General issues
   
32 The appraisal group will need to develop its detailed methodology for judging the evidence, and coming to an overall view on the clinical cost-effectiveness of the intervention. This can never be a mechanical process; an element of informed judgement will be required, and different appraisals may raise different issues. However, the appraisal judgement is likely to involve considering some or all of the following questions:
     
 
i
 how robust is the assessment? For example, if the assessment has had to use modelling (eg to get from measurable clinical outcomes to impact on quality of life) are the assumptions clinically credible?
 
ii
 for those factors which can be quantified, is there convincing evidence that the proposed intervention is likely to be cost-effective, on the basis of the health improvement achieved for given NHS resources, compared with other potential uses of those resources?
 
iii
 how far is clinical cost-effectiveness affected when other health related costs and benefits are taken into account (where relevant)?
 
iv
 what factors should be taken into account which are not amenable to quantification but are still relevant to the assessment of clinical cost-effectiveness?
 
v
 taking all factors into account, can the treatment be recommended as generally clinically cost-effective?
 
vi
 are there any particular subgroups for which the treatment is likely to be more or less clinically cost-effective? Should treatment be targetted on the groups who would derive most benefit?
 
vii
 should use of the intervention be subject to particular conditions (skills/training of the clinicians who can initiate or continue treatment, requirements for monitoring/review, quality control, indications for stopping treatment)?
 
viii
 what factors should be discussed between clinician and patient in order to arrive at an informed joint decision in individual cases (overall balance of risks and benefits, rare side-effects, alternative treatments etc)?
 
ix
 what is the total likely impact on NHS resources and, where different, on government funding of health care as a whole?
 
x
 in the light of the group's discussions, what further research would be desirable either (a) to put the conclusions on a firmer basis or (b) to indicate how the intervention should best be used?