The analysis covers 141 NICE technology appraisals published in the first two years of VPAG (January 2024 to January 2026), spanning 127 individual products across 22 therapeutic markets and 58 companies. Oncology accounts for the largest share of activity, with 90 TAs across all companies. From a company perspective, AstraZeneca leads with 14 submissions, followed by MSD (9), Pfizer (8) and Janssen (7).

This breadth matters. The ValueBase data set is not confined to a single therapy area, cost category or company type. It represents a cross-system view of how NICE recommendations translate into local availability.

Patterns emerge immediately, not least that slow uptake isn’t confined to high-cost specialties. Cardiovascular, respiratory, CNS, blood disorder and anti-obesity medicines all exhibit a consistent pattern of gradual, uneven adoption that extends well beyond the 90-day expectation.

Across all therapy areas, average formulary implementation follows a similar trajectory:

• At 30 days: just 20% of formularies had implemented NICE recommendations
• At 60 days: 23%
• At 90 days: 27%

Delay is only part of the story. Even when medicines are listed, access is often constrained. Across all therapy areas featured in the timeframe of this study, 13% of formulary listings include additional local restrictions. These typically limit prescribing to specific clinics, specialist settings or narrowly defined cohorts, despite clear national guidance.

In certain therapy areas, restrictions are significantly more common:

• Blood disorders – 28% of formularies included additional restrictions for NICE-recommended medicines
• CNS – 20%
• Lipid-lowering – 24%
• Anti-obesity – 25%
• Muscular diseases – 31%
• Respiratory – 20%.

The data demonstrates that national policy alone does not equal local change. Eye-catching announcements create momentum, yet on-the-ground conditions determine whether treatment actually reaches the patient. And too often, it does not.

So why are local systems slow to adopt national recommendations? It is not a question of unwillingness. Local formularies operate at the intersection of national guidance and real-world service pressures. Workforce shortages, commissioning pathways, diagnostic capacity and competing priorities all shape the speed at which a recommendation becomes routine practice. VPAG may have reinforced the 90-day expectation, but it cannot remove these operational constraints.

Given these pressures, delays in implementation are hardly surprising. What matters is understanding where and why they occur, and how those barriers might be addressed. Crucially, many of the forces shaping local uptake sit well beyond the scope of any single national agreement. VPAG was never going to resolve these system dynamics on its own.

So what happens next? A flagship reform is now fast approaching implementation – and will likely shape the answer.

The forthcoming Single National Formulary (SNF) represents a significant shift in how medicines may be listed and managed across England. Set out within NHS England’s medium-term planning framework, the ambition is to reduce duplication, streamline decision-making and create greater national consistency in formulary management over time. The direction of travel is clear: fewer parallel local processes and a more unified approach to implementation of NICE guidance.

However, this transition will be phased and complex. Existing local formularies will not disappear overnight and operational readiness, digital integration and governance alignment will take time to mature.

There is broad support for the principle of greater consistency. A more coordinated national approach has the potential to reduce unwarranted variation and improve transparency. But centralisation does not automatically eliminate local dynamics. Prescribing behaviour, pathway configuration and budget management continue to sit within local systems. Even under a national framework, interpretation, sequencing and service readiness will vary. The data presented here reinforces that implementation is shaped by operational reality as much as policy intent.

So the ultimate question is this: if a national ‘yes’ still results in a local ‘not yet,’ why should a single national formulary, on its own, overcome the same affordability and operational pressures we commonly see at the local level?

For industry, this distinction matters. National recommendation is a milestone, not the finish line. Uptake is shaped over time by local payer decisions, evolving restrictions and changing clinical practice. When intelligence efforts taper off after launch, the ability to respond as access conditions evolve disappears – precisely when insight is most valuable. National frameworks and pricing agreements are essential, but focusing on them alone can obscure meaningful regional variation in implementation and restrictions. Without the ability to measure access below the national level, commercial risk hides in plain sight.

From an industry perspective, the visibility gap remains a critical issue. Victoria Jordan, Director of Value & Access Policy at the ABPI, says maintaining visibility of local implementation will remain essential, even as the system moves towards a more centralised approach:

“We’re very clear from an ABPI perspective that visibility of what’s happening on the ground is really important. Even if the longer-term ambition is to dismantle some of the local formularies or have a more efficient, less duplicative arrangement, it’s going to take time to get there and there are barriers beyond the formulary to overcome. Ongoing visibility of what’s happening at the local level provides a really helpful baseline to monitor the impact of policy commitments and changes that seek to drive rapid, equitable adoption of NICE-recommended medicines. Any changes that are sought must retain plurality of treatment choice and be fully aligned to NICE’s guidance.”

In other words, even if structural reform is coming, the present cannot be ignored.
“Ultimately, you can have national guidance, but if you don’t understand how that’s actually being implemented locally, you don’t really know whether patients are getting access,” says Victoria. “The first step is getting that visibility so you can identify unwarranted variation, then do something about it. Without that data, you’re guessing.”
For pharma, the message is simple if uncomfortable: national guidelines may set the direction, but real-world uptake is shaped by subnational decisions, local capacity and evolving payer-steering mechanisms. Companies that can see those dynamics clearly – and in near-real time – are far better positioned to respond to them.

Although the analysis here is UK-based, the message resonates far beyond England and Wales. Every major European market grapples with the same challenge: translating national reimbursement into consistent subnational availability. The mechanisms differ from country to country, but the friction is universal.
Shane Elder, Head of Global Market Access Strategy & Implementation (Europe, Canada, USA & China) at AstraZeneca, says market access teams must think far beyond launch if they want to understand how national decisions translate into local uptake:
“Market Access teams have a significant role to play not only in the pre-launch planning and technical phase leading up to national reimbursement and launch, but from launch all the way through to loss of exclusivity. Global access for industry is highly complex, not least because every health economy has its own set of subnational steering mechanisms: for example, in Italy, drugs operate in a system with multiple tiers, including 21 Regions documenting their own levels of permission to prescribe; in Germany, it’s more about rebate contracts and quotas. Understanding the nuances of all these and having a dynamic picture of how each influences locality sales is crucial for competitive advantage in each locality.”

The implications extend beyond launch readiness and demand dynamic access intelligence.

“Identifying where these opportunities exist requires a partner who can provide credible data packaged in a way that will drive timely actionable intelligence, in turn increasing, maximising and guiding prescriber permission to prescribe,” says Shane. “In a complex emerging world where market access will continue to play a crucial role solving the pricing and reimbursement challenges of tomorrow, simplifying data solutions and providing insights to direct our teams will be a critical enabler of our success as a key strategic driver.”

The UK data therefore serves as a bellwether. It illustrates how easily policy ambition can be diluted as it travels through local systems, and why companies that remain attuned to subnational dynamics – continuously, not just at launch – are better positioned to drive both patient access and commercial performance.

For pharma companies, the implication is clear. National recommendation may open the door, but what happens next is shaped locally. Understanding local dynamics is essential to ensuring medicines reach target patients in a timely fashion. Until those dynamics are visible and understood, a national ‘yes’ will too often continue to mean a local ‘not yet’. Closing that gap depends on sustained visibility at the local level – because it’s there, not at the centre, that access is ultimately realised or denied.