Will covid-19 vaccines be cost effective—and does it matter?BMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m4491 (Published 26 November 2020) Cite this as: BMJ 2020;371:m4491
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We read with interest Professor Appleby’s article on the cost effectiveness of COVID-19 vaccines . In the article, he asks whether these vaccines would be considered cost effective under NICE’s approach to measuring value – and questions whether NICE’s methods are appropriate.
Appleby is correct that we do not look at vaccines as, to date, NICE has not been asked to evaluate population level vaccination policies. However, we are very interested in responding to his important wider question about how NICE chooses to measure cost effectiveness and what, by extension, we choose to value.
Understanding the value of a health technology by establishing its clinical and cost effectiveness is at the heart of the work of NICE. It allows us to establish whether investing in a new drug, device, diagnostic or digital solution delivers value for money. In most circumstances, our methods look at impact from an NHS and personal social services perspective when calculating the benefits and costs of new interventions. This allows for comparison of trade-offs between the health benefits gained by those receiving a new technology and health lost by those whose treatment will be displaced, seeking to maximise health within the NHS’s fixed budget. Given that our prime focus is ensuring the NHS spends its budget as wisely as possible to achieve the best possible health outcomes, we do not usually consider the wider impacts on other public sectors nor impact on economic productivity and consumption.
Appleby is correct that there are circumstances where NICE can adopt a wider perspective. For NICE guidelines, this can be done where interventions are funded by the public sector with health and non-health outcomes, or with a social care focus. For health technology evaluation, this wider perspective can also be adopted with specific direction to do so given by the Department for Health and Social Care.
More broadly, the COVID-19 pandemic has highlighted fundamental questions about what we choose to value in society, including how to balance health impacts with wider societal and economic impacts. We suggest that this momentous event should be used as an opportunity to reflect on what we choose to value – including in our own methodologies at NICE.
We have always been very interested in exploring how we can look more broadly at what factors we use in our decisions, and whether we should extend this out to a wider societal perspective. As well as economic activity around productivity and consumption, we would also be keen to explore environmental sustainability and how that can be incorporated in our decision making. We would not expect this work to provide easy answers.
We have explored the idea of wider societal benefit previously and found there are technical, ethical and legal issues that will need to be considered particularly around age and equality, and an impact on the threshold range to be used for cost effectiveness. . Our ongoing review of the methods for health technology evaluation does not include consideration of a wider societal perspective in the strict economic sense, but we are looking at wider societal impacts of the use of medicines and medical technologies, including on health inequalities .
NICE has always been keen to push the boundaries of the science and methodology we use in creating our guidelines and making our recommendations. NICE has led the way in how to actively engage with the public on thorny questions of what to value through our citizens council and other deliberative events – and we anticipate this type of engagement would be needed here too. Finally, we believe that the methodologies required to adopt this approach need further exploration, and we are keen to work with others including health economists, methodologists, ethicists and funders to develop these ideas.
NICE has been busy over this pandemic, rapidly creating guidelines to inform front line COVID-19 care and assessing the benefits of new technologies to improve its treatment . We are now developing our strategy for the next few years, and thank Professor Appleby for this useful challenge, which we will take forward in our thinking.
Director, Science, Evidence and Analytics, NICE
Director, Centre for Health Technology Evaluation and Deputy Chief Executive, NICE
1. Appleby J. Will covid-19 vaccines be cost effective—and does it matter? BMJ 2020; 371 :m4491
2. Miners A, Cairns J and Wailoo A. Department of Health proposals for including wider societal benefits into value based pricing: a description and critique. NICE. London. 2013. Available at: https://www.nice.org.uk/Media/Default/About/what-we-do/NICE-guidance/NIC...
3. Reviewing our methods for health technology evaluation: consultation. NICE. London. 2020. https://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/ch...
4. NICE COVID-19 Guidelines and Advice. NICE. London. 2020 Available at https://www.nice.org.uk/covid-19
Competing interests: FG and MB are employed by NICE.