Intended for healthcare professionals

Editorials

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

Authors' response - Re: Cost effective but unaffordable: an emerging challenge for health systems

NICE’s Carole Longson suggests that our recent editorial on NICE’s new affordability test indicates that we “have misunderstood its primary purpose” [1]. We beg to differ. We are acutely aware of the need to minimise costs to the NHS, as the recent update to the Five Year Forward View underlined [2]. The crisis facing the NHS requires more—not less—debate about how NICE and NHS England (NHSE) should address the challenge of drug cost inflation.

In its response, NICE seeks to downplay the significance of the new budget impact test [1]. In addition to affecting only a “minority of drugs”, the test will apparently lead to only minimal delays, as price negotiations will begin “well before” appraisals and “be completed by the time NICE publishes its guidance” [1]. If this is the case, why is the new budget impact test needed at all? NICE can already waive the 90-day funding requirement if it considers that the recommended technology “cannot be appropriately administered until other appropriate health services resources […] are in place” [1].

NICE argues that the new test does not seek to delay access to cost-effective technologies, but aims to trigger price negotiations with industry [1]. Stephen Duckett rightly points out that if this frees up money to be spent gainfully elsewhere, it may be ethically justified [3]. However, the ethical imperative to minimise costs exists for all technologies, not just those costing more than £20 million a year. In addition, the Pharmaceutical Price Regulation Scheme (PPRS) already guarantees the Government a rebate when its annual cap for drug spending has been reached—a routine event in recent years [4]. It would be a shame if upfront price discounts simply replace the existing PPRS repayment, leading to a small cash flow advantage but no actual cost reduction.

Greg Fell questions the fairness of how NICE and NHSE currently judge value for money for health services [5]. We believe that NICE’s “ethics of opportunity costs” framework is generally fair [6]. However, the new budget impact test increases rather than reduces unfairness, particularly if access to some technologies is “phased in” gradually as NICE suggests [1], raising the prospect of inequities arising not just between patient groups but also within them. It is important that this debate on affordability continues to ensure that the NHS achieves maximum value for the money it spends on drugs [7].

Acknowledgments:
With thanks to Catherine Max for her contributions to both the original article and this response.

References:
1. Longson, C. Re: Cost effective but unaffordable: an emerging challenge for health systems. BMJ 2017;356:j1402.
2. NHS England. Next steps on the NHS five year forward view: NHS England, March 2017. https://www.england.nhs.uk/wp-content/uploads/2017/03/NEXT-STEPS-ON-THE-...
3. Duckett, S. Re: Cost effective but unaffordable: an emerging challenge for health systems. BMJ 2017;356:j1402.
4. Ward A and Neville S. ‘Pharma groups to pay NHS £550m ‘rebate’’. Financial Times, December 23 2015. https://www.ft.com/content/6c34f7de-a966-11e5-843e-626928909745
5. Fell G. Re: Cost effective but unaffordable: an emerging challenge for health systems. BMJ 2017;356:j1402.
6. Rid A, Littlejohns P, Wilson J, et al. The importance of being NICE. Journal of the Royal Society of Medicine 2015;108(10):385-89. doi: 10.1177/0141076815598877
7. Charlton V, Littlejohns P, Rid A, et al. Cost effective but unaffordable: an emerging challenge for health systems. BMJ 2017;356:j1402.

Competing interests: No competing interests

13 April 2017
Victoria Charlton
PhD student
Peter Littlejohns, Katharina Kieslich, Polly Mitchell, Benedict Rumbold, Albert Weale, James Wilson and Annette Rid (corresponding author)
Department of Global Health and Social Medicine, King's College London
Room 2.11, East Wing, Strand Campus King's College, London Strand London WC2R 2LS