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Demand for NHS services will always exceed the ability to meet it. Not every treatment can
be provided to every person. NICE has a vital role to play in the rationing arrangements and,
working with Government, should make clear to the public how and why such decisions are
made. ½
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! p #p  p


p #p p* p #### pp  p p* # p p p p* p
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In the past NICE has changed in response to new challenges, and we are sure it can do so
again. Given the difficult environment, NICE requires the backing of the Government.
Ministers must support NICE, not seek to undermine it. NICE must not be left to fight a lone
battle to support cost and clinical effectiveness in the NHS. ½
ppp2 p

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p  #p p  p p  #3p p
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p p3p
p p p p#p p$ p pp p p $ #p pp
#p #   p /#p 
p ½,p  p   p͞statutory instruments and directions do not allow
½ to take budgetary impact or affordability into account when advising on cost effectiveness.͟p
4 pp 5 p $p #p #p pp
p  p# p  p p ppp *p
p # p p  p    #p p  p 
p ½,p ' p # p  # p p p
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÷ separate body, with representation from NICE, the Department, PCTs and others should set
the level, or range, to be used. NICE's threshold should be closely linked to that used by PCTs.
The threshold should also relate to the size of the NHS budget.p

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p# p$p p$ p

å 
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#p

6 #p  #p  p p  p  p  p p  p $p p  # p  p *p p  #p *p
  p #p  p p p p  #p *p  p * p #  p #p ½  #p 2 p  p
17 *  p ½( p   p   5p *p   p $ # #p *p 
p  # #p   p  p # p p
   p$ # #p *pp
p  #p p p  p p #p ##p  p p$p#*p p
  p p   #  p ##p$p p p %p p $p+# p pp ** p
#p *p !p # #p /# p 8by approving technologies of marginalcost effectiveness, NICE is
inflating NHS spending with smallhealth gains for the population.͟‰  p½,p p

p o#pA#p‰ ##p p9   p

6p # p *p ‰  p ½p ' p  *p p p  #p p  p  p  *p
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p   pA#p
p/p # p#p½# pp p'-p, p# p$po p#  #p p
 *p *p    p   #p p *  p * p ͞equivocal or inappropriate
reasons.͟p
$p   po#p
p/po!p#p½ /4p( p #p# p p/   #p p p $ p *pp
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p   p‰ ##p
p! *p #p p$ p ##p p  "p #p4  #pp p½( p# p *pp pp #%p
*  #p  p  p * p  p p 5 #p *p p  #p  p #p +
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p
6p #p # p  #  $p    p p   p  #p p   p < p = p  p #p
 # p # #p p p  #p ! ͞interquartile variation shows that the top 25% of
consultants have activity rates 60 to 85% higher than the bottom 25%>p½ pp p(p p/#p
p  p
p ½p  p  3p 8many treatments currently used are not cost
effective as many studies attest. NICE should adopt a similar standard of cost effectiveness in
assessing such treatments as it uses in its technology appraisals. The organisation must now give
more emphasis to disinvestment.͟

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6p
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"#p$ p p   #p pp
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  p #p p p     p   p #$;p p = p p  p  p  p ½ p
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*# p *p p
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 p p p  p p$ #p p‰ % p p͞almost impossible for NICE not to approve the drug,
once licensed, regardless of cost.͟p ½
p p  p p p 5# p $p p  p p p
‰  #p *p! pp p p4 p    p‰ p# p͞I would absolutely stress that it is not the
role for ministers to contradict, override or directly seek to influence a process where NICE are
already engaged inconsideration.͟½
pp2 p  p  ͞NICE͛s final guidance will be final͟p
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p͞note that it is not the role for Ministers to directly or indirectly seek to
influence the NICE decision-making process.͟p½p2 p

$ p   p  p $p p  p  #p p  p  p p #p p  p  # p # #p
"patients are a powerful force and can highlight the clinical, societal and quality of life benefits of a
treatment far more passionately than any press release ever could."p ½! %#p #p  p p <1p
‰4 pp' pp/p
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media information on health-related issues may induce changes in health services utilisation, both
through planned campaigns and unplanned coverage.͟p   p *p # p $p
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p
p*  p͞The line put forward by many interviewees on the threshold subject was that there
was not a precise value to the threshold but that when the ICER exceeded £30 000 per Q÷  this
began to signal that the technology was unlikely to be cost-effective.͟ 6 #p #p$ %pp$p4 p
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? %p
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p
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p, p#p p# p  p  p p# pp  p p ** p #p#p #p
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/#p   #p ½2 p  #p #p = # p $ p  p #p  p    $p  p  p
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 * p͞better measurement of guidance implementation is also needed. Self-assessment is not
enough. We recommend that the Healthcare Commission conduct more in-depth inspections of this
element of practice.͟
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p
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p
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p #p $ #p ** p pp p $p #p pp  p#  #pp pp *pp p5  *p
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͞Medicare expenditure per capita in 2000 varied from $10550 per enrollee in Manhattan to £4823 in
Portland, Oregon.͟p6p ** p$ pp p  p **#p p *p **#p pp
   p # p  p  #p ;#p * p ##p  #p # p  p p #    p # #p
/ p p p͞there were potential savings for Medicare of 30% of the budget with no adverse
effects on patient health if high spending areas the reduced expenditure and provided safe practices
of conservative low spending areas.͟p

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To enhance the evidence base informing decisions on the effectiveness and cost-effectiveness
of technologies in the NHS, the Review therefore recommends an expansion of the NHS HT÷
programme to fund these developments, which, for a relatively modest investment, could
deliver large improvements in the quality and efficiency of healthcarep½
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p p # p$p #%p p p$ p #p ##p*p  pp$ p  p? %p p
p
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'- p   ͞newspaper coverage of trastuzumab(Herceptin)has been characterized by
uncritical reporting.͟p   p ͞Journalists (and consumers) should be more questioning when
confronted with information about new drugs and of the motives of those who seek to set the news
agenda.͟ /#pp ###pp  p p p   p p p#  p#   #p#  p $ p
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p #p p p p p p ** p; $p p p p  p p p p %p   p p #p
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o p ! #p A** p *p 6  p /#### ½ ½' p Evaluation of the Oregon Medicaid
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