Policy Pantomime: The Consultation That Wasn't

They Asked. We Answered. They Proceeded Regardless.

On 3 March, the Department of Health and Social Care published its response to a five-week consultation on whether ministers should have the power to direct NICE on its cost-effectiveness threshold. The results were unambiguous. 57 per cent of respondents opposed the core proposal. 53 per cent opposed extending it across all NICE guidance. 76 per cent opposed removing NICE’s obligation to consult on methods changes arising from a ministerial direction. The government’s response to this clear opposition? Full steam ahead, no changes.

This is consultation as theatre – a performance of democratic engagement with none of the substance.

The story so far

This is the fourth in our series on NICE’s cost-effectiveness threshold. In the first post, we argued that the apparent stability of NICE’s threshold over two decades masked a quiet drift upward through a patchwork of workarounds – the Cancer Drugs Fund, the Highly Specialised Technologies route, severity modifiers, and the Innovative Medicines Fund. The system has evolved exceptions rather than confronting the threshold question honestly. If recalibration was needed, we argued, it should be done explicitly, linked to GDP per capita, and accompanied by the retirement of these ad hoc mechanisms.

In the second post, published the day after NICE announced its threshold increase to £25,000–£35,000 per QALY, we showed that this was not the evidence-led review we had called for. It was a concession in the US–UK Economic Prosperity Deal – a trade negotiation. But this was the shop window, the real concern was the reform of the Voluntary Scheme for Pricing, Access and Growth (VPAG): a hard cap on the rebate rate at 15 per cent, combined with higher net prices for newly launched drugs. And promises of doubling the drug spend from 0.3% GDP to 0.6% GDP over 10 years, independent analysts warned this could add nearly £1 billion per year to the NHS drugs bill each year, with no published plan for how it would be funded.

In the third post, we proposed an alternative: a centrally funded pharmaceutical budget, sitting alongside rather than within NHS allocations, with its own threshold reflecting the government’s stated willingness to pay more for medicines as a matter of industrial policy. The argument was simple. If this is a political choice – and it plainly is – then design the mechanisms accordingly. Do not incorporate industrial policy into a technical parameter and force an already overstretched NHS to absorb the cost.

The government’s consultation response proves that none of this was listened to.

Five weeks over Christmas (pantomime season)

Let’s be clear how this consultation was performed (and the pun on performance here is quite intentional). It launched on 9 December 2025 – the same week as the threshold increase announcement – and closed on 13 January 2026. Five weeks spanning the Christmas and New Year period, perfect timing for a pantomime. A link was sent to 1,450 stakeholders via a departmental bulletin. Three closed questions with tick boxes.

This is not how you consult on a fundamental change to the governance of health technology assessment in the UK. This is how you create a paper trail.

The timing alone speaks volumes. A serious consultation would have allowed the health economics community, patient groups, and the public to organise a considered response. Instead, the government chose a window designed to minimise engagement. And yet 203 people still responded, and the results were damning.

Who agreed, and who didn’t

The consultation response contains a revealing breakdown. Of those responding on behalf of a business – overwhelmingly pharmaceutical companies – 89 per cent agreed with the proposals. The industry wants ministers to have the power to set the threshold. Of course it does. The pharmaceutical industry has spent years arguing that the threshold is too low. A ministerial power of direction is the fastest route to a higher number, bypassing the evidence-based processes that have historically constrained it.

Everyone else disagreed. Professionals, patient groups, academics, members of the public – all opposed, and by substantial margins. 40 per cent of written responses cited concerns about political interference. Others raised threats to NICE’s independence and the need for evidence-based decision-making.

The government’s response to this split? To note it, and proceed regardless.

‘A matter of public policy’

The most revealing sentence in the entire document is this: the government considers the cost-effectiveness threshold to be ‘a matter of public policy, reflecting the amount of the healthcare budget that should be apportioned to innovative new treatments’.

This is actually an important concession. It says, in black and white, that the threshold is a political choice, not a technical parameter. We have been making exactly this argument since October. The threshold was never a clean estimate of opportunity cost – it was back-calculated from NICE’s own decisions and subsequently given a post-hoc economic rationalisation. The government is now being honest about this.

