Executive summary

What was NICE asked to do?

In response to a recommendation from the Chief Medical Officer for England (Our children deserve better: prevention pays), the Department of Health asked the National Institute for Health and Care Excellence to examine the cost effectiveness of moving the Healthy Start vitamin programme from the current targeted offering to a universal offering. (See the scope.)

This report summarises the findings of a cost effectiveness review and an economic modelling exercise. The methods and range of data sources used to develop the economic model are described in detail in the modelling report.

The economic model tested 2 universal scenarios in which people would be offered supplements regardless of income level or entitlement to qualifying benefits. An incremental cost‑effectiveness ratio (ICER) of less than £20,000 per quality‑adjusted life year (QALY) gained was used to indicate that an intervention was cost effective.

What were the findings?

The economic model indicates that, compared with current provision:

  • It is not cost effective to offer Healthy Start supplements universally to the current target group – that is, to extend the offering to all:

    • pregnant women from 10 weeks

    • women with a child aged under 12 months

    • children over 6 months and under 4 years.

This is because the best estimate of the ICER is £620,898 per QALY gained, compared with the current scheme.

  • It is cost effective to extend the offering of Healthy Start supplements universally to the current target group if it is also extended to all:

    • women who are planning a pregnancy

    • women less than 10 weeks pregnant

    • infants aged 0–6 months

    • children aged from 4 to 5 years.

This is because the best estimate of the ICER is £6528 per QALY gained compared with the current scheme.

Offering the supplements universally to the current target group plus the additional subgroups outlined above is only cost effective if both of the following criteria are met:

  • Women planning a pregnancy and those who are less than 10 weeks pregnant are included. This is because folic acid reduces the risk of a large number of women having a pregnancy affected by a neural tube defect. Hence there is a large gain in QALYs and a reduction in the future costs of caring for those born with neural tube defects.

  • The cost per head of including women planning a pregnancy and those who are less than 10 weeks pregnant is not considerably higher[1] than the cost per head for women already in the scheme. A mechanism would need to be identified to deliver a universal scheme to these 2 groups. In the meantime, the true cost of including these additional groups of women is unknown and may have a substantial impact on overall cost effectiveness.


There are some significant limitations to the conclusions of this report. Lack of data for some of the model inputs meant that many assumptions had to be made and some of the assumptions are crucial in determining cost effectiveness. Sensitivity analyses identified the following 3 factors that particularly influence the findings. Any new evidence in these areas will influence estimates of cost effectiveness:

  • Quality of life data for vitamin D deficiency. A lack of data meant it was not possible to assign a QALY value to the effects of vitamin D in the model. This is a key limitation. As a consequence, folic acid had a dominant impact because it was the only nutrient that could be assigned QALYs. There are some cost savings from reducing the need to treat vitamin D deficiency but these are relatively small.

  • Extent of uptake of Healthy Start supplements by women and children who are not already taking other supplements that have been bought or been prescribed for them. Increasing uptake among these groups is key to cost effectiveness but it is not possible to predict this.

  • Proportion of pregnancies affected by a neural tube defect that are terminated. The aim of folic acid supplementation is to reduce the risk of a pregnancy being affected by a neural tube defect. It is estimated that around 80% of these pregnancies, when they do occur, are terminated. The model suggests that the more affected pregnancies that are terminated, the less cost effective the scheme becomes, because the costs for the treatment and care of those born with a neural tube defect are reduced.

[1] Additional analyses would be needed to determine the actual cost per head beyond which it would no longer be cost effective to include these women in the scheme. This was beyond the scope of the work on which this report is based.