The NICE threshold: How much is too much? Who decides?

By Ryan Li Feb. 19, 2015

Prof Karl Claxton, University of York, and colleagues have argued that NICE is advising the UK National Health Service “to pay too much” for new drugs. NICE typically recommends treatments for use in the NHS where their cost-effectiveness falls below the threshold of around £20,000 and £30,000 per QALY gained (quality-adjusted life year). New research led by Claxton suggests that paying more than £13,000 per QALY for technologies “does more harm than good” by displacing other more effective healthcare from the NHS. Here is how the research was reported in The Guardian:

The NHS is doing more harm than good by approving expensive drugs for a limited number of conditions such as advanced cancer, which use up funds that would benefit other parts of the health service…

Claxton says the patients who lose out are invisible and have no say in the argument over how limited NHS resources are spent – by contrast patients with conditions such as advanced cancer are often featured in the media whenever a new drug with a very expensive price tag is turned down by Nice.

The full report by Claxton et al. is published in the NIHR Health Technology Assessment journal.

And here is the full response from the ‘decision maker’, Sir Andrew Dillon, Chief Executive of NICE:

At the other end of the spectrum, we obviously can’t just say yes to anything and everything… Whether we’ve got the balance right is a question for everyone to reflect on; it’s certainly not a decision just to be left to health economists.

Whether or not the current threshold is indeed to high, and whether or not NICE is ever able to adopt this suggested dramatically lower threshold, this debate highlights very important issues about the real opportunity costs of paying for expensive health technologiesthe invisible patient who suffers and never has a voice; who should decide the rules (and how); and, fundamentally, the importance of having robust, defensible mechanisms of health technology assessment, so that society is informed as to what we are paying for, and at what cost.

It is commendable that the technical experts and decision makers are able to have this honest, open discussion about what the threshold should be. Further, it demonstrates the very principles which crucially underpin the work of NICE: transparency, participation (in particular, a collaborative and productive relationship between decision makers and an independent academic network), and weighing scientific evidence in the context of social and ethical values, for the broader interests of society.

As part of iDSI, our colleagues at the University of York are also leading research to explore the use of cost-effectiveness thresholds in low- and middle-income countries.

It might be new and expensive cancer drugs in the UK, or high-tech viral load monitoring for HIV in Uganda, but reality is the same everywhere: each pound or dollar spent on one part of the health system, means denying that pound or dollar from being spent on something and someone else.

With thanks to Yot Teerawattananon, and Kalipso Chalkidou