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\section{The harder option}  The harder option is for there to be a paradigm shift in the way NICE - ---  and health economics more generally - ---  operates. It could involve programme budgeting and marginal analysis, or the Birch and Gafni approach\cite{Ruta_2005,Birch_1992,Gafni_2006}. This might just be the best option, but it seems unlikely to happen nationally any time soon.