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Citizens Council report on departing from the threshold

In November 2008, the NICE Citizens Council met to discuss whether there were circumstances in which NICE should recommend treatments that we would not normally consider to be cost effective. The resulting report was presented to the NICE Board at its meeting in Belfast on 22 May.

When deciding whether a treatment is cost effective, NICE's independent Appraisal Committee and other advisory bodies use a measure called a QALY (quality-adjusted life year). If a treatment costs more than £30,000 per QALY gained, it is not normally recommended for use in the NHS.

After extensive discussion, the Council concluded, by a majority of 27 to two, that there were circumstances in which NICE and its advisory bodies should recommend treatments costing more than £30,000 per QALY. These included when the treatment in question is life-saving, when the illness under consideration is extremely severe and when the intervention would prevent more harm in the future.

“It is clear from our report that the majority of members do not think that a view based solely on the mathematics of health economics is an acceptable basis for making recommendations about the use of drugs or other interventions by the NHS,” explains Freda McEwan, a member of the Citizens Council. “These judgements need to take into account a number of other factors. The conclusions we reached offer support to the current NICE procedures, which recognise that the Appraisal Committee cannot work by health economics alone. There is continuing debate over which other factors should be considered, and the weight they should carry. Through this report we hope to offer some guidance to NICE and its committees in making these difficult decisions.”

Professor Peter Littlejohns, NICE Clinical and Public Health Director, welcomes the report: “Since the Citizens Council was established in 2002 they have provided valuable guidance on a range of difficult issues including patient safety and the appropriateness of taking age or severity of illness into account when making recommendations. They ensure that the views of those who fund the NHS - the public - are properly included in NICE's decision-making process.

“The independent advisory bodies that develop NICE guidance take into account not just the QALY calculation itself but other factors. These factors include those that come out of the work we do with our Citizens Council.

“The upper end of the range normally considered by our independent advisory committees to represent a cost-effective use of NHS resources is £30,000. However, the committees do have the freedom to interpret the advice we give them on assessing cost effectiveness and they do not use a single fixed cost-effectiveness threshold - a range of considerations, such as the availability of other suitable treatments, are always taken into account as part of the decision-making. As a consequence they have sometimes accepted a cost per QALY of over £30,000.

”We welcome this report and will now consider the recommendations that have been made and set out how we will respond to them.”

The Citizens Council is a board of 30 people, all ordinary members of the public, who represent the makeup of the UK. The council provides NICE with advice that reflects the public's perspective on what are often challenging issues faced by NICE. To learn more about the Citizens Council see our factsheet.

29 May 2009

This page was last updated: 12 July 2010

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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.