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Some of Burnand's comments on Iheanacho's article are astonishing.1 If the mission of any national health system is maximising health, this mission is pursued by assuming that spending on a drug buys not the milligrams of the active substance but the clinical benefit resulting from it. From an ethical point of view, it is bad to use systems not based on clinical benefit (such as the Pharmaceutical Price Regulation Scheme, PPRS).
Outside the UK, many people consider the work done by the National Institute for Health and Clinical Excellence (NICE) in the area of value for money to be an extraordinary example of ethical progress. At last, there is a rationale to support the reimbursement of expensive innovative agents (for example, adjuvant trastuzumab for early breast cancer), as well as a rationale to explain why the reimbursement of poorly innovative agents is subjected to restrictions (such as anti-Alzheimer drugs).
Drug pricing systems not based on the value for money approach (such as the Italian one) can pay from €0.84 (£0.58; $1.17) for lansoprazole to €2.32 for esomeprazole, with no specific rationale behind these choices. They can also decide to pay for agents with very poor cost effectiveness profiles—for example, erlotinib in pancreatic cancer2 and first line sunitinib in renal cancer.3
Competing interests: None declared.