Curated Market Access Research 1

 NHS funding decisions for cardiovascular secondary prevention are documented in public and almost impossible to read as a whole — the answer to "who pays for this, and what has to happen first" is scattered across a Drug Tariff part number, a service condition in the NHS Standard Contract, a QOF indicator that changed in April, a scoring metric in the oversight framework and a modern service framework published in July. This briefing takes one question and follows it end to end: what happens to a new lipid-lowering therapy after NICE says yes — whose budget the cost lands on, which committee lists it and under which clause, what actually gets tendered locally, and what determines whether any of it becomes treated patients. 

Inclisiran is the worked example, because five years of public evidence show what central funding and a Drug Tariff listing bought and what they did not. The questions are the same ones a launch has to answer in the field, which is the point: that priority 7 of the CVD framework, QOF CHOL004 and the oversight metric are one number with one definition is a research finding on the page,

But in an account plan it is the argument that reaches the ICB medical director, the finance director and the practice on a single slide — and turning the mechanism into the account plan, the formulary submission, the funding conversation and the tender response is the work I do at Healthcare Acumen.

 Every figure is traced to a primary source and linked; what could not be verified is listed at the end. Not advice — a map. 

A diabetes technology can be recommended by NICE, wanted by every clinician who has seen it work, and still reach almost nobody for two years. The gap between recommendation and use is rarely a clinical problem. It is a question of which pound pays, under which clause, approved by whom — and diabetes has an unusually large number of answers to that question, because the device is bought by a hospital through a national framework, the sensors are prescribed by a GP against an ICB budget, the money may arrive as a national top-up that is conditional on an audit return, and the clinic that would fit it has no educator free until the spring. Each of those is a different mechanism, with different rules, different decision-makers and a different failure mode.

I write the "Who Pays" series because I have spent my career on the other side of these questions — formularies and area prescribing committees, Blueteq approvals, homecare arrangements, and the business cases ICB and trust finance teams actually sign. That teaches you which mechanism bites, and where a funding pathway quietly stops even after everyone has said yes. AI does the retrieval and the first draft, and every material claim is traced to a primary source. The questions and the judgement are mine. AI is very good at answering. It just does not know what to ask!

 This "Who Pays" briefing takes one question and answers it end to end: when a cardiomyopathy therapy has a positive NICE technology appraisal, who is obliged to pay for it, out of which budget, under which clause and on whose signature. It follows the money from the funding requirement through the payment scheme, the contract and the planning and commissioning frameworks, out to how a medicine is actually tendered — naming, at each step, the point where a pathway usually stalls.

I write the Who Pays series because I have spent my career on the other side of these questions — formularies and area prescribing committees, Blueteq approvals, homecare arrangements, and the business cases ICB and trust finance teams actually sign. That teaches you which mechanism bites, and where a funding pathway quietly stops even after everyone has said yes. AI does the retrieval and the first draft, and every material claim is traced to a primary source. The questions and the judgement are mine. AI is very good at answering. It does not know what to ask. 

  A positive NICE technology appraisal is supposed to settle the question of funding: NICE recommends, and commissioners must pay within three months. Obesity is where that stopped being true. NICE granted a funding variation for tirzepatide, replacing the usual funding requirement with a three-year phased rollout in which roughly 220,000 patients are treated against an eligible population of 3.4 million — and the money reaching integrated care boards is calculated on local obesity prevalence, not on the patients in front of them, and is not ring-fenced. So the question is not whether an obesity medicine is approved. It is who pays for it, out of which budget, on whose signature, and why eligible patients still wait. This briefing traces that route from the national settlement to the prescription: the NHS Payment Scheme, the Strategic Commissioning Framework, the NHS Standard Contract, the Medium Term Planning Framework, the Better Care Fund, the Quality and Outcomes Framework, the NHS Oversight Framework and the new Modern Service Frameworks — what each one does, who signs it off, and where a funded product can still fail to reach a patient. 

I have spent my career on the NHS side of pharmaceutical commercialisation: market access and specialty sales in the UK, mostly cardiovascular and specialist medicines, working through formularies and area prescribing committees, high-cost drug approvals and homecare supply, and the long unglamorous business of getting a funded product to actually reach a patient. That is why these briefings are written the way they are. Every one of them starts from a question I have had to answer in a room — usually with a finance director who has already decided the answer is no — rather than from a policy document. The frameworks in them are not summarised for their own sake; they are traced because each one is a place where the money can stop. I use AI to do the retrieval and the first draft, which it does faster and more completely than I can, and then I check it against what I know happens in practice. Every material claim here is linked to a primary source. The framing, the judgement and the warnings are mine,.

 This reference covers the eight NHS financial and planning instruments that govern commissioning and funding decisions in England and, for each, sets out the mechanics, how money actually reaches a digital mental health product, and the levers available to an access lead working cross-functionally with Medical, Commercial and External Affairs. England only; devolved nations operate different machinery 

 Under DHSC's Value Based Procurement guidance, non-price value must now carry a minimum 60% of evaluation criteria in an NHS medtech tender. Social value a minimum 10%. Whole life cost capped at 40%. Price alone can no longer win.
That is the newest change. It is not the deepest one.
For a medicine, a positive NICE technology appraisal carries a statutory funding requirement, normally within 90 days. For a device, NICE HealthTech guidance carries no such requirement. Approval is permission to sell. It is not a budget.
Only four national mechanisms create anything close to an obligation to pay, and three are shut to most products: the National HealthTech Access Programme is deliberately narrow, the MedTech Funding Mandate has taken no new products for 2026/27, and the high cost tariff-excluded list covers fifteen categories. For everything else there is no obligation at all — only a trust-by-trust business case.
So roughly two thirds of a device access plan is local. Launches fail at the payment mechanism, the procurement route and the pathway redesign. They do not fail at NICE.
The briefing maps all eight instruments and ranks the funding routes by realism.

