The National Institute for Health and Clinical Excellence (NICE) allows too many expensive treatments to be available on the NHS, rather than too few, health economists claim in this week’s British Medical Journal.

Since its inception in 1999, NICE has adopted a cost-effectiveness threshold range of £20,000 to £30,000 per quality adjusted life year (QALY) gained. A QALY is a combined measure of quantity and quality of life but NICE’s threshold has no basis in either theory or evidence, Professor John Appleby, Chief Economist at the King’s Fund, and colleagues Nancy Devlin and David Parkin at City University in London, argue.

Despite coming under fire for limiting or withholding expensive treatments for Alzheimer’s, cancer and other diseases, the academics say NICE has adopted a cut-off point that is too generous, and that this may have profound implications for the NHS as NICE has recommended too many new technologies. In addition, when primary care trusts implement NICE’s guidance, resources might be diverted from other healthcare services that represent better value for money, the authors claim.

NICE/NHS mistmatch

They add that there is evidence of a mismatch between NICE’s threshold range and that apparent elsewhere in the NHS. As an example, they note that the average primary care trusts spent £12,000 to gain an extra QALY in circulatory disease and £19,000 in cancer. In contrast, an analysis of NICE’s decisions suggests that its threshold is in practice even more generous than NICE admits, being closer to £45,000.

However, Prof Appleby said that the Institute was not to blame. “Why should NICE be required to set and defend what is an NHS-wide cost effectiveness threshold?” he said. “The factors that should determine this threshold – such as society’s willingness to pay for health improvements, the size of the NHS budget, and the level of health sector inflations are all beyond NICE’s control.”

He called for the NHS to be given independence from the Department of Health on the specific matter of setting a cost-effectiveness threshold, in the same way that the Bank of England has operational independence from the treasury so that it can set UK interest rates to contain inflation. The professor claimed that the NHS should have a threshold committee, and that NICE, primary care trusts and other NHS purchasers should all be required to abide by its cost-effectiveness cut-off points.

The current situation in which NICE “conjured up a threshold”, and other organisations did not use one created “neither efficiency nor fairness in the NHS”, Prof Appleby concluded. By Michael Day