Are drugs quietly deciding who gets seen in the NHS?

I’m going to be deliberately provocative: we’ve built a system where funded therapies set the agenda and everything else fights for oxygen. This doesn’t just highlight the outsized influence that the launch of a high‑cost drug can have on NHS investment; it also shows the challenge of launching into a disease area not previously served by major drug development. A recent 1‑1 in respiratory didn’t reveal a new problem so much as it made the cycle impossible to ignore: a drug gets reimbursed - policy and governance rush in - services organise around the therapy - conditions without that anchor drift into variability—creating pressure on services and reducing the ability to implement improvements.

Respiratory was just the clearest example on my desk; the pattern shows up across specialties. Let’s talk about that—and what it’s doing to patients, budgets, and priorities.

Exhibit A: severe asthma

Biologics arrive. The national service specification makes specialist centres the gatekeepers for high‑cost technologies—explicitly naming biological agents—and anchors decisions in the severe‑asthma MDT. ODNs knit those centres together to standardise referral, initiation, and monitoring. A CQUIN backs it with money and governance (Blueteq, specialist oversight). The Accelerated Access Collaborative then turns it into an adoption programme—toolkit, pathway, the works. Not just a drug—an infrastructure. Today, more than 99% of hospitals report access to a severe‑asthma service where MDTs initiate and oversee biologics. Follow the cash; follow the pathway.

Measurement and money shape attention

We improve what we count. QOF publishes full indicator sets for asthma and COPD; the National Respiratory Audit Programme focuses on adult asthma, COPD (and PR). There’s no equivalent national audit domain for bronchiectasis or chronic cough. That’s a loud system signal about priorities.

Who falls through the cracks?

Refractory chronic cough (RCC). NICE terminated gefapixant’s appraisal in 2024—“unable to make a recommendation.” No reimbursed medicine. No national commissioning pull. No audit stream. Meanwhile, burden doesn’t wait: an independent estimate puts England’s chronic‑cough cohort at ~900,000 people a year, driving ~15.6 million GP appointments (17.3 visits per person‑year). In hospitals (HES 2023/24; primary diagnosis R05): 13,892 emergency admissions, 17,726 FAEs, and 7,101 bed days—~74% of emergency cough admissions are zero‑day. Direct admitted‑care costs are ≈ £27.9m (national short‑/long‑stay tariffs). It’s a quiet avalanche.

Bronchiectasis. Fieldwork and interviews show an invisible majority:

  • 60–70% of the bronchiectasis population have an emergency admission every year across ICBs—even in “gold‑standard” centres.

  • A sizeable middle cohort is diagnosed but not actively managed—likely driving unplanned activity and repeat attendance.

  • 27% of bronchiectasis cases are diagnosed in A&E.

  • Signals of ~40% 12‑month readmissions in some datasets suggest a small group accounts for a large share of admissions.

  • No standardised bundle (unlike asthma/COPD): variable checks on macrolide candidacy, physio access, and follow‑up triggers.

  • Antimicrobial stewardship tensions (duration, sign‑off) and a lack of algorithmic protocols impede GP‑led care.

  • Trusts within the same ICB often operate in silos with differing access and practices.

Commissioners recognise the cost signal: one ICB cut shows ~293 annual admissions (~£1m) with a known frequent‑attender list (~30 patients) where targeted pathway fixes—hot clinic, rapid review, community IV/physio, clear antibiotic rules—could deliver outsized gains. Start with the unplanned cohort, fix access, and network it at ICB level to reduce variation. Pragmatic, not a moonshot.

The uncomfortable truth

When a high‑cost therapy is funded, the NHS builds a home for it—specs, ODNs, MDT rules, incentives, adoption support. When a condition lacks a funded therapy or national audit, it lives in variability—even when workload and cost are real. Severe asthma shows the former. Chronic cough and bronchiectasis show the latter.

What I want the system to debate (and do)

  1. Stop letting drugs decide the map. If QOF and NRAP are our spotlights, widen them—or we’ll keep missing big, messy cohorts that don’t come with a shiny medicine. Add measurement for conditions such as bronchiectasis and chronic cough so local teams have permission to improve them.

  2. Design a broad, condition‑led default route that drugs, tech, and therapies can launch into—not the other way around. Build algorithm‑driven community protocols (clear stewardship rules, green‑route prescribing) with fast escalation; stand up ICB‑level networks to own variation and metrics.

  3. Make the basics easy:

Access: direct diagnostics (e.g., CT in respiratory) where appropriate; rapid community review; same‑day assessment options.

Green‑route prescribing: minimise routine specialist sign‑off once criteria are met.

Standardised bundles: across conditions, focusing on case‑finding and exacerbation management.

Pilots with purpose: prioritise neighbourhoods with priming funds; leverage existing community services to go live quickly.

Measure what matters: unplanned admissions, length‑of‑stay (LOS) distribution, 12‑month readmissions, time to antibiotics, and physio access—tracked at trust and ICB levels.

And pharma? When you’re working through NICE prioritisation, engage earlier and think beyond your molecule. If you help build the pathway, the system will identify the right patients faster, reduce unplanned activity, and free up money to fund innovation. Apply the same operational discipline to non‑drug pathways that soak up time and money—so the patients who need your therapy are clearly defined and progressed, not assumed to be inside specialist services already.

If the condition has a reimbursed drug, the NHS eventually builds a home for it.If it doesn’t, patients live in the A&E waiting room. Let’s fix that.