To meet the needs of an evolving health and care system, the National Institute of Health and Care Excellence (NICE) is changing its approach to topic prioritization so it can focus on what matters most. To support this, NICE ran a public dialogue to gather informed opinion on how it should select topics for guidance, including for some technology evaluation programs.

Fifty-five general public participants from across England took part in two face-to-face and three online deliberative workshops (each lasting two or three hours, held over four weeks in 2023). Participants were asked to consider the following criteria in the context of prioritization: health and care need, evidence availability, system impact, budget impact, health inequalities, and environmental sustainability. The workshops were designed to understand whether any aspects were more important than others and explore the reasons why. They used deliberative engagement methods and included trade-off exercises, role-play, group discussion, ranking tasks, and interactions with specialists.

Emerging findings show that the participants think NICE should consider several aspects when prioritizing topics for guidance. Health and care need was of primary importance for people, followed by evidence availability, budget impact, and system impact. Health inequalities and environmental sustainability were generally considered to be less important, though participants still felt these were areas that should inform NICE’s prioritization decisions. Participants identified relevant interactions between the criteria, suggesting that each criterion cannot be considered in isolation. Full results will be available to present at HTAi 2024.

Deliberative public engagement is a meaningful way to involve the public in complex policy decisions with a social value element. Broad public agreement was found with the criteria NICE has proposed to consider when prioritizing topics for guidance, and some criteria are more important to people than others. The findings will feed into NICE’s new approach to topic prioritization.

Involving the public is essential to building trust in health technology assessment (HTA) organizations. The National Institute for Health and Care Excellence (NICE) runs a deliberative public engagement program, NICE Listens. It was used to explore informed public opinion on how environmental sustainability should be taken into account in HTA.

Twenty-three general public participants from across England took part in three iterative online workshops (each lasting two or three hours, held three weeks apart in 2022). The workshops included trade-off exercises, role-play, group discussion, and video clips from interviews with sustainable healthcare experts.

Strong support was found for NICE taking action to make healthcare more environmentally sustainable. Support increased as participants learned that sustainable healthcare offers co-benefits, such as reduced burden on the National Health Service through better self-management of conditions. Participants did not want health outcomes to be compromised in pursuit of sustainability. We identified some circumstances where they found it acceptable to consider the environmental impact of interventions in decision-making: when effective treatments already exist; when the condition is not severe; when the alternative is equally cost effective; and when greener options are marginally higher in cost but as clinically effective as the alternative.

The findings demonstrate that environmental sustainability is clearly considered a relevant element of value. They also offer insight into how the environmental impact of health interventions should be considered in HTA. Further research should focus on methods for consistent measurement of the environmental impacts of health interventions and the incorporation of those impacts into decision-making.

The National Health Service (NHS) in England aims to be carbon neutral by 2045, acknowledging the link between planetary and human health. By 2028, NHS suppliers will need to report carbon footprint data for their products, including the medicines and technologies that the National Institute for Health and Care Excellence (NICE) appraises. Additionally, company level data are already being reported. This type of data may provide NICE with an opportunity to support system environmental sustainability goals.

The NICE Science Policy and Research team conducted an options appraisal to consider the feasibility and acceptability of different ways NICE might engage with environmental impact data (EID). We held discussions with NICE teams that could be affected by the collection and use of EID. Discussions examined the array of potential options for NICE—from being a simple conduit for EID to incorporating EID into its decision-making—and sought to identify those that were practical for further consideration. We then discussed these options with key external stakeholders (NHS England, industry, and commissioners) to understand their expected usefulness and practicality.

Several options for NICE to use EID were identified as suitable for further consideration. Using company level data, NICE could encourage companies to engage with NHS sustainability goals by citing their carbon reduction plans alongside guidance or using them to prioritize its activities. Using product level data, NICE could pilot an evaluation comparing the environmental outcomes of competing health technologies that have no differential direct health outcomes. NICE could also publish environmental impact assessment tools to help commissioners consider EID in procurement decisions. Better data and methodological standards are needed before NICE might consider embedding product-level EID in its usual decision-making frameworks.

Our options appraisal has identified several ways that NICE might start to engage with EID to have a positive impact on NHS sustainability goals and wider planetary health. Future work will scope out how these activities should proceed. The identified options are not necessarily mutually exclusive and may evolve as the data and methods around sustainable health care continue to advance.

