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NICE in trouble over ‘value for money’ cancer drug decisions


Many oncologists and patient groups unhappy with recent cost-based judgements made by NICE over promising cancer treatments are calling for the organisation to be scrapped

Brian Edwards

Emeritus Professor of Healthcare Development
University of Sheffield

NICE, the National Institute for Health and Clinical Excellence in the UK, has been under substantial media and political pressure in recent weeks for concluding that four new drugs for the treatment of patients with kidney cancer did not represent value for money and should not be prescribed as part of NHS treatment. (In fact it was a preliminary opinion and is out for consultation.) This follows on the back of a similar decision about drugs for the treatment of prostate cancer.

There is a growing clamour for NICE to be wound up among clinical specialists and special-interest patient groups. In their view, drugs with a potential to extend life are being denied to patients. In its defence, NICE has pointed out that, in a world in which the demand for health care is infinite, choices have to be made if nations are to secure the greatest value out of their healthcare investment. It will always be better if these judgements are based on solid evidence. The value of drugs that produce short extensions of life for a small number of patients at substantial cost do need to be reviewed as they soak up resources that could have been used to treat other patients with other better-tested drugs. This is a solid economic argument, but it cuts no ice with doctors and patients who value any clinical gain, no matter how small or at what cost.

The chair of NICE has also attacked the pharmaceutical industry for driving up the price of new drugs in order to boost profits, protect executive bonuses and keep share prices high. Pharmaceutical companies have, of course, denied this. The row was a lead story for days and drew in political comment from all sides. The problem has been further complicated by different countries within the UK taking a different decision about the value of particular drugs, thus generating a cross-border problem. Scotland was thought to be the most liberal.

This comes at a time when the European Commission and the Council of Ministers have targeted health technology assessment (HTA) as a political priority, recognising an urgent need to establish a sustainable European network for HTA. It was the Danish Centre for HTA that led 35 organisations throughout Europe in creating the European Network for HTA (EUnetHTA), which has now been operating for three years. The
members circulate their work amongst themselves and draw upon their collective expertise and databases. It all sounds very sensible and productive if you believe in HTA.

The next stage would be to move the network into a more formal collaboration with a European Advisory Council for stakeholders, presumably involving the pharmaceutical industry. This is planned for 2009. The Commission may contribute some of the core costs, but if it becomes too involved the new organisation will lose the credibility it will gain from its independence from the Commission.

Sharing and publishing evidence about clinical effectiveness is clearly valuable; the problems arise when ‘value for money’ judgements are made. What may be judged to be economically justified in one health economy may not be in another. There is no standard EU pricing structure for pharmaceutical products, which will alter the economic benefit calculation from country to country (but probably only at the margins).

The real issue is what happens with these assessments. Although I have seen no evidence, there must now be signs of assessment convergence in Europe – which is great if you have a product that gets endorsement, but disastrous if it fails. There can be no question of the value of technology assessment in the health field. It is the economic equation that needs to be well attuned to national circumstances. Collaboration between national centres is sensible, but what it must not lead to is an EU health technology organisation that seeks to intrude in difficult and sensitive national decision-making.

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