London School of Hygiene & Tropical Medicine

The UK cost-per-QALY threshold remains a pivotal component of health technology assessment (HTA). Yet its meaning, credibility, and operational role are increasingly contested. The threshold is often presented as an empirically anchored estimate of NHS opportunity cost. But persistent reliance on the £20,000–£30,000 range masks significant structural shifts: pandemic-driven backlog pressures, chronic workforce constraints, widening productivity variation, and intensifying demands for innovation.

At the same time, valuation frameworks outside health – most notably the Department for Transport’s Value of a Prevented Fatality (VPF) and environmental cost-benefit metrics – routinely imply much higher implicit values of life and health. Treasury guidance tolerates such divergence, raising questions about whether a single NICE threshold can remain coherent within a multi-sector public-spending environment.

Finally, international institutions (Organisation for Economic Co-operation and Development, World Bank) largely favour Value of Statistical Life (VSL) with the World Health Organization (WHO) using both monetised QALY/DALY approaches in some departments and VSL in others. This creates tensions and confusion when governments/institutions are allocating resources across departments with different implied values for health benefits.

This symposium aims to bring these strands together for the first time: the empirical basis for the threshold, the political-economic case for its evolution, the challenge of cross-sector consistency, and the international debate over QALYs versus VSL.

This event is designed for participants to join in-person. However, online tickets are available for attendees to watch the symposium. 

Programme

09:30-10:00: Registration

 

10:00-10:15 Welcome & symposium aims

Speakers:

• Andrew Briggs (Professor in Health Economics, LSHTM)
• Francis Ruiz (Senior Policy Advisor, LSHTM)

10:15-11:15: Session A: Who sets the value of health? Thresholds and cross-sector policy evaluation

This session will take as its starting point that a range of methods and empirical estimates exists that place a monetary valuation on health for potential use of economic evaluation.

It will seek to explain the different concepts reflected in this variation, including empirical measures of how individuals are willing to exchange general consumption for improved health, the rate at which marginal changes in budget-constrained expenditure impact on health, and policy-driven ‘cost-effectiveness thresholds’ or ‘approval norms’ associated with medical technologies.

Are these different concepts and relevant empirical estimates mutually exclusive in economic evaluation?  Or do they each have a potential role in economic evaluation studies depending on the decisions being informed and the range of impacts interventions and policies?  If so, what are suitable analytical frameworks to achieve this?

Moderator

Mark Sculpher (University of York) 

• Mark is Professor at the University of York and is Director of the Centre for Health Economics. He is also Co-Director of EEPRU, a NIHR-funded policy research unit focused on economic evaluation methods. EEPRUs research programme includes themes in estimating marginal productivity as a measure of opportunity costs for the NHS, adult social care and public health, and in medicines pricing.

Panel members

Soryah Haggarty (HM Treasury) 

• Soryah is Head of Health Resilience and Growth in the Health and Social Care team at HM Treasury. Her role involves aspects of public finance, health system sustainability, and economic growth - with responsibility for advising on health-related spending decisions, long-term resilience, and the contribution of the life sciences sector to the UK economy. She works closely with DHSC, NHS England, and other partners on the fiscal and strategic implications of health and innovation policy.Soryah will outline the current principles of how various monetary values of health should be used in economic appraisal across government.

Patricia Cubi-Molla (Office of Health Economics)

• Patricia Cubi-Molla is a Senior Principal Economist at the Office of Health Economics, leading its research theme on Value, Affordability, and Decision-Making, and an Honorary Research Fellow at City St George’s, University of London. Her research combines theoretical and applied approaches and spans the value of health in healthcare decision-making and wider public spending.  Patricia will consider the in differences in monetary values of health across government and describe frameworks to achieve optimal allocation of budgets.

Susan Griffin (Professor of Health Economics, University of York)

• Susan is Professor of Health Economics at the University of York. She co-directs the REAL Supply Unit and contributes to Policy Research Units in economic evaluation and public health. Her research spans applied and methodological topics, incorporating decision-analytic models, uncertainty analysis and the role of inequality concerns in cost effectiveness analysis. Susan and colleagues have developed analysis to evaluate interventions with costs and effects which fall across different areas of the public sector and the economy more generally, with a role for different health values.

Ivan Stead (Department of Transport)

• Iven is a senior economist at DfT, leading the development of its appraisal guidance. He has previously worked at DECC and the ONS. His main areas of focus are cost-benefit analysis, transport and the economy, and social and environmental impacts of transport.  Iven will bring his experience of economic appraisal in transport to the discussion.  He will reflect on how different approaches to monetary valuation of health are used in that sector.

