The quarterly medicines leakage report every ICB should want in 2026/27

The quarterly medicines leakage report every ICB should want in 2026/27

manage medicines value. That may sound narrow. It is not. Medicines sit at the intersection of population need, pathway design, prescribing behaviour, provider delivery, procurement discipline and financial stewardship. They are one of the clearest tests of whether an ICB can move from oversight rhetoric to evidence-based action. NHS England’s strategic commissioning framework could not be clearer about the direction of travel. Strategic commissioning is described as the central purpose of the ICBs of the future, and the framework set out a sequence of milestones from its publication in November 2025 through baseline assessment in March 2026 and a development programme launch in April 2026. At the same time, NHS England has confirmed new ICB footprints from 1 April 2026 in several areas, with six new ICBs created through the abolition of twelve existing ones and a further boundary change elsewhere. In plain English: systems are being asked to think more strategically while also becoming leaner, larger and more standardised. That combination should force a more disciplined approach to medicines. The NHS already has enough public data to identify many of the issues. NHSBSA’s prescribing data, ePACT2 dashboards, Secondary Care Medicines Data and the refreshed medicines optimisation materials give systems a large amount of visibility. NHS England’s archived medicines optimisation opportunities guidance remains relevant in 2026/27, and its 2024/25 version previously recommended that ICBs choose at least five opportunities, review prescribing trends monthly through governance structures and focus on areas that deliver efficiency savings. Regional guidance reinforces the point, calling for a clinically led but operationally driven, data-driven, whole-system approach, with a “do once” principle to reduce duplication. And yet many systems still lack one simple management instrument: a single, recurring commissioner-facing report that shows where medicines value is being lost, what has been approved, what is being implemented, and what value has actually landed. Call it a quarterly medicines leakage report. The word leakage matters because it reframes the discussion. Leakage is not just “something looks expensive”. Nor is it a critique of clinicians. It is avoidable spend or avoidable risk that persists because the system has not yet converted insight into coordinated action. That might mean unwarranted variation in generic or off-patent prescribing. It might mean delayed uptake of best-value biological medicines. It might mean contract or framework non-compliance. It might mean premium-priced generics, slow response to shortages, oversupply, avoidable waste or failure to spread an agreed pathway change across a cluster. Different systems will find different categories. The important point is that leakage is operationally actionable. Most ICBs do not need more dashboards for this. They need a better synthesis. A good quarterly medicines leakage report would have six sections.

quarter, realised value to date, and the most material unresolved blockers. This gives the board-level answer quickly.

one number: price inefficiency, non-adoption of best-value products, supply-risk substitutions, formulary or pathway drift, and other locally relevant categories. The purpose is not perfect taxonomy. The purpose is to make the sources of value loss visible enough to manage.

ranked by likely value, confidence and delivery complexity. Not every opportunity belongs here. Some should be ruled out because the data is weak, the clinical case is poor or the implementation burden is disproportionate. That triage is part of good commissioning.

blocked? This is the section that turns a finance discussion into a management discussion. If a value opportunity is blocked because of clinical capacity, pathway redesign, homecare issues or local politics, the report should say so.

target date? What are the dependencies? What is the current risk rating? This matters even more as ICB footprints change, because larger organisations can otherwise fall into the trap of assuming that agreement in principle equals delivery in practice.

most important discipline of all. It prevents gross opportunity estimates from being mistaken for delivered benefit and improves the system’s ability to predict future value honestly. Why quarterly? Because annual review is too slow for an area that moves with product entry, shortages, pricing shifts and implementation cycles, while monthly board-level reporting is often too noisy and detailed. Quarterly is frequent enough to drive action and strategic enough to support decision-making. The deeper reason an ICB should want this report is that it operationalises strategic commissioning. It gives finance, pharmacy, procurement, clinical and provider leaders a shared view of what matters now. It reduces duplication across places and organisations. It creates a “do once” structure for the new era of clusters and larger footprints. And it gives the system a way to prove that medicines optimisation is not an abstract aspiration but a managed route to better value. Without something like this, strategic commissioning risks collapsing into three unhelpful habits. One is endless exploration: lots of data, little decision. Another is episodic heroics: value gets captured when one exceptional pharmacist, finance lead or procurement specialist drives it through manually, but the model is not repeatable. The third is narrative inflation: big claimed opportunities, weak realised-value tracking. A quarterly medicines leakage report is not glamorous. It is simply the sort of management tool that serious commissioners use when they want to move from policy language to operational grip. And that is what the new ICB era requires. If strategic commissioning really is becoming the central purpose of ICBs, then medicines is one of the first places where that purpose should become visible. Not in another slide deck. In a report that shows what the system is losing, what it has chosen to do about it, and what it has actually delivered. Research base used in drafting

opportunities guidance (16 February 2026).