Why NHS Engagement Fails: Talking To The Right Organisations But The Wrong People
Most pharmaceutical, medtech and device companies that come to speak with me are doing something right.
They’ve mapped the system. They know which Integrated Care Boards (ICBs) matter. They’ve identified the right Trusts, PCNs, federations or provider collaboratives. They’ve booked meetings, delivered presentations and had what feel like positive conversations.
And yet … nothing moves.
- The pilot doesn’t start.
- The pathway doesn’t change.
- The formulary decision stalls.
- The momentum fades.
When we unpack what’s really happening, the issue is rarely the product, the evidence or even the organisation being targeted.
The problem is much simpler, and much more uncomfortable. They’re talking to the right organisations, but the wrong people.
They’re not alone in their challenge. Many pharma, medtech and device companies struggle to progress NHS pilots, pathway changes or formulary decisions, even after positive meetings with the right organisations.
This article explains why NHS engagement often stalls, who really influences adoption and how distributed leadership now shapes decision making across the system.
Why NHS engagement so often stalls (even after senior meetings)
From the outside, the NHS looks hierarchical. There are boards, directors, committees and governance structures. It’s natural for industry teams to assume that if they can get in front of someone senior enough, particularly at ICB level, progress will follow.
But the NHS doesn’t work like a traditional corporate buyer.
Decisions don’t flow cleanly from the top down. Authority and influence are often split.
And the person who can approve something is very rarely the person who will make it happen.
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Authority vs influence in NHS decision making
One of the biggest mistakes industry teams make is confusing formal authority with practical influence.
In the NHS, the person who signs off funding is rarely the person who delivers the service. The most senior voice in the room may not be the most trusted one.
Real change happens when the people responsible for delivery believe something will make their lives easier, safer or more sustainable.
The four groups that influence NHS adoption and delivery
To move from agreement to adoption in the NHS, industry teams must engage four distinct groups who collectively shape delivery, risk and decision making.
Influence no longer sits neatly at the top of an organisational chart. It is distributed across clinical, operational, financial and governance roles, each with the ability to enable or quietly block change.
This is the practical engagement model I have used for more than 20 years across primary care, secondary care, ICBs, provider collaboratives and place based systems.
When NHS projects succeed, it is almost always because these groups have been engaged deliberately, in the right sequence and with the right conversations. When they fail, one or more has been missed.
To progress beyond discussion and into delivery, all four must be engaged.
1. Clinical Owners (NHS Pathway Owners)
These are the clinicians who own the pathway in practice, GPs, consultants, specialist nurses, pharmacists and clinical leads. They care about patient outcomes, clinical safety and alignment with guidance. Without their belief and advocacy, nothing embeds. But clinical support alone is never enough to secure adoption.
2. Operational Leaders (NHS Service Delivery and Capacity Owners)
Service managers, practice managers, transformation leads and pathway managers are often the most influential people in the system. They understand how services actually run, where capacity is constrained and what will break under pressure. If they see risk, additional workload or operational fragility, progress will slow, quietly and effectively.
3. Strategic and Financial Influencers (ICB and System Decision-Makers)
These include ICB programme leads, finance managers and contracting teams. They think in terms of system impact, affordability, opportunity cost and alignment with wider priorities. They may not initiate change but, without their support, scale and sustainability are impossible.
4. Governance and Risk Gatekeepers (Information Governance, Digital, Procurement and Safety)
Information governance, digital, procurement, quality and safety teams rarely say yes, but they can always say no. Engage them too late and previously “agreed” projects can stall for months or collapse entirely at the final hurdle.
Ignoring any one of these groups will stall progress.
But even this is not enough.
Within and around each group sit less visible influencers, highly experienced nurses, pharmacists, digital leads, administrators and long standing staff who understand what has failed before, who others trust and who quietly shape opinion.
If they are not identified and engaged early, they often surface late in the process as “sudden” objections, new risks or unexpected blockers.
By the time that happens, momentum, credibility and time have usually already slipped away.
This is why effective NHS engagement is not about chasing senior titles. It is about understanding how distributed leadership really works and building coalitions of trust before resistance has a chance to form.
