The aims of the NHS
professionals. NICE aims to create consistency around the NHS and reduce the disparities in the quality and availability of treatment, depending on where you live. NICE is accountable to the Department for Health, but operates independently. 42 NICE, stated by its chair and previous vice chair, 43 makes it clear that it has to strike a balance between social and scientific value judgements. NICE uses the quality-adjusted life year (QALY) to assess the value of new treatments. Most treatments will cost more than the original, but NICE comes to a conclusion as to whether the further improvement in health will be compensated by the greater cost. An example of NICE’s work is the finding of a suitable second line treatment for chronic lymphocytic leukaemia. NICE conducted several randomized controlled trials with the drug fludarabine, in two forms, to come to a conclusion 44 that ‘orally admin istered fludarabine is likely to have similar clinical efficacy to the intravenously administered preparation ’ . NICE made a scientific judgement, and now they needed to look at the cost. Oral and intravenous administration, over four cycles, came to £3000 and £5300 respectively. 45 Thus, they decided that oral administration is the way forward and fludarabine is currently administered 46 orally in the NHS. NICE calculates the £/QALY ratio for various treatments and usually, except in special circumstances, will reject ratios of over £25k-£35k. Interferon beta and glatiramer acetate were deemed not suitable, due to an immense ratio of £580,000 for five years. Importantly, NICE does not look at ‘affordability’. It looks at ‘cost effectiveness’. It makes decisi ons to the level of resources that the NHS receives from the government. NICE’s social value judgements are essential to equity and efficiency in the NHS. NICE has a Citizens Council, to be sure that the public are happy with their values. Efficiency must be looked at in terms of the way it measures the maximization of health and its scope. NICE uses the QALY as a means of measuring health and it aims to increase efficiency, without any determent to vulnerable members of society. Equity is one of the key principles of NICE. It aims to put an end to any form of inequality that exists around the country and make sure that the users of the NHS receive the same standard of healthcare everywhere. 47
IVF (in-vitro fertilisation) is a perfect example for this. In 2014, NICE made it clear that it believes that the NHS should stop the inequality in fertility treatment and gave a guideline of what should be offered: 48
• 3 full cycles of IVF treatment to women aged under 40 who have failed to get pregnant after 2 years of trying • 1 full cycle for some women aged 40-42
According to data from 2018, less than 15% 49 (with a high majority in the North of England) of Clinical Commissioning Groups (CCGs) in England are offering 3 full cycles. This is in direct breach of NICEs
42 Welch, 2018. 43 Rawlins & Culyer, 2004. 44 National Institute of Health and Care Excellence, 2001. 45 Rawlins & Culyer, 2004. 46 NHS, 2019. 47 Rawlins & Culyer, 2004. 48 National Institute of Health and Care Excellence, 2014. 49 Fertility Fairness, 2018.
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