The single national formulary: how will it work?

By Ewan Maule FRPharmS, member of the RPS England Board and Chair of the ICB Chief Pharmacist Network

Formularies bring order to complexity. We like that as pharmacists. The NHS 10-Year Plan has now proposed something radical: a single national formulary. It is an ambition with boldness only recognised by those who understand the myriad of systems, processes and people working behind the scenes to deliver £20 billion of medicines to patients across England.

But behind that ambition lie difficult questions. What exactly would a national formulary do? Who would it serve? And crucially, what difference will it make to the medicines patients access? Unless these issues are addressed, the promise of national alignment risks being overshadowed by unintended consequences.

The attraction of consistency

For policymakers and the pharmaceutical industry, the appeal of a national formulary is obvious. It offers the prospect of reducing variation in prescribing and access across England – something that has long frustrated patients, clinicians and companies alike. 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.

It is no coincidence that this proposal sits within the life sciences section of the 10-Year Plan. This is not about cost containment. It is about positioning the NHS as a more attractive partner for pharmaceutical innovation and adoption. That framing matters.

What is a formulary?

One of the biggest risks is definitional. For some, a formulary is a high-level list of approved medicines aligned with NICE guidance, maximising clinician autonomy. 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.

If this ambiguity is not resolved, the outcome may be the policy equivalent of homeopathy — so dilute it has no meaningful impact, with local sub-formularies emerging regardless.

The role of NICE

NICE will also be pivotal. Its remit is expanding beyond individual technology appraisals to sequencing medicines within therapeutic pathways. This could bring greater coherence where multiple products exist, but it also carries real complexity. Sequencing decisions made centrally may not always reflect local realities, and applying cost-effectiveness models rigidly could create unintended consequences for patients and markets, particularly given rapidly changing prices and emerging real-word evidence. It also risks driving some companies from the UK market, thereby placing all our eggs in too few baskets.

Community pharmacy and supply chains

The implications for community pharmacy are significant. The majority of contractors’ income still derives from dispensing, even as policy signals a long-term shift toward service delivery. A poorly designed formulary could unintentionally destabilise this model – by concentrating supply, limiting choice or removing the flexibility that pharmacies rely upon to maintain resilience.

Supply chains are already fragile, with shortages and cost concessions a daily reality. Centralising decisions without building resilience risks pushing to the other extreme: an overdose. A formulary imposed without the right enablers could overwhelm the system and lead to serious unintended consequences.

The wider policy context

For the pharmaceutical industry, who are a huge part of the government's economic strategy, reduced variation and faster adoption are attractive, but a formulary that's a blunt tool risks worsening already strained relations with government, especially in the context of a stand-off in VPAG negotiations.

Conditions for success

For a national formulary to deliver on its ambition, certain conditions must be met:

Clarity of purpose: agreement on whether it is a therapeutic list, an operational tool, or something in between.
Supply chain resilience: modelling, safeguards and industry liaison to avoid destabilisation.
Contractual alignment: reforms that do not clash with existing GP or community pharmacy contracts.
Digital integration: embedding the formulary into prescribing and dispensing systems.
Independent governance: strong oversight balancing all stakeholder voices.

Homeopathy, overdose — or the therapeutic dose?

A single national formulary could be one of the most transformative medicines policies in decades. The attraction is clear: reduced variation, greater consistency, and a more coherent national offer. But these benefits will not materialise unless the formulary is well designed and carefully implemented.

The risks sit at two extremes. At one end is homeopathy: a formulary so diluted it achieves nothing, leaving local variation unchecked. At the other is the overdose: a formulary imposed without the right enablers, destabilising community pharmacy, constraining flexibility, and undermining supply resilience.

Neither is acceptable. The profession must therefore press for a third path: the therapeutic dose. A carefully designed, phased and properly governed formulary that reduces variation while safeguarding resilience.

Pharmacists across all sectors must step forward — contributing expertise on clinical pathways, highlighting risks to supply chains, and ensuring patient perspectives are heard. The ambition is bold. The opportunity is real. But whether it lands as homeopathy, overdose, or the therapeutic dose will depend on how well we shape and implement it together.