Not advice — a map.

AI is very good at answering. It does not know what to ask. This briefing is the part that is mine: knowing the question is not "has NICE approved it" but whose budget, under which payment mechanism, signed off by whom, against a metric that organisation is publicly measured on. Mapping a funding pathway end to end is the same skill whether the product is a specialty medicine or a device. My own background is NHS market access in cardiovascular and specialty medicines, including high-cost drugs funding through Blueteq and homecare — medical technology is adjacent territory, not home ground. What transfers is the method: read the instruments, find where the money actually sits, and turn it into something a clinical champion and a finance director can both act on.

That is the work, and it is what I can do for a commercial team. 

 A NICE recommendation for a digital therapeutic is not a funding decision. Unlike a medicine with a technology appraisal, which carries a statutory funding requirement inside 90 days, most digital mental health products reach NICE through an early value assessment — conditional, time-limited, no mandate, no money attached. The decision goes straight to local discretion.
And it lands somewhere awkward. Mental health sits in the fixed element of the NHS Payment Scheme, so there is no tariff, no unit price and no marginal income for a provider that adopts your product. Anyone waiting for the tariff has misread the scheme.
This briefing follows the money instead. Who holds the budget once you get past NICE. Which contract clause the product actually enters through. Whether you are selling a clinical service under the Provider Selection Regime or software under the Procurement Act 2023 — a choice that governs process, timescales and challenge risk, and one that is too often made by whichever NHS department picks up the phone. And the eight funding routes available, ranked by how often each one works.
Compiled 16 September 2026. Every material claim traced to a primary source and linked.

Not advice — a map.

The problem here isn't clinical. A NICE early value assessment gives you conditional standing and no mandate, and mental health sits in the fixed element of the NHS Payment Scheme — so adoption earns the provider nothing. Every pound has to be won locally, from people who need a displacement and capacity-release case for a finance director.
That's the work I've done: NHS market access across ICB and hospital routes, getting high-cost products written into the mechanisms that actually release money — Blueteq, homecare pathways, funding variations. The mechanism differs for a digital product; the skill doesn't.

I publish on it — the Who Pays briefings map the eight NHS funding and planning instruments.

I don't bring a digital therapeutics or mental health background. I bring the funding pathway, the account plan and the tender. 

Seven briefings in, the Who Pays series has taught me one thing I didn't expect: the architecture doesn't change.

I set out to answer the same question for seven different products — a lipid-lowering therapy, a diabetes technology, a cardiomyopathy medicine, an oncology medicine, an obesity product, a digital mental health product, and a medical device. Who pays, out of which budget, under which clause, on whose signature.

The same eight instruments governed the money every time. What changed was which one bit — and where the launch actually got stuck. Aseptic minutes. Echo slots. Educator time. Therapist hours. Wraparound capacity. Never the drug.

Three things I'd carry into any launch:

→ "NICE approved" is four or five different statuses, and only one of them is money.

→ What gets tendered is usually not your product. In CVD it was prescriber capacity; in obesity, weight management services.

→ The NHS Oversight Framework is public, and it tells you which accounts have the headroom to say yes.

I've written up what the seven have in common — and named the areas that meet the same test but have no entry yet.AI is very good at answering. It does not know what to ask.

Not advice — a map

In one week I wrote seven briefings, each answering the same question for a different product type — a lipid-lowering therapy, a diabetes technology, a cardiomyopathy medicine, an oncology medicine, an obesity product, a digital mental health product, a medical device. Who pays, out of which budget, under which clause, on whose signature.

Four things that work says about how I would do the job.

I go to the mechanism. Each briefing names the clause: SC27.1.2 and where the formulary obligation stops; Drug Tariff Part VIIIC and the £60 that lands on the ICB prescribing budget; the Blueteq form that works as a second, narrower label. A case built on "NICE approved it" loses to a finance director. One that names the budget line, the payment mechanism and the approval route does not.

I know where launches fail, because it is the same four places — payment mechanism, procurement route, pathway redesign, capacity. Across all seven the binding constraint was aseptic minutes, echo slots, educator time or therapist hours. Never the product. I went looking for that because I have watched it happen.

I carry the same architecture across product types. The eight instruments held for a specialty medicine, a device, a digital therapeutic and a primary-care product alike. Knowing which one bites for which is the portfolio literacy a Lead or a consultant needs.

I publish what I could not verify. One briefing lists six things it could not confirm. Flagging them rather than smoothing them over is what makes the rest usable in a board paper — and the same instinct stops a market access lead over-promising a commissioner.

What it does not show: this is desk work, not delivered access, and England only. It evidences current capability and current system knowledge, not a track record — that sits in my CV and case studies.

I wrote it to be certain that what I know about NHS funding is true in September 2026, not true in 2019.