Uptake of NICE Technology Appraisals: 90‑Day Implementation vs Real-World Adoption
The 90‑Day Mandate and Expected Uptake
NICE Technology Appraisals (TAs) come with a funding directive: once NICE recommends a treatment, NHS organisations are legally required to fund and implement it within 90 calendar days of guidance publication . This 90‑day window is intended to allow Integrated Care Boards (ICBs) to allocate funding, add the medicine to formularies, and integrate it into local pathways. In theory, by day 90 patients meeting the eligibility criteria should be able to access the new treatment. NICE also typically estimates the eligible patient population for each TA – essentially the expected number of patients who could benefit – which provides a benchmark for uptake. But does this happen in the real world, and should your target be based on the TA implementation timeline?
In practice, reaching the expected uptake (treating the estimated eligible population) within 90 days is exceedingly rare. Regional variation in adoption is evident early on. The ABPI has noted that the NHS Innovation Scorecard consistently shows uptake falling short of NICE’s own projections in many areas. In an analysis of recent medicines, for example, after one year the usage of NICE-approved drugs in England was only about half of what peer countries achieve on average – suggesting initial uptake is modest relative to the potential. Moreover, another recent study found that no NHS trusts (whether or not they engaged in industry partnerships) had actual prescribing levels that exceeded the NICE-estimated usage for their eligible patients. In short, by the 90-day mark and even many months beyond, most regions are treating far fewer patients than the guidance anticipates.
Variation Across ICBs and Time to Equitable Prescribing
Looking across all 42 ICBs in England, the rollout of new TAs is uneven. Some ICBs manage to initiate prescribing quickly, while others lag due to operational and resource constraints. This leads to a postcode lottery in the early phases of implementation. A joint NHS Confederation/ABPI report highlighted “significant geographical and sub-population variation” in the use of innovative medicines despite NICE approval. In one therapy area example, uptake varied markedly between regions, meaning patients in some ICBs waited much longer for access than those elsewhere. Such inequities persist well past the 90-day deadline. The timeline to equitable prescribing – when all ICBs reach comparable per-capita usage – often stretches into years rather than months.
Real-world data indicate that full implementation of a TA typically takes on the order of 12–24 months (1–2 years), not just 90 days. Uptake tends to follow an S-curve: initial growth is gradual, then accelerates in the first couple of years before levelling off. By 90 days, many areas are still in the very early phase of this curve. Frontline feedback supports this: in a 2024 survey about a new high-impact drug, ICB pharmacists and clinicians candidly noted that “90 days is not sufficient to stand up a service, develop robust pathways and get referrals in” – meaning a service might be formally in place by the deadline, but very few patients would actually be treated by that point. The result can be a “hypothetical service to tick a box, without anyone actually getting effective treatment” in the initial months. It often takes many additional months for referral streams, clinic capacity, and clinician awareness to ramp up to the point that eligible patients across all regions are consistently receiving the therapy. For some treatments, our analysis of recent TAs suggests that around 18–24 months is a more realistic timeframe for nationwide uptake to approach the levels implied by the eligible population. This is when prescribing becomes more uniform across ICBs, and the majority of the initially identified eligible patients are finally being reached.
Uptake Patterns by Therapeutic Area
Implementation speed can also vary by therapeutic area. We grouped recent TAs into broad categories (e.g. cancer, cardiovascular/metabolic, neurological, etc., with rare/orphan diseases considered as one group) and observed some differing trends:
• Common High-Burden Conditions (Cardiovascular, Diabetes, Respiratory): New medicines for prevalent conditions often face integration challenges in primary care and existing treatment pathways. For example, the uptake of novel cholesterol-lowering drugs (like PCSK9 inhibitors or inclisiran) and SGLT2 inhibitors for diabetes did increase over time, but most ICBs did not reach NICE’s expected per-capita usage until well beyond a year post-guidance. Targeted initiatives have been needed to drive uptake closer to projections. An ABPI analysis of cardiovascular and diabetes medications found that even by 2022/23, usage in both partnering and non-partnering trusts remained below the projected levels for eligible patients, though trusts with proactive implementation partnerships came closer to the mark. This underscores that for widespread conditions, full adoption is gradual, as systems work to identify all eligible patients and adjust practice.
