Recommendation from the National Institute for Health & Care Excellence (NICE) provides critical validation for drugs launching in England. Commissioners have a statutory responsibility to fund, but uniform patient access is not automatic. This analysis assessed whether current regulation is sufficient to ensure timely adoption of a key new treatment. The Innovation Scorecard 2018-2020 was analysed, and tyrosine kinase inhibitors (TKIs) were identified as under-utilised (∼124,000 actual daily dose (ADD)/quarter) versus NICE expectations (∼300,000 ADD/quarter). Osimertinib, indicated for advanced EGFR+ NSCLC, was selected for further study. Technology appraisal guidance (TA653+TA654) and relevant guidelines were reviewed. NICE-reported actual regional uptake (ADD/100,000 standardised population) was compared to published global data, and oncology pharmacists and clinical leads in two low-uptake regions were interviewed to explore NICE guidance implementation processes and barriers. Regional variation in osimertinib utilisation was observed, with Midlands and North East & Yorkshire predominantly in the lowest 20%. Annual purchase data showed that Clatterbridge (33,481), Royal Marsden (16,540) and Christie (13,805) NHS Foundation Trusts led acquisition, with 19 Trusts 500-1958; 33 300-499; and 47 <299 ADD/100,000 finished consultant episode (FCE) day hospital care. Potential barriers to adoption included treatment positioning, patient identification, biopsy, accessibility of genetic testing, poor data quality and Cancer Drugs Fund restrictions. Osimertinib utilisation was driven by London and the Northwest, with only modest uptake at other oncology centres over the study period. National adoption of osimertinib increased in Q3 2020 and will likely accelerate following the May 2021 approval of adjunctive use in early-stage patients. However, data suggest that usage was at the lower end of expectation for 3 years, potentially denying some patients access to important new treatment. NHS Trust implementation of NICE guidance appears to be inconsistent, and structured equitable frameworks are required to ensure timely access for all eligible patients.