Innovation as a value in healthcare priority-setting: the UK experience

Abstract

All healthcare systems operate with limited resources and therefore need to set priorities for allocating resources across a population. Trade-offs between maximising health and promoting health equity are inevitable in this process. In this paper, we use the UK's National Institute for Health and Care Excellence (NICE) as an example to examine how efforts to promote healthcare innovation in the priority-setting process can complicate these trade-offs. Drawing on NICE guidance, health technology assessment reports and relevant policy documents, we analyse under what conditions NICE recommends the National Health Service fund technologies of an "innovative nature", even when these technologies do not satisfy NICE's cost-effectiveness criteria. Our findings fail to assuage pre-existing concerns that NICE's approach to appraising innovative technologies curtails its goals to promote health and health equity. They also reveal a lack of transparency and accountability regarding NICE's treatment of innovative technologies, as well as raising additional concerns about equity. We conclude that further research needs to evaluate how NICE can promote health and health equity alongside healthcare innovation and draw some general lessons for healthcare priority-setting bodies like NICE.

Keywords: Accountability; Health equity; Healthcare priority-setting; Innovation; Justice; National Institute for Health and Care Excellence (NICE); Social values.

Fig. 1

Factors recognised by NICE to justify funding technologies with an ICER > £20,000/QALY. Adapted from the 2013 Methods Guide, paras 6.3.3 and 6.2.10–11, by drawing on Social Value Judgements (2nd edition) and the 2017 Interim Methods Guide for the Highly Specialised Technologies programme (NICE, 2008a, 2013a, 2017a). A similar figure is included in NICE,

Fig. 2

Consideration of innovation in NICE drug HTAs (March 2000–June 2018). Data are not included for HTAs completed in 2000 and 2005 as none met the criteria for inclusion in this study (i.e. non-obsolete, non-terminated drug appraisals)

Fig. 3

Consideration of NICE’s three conditions for innovation (March 2000–June 2018)

Fig. 4

NICE drug HTAs in which innovation formed a substantive consideration, with recommendation for funding and estimated ICERs (March 2000–June 2018)

Fig. 5

NICE HTAs in which drugs with ICERs > £20,000/QALY were recommended for funding (March 2000–June 2018). Innovation conditions considered to be met: HTA committees judged condition to be met; innovation conditions not considered to be met: HTA committees did not consider condition to be met or did consider condition and therefore failed to establish whether it was met