PharmacoEconomics

, Volume 21, Issue 3, pp 149–157 | Cite as

NICE Methodological Guidelines and Decision Making in the National Health Service in England and Wales

  • Amiram Gafni
  • Stephen Birch
Current Opinion

Abstract

The National Institute for Clinical Excellence (NICE) responds to requests by the Department of Health for guidance on the use of selected new and established technologies in the National Health Service (NHS) in England and Wales. This paper asks whether the NICE methodological guidelines help NHS decision makers meet the objectives of maximum health improvements from NHS resources and an equitable availability of technologies. The analytical basis of the guidelines is a comparison of the costs and consequences of new and existing methods of dealing with particular conditions using the incremental cost-effectiveness ratio. We explain why information on the costs and consequences of a particular technology in isolation is insufficient to address issues of efficiency of resource use. We argue that to increase efficiency, decision makers need information on opportunity costs. We show that in the absence of such information decision makers cannot identify the efficient use of resources. Finally we argue that economics provides valid methods for identifying the maximisation of health improvements for a given allocation of resources and we describe an alternative practical approach to this problem. Drawing on the experience of Ontario, Canada where an approach similar to that proposed by NICE has been in use for almost a decade, and recent reports about the consequences of NICE decisions to date, we conclude that instead of increasing the efficiency or equity of the use of NHS resources, NICE methodological guidelines may lead to: (i) uncontrolled increases in NHS expenditures without evidence of any increase in total health improvements; (ii) increased inequities in the availability of services; and (iii) concerns about the sustainability of public funding for new technologies.

References

  1. 1.
    House of Commons’ Select Committee. Health: National Institute for Clinical Excellence. London: Her Majesty’s Stationery Office, 2002Google Scholar
  2. 2.
    National Institute for Clinical Excellence. Technical guidance for manufactures and sponsors on making a submission to a technology appraisal. London: National Institute for Clinical Excellence, 2001Google Scholar
  3. 3.
    Birch S, Gafni A. On being NICE in the UK: guidelines for technology appraisal for the NHS in England and Wales. Health Econ 2002; 11: 185–91PubMedCrossRefGoogle Scholar
  4. 4.
    Hutton J, Maynard A. A NICE challenge for health economics. Health Econ 2000; 9: 89–93PubMedCrossRefGoogle Scholar
  5. 5.
    Sculpher H, Drummond M, O’Brien B. Effectiveness, efficiency and NICE. BMJ 2001; 322: 943–4PubMedCrossRefGoogle Scholar
  6. 6.
    Cookson R, McDaid D, Maynard A. Wrong SIGN, NICE mess: is national guidance distorting allocation of resources? BMJ 2001; 323: 743–5PubMedCrossRefGoogle Scholar
  7. 7.
    Weinstein HC, Stason WB. Foundation of cost-effectiveness analysis for health and medical practices. N Engl J Med 1977; 296: 716–21PubMedCrossRefGoogle Scholar
  8. 8.
    Taylor R. Generating national guidance: a nice model? Paper presented at the Fifth International Conference on Strategic Issues in Health Care Management Policy, Finance and Performance in Health Care; 2002 Apr 11–13; St Andrews, ScotlandGoogle Scholar
  9. 9.
    Weinstein M, Zeckhauser R. Critical ratios and efficient allocation. J Public Econ 1973; 2: 147–57CrossRefGoogle Scholar
  10. 10.
    Birch S, Gafni A. Cost-effectiveness/utility analysis: do current decision rules lead us to where we want to be? J Health Econ 1992; 11: 279–96PubMedCrossRefGoogle Scholar
  11. 11.
    Birch S, Gafni A. Changing the problem to fit the solution: Johannesson and Weinstein’s (mis)application of economics to real world problems. J Health Econ 1993; 12: 469–76PubMedCrossRefGoogle Scholar
  12. 12.
    Laupacis A, Feeny D, Detsky A, et al. How attractive does a new technology have to be to warrant adoption and utilization?: tentative guidelines for using clinical and economic evaluations. CMAJ 1992; 146: 473–81PubMedGoogle Scholar
  13. 13.
    Gafni A, Birch S. Guidelines for the adoption of new technologies: a prescription for uncontrolled growth in expenditures and how to avoid the problem. CMAJ 1993; 148: 913–7PubMedGoogle Scholar
  14. 14.
    Laupacis A. Inclusion of drugs in provincial drug benefit programs: who is making these decisions, and are they the right ones? CMAJ 2002; 166: 44–7PubMedGoogle Scholar
  15. 15.
    Williams A. The economic role of ‘health indicators’. In: Teeling Smith G, editor. Measuring the social benefits of medicine. London: Office of Health Economics, 1983Google Scholar
  16. 16.
    Sendi P, Gafni A, Birsh S. Opportunity costs and uncertainty in the economic evaluation of health care interventions. Health Econ 2002; 11: 23–31PubMedCrossRefGoogle Scholar
  17. 17.
    Naylor CD. Cost-effectiveness analysis: are the outputs worth the inputs? ACP Journal Club 1996; 124: A12–4PubMedGoogle Scholar
  18. 18.
    Culyer AJ. Health, economics and health economics. In: van der Gaaf J, Perlman M, editors. Health, economics and health economics. Amsterdam: North-Holland Publishing Company, 1981: 3–11Google Scholar
  19. 19.
    Maynard A, Sheldon T. Health economics: has it fulfilled its potential? In: Maynard A, Chalmers I, editors. Non-random reflection on health services research. London: BMJ Press, 1997Google Scholar
  20. 20.
    Burk K. NICE may fail to stop “postcode prescribing”, MPs told. BMJ 2002; 324: 191CrossRefGoogle Scholar

Copyright information

© Adis International Limited 2003

Authors and Affiliations

  • Amiram Gafni
    • 1
  • Stephen Birch
    • 1
  1. 1.Department of Clinical Epidemiology and Biostatistics and the Centre for Health Economics and Policy AnalysisMcMaster UniversityHamiltonCanada

Personalised recommendations