11:15-11:30: Break

 

11:30-12:30 Session B: What is a QALY worth? Supply, Demand, and the UK Threshold Reset

Two decades of research into the value of a QALY have produced not convergence on this question but a growing divide.  On the supply side, econometric analyses of NHS spending and mortality from York University, suggest that the marginal productivity of the health system is around £6,000–£8,000 per QALY, reflecting the true opportunity cost of constrained budgets.  

On the demand side, willingness-to-pay studies consistently imply values closer to £60,000–£70,000 per QALY, capturing what individuals say health gains are worth to them. This is not a technical disagreement but an order-of-magnitude gap, with NICE’s current £25,000–£35,000 threshold sitting uneasily between the two, shaped more by political economy than empirical resolution. 

The question, then, is not simply which number is right, but whether the very idea of “estimating” a single threshold is fundamentally misguided?

Moderator

Andrew Briggs (LSHTM)

• Andrew is Professor of Health Economics at the London School of Hygiene and Tropical Medicine and a Director of the School’s Global Health Economics Centre (GHECO). He recently completed a Wellcome-funded project examining how methods for valuing health diverge across environmental and health economics, and whether greater alignment is possible.

Panel members

Francesco Longo (University of York)

• Francesco is a Research Fellow at the Centre for Health Economics, University of York, where he has worked since 2017. His research focuses on economic evaluation and opportunity costs in the NHS and adult social care in England, working closely with Karl Claxton and colleagues on econometric estimates of the marginal cost per QALY. His work extends the York programme on health system productivity, with recent publications examining the effects of public spending on quality of life for service users and informal carers, and informing DHSC’s use of a £15,000 per QALY benchmark in health impact assessments.

Chris Sampson (Office of Health Economics)

• Chris is Senior Principal Economist at the Office of Health Economics, where his research addresses methodological and policy challenges in valuing health interventions. His work spans environmental sustainability, digital therapeutics, cost-effectiveness thresholds, and the conceptual foundations of QALYs. As a member of the EuroQol Group, he contributes to the development of EQ-5D bolt-on items. He is also founder and Editor-in-Chief of The Academic Health Economists’ Blog and webmaster of the UK Health Economists’ Study Group, and has published extensively on cost-effectiveness thresholds, including critical work on supply-side approaches to estimating the marginal cost per QALY in the NHS.

Jytte Seested Nielsen (Newcastle University)

• Jytte is Professor at Newcastle University Business School, where she has worked since 2011 within an internationally recognised group in the economics of safety, health, environment, and risk. Her research focuses on stated preference methods for valuing mortality and morbidity risks, including willingness-to-pay for health gains and the value of a life year (VOLY). She was a co-author of the UK government’s VOLY scoping study (2018–2020) and contributed to the EuroVaQ project on European QALY values. Her influential 2021 Health Economics paper showed that the proportionality conditions required for a constant WTP per QALY are empirically violated, even under stringent sample restrictions, with her work directly informing Treasury Green Book guidance and departmental health-risk valuations.

Danny Palnoch (NHS England)

• Danny Palnoch is Deputy Director and Head of Medicines Analysis in Medicines Value and Access at NHS England, where he leads medicines analysis to support policy and strategy development. His work sits at the interface between health economics and NHS commissioning, informed by prior experience at the Department of Health and Social Care. His expertise spans pricing of new and generic medicines, NICE methods, innovative pricing models – including outcomes-based and subscription approaches – the Voluntary Scheme for Pricing, Access and Growth (VPAG), and community pharmacy funding.

12:30-13:30: Lunch

To keep this event free of charge to attendees, no lunch and tea/coffee will be provided. Please do make the most of our Pumphandle Social Cafe facilities, selling hot and cold food, or take a walk (weather permitting) to visit one of the many neighbouring venues in the historic Bloomsbury area.

13:30-14:30: Session C: Implications for NICE's thresholds in the UK

This session will examine how NICE’s cost-effectiveness threshold is currently used in the UK, how recent changes have reshaped its interpretation, and what this implies for NHS decision-making and pharmaceutical policy. 

While the threshold was originally a deliberately underspecified decision aid, it has increasingly been treated as a benchmark for health maximisation within a fixed NHS budget, while also being expected to accommodate objectives related to access, affordability, and innovation.  Recent reforms and proposals for alternative funding routes raise the question of whether these developments represent a substantive change in how trade-offs are made, or primarily a more explicit way of handling exceptions. 

Bringing together perspectives from policy analysis, empirical research, NICE’s institutional framework, and industry, the panel will discuss the evolving role of thresholds and the implications for transparency, legitimacy, and decision-making in the UK health system.

Moderator

Mireia Jofre-Bonet (Office of Health Economics)

• Mireia Jofre-Bonet is Chief Research Officer and Head of Education at the Office of Health Economics (OHE), and an Honorary Professor at City St George’s, University of London. She co-convenes the UK Health Economics Heads of Units network and has held advisory roles across UK research councils, NICE, and government. Her work spans academic research and policy work, including pharmaceutical policy and decision-making in health systems.

