How does NICE decide which treatments the NHS provides?
By assessing whether a treatment represents an acceptable use of limited resources — combining how well it works with what it costs, since a health service with a fixed budget funding one thing necessarily does not fund another.
What NICE is. The National Institute for Health and Care Excellence, which produces guidance on treatments, procedures and care pathways for the NHS in England, with arrangements in the other UK nations.
The core method: cost per QALY. A quality-adjusted life year combines length of life gained with quality of that life. One year in perfect health is one QALY; a year in a state valued at half is 0.5.
This allows comparison across entirely different conditions — a cancer drug and a hip replacement — in a common unit, which is the only way a single budget can be allocated coherently.
The threshold. NICE has historically worked to a range of roughly £20,000 to £30,000 per QALY, above which a treatment is less likely to be recommended without additional justification. It is a guide rather than a hard rule, and several modifiers apply.
The modifiers and flexibilities:
End of life criteria, historically allowing a higher threshold for treatments extending short life expectancy, subsequently revised into a severity modifier.
Highly specialised technologies for very rare conditions, assessed under a separate route with a much higher threshold — recognising that rare disease treatments cannot achieve population-scale cost-effectiveness.
Managed access agreements, funding a treatment while evidence is collected.
Confidential commercial arrangements, where the price paid is lower than the list price — which is why published cost-effectiveness figures can be misleading.
Why the approach attracts criticism: it is distressing to be told a treatment that might help is not funded; QALY valuations involve contested judgements, and disability advocates have argued the method systematically undervalues life with a disability; and the threshold has not risen with inflation for many years.
Why it is nonetheless defended. The alternative is not funding everything — it is allocating implicitly, by waiting list, by postcode, or by whoever campaigns most effectively. An explicit method can be examined and argued with; an implicit one cannot.
Individual funding requests exist for exceptional cases.
General information, not medical advice.