These principles are explored in more depth in my book Embedded: How Pharma, MedTech, and Device Companies Can Get Their Innovations into NHS Pathways – and Keep Them There – a practical guide to understanding NHS decision making, delivery risk and real world adoption.
Why this matters more than ever
The NHS is moving rapidly toward provider led models, provider collaboratives and standardised pathways. This is not a policy aspiration. It is a practical response to sustained pressure, workforce shortages and the need to deliver care more consistently across populations.
As a result, decisions are increasingly being shaped, and often effectively made, by the people responsible for making services work at scale, not by those whose role is simply to approve them.
In this environment, adoption is no longer about whether a product is clinically sound or cost effective in isolation. It is about whether it can be implemented safely, consistently and repeatedly across multiple sites, often with fewer staff and less flexibility than ever before.
Anything that introduces variation, complexity or delivery risk is treated with caution, no matter how compelling the evidence.
Watch a replay of my free webinar – How To Sell To The NHS In 2025 – here.
Provider collaboratives accelerate this reality. When multiple organisations are responsible for delivering a single pathway together, decisions are no longer local or discretionary. They become system choices.
A solution that works well in one hospital, one PCN or one service but cannot be operationalised across the wider footprint will struggle to progress.
This fundamentally changes who matters.
Influence now sits with clinical and operational leaders who are accountable for flow, capacity, workforce deployment and outcomes across entire pathways. These individuals may never sit on a formulary committee or appear as a named decision maker but, without their confidence, change simply does not happen.
For more on this topic, read my blog on finding the right NHS customer here.
For industry, this raises the bar. Engagement can no longer rely on product excellence alone or on senior level endorsement in isolation. Success depends on understanding delivery realities, aligning with pathway pressures and building confidence among those who carry implementation risk.
Put simply, the NHS is no longer buying ideas. It is buying certainty of delivery. Companies that recognise this and adapt their engagement accordingly will continue to find opportunities. Those that don’t will increasingly find themselves having good conversations that go nowhere.
The NHS is not rejecting innovation – it is rejecting delivery risk
For pharma, medtech and device companies, NHS adoption increasingly depends on engaging the people who carry delivery risk, not just those who hold formal authority.
The NHS is not rejecting innovation, but it is rejecting delivery risk.
In a system under relentless pressure, NHS leaders cannot afford solutions that look good on slides but fall apart in practice. They are accountable not just for clinical outcomes, but for workforce capacity, patient flow, operational stability and system performance. That reality shapes every decision they make.
The organisations that succeed are not the ones with the loudest messages or the most polished decks. They are the ones who understand how change actually happens inside the NHS.
They identify where pressure really sits. They engage the right people, in the right order. And they help NHS teams solve problems they already feel, rather than selling solutions they didn’t ask for.
This shift, from selling products to supporting pathways, from hierarchy to distributed leadership, from approval to adoption, is not optional. It is now the price of entry.
My book Embedded covers this in more depth, distilling more than 20 years of frontline NHS and industry experience into a practical guide for teams who want their work to move beyond good conversations and into real, sustained impact.
If your NHS engagement feels slow, fragmented or inconsistent, it’s rarely because the system is “resistant to change”. More often, it’s because the engagement model hasn’t yet caught up with how the NHS actually works.
Understanding that difference is where progress begins.
At www.scottmckenzieconsultancy.com, we work directly inside the NHS, supporting provider organisations, commissioners and system leaders to implement real change. We then help pharma, medtech and device companies interpret what’s happening, so they can engage the right stakeholders, align with NHS priorities and get their innovations embedded into care pathways.
With 10 years in pharma and more than 20 years working within the NHS, Scott brings a unique dual perspective, now captured in his book Embedded: How Pharma, MedTech, and Device Companies Can Get Their Products into NHS Pathways and Stay There, which distils everything he’s learned into a practical playbook. Whether you’re launching a new product or trying to unlock stalled adoption, Embedded shows you how to reframe your offer, align with NHS priorities and make change stick.