Intended for healthcare professionals


NICE’s end of life decision making scheme: impact on population health

BMJ 2013; 346 doi: (Published 21 March 2013) Cite this as: BMJ 2013;346:f1363
  1. Marissa Collins, researcher in health economics1,
  2. Nicholas Latimer, research fellow in health economics2
  1. 1Glasgow Caledonian University, Yunus Centre for Social Business and Health, Glasgow G4 0BA, UK
  2. 2ScHARR, University of Sheffield, Sheffield, UK
  1. Correspondence to: M Collins marissa.collins{at}
  • Accepted 17 February 2013

Marissa Collins and Nicholas Latimer quantify the impact of raising the cost effectiveness threshold for end of life drugs and find that the effect on other NHS services could be substantial

In January 2009 the National Institute for Health and Clinical Excellence (NICE) introduced supplementary advice to improve NHS access to end of life treatments. The advice means that treatments for patients with short life expectancy can exceed NICE’s cost-effectiveness threshold of £30 0001 (€35 000; $45 000) per quality adjusted life year (QALY) provided that they are for patients with a short life expectancy, they extend life by at least three months compared with current NHS treatment, and apply to small patient populations.2 The advice gives increased access to drugs for patients who need them, but, since the cost of the new treatments has to come from somewhere in a fixed NHS budget, funding of drugs under the end of life criteria has important implications for the NHS and patients. The applicability of the supplementary advice to cancer drugs refused by NICE before 2009 has been analysed.3 However, the wider potential costs and benefits to the NHS have yet to be quantified. We estimate the effect of the end of life criteria on the NHS in England and Wales since they were introduced in 2009.

Funding decisions

NICE normally recommends a new intervention if its incremental cost effectiveness ratio (ICER) is below £20 000 per QALY gained.1 The ratio is calculated by dividing the incremental costs of an intervention by its incremental QALY gain compared with standard treatment. If the ratio is above £20 000/QALY the appraisal committee will take other factors into account. As the ratio increases from £20 000 to £30 000, there must be a stronger case for supporting the intervention based on the degree of certainty in the ICER, inadequately …

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