Decisions about which drugs to abandon to fund new treatments recommended by the National Institute for Health and Clinical Excellence (NICE) are inconsistent and may be contributing to the postcode lottery - one of the key issues that NICE was set up to tackle, warn experts on bmj.com today.
Dyfrig Hughes and Robin Ferner argue that the methods for identifying drugs that can be discontinued need to be as rigorous as those for assessing potential new treatments to ensure best use of NHS resources.
The aim of NICE guidance on medicines and other health technologies is to derive the maximum health benefit from finite NHS resources, explain the authors.
The NHS in England and Wales is legally obliged to fund treatments recommended by NICE but does not receive extra money to do so. This means that the funding of new, expensive medicines relies increasingly on releasing funds by displacing other treatments, but NICE does not specify which.
But if the treatments being displaced are not the least effective, overall population health is reduced. So how should we establish which medicines to discontinue, ask the authors?
Obvious targets for disinvestment include treatments that have been superseded by newer, more effective medicines and others that bring only trivial benefits over existing therapies while costing much more. Meanwhile, new measures to increase rates of generic prescribing are expected to produce annual savings of £72m by 2013.
However, the authors point out that sometimes it makes sense to maintain an older treatment that is only marginally less effective but much cheaper than a new drug. Disinvestment is also impractical when new treatments are not substitutes for old ones but are used in addition, or in sequence.
The authors acknowledge that implementing guidance on the withdrawal of NHS use of existing medicines on the grounds of cost effectiveness poses a different challenge from adoption of approved treatments. However, they argue that NICE is well positioned to recommend candidates for disinvestment.
As such, they call for an explicit framework for the identification and appraisal of medicines for disinvestment to provide better value for money while reducing inequity.