Panel members

Sally Gainsbury (Nuffield Trust)

• Sally Gainsbury is a senior policy analyst at the Nuffield Trust, a UK health policy research organisation. The Trust has a strong track record on issues including NHS funding, regulation, and innovation. Sally’s work focuses on how evidence and policy interact in practice, including the implications of health technology assessment and pricing mechanisms for system objectives.

Beth Woods (University of York)

• Beth Woods is a Senior Research Fellow at the University of York. Her research covers pharmaceutical pricing and market behaviour, firm responses to HTA assessment signals, and the empirical impacts of reimbursement policies on markets and innovation incentives.

Jacoline Bouvy (National Institute for Health and Care Excellence (NICE))

• Jacoline Bouvy holds a senior role at the National Institute for Health and Care Excellence (NICE). NICE’s remit includes developing and applying methods within a robust governance framework. Her work involves overseeing aspects of institutional decision-making, guidelines and evidence review processes that determine how thresholds are operationalised in practice. 

Victoria Jordan (The Association of the British Pharmaceutical Industry)

• Victoria Jordan is Director of Value and Access Policy at the Association of the British Pharmaceutical Industry, the UK trade association representing companies that research, develop and supply branded medicines. She leads on policy related to health technology assessment, market access and value frameworks, working with industry, government, patient groups and academics to shape medicines evaluation and adoption. 

14:30-14:45: Break

 

14:45-15:45: Session D: Further afield: Devolved and international threshold use

This final session examines how cost-effectiveness thresholds are used in practice, both internationally and in the UK. We begin at home, questioning whether a single national threshold remains appropriate in the presence of devolved decision-making, local budget constraints, and priorities that may be better addressed through public health and non-NHS interventions. 

We then broaden the lens to global health, considering how thresholds are understood and applied in aid allocation, particularly in low- and middle-income countries, where donor funding, vertical programmes such as HIV/AIDS, and differing recipient and donor perspectives complicate the use of a single benchmark for value.

Moderator

Francis Ruiz (Senior Policy Advisor, LSHTM)

• Francis is Senior Policy Fellow at the London School of Hygiene and Tropical Medicine, with over a decade of experience at NICE working on health technology assessment and national coverage decisions for the NHS. He has recently contributed to public debate on changes to the NICE cost-effectiveness threshold and who should decide what the NHS pays for health. Since 2010, his work has focused on supporting evidence-informed priority setting in low- and middle-income countries through the International Decision Support Initiative (iDSI), with extensive engagement across Sub-Saharan Africa and South-East Asia.

Panel members

Sir Francis Atherton (former Chief Medical Officer of Wales)

• Sir Frank is a British physician who served as Chief Medical Officer for Wales from 2016 to 2025. I n this role, he provided national leadership on public health, including during the COVID-19 pandemic, and advised on the implications of health policy decisions within a devolved system. His career spans senior public health leadership in the UK and Canada, international health and development work with WHO and the UK government, and service as President of the Association of Directors of Public Health.

Peter Craig (University of Glasgow)

• Peter is Professor in the Health Economics and HTA group at the University of Glasgow’s School of Health and Wellbeing. He previously co-led the Inequalities in Health programme at the MRC Social and Public Health Sciences Unit and has held research and research management roles in the UK and Scottish Governments. Trained in social policy and epidemiology, he is best known as lead author of the MRC/NIHR framework for using natural experiments to evaluate population health interventions, which has been highly influential in public health and policy evaluation.

Anna Vassall (World Health Organization (WHO))

• Anna is a health economist with over 25 years’ experience in economic analysis and priority setting in low- and middle-income countries. Her work has supported national health planning, aid effectiveness, and cost-effectiveness analysis across a wide range of settings, including leading World Bank – and European Commission – funded health sector reform programmes. She is currently Unit Head of the Economic Evaluation and Analysis Unit in WHO’s Department of Health Financing and Economics.

Geoff Garnett (Dean of the Faculty of Public Health and Policy, LSHTM)

• Geoff Garnett is Professor of Infectious Disease Dynamics and Control and Dean of the Faculty of Public Health and Policy at the London School of Hygiene and Tropical Medicine. Before joining LSHTM, he was Deputy Director at the Bill & Melinda Gates Foundation, with responsibility for improving the global efficiency of HIV interventions. His research focuses on modelling the transmission and control of HIV and other sexually transmitted infections, and he founded the UNAIDS Reference Group on Estimates, Models, and Projections, collaborating on studies across Africa, Europe, and the Americas.

15:45-16:15: Next steps: Suggestions and discussion from the floor

 

16:15: Close

 

16:30-18:00: Networking reception

Pumphandle Social: Cafe & Courtyard

Event notices

• Please note that you can join this event in person or you can join the session remotely
• Please note that this session will not be recorded