Methods and processes for health technology assessment (HTA) must be sufficiently flexible to reflect emerging best practice and adapt to changes in the health and care landscape. They must also be clearly documented and subject to review, assessment, and consultation. This requires a framework to flexibly update HTA manuals, while providing stability and predictability for stakeholders.

The National Institute for Health and Care Excellence (NICE) is introducing a modular approach to updating its manuals. Previously, NICE completed full, but infrequent, updates to its manuals. A modular update is a review of the process and/or methods informing NICE’s guidance in a specific subject area, which can then be updated in the appropriate manual(s) if required. We are developing a modular updates framework that sets out NICE’s approach for identifying and prioritizing modular updates to review, reviewing the evidence and proposing changes to the manual(s), engaging and consulting with stakeholders, and implementing the modular updates.

The proposed approach allows external stakeholders to contribute to topic identification and the content of updates, helping to ensure that the manuals meet the needs of users. The first modular update to the NICE manual for health technology evaluations was published in October 2023. This included updated processes for carrying out cost comparisons, streamlining committee decision-making and handling confidential information. Potential future modular updates may include updated methods to consider health inequalities.

The introduction of a modular approach will enable NICE to be more agile and responsive in monitoring, reviewing, and improving our methods and processes, making sure they remain cutting edge as the health and care landscape continues to evolve.

Involving and engaging the public is an essential step to engender trust and confidence in HTA organizations. In 2021 the National Institute for Health and Care Excellence (NICE) launched NICE Listens, a new programme of deliberative public engagement seeking to address topics that have complex social, moral, or ethical dimensions. Health inequalities (HI), defined as unfair and avoidable differences in health across populations, was the first topic. The aim was to understand how the public would like NICE to act in regard to HI. Despite repeated attempts to tackle HI in England, the gaps in life expectancy between the most and least deprived continue to widen. NICE has committed to addressing HI in its five-year strategy and NICE Listens forms part of a comprehensive engagement strategy to understand how best to do this.

Twenty-eight (28) members of the public from across England took part in four iterative two-hour online workshops, held fortnightly in late 2021. They consisted of both plenary and breakout sessions and incorporated a range of stimuli including trade-off exercises and interview clips with HI experts.

The findings show clear public support for HI being a high priority for NICE, albeit with limits on how and when HI should be addressed. Actions towards reducing HI should focus on supporting a preventative and systemic response. Importantly, there is a need for a transparent process for incorporating HI within NICE guidance as well as rigorous staff training in understanding and addressing HI. Recommending technologies that benefit the majority even when not accessible for all is acceptable if there are clear plans to manage access gaps.

Reducing health inequalities should be a high priority for NICE and other HTA organizations. Organizations should seek to have clear processes for embedding HI in decision-making. Priority should be given to actions that focus on prevention of ill health and those that have wider system impacts.

In light of government and healthcare system commitments to reducing the carbon footprint of healthcare, health technology assessment (HTA) agencies are increasingly motivated to investigate how to consider environmental sustainability in their assessments and guidance. This constitutes a major departure from the existing remits and objectives of most agencies, which typically focus on improving population health outcomes. This presentation seeks to identify options for incorporating environmental impact data into HTA and to examine the main challenges, focusing on the National Institute for Health and Care Excellence (NICE) as a case study.

We present four broad approaches that could be pursued, informed by policy analysis undertaken by NICE. The strengths, weaknesses and implications of each approach are assessed.

The first option is to act as an ‘information conduit’, aggregating and distributing in a standardized format environmental impact information that is provided voluntarily by health technology manufacturers. The second is to present complementary analyses of environmental impact data, separately but alongside results from established health economic analyses (‘parallel evaluation’ model). The third is to incorporate environmental impact data into health economic analyses, for example by monetizing environmental outcomes, so that quantitative estimates of treatment value are directly affected by environmental benefits and costs (‘integrated evaluation’ model). The fourth is to create new decision-making frameworks for evaluating healthcare interventions that are not expected to improve health-related outcomes, but claim to have relative environmental benefits.

We conclude that these approaches are not mutually exclusive, and all involve some degree of benefit and risk. We explain why the parallel evaluation model may be the most appropriate approach for NICE as a first response to the increased demand for guidance on the environmental impact of health technologies. We also outline activities being undertaken by NICE and other agencies such as the Canadian Agency for Drugs and Technologies in Health to develop new methodologies for incorporating environmental impact data into their HTAs.

Assessing the cost utility of health technologies for pediatric patients requires robust utility values for child health states, but the methods for valuing these pediatric health states are much less established than those for valuing adult health states. This is partly because the elicitation of preferences for child health states poses many normative, ethical, and practical challenges.

