Intended for healthcare professionals


Cost effective but unaffordable: an emerging challenge for health systems

BMJ 2017; 356 doi: (Published 22 March 2017) Cite this as: BMJ 2017;356:j1402
  1. Victoria Charlton, PhD student in bioethics and society1,
  2. Peter Littlejohns, professor of public health2,
  3. Katharina Kieslich, research fellow in health policy2,
  4. Polly Mitchell, PhD student in philosophy4,
  5. Benedict Rumbold, research fellow in philosophy4,
  6. Albert Weale, emeritus professor of political theory and public policy3,
  7. James Wilson, senior lecturer in philosophy4,
  8. Annette Rid, senior lecturer in bioethics and society1
  1. 1Department of Global Health and Social Medicine, King’s College London
  2. 2Department of Primary Care and Public Health Sciences, King’s College London
  3. 3Department of Political Sciences, University College London
  4. 4Department of Philosophy, University College London
  1. Correspondence to: A Rid annette.rid{at}

New “budget impact test” is an unpopular and flawed attempt to solve a fundamentally political problem

With hospital wards overflowing and trusts in deficit, the introduction of cost effective but expensive new technologies places increasing strain on NHS finances. The National Institute for Health and Care Excellence (NICE) and NHS England plan to tackle this problem by delaying the introduction of interventions with a “high budget impact.”1 The change may deliver short term savings but is flawed.

What prompted the new policy? In 2015 NICE recommended the use of several new drugs for hepatitis C.2 Although they were judged clinically useful and cost effective, NHS England considered them unaffordable, with annual costs of between £700m and £1bn, and delayed adoption.34

From 1 April 2017, the current requirement to fund NICE recommended technologies within 90 days will not apply for those with annual costs that exceed £20m (€23m; $24m).1 Instead, NHS England will be granted up to three years—longer in exceptional circumstances—to conduct commercial negotiations.1 As a result, patient access to some new technologies will be substantially slowed.

Views expressed during the consultation on this policy were far from supportive. Respondents recognised the …

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