2013, nice and the nccsc had scheduled guidance delivery for five topics: domiciliary care, older adults with long-term conditions, transition between health and social care settings, transition from children's to adults' services and child abuse and neglect. cost–effectiveness as with any system financing health care, the nhs has a limited budget and a vast number of potential spending options. choices must be made as to how this limited budget is spent. economic evaluations are carried out within a health technology assessment framework to compare the cost-effectiveness of alternative activities and to consider the opportunity cost associated with their decisions. by choosing to spend the finite nhs budget upon those treatment options that provide the most efficient results, society can ensure it does not lose out on possible health gains through spending on inefficient treatments and neglecting those that are more efficient. nice attempts to assess the cost–effectiveness of potential expenditures within the nhs to assess whether or not they represent 'better value' for money than treatments that would be neglected if the expenditure took place. it assesses the cost–effectiveness of new treatments by analysing the cost and benefit of the proposed treatment relative to the next best treatment that is currently in use. quality-adjusted life years nice guidance supports the use of quality-adjusted life years (qaly) as the primary outcome for quantifying the expected health benefits associated with a given treatment regime. by comparing the present value (see discounting) of expected qaly flows with and without treatment, or relative to another treatment, the net/relative health benefit derived from such a treatment can be derived. when combined with the relative cost of treatment, this information can be used to estimate an incremental cost-effectiveness ratio (icer), which is considered in relation to nice's threshold willingness-to-pay value. as a guideline rule, nice accepts as cost-effective those interventions with an incremental cost-effectiveness ratio of less than £20,000 per qaly and that there should be increasingly strong reasons for accepting as cost-effective interventions with an incremental cost-effectiveness ratio of over a threshold of £30,000 per qaly. over the years, there has been great controversy as to what value this threshold should be set at. initially, there was no fixed number. but the appraisal teams created a consensus amount of about £30,000. however, in november 2008 alan johnson, the then secretary of state, announced that for end-of-life cancer drugs the threshold could be increased above £30,000. the first drug to go through the new process was lenalidomide, whose icer was £43,800. cost per quality-adjusted life year gained the following example from nice explains the qaly principle and the application of the cost per qaly calculation. a patient has a life-threatening condition and is expected to live on average for one year receiving the current best treatment which costs the nhs £3,000. a new drug becomes available that will extend the life of the patient by three months and improve his or her quality of life, but the new treatment will cost the nhs more than three times as much at £10,000. patients score their perceived quality of life on a scale from 0 to 1 with 0 being worst possible health and 1 being best possible health. on the standard treatment, quality of life is rated with a score of 0.4 but it improves to 0.6 with the new treatment. patients on the new treatment on average live an extra 3 months, so 1.25 years in total. the quality of life gained is the product of life span and quality rating with the new treatment less the same calculation for the old treatment, i.e. (1.25 x 0.6) less (1.0 x 0.4) = 0.35 qaly. the marginal cost of the new treatment to deliver this extra gain is £7,000 so the cost per quality life year gained is £7000/0.35 or £20,000. this is within the £20,000-£30,000 that is suggested by nice to be the limit for drugs to be cost-effective. if the patient was expected to live only one month extra and instead of three then nice would issue a recommendation not to fund. the patient's primary care trust could still decide to fund the new treatment, but if not, the patient would then have two choices. he or she could opt to take the free nhs standard treatment, or he or she may decide to pay out of pocket to obtain the benefit of the new treatment from a different health care provider. if the person has a private health insurance policy the person could check to see whether the private insurance provider will fund the new treatment. about 8% of the population has some private health insurance from an employer or trade association and 2% pay from their own resources. basis of recommendations theoretically, it might be possible to draw up a table of all possible treatments sorted by increasing the cost per quality-adjusted life year gained. those treatments with lowest cost per quality-adjusted life year gained would appear at the top of the table and deliver the most benefit per value spent and would be easiest to justify funding for. those where the delivered benefit is low and the cost is high would appear at the bottom of the list. decision makers would, theoretically, work down the table, adopting services that are the most cost effective. the point at which the nhs budget is exhausted would