New drugs for old: disinvestment and NICEBMJ 2010; 340 doi: http://dx.doi.org/10.1136/bmj.c572 (Published 26 February 2010) Cite this as: BMJ 2010;340:c572
- Dyfrig A Hughes, reader in pharmacoeconomics1,
- Robin E Ferner, professor of clinical pharmacology2
- 1Centre for Economics and Policy in Health, Institute for Medical and Social Care Research, Bangor University, Bangor LL57 1UT
- 2West Midlands Centre for Adverse Drug Reactions, City Hospital, Birmingham B18 7QH
- Correspondence to: D A Hughes
- Accepted 12 January 2010
The aim of guidance from the National Institute for Health and Clinical Excellence (NICE) on medicines and other health technologies is to derive the maximum health benefit from finite NHS resources. The NHS in England and Wales is legally obliged to fund treatments recommended by NICE’s technology appraisals but does not receive extra money to do so. This means that the funding of new, expensive medicines relies increasingly on releasing funds by displacing other treatments, but NICE does not specify which. One of the reasons that NICE was formed was to end inequitable geographical variation in the availability of new medicines (the postcode lottery). However, inconsistent decisions on which treatments to abandon will also lead to geographical variation. If the treatments being displaced are not the least efficient, overall population health is reduced. So how should we establish which medicines to discontinue?
Identifying medicines for disinvestment
Elshaug et al suggested several signals that might identify treatments offering poor value for money.1 These include new evidence on effectiveness, safety, or cost effectiveness; variations in care (which may indicate differences in clinical opinion or the use of drugs outside licensed indications); technological development (such as change in formulation); and consultations with special interest groups. They also proposed criteria for prioritising shortlisted treatments for appraisal,1 2 looking first at those that are associated with high overall costs; are not used for severe or life threatening conditions; have underused, more cost effective alternatives; are futile; or in which disinvestment may potentially reduce harm or would have limited effect on vulnerable populations.
NICE has taken a less systematic approach. It focuses on …
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