Comprehensive spending review and the NHSBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h6477 (Published 01 December 2015) Cite this as: BMJ 2015;351:h6477
All rapid responses
In their editorial Walshe and Smith suggest that in order to meet the savings required from the comprehensive spending review NICE should consider reducing their threshold for recommending treatments (currently £20,000-£30,000 per QALY).(1) This does not go far enough. NICE should abolish the threshold and use a notional budget approach.
The threshold policy that if a drug costs less than £30,000 per QALY it represents value for money and should be recommended is out of touch with the realities of the NHS. The NHS is facing unprecedented financial challenges but NICE do not readily incorporate this financial constraint into their decision making process. Under the threshold system NICE will continue recommending more and more drugs with the financial implications falling on the NHS, not NICE.
No one in real life would only take a threshold approach to personal or organisational finances. The notion that one would keep spending more money as long it met a certain threshold which represented “value for money” without consideration of funds available is unrealistic. Yet this is NICE’s policy leaving commissioners in the NHS to pick up an ever increasing drugs bill.
Instead NICE should take a budget approach; having a notional fixed budget every year which they stick to. Therefore they would not be able to keep recommending drugs if the cost of those drugs exceeded this notional budget. Drugs would be ranked according to their cost per QALY and only the drugs which over the best value for money within the fixed budget would be funded. This would mean that there would be some link between the annual funding of the NHS and the recommendations that NICE makes. This will inevitably mean that some drugs with a higher cost per QALY will no longer be affordable and would drop off the recommended list. If the public and government want these drugs then the Treasury would need to increase NICE’s operating budget for drugs and associated funding to the NHS. This method would incentivise pharmaceutical companies to offer better value for money and make sure that NICE is in touch with the realities of the NHS.
John Ford, NIHR Doctoral Research Fellow, Norwich Medical School, University of East Anglia
Robert Fleetcroft, Clinical Lecturer in General Practice, Norwich Medical School, University of East Anglia
1. Walshe K., Smith J., Comprehensive spending review and the NHS BMJ 2015;351:h6477
Competing interests: No competing interests