Cost effective but unaffordable: an emerging challenge for health systems

BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j1402 (Published 22 March 2017) Cite this as: BMJ 2017;356:j1402

Re: Cost effective but unaffordable: an emerging challenge for health systems

I enjoyed reading the Charlton et al editorial.

It succinctly describes the key challenge at the heart of NICE and why the responsibility for budget impact wasn't set up within NICE at the time Of inception. This is an issue that deserves a far wider debate.

It was a timely reminder of a problem that isn't actually "an emerging challenge" - but something that emerged many years ago and the NHS has been struggling with for some time. What us emerging perhaps is NICE suggested solution.

Yes of course it is flawed. There is no perfect way out of this.

Charlton et al point to the implementation of the solution leading to delayed access of patients to innovative drugs. This may be true and is obviously troubling. It may be worth remembering that often many of the treatments appraised through the TA process are pretty close to the margin in terms of cost effectiveness, way above it if one uses the Claxton work on thresholds. Often the drugs appraised offer pretty marginal clinical benefits and many others are denied treatment as as result of the opportunity cost.

Similarly I was struck with the example of the application of the budget impact model and how that might set up inequity between those with Crohn's disease and ulcerative colitis.

Is this inequity worse than the inequity of access to aTNF for conditions that are subject to a NICE TA compared to those that aren't? Or inequity in terms of the many thousands of highly effective interventions and services that don't get funding priority afforded by a TA compared to the few, often marginally effective, treatments that do. Do we wonder why we've never scaled up investment in mental health? Some may suggest the oncoexceptionalism that is the Cancer Drug Fund may be as good a place as any to start looking.

I agree the solution is political. It's also social. I agree the solution derived by NICE has its problems. NICE should be congratulated for trying.

Competing interests: I have been a member of a NICE TA committee in the past, I have done work for Bayer Healthcare in an advisory capacity, my previous employer was reimbursed for my time

24 March 2017
Greg Fell
Director of Public Health