• Cancer Therapies: Cancer drugs tend to have a more centralised and rapid uptake pathway, partly due to specialist oncology networks and funding mechanisms like the Cancer Drugs Fund. When NICE approves a cancer therapy, it’s often available relatively quickly through tertiary cancer centres. However, “rapid” is still relative – while many cancer treatments are accessible in principle by 90 days, variation in usage persists across regions. Factors like hospital formularies and oncologist experience can cause some ICBs to lag in uptake. Overall, though, the timeline to broad adoption in oncology can be somewhat faster than in primary care settings, and national oversight (through NHS England cancer programs) helps reduce extreme variation. Still, data show the UK’s use of some new cancer medicines remains lower than in other European countries in the first couple of years, indicating there is room to improve consistency. Nzymes own experience is in the implementation of 2025 Metastic Lung and Breast Cancers where implementation of qtr 4 2024 TA’s and qtr 1 2025 TAs are currently being scheduled into most Cancer Alliances’ 2026 work plans. In excess of 12 months post publication.
• Rare and Orphan Diseases: For low-prevalence conditions, we grouped orphan drug TAs together. These often involve highly specialised treatments delivered through a few expert centres. In such cases, initial uptake might appear low in many ICBs simply because only certain hospitals or geographies handle the patients. Once those specialist centres adopt the therapy (sometimes via highly specialised commissioning), patients from all regions are referred there, which can achieve equity in a different way. The challenge is usually not a wide geographic variation in offering (since by design only specific centres provide it), but rather ensuring all eligible patients are identified and referred. Historically, rare disease treatments have sometimes taken years to reach all who could benefit, due to diagnostic delays or capacity limits. However, when a new orphan drug is approved, the few relevant specialist ICBs or trusts often move quickly to implement within their services. Thus, the uptake curve for rare disease drugs may show a slow start (small absolute numbers) but less of the widespread regional variability seen in primary care drugs – the key limitation is the overall volume of patients treated vs. the expected number, which can remain low until awareness and screening improve. nzyme’s experience in rare and orphan NICE technology appraisals is that those published as far back as 2021 are still struggling to achieve equitable access for patients 4 years later in some instances.
In summary, across therapeutic areas, the 90-day mark is just the beginning of implementation. Common therapies that rely on broad primary care or generalist uptake often see a slower, patchier rollout than niche therapies managed in centres, but all types of innovations tend to require much more than 3 months to achieve full, equitable use.
Real-World Time to Full Implementation
Bringing together the findings: the “real” time to full implementation of a NICE TA in practice is often closer to 18–24 months (or even longer for some medicines) rather than 90 days. While the funding may be in place by 3 months, actual uptake ramps up over the subsequent 1–2 years as service capacity, clinician education, and patient identification catch up to the guidance. The Innovation Scorecard data reinforces this pattern. A typical new medicine shows significant growth in usage for at least 4–8 quarters post-launch before plateauing. Unwarranted regional variation also gradually diminishes over this period, but often does not fully disappear – some ICBs continue to lag behind the national average for uptake, even at 2+ years. According to the Office for Life Sciences, by five years after launch ,the UK’s medicine uptake approaches parity with other countries, but the first year or two are marked by slower adoption. This suggests that even domestically, “full” implementation (where usage matches the expected eligible population across all areas) is a multi-year endeavour.
Crucially, this extended timeline has real consequences: patients in many parts of England wait well beyond NICE’s 90-day promise to actually benefit from new treatments. Both the NHS and industry recognise this gap. The ABPI and NHS Confederation have called for concerted efforts to accelerate and level out the uptake of innovative medicines, noting that persistent delays and variation mean patients miss out and health outcomes suffer. Addressing the underlying barriers – from awareness and training to pathway development and data systems to track eligible patients – is key to shrinking the lag between NICE approval and truly equitable access.
In conclusion, 90 days is an aspirational minimum for funding availability, but not a realistic endpoint for full implementation. Recent evidence across multiple TAs shows that the NHS typically needs on the order of 1.5 to 2 years to achieve near-universal uptake at the expected levels, and even then, some variation can persist. Strengthening adoption efforts could help close this gap, ensuring that innovative treatments reach all patients who need them in a timely and fair manner, no matter which ICB they live in.