When the NHS decides which drugs to make available, it’s not just about clinical benefits but also about economic value. Every year, the NHS faces difficult choices, balancing the introduction of new treatments with the need to manage finite resources. A key tool in this decision-making process is the concept of cost-effectiveness, measured using Quality-Adjusted Life Years (QALYs). This measure helps the NHS determine whether a treatment provides sufficient value for money by assessing both the quality and quantity of life that a treatment can offer to patients.
The QALY framework allows the NHS to compare different treatments by quantifying the benefit a drug offers in terms of extending life and improving its quality. For example, if a drug can extend a patient’s life by five years but with significant side effects, the quality of those additional years would be lower. QALYs adjust for this reduction in quality, ensuring that the benefits of a drug are not just measured by how long a person lives but also by how well they live during that time.
The NHS aims to maximise health benefits across the population, so treatments that provide the most QALYs for the least cost are prioritised. NICE (the National Institute for Health and Care Excellence) sets a threshold of around £20,000 to £30,000 per QALY when evaluating whether a drug offers good value for the NHS.
Drugs that exceed this cost-effectiveness threshold often face rejection, even if they show clinical promise. A prime example of this is the recent decision by NICE to reject the Alzheimer’s drugs Donanemab and Lecanemab for widespread use within the NHS. Both drugs, which target the build-up of amyloid protein in the brain and slow cognitive decline, were hailed as breakthroughs in Alzheimer’s research. However, despite these clinical benefits, NICE found that the cost per QALY for these drugs was five to six times higher than what is considered acceptable. The economic rationale behind this decision was straightforward: while Donanemab could slow cognitive decline by 4-7 months, NICE concluded that this modest benefit did not justify the significant cost to the NHS. The rejection of these drugs highlights the difficult trade-offs the NHS must make to ensure that its limited resources are used in the most efficient way possible.
The decision to reject high-cost treatments like Donanemab and Lecanemab has broader implications beyond the patients who miss out on these drugs. One concern is the potential for a two-tier healthcare system, where wealthier individuals who can afford private treatment gain access to these drugs, while NHS patients are left without. This could exacerbate health inequalities and undermine public trust in the NHS.
At the same time, rejecting expensive treatments frees up resources for the NHS to invest in other, more cost-effective treatments. This means that while some patients may miss out, more patients overall benefit from the NHS’s ability to stretch its resources across a wider range of services.
There are also hidden economic effects in the wider pharmaceutical market. The rejection of costly drugs by a major healthcare system like the NHS can influence pharmaceutical companies’ decisions on where to invest in research and development. If high-cost drugs are consistently rejected, companies may shift their focus towards developing treatments that are more cost-effective, influencing the future landscape of drug availability.
The NHS’s approach to drug approvals, governed by cost-effectiveness and QALYs, plays a crucial role in ensuring the sustainability of the health service. While the rejection of drugs like Donanemab may be disappointing to patients and their families, it reflects the NHS’s need to allocate resources where they can have the greatest overall impact.