Seeking value: Experience from the UK’s National

Institute for Health and Care Excellence

Tommy Wilkinson

Advisor, NICE International

Copyright NICE International 2014

17th February 2015

4th Joint OECD Network on Fiscal

Sustainability of Health Systems

The vision: 5th July 1948

A National Health Service that: • meets the needs of everyone • is free at the point of delivery • is based on clinical need, not ability to pay

• Doctors adopting new health technologies without adequate

evidence of their clinical and/or cost effectiveness

• Out of date technologies and services being used even though they

had been superseded by newer developments

• Lack of national clinical guidelines and many of the existing clinical

guidelines not updated and of poor quality.

• Postcode lottery inappropriate variation in access to care and care

standards

• (later) Prospect of significant reinvestment in the NHS: plan to grow

from about 6.5% to about 9% of GDP

Roll forward to the 90s…

The role of NICE

To improve outcomes for people using the NHS and other public health and social care services by...

Producing evidence-based guidance and advice for health, public health and social care practitioners.

Developing quality standards and performance metrics for those providing and commissioning health, public health and social care services

Providing a range of information services for commissioners, practitioners and managers across the spectrum of health and social care.

The NICE portfolio in 2014

“You have the right to drugs and treatments that

have been recommended by NICE for use in the

NHS, if your doctor says they are clinically

appropriate for you.” Jan 2009

What is a NICE Technology Appraisal?

• A review of clinical and economic evidence leading to recommendations on the appropriate use of new and existing technologies for the NHS

• A positive recommendation requires providers to make the recommendation available within three months

• Opportunity to challenge decision

(formal appeal process)

Under controlled conditions and compared to placebo: • Is the drug safe? • Does the drug do more good than

harm?

In routine clinical practice and compared with existing treatments: • Do the additional clinical benefits

justify the expected additional cost?

Drug development

Regulatory approval

Technology Appraisal

Use in healthcare system

Incorporating the consideration of relevant social value judgements

Determining value: Incremental Cost-Effectiveness Ratio (ICER)

At NICE, health gain is expressed as quality adjusted life years

(QALYs) which allows us to calculate the cost per QALY for

any technology under consideration

costnew – costcurrent

health gainnew – health gaincurrent

Determining value:

Social Value Judgements

“Those developing clinical guidelines, technology appraisals or

public health guidance must take into account the relative costs and

benefits of interventions (their ‘cost effectiveness’) when deciding

whether or not to recommend them.” (Principle 2)

BUT

“Decisions about whether to recommend interventions should not

be based on evidence of their relative costs and benefits alone.

NICE must consider other factors when developing its guidance,

including the need to distribute health resources in the fairest way

within society as a whole.” (Principle 3)

NICE Social Value Judgements 2nd Edition 2008 http://www.nice.org.uk/media/C18/30/SVJ2PUBLICATION2008.pdf

Appraisal decision making P

rob

abili

ty o

f re

ject

ion

Cost per QALY

1

£10K £20K £30K £40K £50K

0

• Uncertainty ↑

• Features of condition • Equity judgments ↕ • Availability of treatments

• Innovation ↓ • Uncaptured health gain

The Committee will want to be increasingly certain of the cost-effectiveness of a

technology as the impact of the adoption of the technology on NHS resources increases (Para 6.2.14 Guide to Methods of Technology Appraisal, NICE 2013)

Therapeutic areas in technology appraisal topics Blood & immune

Cancer

Cardiovascular Central nervous system

Digestive system

Ear & nose

Endocrine, nutritional &

metabolic

Eye

Gynaecology, pregnancy & birth

Infectious diseases

Injuries, accidents & wounds

Mental health & behavioural conditions

Mouth & dental

Musculoskeletal

Respiratory Skin Urogenital

Most credible ICER for technologies appraised by NICE 2007 – Sept 2013

£0

£20,000

£40,000

£60,000

£80,000

£100,000

£120,000

£140,000

£160,000

Recommended/ optimised Not recommended Recommended under EoL

TA114 TA296 →

Decision outcomes

Decision Recommendations

Recommended in line with marketing authorization

333 62%

Optimised 97 18%

Only in research 26 5%

Not recommended 82 15%

Total 535 100%

Breakdown of all decisions contained in published NICE Technology Appraisals 1–321 (January 2000 to October 2014). Note 6 withdrawn recommendations and 18 non-submissions are not included

80% of NICE

guidance is positive

Scientific Rigour

Inclusiveness

Social values

Transparency

Independence Challenge

Review

Support for implementation

Timeliness

Accountability

for

reasonableness

NICE’s procedural principles for

guidance development