Intended for healthcare professionals

Head To Head

Should NICE’s threshold range for cost per QALY be raised? Yes

BMJ 2009; 338 doi: (Published 26 January 2009) Cite this as: BMJ 2009;338:b181

Insufficient arguments for a higher threshold

Towse’s arguments for increasing the QALY threshold are unconvincing.
Introducing a higher QALY threshold will not address his concerns about
PCTs. Opportunity costs will continue to be a feature of our health care
system whatever threshold applies. In stating that there is no evidence
that cost effective interventions are being cut to make room for NICE
approved technologies, does he mean that no evidence exists, or that there
is evidence showing that cuts have not been made? All PCTs have an annual
planning round involving prioritisation decisions. It is more likely that
opportunity costs are reflected in decisions not to fund in the first
place, rather than disinvestment ‘cuts’.

Service proposals are assessed against criteria reflecting the range
of PCT values and responsibilities. Cost effectiveness is only one
criterion that PCTs take into account. Commissioning decisions should and
do reflect more than just willingness to pay. Published accounts of how
PCTs undertake prioritisation and advice from ethicists on values
frameworks amply demonstrate the complexity of the task, limitations of
current practice and development needs. QALYs are not supremely
influential in local decision making nor should they be. It is not self
evident that a higher threshold would improve this situation or the health
impacts of commissioning decisions. Whose interests would be best served
by a higher threshold?

Interventions for which cost effectiveness has been estimated may be
advantaged in PCT prioritisation compared to those simply described as
‘cost effectiveness unknown’. If the NICE threshold increases, it will
further disadvantage these health services in favour of new interventions
of demonstrable, but relatively poor cost effectiveness. There is no
prospect of all cost effectiveness evidence gaps being filled.

Finally, there is no clear link between the suggested sums for
willingness to pay and the affordability of health services in future. If
a new threshold is introduced, what would the impact be on affordability
and access to healthcare? If we can’t answer this question then policy
pragmatism is indeed appropriate. Raftery is right to emphasise a need
for improved links between NICE and NHS decision makers, rather than
adjustments to thresholds. The implications of NICE practice on local
services need to be better understood.


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Competing interests:
None declared

Competing interests: No competing interests

06 February 2009
Christine E Hine
Consultant in Public Health
NHS South Gloucestershire BS16 7FL