Intended for healthcare professionals

Analysis And Comment

How NICE may be outflanked

BMJ 2006; 332 doi: (Published 25 May 2006) Cite this as: BMJ 2006;332:1268
  1. R E Ferner, director (,
  2. Sarah E McDowell, research officer1
  1. 1 West Midlands Centre for Adverse Drug Reaction Reporting, City Hospital, Birmingham B18 7QH
  1. Correspondence to: R E Ferner

    We argued a decade ago that the NHS should not have to pay for new drugs unless they are at least as good as older ones, nor for expensive drugs whose benefits are uncertain.1 Since then, the National Institute for Health and Clinical Excellence (NICE) has been created. NICE appraises technologies that are available to the NHS and recommends whether they should be used unreservedly, with restrictions, or not at all.2 Part of its remit is to ensure equity, but equity is not in everyone's interests. Here, we consider how individuals or groups with specific interests may seek to outflank NICE.

    Individual benefit or common good?

    When many people share common resources, it is rational for each individual to increase personal use of the resources. But if all individuals do this, the resources are overexploited and eventually everyone will be ruined. This is termed the tragedy of commons.3 The NHS is a common resource. A patient acts rationally in seeking an expensive treatment that produces a benefit (even if small), because the cost falls almost entirely on others. But the NHS cannot support overexploitation indefinitely. It already spends £10.3bn (€15bn; $19bn) a year on drugs, and costs are rising rapidly.w1 One way to avoid overexploitation is to appoint a guardian to administer the commons. NICE plays this role but faces many challenges.

    Appraisal process

    NICE examines the value of drugs only when it is invited to do so by the Department of Health and Welsh Assembly, so it may never review some important aspects of therapeutics. The process is complex, involves many interested parties (stakeholders), and takes around two years to complete.w2 The delays between the initial suggestion and the final determination can allow patterns of treatment of uncertain cost effectiveness to become established. The longer the patterns persist, the harder they …

    View Full Text

    Log in

    Log in through your institution


    * For online subscription