NICE recommendations: why no disinvestment recommendations to offset investment decisions?

Growing demand, alongside ever increasing costs, means that funding arrangements for new treatments are a major concern. The NHS in England and Wales is legally obliged to fund and resource interventions recommended by National Institute for Health and Care Excellence (NICE) technology appraisals, but NICE has no budgetary responsibilities over its recommendations.1

Other activities have to be displaced to fund new interventions. NICE determined that a designated disinvestment programme was not warranted.2 However, it has a database of “do not dos,” mainly based on negative appraisals, clinical guidelines, and low value practices, although evidence suggests that this database may not improve clinical practice or achieve disinvestment.3 The database recommendations do not generally take cost effectiveness into account; this has led to calls for more research into existing interventions and those of uncertain cost effectiveness to provide evidence based disinvestment guidance.4

Saying “no” or ceasing to provide a service is a far greater challenge than introducing a new healthcare intervention. Published evidence on how to carry out disinvestment is limited, with funding of new NICE mandated interventions being achieved through efficiency savings, rather than service displacement or explicit disinvestment.5

There are indications of no formal disinvestment processes, collaboration difficulties between commissioners and healthcare providers, a reluctance to engage in explicit rationing, and limited central and political support for disinvestment.6 The burden of disinvestment is shifted away from NICE or central government to local powers, where decision making tends to be less systematic and covert. Such an ad hoc approach may result in cost effective interventions being displaced in favour of newer, less cost effective ones and may result in fresh accusations of a “postcode lottery.” In these times of increasing demands for efficiencies within the NHS, an explicit framework for the disinvestment of less cost effective interventions is warranted.