Context:
Specialised commissioning in the NHS is undergoing its most significant transformation in over a decade. At the NeoNavitas Sub-National Access Conference, Indi — a senior leader in NHS medicines optimisation — laid out a stark and urgent picture: the days of national ring-fenced funding for high-cost drugs are numbered. Within two years, most — if not all — specialised medicines budgets will be fully devolved to Integrated Care Boards (ICBs), and the implications for industry are profound.

1. The End of NHS England as We Know It

The government’s plan to abolish NHS England within two years, accompanied by a 50% cut in central staffing, will radically reshape how medicines are commissioned. With the dissolution of centralised specialised commissioning, responsibility — and risk — for funding these drugs is shifting directly to ICBs.

This means an end to the era where, once a medicine was listed in a Specialised Services Circular, it was automatically funded. Going forward, ICBs will make those decisions based on local pressures, priorities and budgets — all of which are already stretched to breaking point.

2. From Central Mandate to Local Scrutiny

Indi warned that as ICBs take control of high-cost drug budgets, access barriers will increase. NICE approval will no longer guarantee automatic funding. Many ICBs are already breaching statutory timelines and are introducing:

• Strict internal guidelines on lines of treatment

• Blue-teq-style approval processes within trusts

• Monthly audits and prescribing caps

• Delayed or rejected uptake of NICE-approved therapies

Postcode variation, previously kept in check by national oversight, is already starting to re-emerge — and it’s likely to worsen.

3. Budgets Are Finite — And Shrinking

ICBs are already forecasting serious financial deficits. Many are operating with outdated block contracts that provide no flexibility for new therapies. Indi shared figures from his own trust: a £480 million drug spend, 80% of which is currently funded by NHS England. Once this is devolved, there will be no new money to support growth in demand or new treatments.

“We’re heading into a world where we can’t pay for what we’re expected to deliver — and something will have to give.”

4. The Shift to Guideline-Based Practice

To manage this financial pressure, ICBs are moving rapidly toward guideline-driven prescribing, particularly for areas like ophthalmology, dermatology, and rheumatology. New therapies will only be considered if their place in the treatment pathway is clearly defined, justified, and economically sustainable.

In some cases, trusts are developing internal approval models where clinicians must exhaust specific sequences of therapies before escalating. Even then, third-line options may require formal approval — and could be rejected outright.

5. What Industry Must Do Differently

For pharmaceutical companies, this transformation requires a fundamental rethink of engagement strategy:

• Understand local funding models: Whether an ICB uses pass-through or block funding will shape prescribing decisions.

• Support real-world value cases: It’s no longer enough to rely on NICE approval — companies must provide outcomes and economic evidence tailored to local system pressures.

• Engage earlier and more widely: Build relationships with the clinical, financial and commissioning leads who will ultimately hold the purse strings.

• Anticipate greater scrutiny: Prepare for formulary reviews, tighter thresholds, and outcome-based audits of drug use.

Conclusion: A System Under Pressure, a Moment for Pharma to Adapt

Specialised commissioning is no longer centrally protected. It is becoming local, discretionary — and financially constrained. The challenge for pharma is clear: adapt your approach to reflect the real-world pressures on ICBs, or risk being excluded from the conversation entirely.

At NeoNavitas, we help pharmaceutical companies navigate this complexity — from mapping new funding structures to shaping locally relevant value propositions.

If you're planning your access strategy for specialised medicines, now is the time to act. Contact the NeoNavitas team to explore how we can support you.