National Institute for Health and Care Excellence

Review Guide to the Methods of Technology Appraisals Addendum - 2014

Comments

Name / Mark Weiss
Role / Senior Policy Officer
Organisation / UK Faculty of Public Health
About the Faculty of Public Health
The Faculty of Public Health is the standard setting body for specialists in public health in the United Kingdom. The Faculty of Public Health is a joint faculty of the three Royal Colleges of Physicians of the United Kingdom (London, Edinburgh and Glasgow) and also a member of the World Federation of Public Health Associations. The Faculty of Public Health is an independently constituted body with its own membership and governance structure.
The Faculty of Public Health is the professional home for more than 3,300 professionals working in public health. Our members come from a diverse range of professional backgrounds (including clinical, academic, policy) and are employed in a variety of settings, usually working at a strategic or specialist level. The Faculty of Public Health is a strategic organisation and, as such, works collaboratively, drawing on the specialist skills, knowledge and experience of our members as well as building relationships with a wide range of external organisations.
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Consultation questions

1 Does proportional QALY shortfall appropriately reflect burden of illness? / It is difficult to make a judgment without good evidence from any detailed research of a quantified link between the two concepts (QALYs and BoI) or from substantial experience of this approach having been used elsewhere. On balance, the specific response to the question would be “No”, as the lack of evidence would mean somewhat of a step into the dark. If implemented it is not clear that many stakeholders, or the public more widely, would understand clearly what reasoning sits behind any appraisal decision using these methods. The uncertainties and complexities, as discussed in some of the background papers, would cause confusion and a sense of not knowing if there was any consistency between NICE appraisal decisions. This possible confusion is illustrated by the fact that the Office of Health Economics felt the need to produce a briefing paper on absolute versus proportional shortfall in response to confusion at the Value Based Pricing Methods Group meeting in July 2014. Presumably this was group with some experience in this area.
Some of these comments also apply to wider societal impact and so are repeated below.
2 Does absolute QALY shortfall provide a reasonable proxy for wider societal impact of a condition? / Again there is a lack of good evidence to support the use of linking these concepts as well as whether the aspects that are being defined through wider societal impact actually reflect society’s values. This latter aspect is a particular constraint as we do not know what, if any, extra value society places on people who contribute towards the country’s economy as opposed to having some other role in life and whose life is not defined by a salary or wage, such as a carer, or a drug addict, or someone with a chronic mental illness. Overall there are similar uncertainties and complexities to those for using the BoI that would mean many stakeholders, or the public more widely, would not understand clearly what reasoning sits behind any appraisal decision using these methods.
3 Does a maximum weight of 2.5 in circumstances when all modifiers apply function as a reasonable maximum? / If value based assessment does go ahead as outlined then setting a low maximum weight will tend to limit any unintended consequences that might occur owing to the lack of a reasonable evidence base and the documented uncertainties and complexities.
4 Should we allocate specific ‘weights’ to each of the ‘modifiers’ so that they add up to a maximum of 2.5? If so, do you have a view on what weight should be added in each case / This seems somewhat arbitrary in the light of the lack of evidence.
5 Will the approach outlined in this document achieve the proposed objectives of improving consistency, predictability and transparency in the judgements made by our independent Appraisal Committees when they consider the clinical and cost effectiveness of health technologies? / The approach may help somewhat if it is giving more specific guidance and detail to judgments that are already being made by NICE committees. However, given the uncertainties and complexities it has the feeling of being an “only in research” approach.
6 Are there any risks which might arise as a result of adopting the value-based assessment approach as outlined above? If so, how might we try to reduce them? / The major risk would seem to be the obvious one of overstating the value of a technology that has had the benefit of resources for focused evaluation and assessment and therefore, possibly, given a spurious justification for being of reasonable clinical effectiveness. This in turn leads to an opportunity cost, i.e. lost opportunities, for other technologies and interventions that are not subjected to similar in-depth assessments. There is a major piece of research commissioned around NICE’s work that suggests the QALY for many technologies is substantially below the £20,000 to £30,000 ICER in any case.
7 Are there any other comments you wish to make? / Please enter these comments in the table below
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Closing date: Friday 20 June 2014 5pm

PLEASE NOTE: NICE reserves the right to summarise and edit comments received during consultations, or not to publish them at all, where in the reasonable opinion ofNICE, the comments are voluminous, publication would be unlawful or publication would be otherwise inappropriate.