This presentation examines the conceptual issues in the valuation of health states in children by addressing the following questions.

• (i) Normative theories of health state values: What are we attempting to elicit?

• (ii) Sources of preferences: Whose preferences should we elicit, and from which perspective?

• (iii) Valuation methodologies: How should we elicit preferences?

• (iv) Attaching different values to child and adult health: Is a lack of consistency problematic?

To answer these questions, we used desk research (non-systematic literature reviews) and findings from a two-part workshop held in April 2021. The workshop included 25 participants with expertise in health economics, health state valuation, child health, health technology assessment (HTA) decision-making, and ethics.

We identified a lack of consensus on what is being elicited for both adults and children. Many HTA agencies recommend that the public be involved in utility generation exercises, but some criteria for defining who constitutes a member of the public exclude children. Of the many candidate sample types, perspectives, and methodologies, only a few were deemed relevant, acceptable, and feasible for use in the child health context. In addition, there were diverging views on whether it is possible to compare and integrate adult and child value sets with different properties.

Several questions remain to be answered before the public and other stakeholders can have confidence in child health state valuation protocols. We propose a research agenda, including both empirical and conceptual work, to inform future methodological development and to help HTA agencies make recommendations about how child utility values should be generated.

Patient preferences (PPs) are an important source of evidence in health technology assessment (HTA). However, a methodological framework to achieve their integration in decision-making is lacking. We aim to investigate the potential role of evaluative frameworks to integrate PP evidence into HTA and decision-making.

We undertook a scoping review to identify potential methodological frameworks to consider PP evidence in HTA and evidence of the acceptability of these frameworks for decision-makers. We searched PubMed, Cochrane, and the grey literature to identify relevant studies, reports, or guidance documents. We restricted our search to the use of PP rather than patient experience data and excluded articles solely relating to deliberative approaches.

Frameworks identified as having the potential to integrate PP evidence included cost-utility analysis, cost-consequence analysis (CCA), the efficiency-frontier approach, and multi-criteria decision analysis. All have been used in various HTA contexts, but not necessarily for inclusion of PP evidence. Distinct benefits and challenges of integrating PP data were identified for each framework. These included the theoretical basis of the frameworks, their ability to consider non-health as well as health outcomes, and their ability to separate outcomes based on PPs from outcomes based on population preferences. There is limited evidence and no consensus on the application of these frameworks to consider PPs in HTA or on their acceptability for decision-makers. However, CCA has the advantage that it is both based on economic decision theory and it leaves patient preferences disaggregated from population preferences in an HTA.

The frameworks identified in this review offer potential approaches to systematically and transparently integrate PPs into HTA and decision-making. Based on the review findings, we propose a research agenda to explore the potential of CCA in particular. We anticipate that our findings will augment the recommendations of the Innovative Medicines Initiative PREFER project, which are expected to report in 2022.

A source of debate among the health technology assessment (HTA) community is what perspective should be taken in health economic evaluations. Many stakeholders advocate that a societal perspective is taken in order to include a comprehensive range of costs and outcomes and (in theory) make societally optimal decisions. The Second Panel on Cost-Effectiveness in Health and Medicine recommended that a societal perspective be presented alongside a health sector one. The Second Panel included environment as one item on its impact inventory—alongside productivity, education, and others—intended to support the use of a societal perspective. However, many HTA agencies, including the National Institute for Health and Care Excellence (NICE), have continued to use health sector-specific evaluations to inform decision-making. The presentation seeks to examine whether consideration of the environmental impact of healthcare requires/implies the formal adoption of a societal perspective in health economic analyses.

The presentation will provide an overview of the societal perspective, explaining how it differs from a health sector perspective and describing its main strengths and weaknesses. We then present policy analysis undertaken by NICE’s Science Policy and Research team to identify reasons for measuring environmental impact in HTAs and examine whether these align with the broader arguments for or against adopting a societal perspective in economic analyses.

Three reasons for considering environmental impact are identified: (i) to support parallel policies which demand healthcare system transformation against emissions targets; (ii) to ensure planetary and human health, in the future as well as the present; and (iii) to offset future healthcare resource use. We show that only the third reason aligns with arguments related to the choice of perspective for economic analyses. Moreover, this reason is arguably better aligned to maintaining a (potentially modified) health sector perspective. The implications of the results will be discussed with reference to updating reimbursement decision-making frameworks, such as those used by NICE, to account for the environmental consequences of healthcare.