While National Institute for Health and Clinical Excellence (NICE) technology appraisals focus on cost-effectiveness, this does not appear to be "the dominant consideration" in NHS decisions about resource allocation, according to a new study.

NICE generally measures a technology's cost-effectiveness in terms of incremental cost per Quality-Adjusted Life Year (QALY). However, only eight of the 51 Impact Assessments (IAs) conducted by the Department of Health (DH) during 2008-9 used QALYs to evaluate benefits, says the study, which is published by the UK Office of Health Economics (OHE).

Since 2008, the DH has been required to undertake and publish IAs which identify the costs and benefits expected from all new policy implementation. For the 51 IAs assessed by the OHE researchers, 18 benefits other than QALY gains were identified, most of which can be grouped into the following categories: - improvement in health outcomes (26 of the 51); - improvements in quality (15); and - enhancing the patient and carer experience (11). For 21 of the IAs, no monetary impact was estimated and it was stated that the benefits could not be monetised or qualified, they say.

Existing research also shows that cost-effectiveness evidence seems rarely to be used by NHS commissioners of health care when allocating their local budgets, or in the criteria taken into account when making local-level investment and disinvestment decisions, say the researchers. Similarly, at policy level, a number of key DH initiatives appear not to be driven primarily by the pursuit of QALY gain, but to focus instead of "process of care" considerations, such as NHS waiting time targets.

NICE focuses its technology appraisals on "health-related benefits" and "costs to the NHS and personal social services," and the comparison of these health benefits is then modified by consideration of what NICE terms "social value judgements." These do include considerations of social equity but not, apparently, some benefits which the DH considers relevant to its IAs, say the authors. Such elements which the DH takes account of - but NICE does not - include benefits to external stakeholders, patient and public empowerment, public trust and confidence in the NHS, procedural and institutional benefits, benefits to staff morale, patient costs and convenience and benefits to researchers.

Setting aside the issue of what cost and benefit perspective might be "appropriate," the study's findings suggest that NICE and the DH have different views about how to assess the impact of NHS spending, and this "misalignment of aims" has clear implications for efficiency across the system, say the researchers. If the underlying basis for decision-making by NICE is out of keeping with that elsewhere in the NHS, the authors say they see a need for greater consensus about what the goal of the NHS is, and that, if there are multiple goals, what are their relative importance.