Decisions about health care rationing inevitably involve value judgements, says new book

The NHS should ration its services fairly and transparently, says a book published today by the Office of Health Economics and The King's Fund.

Cost Effectiveness Thresholds: Economic and ethical issues, edited by Adrian Towse, Clive Pritchard and Nancy Devlin, argues that the way economic evidence is used by NICE involves an important judgement about the value attached to improvements in length and quality of life.

The book shows that, in general, the National Institute for Clinical Excellence (NICE) has given the go-ahead for treatments which cost less than £30,000 for every year of healthy life (or Quality-Adjusted Life Year, QALY – a standard economic health care assessment measure) they give to patients, while it is more likely to place restrictions on those costing more than £30,000. But this is not a blanket restriction. It is evident that NICE also takes many other factors into account in its guidance.

Adrian Towse, Director, Office of Health Economics, said: 'Fairness is one of the defining values of the NHS. NICE has a vital and difficult role in helping to ensure fairness and value for money in the use of NHS resources. NICE needs to be transparent and consistent in deciding which factors are used in assessing new treatments.

'Cost effectiveness evidence can inform rationing decisions, but whether any treatment is 'good value for money' depends on the value placed on improvements in health. NICE has an approximate £30,000 threshold, but takes other important factors into account. In the case of riluzole, a drug for motor neurone disease, NICE took account of the severity of the illness and the short life expectancy of patients.

'We need to be clear whether the £30,000 figure is an appropriate benchmark and the basis on which exceptions will be made. NICE also needs public acceptance and support for its decisions, and indeed has taken the two important step to achieving this with the establishment of its Citizen's Council and the commissioning of research on the value the public attaches to improvements in health.'

Rabbi Julia Neuberger, chief executive of The King's Fund, said:

'The National Institute for Clinical Excellence has taken a big step forward by establishing its Citizens Council. This will create a new dialogue between NICE and members of the public about how rationing decisions are made in the NHS.

'But two further steps are required. First, the government itself needs to develop measures that enable consistency in valuing the work of different public services such as health, transport and environmental improvements by creating a common currency. Second, primary care trusts need to engage with their local communities to ensure that their commissioning decisions on issues not addressed by NICE reflect the values and circumstances of the people they serve.

'Through these reforms, the NHS could begin to attain the fairness and transparency in its rationing decisions that the public expects of it.'

For further information please contact:

Office of Health Economics,
Melanie York
Tel 020 7930 9203 xt 1461 or M: 07979 526 415

The King's Fund
Andy Bell
Tel 020 7307 2585

Notes to editors: 

Nancy Devlin is Professor of Health Economics at City University. She was Fellow in Health Systems at The King's Fund at the time of writing.

Adrian Towse is Director of the Office of Health Economics. He undertakes research on policy and economic issues within the pharmaceutical, health care and biotechnology industries. He is a non-executive Director of the Oxford Radcliffe NHS Trust and is chair of its Clinical Governance Board.

Clive Pritchard is a researcher specialising in health technology assessment at the Office of Health Economics. His work includes examining the health care decision making processes of NICE, and similar organisations around the world.

The Office of Health Economics provides independent research, advisory and consultancy services on policy implications and economic issues within the pharmaceutical, health care and biotechnology industries. Its main areas of focus are: the pharmaceutical and biotechnology industry, health care systems - their financing and organisation, and the economics of health technology assessment.