But it draws entirely the wrong conclusion. If the threshold is political, the answer is not to hand a minister a dial they can turn without scrutiny. The answer is to build transparent mechanisms that separate the political choice (how much to spend on pharmaceuticals) from the technical assessment (which pharmaceuticals and indeed other technologies represent good value). That is what a ring-fenced pharmaceutical budget does. That is what a ministerial power of directing the NICE threshold emphatically does not.

The real power grab: no obligation to consult

The headline is that ministers will be able to direct NICE on the cost-effectiveness threshold. Let that sink in. A future Health Secretary can instruct NICE to raise the threshold – to, say, £40,000 or £50,000 per QALY – and there is no obligation to consult the public, patients, professionals, or the health economics community on that decision. It is a minister turning a dial.

But there is a secondary removal that makes it worse. Currently, when NICE changes its evaluation methods, it is required to consult. The government is removing that requirement for any methods changes that flow from a ministerial direction on the threshold. 76 per cent of respondents opposed this. The government is doing it anyway. The government offers the reassurance that NICE retains the ‘discretion’ to consult. Discretion is not obligation. When political pressure is applied, discretion evaporates.

The government also states that ‘any decisions taken by ministers must conform to the law governing public administration and must therefore be fair and reasonable’. This is lawyerly throat-clearing. The Wednesbury reasonableness test is a floor, not a standard of good governance. Meeting it means only that a decision is not so absurd that no reasonable minister could have made it. That is not the bar we should be setting for changes to how the NHS allocates its resources.

The symposium (and community) the government ignored

On 11 February 2026, we convened a symposium at the London School of Hygiene & Tropical Medicine – ‘How Should Health Be Valued in UK Policy Evaluation?’ – bringing together nearly 400 health economists, policymakers, NICE representatives, and industry figures, to discuss the threshold change and the consultation. If we could, we would have organised the symposium before the consultation closed, but that proved impossible given the timing that was imposed. But despite being outside the consultation window, the participants would have made up a large proportion of the consultees. And the degree of consensus at the meeting was striking.

Displacement is real and regressive: when pharmaceutical spending rises within fixed budgets, the cuts fall on community care, mental health, elective recovery, and prevention – the services that serve the poorest and generate the largest health gains per pound. The threshold should not be the primary instrument for industrial policy – this was a widely shared view, though not universal. And the health economics community was not consulted on the December 2025 decision. This was described, in the symposium’s concluding session, as a governance failure.

The government’s consultation response landed just three weeks later. It addresses none of these concerns. The word ‘displacement’ does not appear in the document. There is no analysis of the health impact of higher pharmaceutical spending. There is no engagement with the question of who bears the cost. The consultation asked narrow procedural questions about the mechanism of ministerial direction. It did not ask whether the policy was right.

Where we go from here (‘He’s behind you!’)

The case for a ring-fenced pharmaceutical budget as an alternative to the current approach that we made in our previous post solves at least some of the problems the government has so far failed to anticipate with this policy change. The argument is straightforward. If the government wishes to spend more on medicines as a matter of industrial and trade policy, it should ring-fence the funds for that choice not try to fund it from NHS programme budgets. This would allow the same level of control that ministers desire without the downsides. NICE would continue to assess value, but the pharmaceutical fund could have its own threshold (the shadow price of the funding envelope) which creates a self-correcting mechanism that maintains allocative discipline without ad hoc political interventions.

This is not a radical proposal. It is the logical consequence of the government’s own stated position that the threshold is a political choice. It simply insists that political choices should be funded politically, not offloaded onto patients. It doesn’t solve the opportunity cost problem, but ring-fencing allows consistency between the government’s ambition and NICE’s role as an independent arbiter of value. What no-one is talking about, at least in the consultation, is that the NICE threshold applies beyond pharmaceuticals. Ring-fencing solves this.

The consultation response is 4,000 words long. It took five weeks to collect and two months to publish. It changes nothing. The government asked a question, received a clear answer, and ignored it. This is not consultation. It is pantomime.

And like all good pantomimes, this one has its ‘he’s behind you’ moment. The audience – health economists, patient groups, professionals, the public – can see the displacement, the regressive impact, the institutional damage. We are all shouting our warnings of the danger from the stalls. But the protagonist on stage refuses to turn around.

The question is no longer whether the government will do this. It will. The question is whether the health economics community will accept the terms on which it has been done, or whether we will insist – loudly, publicly, and with the evidence on our side – that there is a better way. We need to keep shouting until the government turns around.