Introduction

Even with recent large increases in NHS expenditure, acute funding difficulties continue to emerge. It is essential that a national mechanism to prioritise new and existing technologies is available to inform decision making. The National Institute for Clinical Excellence (NICE) was created to meet this need.1 However, despite Rawlins and Culyer's essay on consultation and equity,2 NICE has yet to mature into the efficient prioritisation mechanism that is required to ensure the best use of NHS resources.

Rationing

Rawlins has stated that there is “no role for NICE in the rationing of treatments to NHS patients.”3 These weasel words belie the inevitability of healthcare rationing, which is ubiquitous in all healthcare systems. Rationing involves depriving patients of care from which they may benefit and which they wish to have4; this is inescapably the business of NICE. Indeed, rationing is the inevitable corollary of prioritisation, and NICE must fully inform rationing in the NHS.

The issue is not whether but how to ration. The criteria determining access to care depend on the health goals society is seeking to achieve. Are we solely interested in efficient use of resources—maximising health from a given budget? Or does society seek efficiency and equity and, if so, is it prepared to sacrifice some efficiency to achieve equity goals? The central nature of NICE as a prioritisation (and hence rationing) body means that four fundamental challenges emerge. These challenges need to be managed carefully and robustly if NICE is to prosper, as we discuss below.

Restricting access to NHS funding

Currently the role of NICE is too peripheral to the NHS. For instance, the government should make it impossible for the NHS …