A role for MCDA to navigate the trade-offs in the National Institute for Health and Care Excellence's public health recommendations

Recommendations made by the UK's National Institute for Health and Care Excellence (NICE) consider a range of relevant factors. Most famously, this includes interventions’ incremental cost-effectiveness ratios (ICER). Given the ICER's primacy in such decision-making, it is sometimes assumed as almost analogous to an optimisation problem, maximising the number of Quality Adjusted Life Years generated by the health system subject to costs. However, structured OR techniques could still prove beneficial in informing the broader decision-making problem. Decisions are currently arrived at by advisory committees through a combination of structured processes and relatively unstructured deliberations. In principle, decision makers are expected to consider dozens of relevant factors after the completion of the economic modelling stage. No model is currently used to combine these, and MCDA may be suitable to better structure and aid these discussions and to highlight the opportunity costs associated with them. This paper outlines some of the factors currently considered in public health settings, proposes a number of approaches as to how MCDA-inspired techniques could be grafted onto current NICE processes incrementally, and considers the appropriateness of their use in this setting given NICE's role in the health system. The paper focuses on the formulation of NICE's public health guidance, as this area has a specific focus on equity and the determinants of health, and is therefore has the most obvious need to balance ICERs and other factors.