As of April 2017, NICE provided a tool to assist NHS organisations achieve financial balance in the form of the Budget Impact Test. This test provides the NHS opportunity to delay patient access to drugs on the basis of affordability, not just cost-effectiveness.

Analysis

The test stipulates that drugs costing more than £20m in any one of their first three years from introduction (approximately 20% of the treatment appraised by NICE) will prompt pricing negotiations between the manufacturer and NHS England to moderate potential long-term budgetary impact. When agreement to contain pricing cannot be reached, NHS England can now extend the current maximum 90 day adoption delay limit to 3 years.

Whilst financial benefits of the budget impact test are evident, it ultimately fails to maintain the patient’s interest at the heart of decision making. Budget impact analysis essentially represents multiplication of the cost per patient by the number of patients likely to be treated. Therefore patients in more prevalent disease areas are likely to be discriminated against given larger budget impacts these calculations would result in. This results in larger patient groups being used as a bargaining chip by the NHS to drive down drug prices. The test could also be contradictory to the NHSs Constitution, which states patient access to interventions should not be limited on the basis of net acquisition and administration costs. Furthermore, the test may disproportionally impact first to market drugs who often represent a considerably cost-effective alternative to current standards of care but may also be costly to introduce due to existing unmet need.

Conclusion

Whilst the Budget Impact Test provides the NHS opportunity to contain future costs, it pushes the patient further into the back seat in terms of service commissioning, allowing financial interest to increasingly drive decision making.