reveal the shadow price, the threshold lying between the cqg gained of the last service that is funded and that of the next most cost effective service that is not funded. in practice this exercise is not done, but an assumed shadow price has been used by nice for many years in its assessments to determine which treatments the nhs should and should not fund. nice states that for drugs the cost per qaly should not normally exceed £30,000 but that there is not a hard threshold, though research has shown that any threshold is "somewhat higher" than being in the range £35,000 - £40,000. the house of commons health select committee, in its report on nice, stated in 2008 that "the ... cost-per-qaly it uses to decide whether a treatment is cost-effective is of serious concern. the threshold it employs is not based on empirical research and is not directly related to the nhs budget, nor is it at the same level as that used by primary care trusts (pcts) in providing treatments not assessed by nice, which tends to be lower. some witnesses, including patient organisations and pharmaceutical companies, thought nice should be more generous in the cost per qaly threshold it uses, and should approve more products. on the other hand, some pcts struggle to implement nice guidance at the current threshold and other witnesses argued that a lower level should be used. however, there are many uncertainties about the thresholds used by pcts." it went on to recommend that "an independent body should determine the threshold used when making judgements of the value of drugs to the nhs." criticism the work that nice is involved in, attracts the attention of many groups, including doctors, the pharmaceutical industry, and patients. nice is often associated with controversy, because the requirement to make decisions at a national level, can conflict with what is (or is believed to be) in the best interests of an individual patient. approved cancer drugs and treatments such as radiotherapy and chemotherapy are funded by the nhs without any financial contribution being taken from the patient. where nice has approved a treatment, the nhs must fund it. but not all treatments have been assessed by nice and these treatments are usually dependent on local nhs decision making. in the case of cancer the cancer drugs fund was set up in 2011 after complaints about nice decisions on new and expensive cancer drugs with limited benefits. treatment for fertility problems are approved but not always funded by clinical commissioning groups and they may cap the number of rounds. nice has been criticised for being too slow to reach decisions. on one occasion, the royal national institute of blind people said it was outraged over its delayed decision for further guidance regarding two drugs for macular degeneration that are already approved for use in the nhs. however the department of health said that it had 'made it clear to pcts that funding for treatments should not be withheld simply because guidance from nice is unavailable'. some of the more controversial nice decisions have concerned donepezil, galantamine, rivastigmine (review) and memantine for the treatment of alzheimer's disease and bevacizumab, sorafenib, sunitinib and temsirolimus for renal cell carcinoma. all these are drugs with a high cost per treatment and nice has either rejected or restricted their use in the nhs on the grounds that they are not cost-effective. a joint statement of medical leaders, published by the royal college of physicians, expressed concern that the nice guidelines for me/cfs (october 2021) did not properly evaluate or recommend graded exercise therapy and cognitive behavioral therapy for the treatment of me/cfs. a conservative shadow minister once criticized nice for spending more on communications than assessments. in its defence, nice said the majority of its communications budget was spent informing doctors about which drugs had been approved and new guidelines for treatments and that the actual cost of assessing new drugs for the nhs includes money spent on nice's behalf by the department of health. when these were added to nice's own costs, the total cost of the technology appraisal programme far outstrips the cost of nice communications. a report from the university of york centre for health economics written by karl claxton in february 2015 suggested that the maximum threshold, currently around £30,000 a year, for judging a medicine cost-effective should be more than halved. they found that any intervention costing more than £13,000 per quality-adjusted life year risked causing more harm than good by denying cost effective treatment to other patients. the institute's approach to the introduction of new oral therapy for hepatitis c has been criticised. sofosbuvir was approved in 2015. it costs about £30,000 for 12 weeks treatment. nhs england established 22 operational delivery networks to roll out delivery and proposes to fund 10,000 courses of treatment in 2016-17. each has been given a “run rate” of how many patients they are allowed to treat. this is the nhs’ single biggest new treatment investment this year. in the north east london network patients with cirrhosis or fibrosis go to the front of the queue and three new patients at the grahame hayton unit at the royal london hospital start treatment each month. those without such complications may faced considerable delays before they start treatment.