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Aim To review non-formulary and high-cost drug (HCD) requests across Children’s Hospital Alliance (CHA) Trusts, 1 assess patterns in prescribing, financial impact, and identify opportunities for improved governance, equity, and collaboration.Methods A retrospective review was conducted over a two-month period, including a detailed analysis of all non-formulary drug submissions across CHA hospitals. A focused analysis of September 2024 data from eleven Trusts was also undertaken, examining request volume, drug types, clinical specialties, approval outcomes, and associated costs.ResultsA rising number of HCD requests were identified, many of which were urgent and required executive–level approval due to cost. In one paediatric centre the non–formulary requests had increased from an average of 1 every 2 weeks in 2019 to an average of 2 a week in 2025.Trust-level processes varied significantly, with some decisions made with minimal scrutiny, leading to inequitable access.In September 2024, three Trusts received the highest number of requests.Infliximab for IBD was the most frequently requested drug; haematology was the leading specialty.Total approved HCD spend was £546,666, with £309,274 on compassionate use and £159,135 representing financial losses to Trusts.Most requests involved off–label drug use.Data capture was limited, restricting insight into clinical outcomes.Conclusion There is an urgent need for consistent, transparent processes across Trusts to ensure equitable access to non-formulary and high-cost drugs. Collaborative efforts—such as clinician engagement through specialty networks, participation in policy working groups, and improved training—are essential. Strategic partnerships with industry and patient groups, alongside better use of Early Access Schemes, 2 could enhance access and governance. Improved data capture is critical to understanding the true impact of these prescribing decisions.References Children’s Hospital Alliance. https://childrenshospitalalliance.co.uk/ (accessed 14/01/26).Early Access to Medicines Scheme. https://www.gov.uk/guidance/apply-for-the-early-access-to-medicines-scheme-eams (accessed 14/01/26).