNF in England would replace these with a standardised list of medicines approved for NHS use across the country. To do this, the Department for Health and Social Care is creating a new formulary oversight board, responsible for sequencing products based on clinical and cost effectiveness, supported by NICE, and working with industry. Local prescribers, such as clinicians and pharmacists, will be encouraged to use products ranked highly in the SNF but will retain clinical autonomy if they prescribe in line with NICE guidance.
Pros and cons
Ewan Maule, a member of the Royal Pharmaceutical Society’s English Pharmacy Board and chair of the ICB Chief Pharmacist Network, says the appeal of a national formulary is “obvious” for policymakers and the pharmaceutical industry.
“It offers the prospect of reducing variation in prescribing and access across England — something that has long frustrated patients, clinicians and companies alike,” he says.
“From a medicines optimisation perspective, it could eliminate duplication across local system, support digital integration of prescribing platforms and provide a more transparent and consistent marker of clinical quality and effectiveness.”
However, one of the biggest risks Maule sees is in its definition. “For some, a formulary is a high-level list of approved medicines aligned with NICE guidance, maximising clinician autonomy,” he says.
“For others, it is an operational tool that specifies brand, dose or formulation, closely linked to drug acquisition price. These are fundamentally different. A formulary that is too abstract may be meaningless for clinicians and commissioners. One that is overly prescriptive risks narrowing supply chains and exposing patients to even greater shortages.”
As a result, Maule says for a national formulary to deliver on its ambition, certain conditions must be met. “Whether it is a therapeutic list, an operational tool, or something in between; modelling, safeguards and industry liaison to avoid destabilisation; reforms that do not clash with existing GP or community pharmacy contracts; embedding the formulary into prescribing and dispensing systems; and independent governance balancing all stakeholder voices,” he explains.
Development decisions
When it comes to developing the formulary, previous projects suggest there is also room to include – and improve – the sustainability of medicines.
In November 2022, NHS Highland, which is running a project in Scotland, received £100,000 from the Medical Research Council to help prescribers select the most environmentally friendly medicines for their patients via the first “eco-directed formulary” that incorporated environmental data on medicines into the prescribing process, alongside clinical and cost effectiveness.
In January 2025, the research team at NHS Highland, the University of Highlands and Islands’ Environmental Research Institute and the University of Nottingham published results of the study. They showed that, from the prescriber perspective, eco-directed sustainable prescribing as a mitigation strategy to reduce the environmental impact of prescribing in Scotland “resonated well” with current sustainability initiatives in Scotland. However, the results also revealed barriers to eco-directed sustainable prescribing, including lack of knowledge, confidence, time and resources to implement changes.
Martin Bradley, former formulary and interface pharmacist at Guy’s and St Thomas’ NHS Foundation Trust, says a new SNF will opens up the opportunity for “sustainability and environmental impact, polypharmacy (deprescribing) considerations and health inequalities [to be] considered more robustly than the current approaches as many integrated care boards may not be able to consider these points at all currently”, but warns that harmonising current local formularies into an SNF will be challenging.
“I have witnessed several formulary mergers, and it is extremely difficult to implement restrictions to current practices,” he says.
“Consolidating the different local formularies will require a lot of effort and engagement. Will outlier centres, which provide treatments that most others don’t, have to stop using their treatments? Or will the SNF process evaluate those treatments for potential SNF inclusion?”
“If the intention is not to review current formularies and only review new treatments in the SNF, then the current variations are not accounted for, which would be a significant limitation. A centrally driven approach will be easier to manage, but it will disempower local clinicians as they will no longer have a mechanism to be able to request to use the specific treatments they want to have available if the SNF is not reviewing them, or reviewing them for use in a different manner.”
Prescriptive or flexible?
Having room to manoeuvre will be crucial for clinicians, according to Richard Torbett, chief executive of the Association of the British Pharmaceutical Industry. “The proposal for a new national formulary that seeks to sequence products raises a number of questions and concerns,” he explains.
“Any measure that reduces the many layers of bureaucracy and inefficiencies in the system and speeds equitable adoption of medicines is welcome. However, moves that push prescribers into adhering to set treatment rankings, alongside tasking NICE with identifying innovations that can be retired, risks restricting patient and clinician choice.”
On the plus side, Jonathan Silcock, associate professor in pharmacy practice and pharmacy director of practice learning at the University of Bradford, says that while “higher-level decision-makers may be faced with some tough choices, local experts (currently focused on formulary decisions) may be able to spend more time monitoring effectiveness and value in practice, and patients with treatable conditions should see quicker and more evenly distributed access to medicines”.
From a patient perspective, Chris McCann, deputy chief executive of Healthwatch England, adds: “[While] introducing a SNF may help provide better availability and consistency of medicines, this must be introduced with the involvement of patients, which is why we’re calling for patient representation on the oversight board.
“Ultimately, the effectiveness of a national formulary will be judged by whether patients get more reliable access to the most appropriate medicine.”
The creation of a SNF was one of the few specific promises made in the ten-year plan, so NHS England must be confident that it will make a significant improvement to the health service. However, it will be a complex and time-consuming process, with several conflicting interests to be resolved.
NHS England was approached for comment but did not respond.
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There is already a high level formulary which incorporates NICE decisions, cost information and highlights some medicines as 'less desirable' to prescribe. i.e. The British National Formulary which is updated several times a year presumably at some expense to stakeholders, contributors and the NHS. Any attempt to introduce a SNF for England, especially as a cost-saving measure , is doomed to fail and would entail yet more expensive bureaucracy and editorial costs. Even within a single Hospital Trust considerable time and expertise is expended in considering 'Non-formulary requests' which inevitably arise as Clinicians attempt to tailor available treatments to specific patient characteristics. Would the SNF include decisions currently taken under the auspices of the Cancer Drugs Fund which encompasses very many high cost treatments in order to give patients speedier access to life enhancing treatments and which may still be awaiting a NICE review?
The devil is always in the detail - and the only detail within the plan was that it was to happen within 2 years.
One interesting development which is a direct consequence of Trump's tariff threat is the positioning of pharma within the UK, as GSK Chief Commercial Officer bows out. Last week Emma Walmsley said that Britain will struggle to be a life sciences superpower unless it overhauls drug pricing. Patrick Vallance accepts that some degree of price increase is inevitable and the Chancellor knows just how critical big pharma is to the UK economy. 10 weeks post VPAG stalemate, the DSHC remains silent. The single national formulary will be a functional political tightrope over a clinical decision aid.