A great therapy can clear every scientific hurdle and still fail to reach the patient. Often, the difference is friction: a series of small barriers that can have major consequences
Words by Isabel O’Brien
The alarm goes off at 6am. You need to be at the gym for 6:30. In theory, there is plenty of time. Then there is the small matter of getting out of bed. You have to find your shoes, fill your water bottle, make coffee and locate your keys. Perhaps it is raining. Perhaps, after all that, you decide that missing one session isn’t all that bad.
None of these is a serious obstacle. That is precisely why they matter. Friction is rarely a wall: it is a succession of small impediments between an intention and an action, each easy to dismiss until there are enough of them.
Speaking on the EMJ GOLD podcast, behavioural scientist Richard Shotton, Author, Hacking the Human Mind, describes friction as the accumulation of “seemingly trivial barriers” that can have a “disproportionate effect on behaviour”. The same applies after a medicine has cleared the scientific and regulatory hurdles. Access depends on what happens next, and every hurdle creates another opportunity for failure.
When approval isn’t access
At the broadest level, the first hurdle is whether an approved medicine is available in a country at all. EFPIA’s Patients W.A.I.T. Indicator 2025 found that, on average, a new medicine takes 597 days to travel from European marketing authorisation to a patient, with 49% of those approved between 2021 and 2024 not yet accessible in Europe.
“Not available” seldom means rejected. More often the medicine is still moving through health technology assessment and price negotiation, or the company has not filed for reimbursement in that country. On average, manufacturers apply in only 16 of the 27 EU member states, and where they do not, the reasons are usually commercial: a patient population too small, or a price that, once other countries copy it through international reference pricing, sets an unworkable benchmark elsewhere.
The result is that where a patient lives determines what they can be prescribed. The same W.A.I.T. data puts average time to availability at around two months in Germany and more than three years in Romania. This reveals a system-level challenge to be tackled. As Nathalie Moll, Director General, EFPIA, puts it, ensuring medicines reach patients wherever they live in Europe is “a shared ambition and a shared responsibility”.
When the best treatment can’t be reached
Clear the border and the patient can still be no closer. In precision oncology, a medicine can be licensed, funded and on a hospital formulary, yet an eligible patient may never receive it because the drug cannot be prescribed until a biomarker is found. The question is no longer whether the treatment exists, but whether the patient can reach the best, most tolerable option for their disease.
“The gap can open at several points,” says Dr Michael Zaiac, Head of Oncology Medical Affairs, Europe & Canada, Daiichi Sankyo. Clinicians may be unaware of a targeted treatment and therefore not request the relevant test. Results presented at a major oncology congress may change what is possible, but the clinician treating a particular patient may never see them.
Even when the test is requested, it can fail for reasons that have nothing to do with the medicine. The IQVIA Institute’s 2026 report, Advancing Precision Oncology, found the biggest testing barriers were the availability of usable tissue samples, test cost and reimbursement, turnaround time and patients’ willingness to be tested.
Each of these behaves like friction rather than a wall. A biopsy may be too small to run a full panel, or the tissue may already have been used by earlier tests, leaving the patient facing another procedure. A result that arrives after a treatment decision has been made is, in practice, a result that never arrived. None of this stops a patient outright. It simply makes the targeted route slightly harder than the conventional one, and the conventional one proceeds.
A Diaceutics analysis published in JCO Precision Oncology found that, in advanced lung cancer, only around 356 of every 1,000 eligible patients were estimated to benefit, with most losses occurring around testing. The ceiling on a targeted therapy, in other words, is set less by how well it works than by how reliably the system finds the patients it works for.
As Zaiac puts it, “the reality of testing determines the real-world population that can benefit”. His conclusion is that the diagnostic pathway has to be treated as part of the product: “Launching a targeted medicine is as much about launching and embedding the biomarker pathway as it is about launching the medicine itself.”
That makes pathway design as important as the medicine itself, and small changes to how a decision is presented can shift behaviour at scale. A 2016 JAMA Internal Medicine study by researchers at the University of Pennsylvania found that changing the electronic health record default lifted generic prescribing from around 75% to 98%. Nobody had to be persuaded: the easier option became automatic.
Reflex testing applies the same principle, triggering biomarker testing at diagnosis rather than relying on someone to remember to request it. It does not solve laboratory capacity or who funds the test, which remain questions for health systems. What it removes is the need for a busy clinician to think of it.
When a potential cure never gets discussed
The stakes rise again with cell and gene therapies. Here the question is whether a patient can reach a treatment that could potentially cure them. These are among the most expensive medicines ever made, so it is natural to assume price is what stops them. It is, but only the second one.
In sickle cell disease (SCD), Sarah Hendry, Franchise Head, Hematology, Spherix Global Insights, says the first filter is perceptual: “Physicians are making judgment calls about who is and isn’t a good candidate for gene therapy,” she says, “often excluding the patient from that consideration discussion.”
An audit of SCD patient charts cited by Hendry found that around 80% were considered good candidates, yet only about 10% had active plans to proceed, with “patient motivation” and “likelihood to comply” among the reasons cited.
The pattern holds even among clinicians who are broadly supportive. At the 2026 EBMT Annual Meeting, a survey of 138 US clinicians reported that 86% were likely or very likely to refer an eligible child with SCD for gene therapy, yet only 18% routinely discussed specific products during referrals. Willingness in principle does not always become a real conversation or treatment plan.
Some reluctance is rational. The process is long, costly and available at only a handful of accredited centres, so clinicians must consider whether a patient can realistically complete it. However, that judgement can still be made before the patient has a say. Hendry argues the responsibility is shared: developers too must “ensure their therapies are accessed by patients who need them most, not just by those who are deemed to be appropriately motivated”.
That makes candidacy one of the most complex frictions of the three. The answer is not simply better referral pathways, but clearer candidacy criteria, better education and, crucially, including patients in their own care decisions.
Making access the easier choice
Follow an innovative therapy from approval to a patient and hurdles appears at every stage. First a border, where reimbursement stretches out. Then a pathway, where a specialised test goes unordered. Then a consulting room, where a candidacy judgement is made before the patient is part of the decision.
These are all frictions, but often the unconscious behaviours behind them are what make each one easy to miss. The remedy is the same at every level: name the friction, examine its impact and make the better choice easier. For pharma, the task is not to argue the evidence harder, but to find the friction and remove it.
It is not unlike making that 6:30am session. Shoes by the door, bottle filled up the night before, keys where you can find them and don’t look out the window.
