When four drugs were licensed for the treatment of relapsing-remitting multiple sclerosis in the mid-1990s, patients sensed that at last something could be done to modify the course of their illness. But the decision of the National Institute for Health and Clinical Excellence (NICE) that these drugs were not cost effective soon dashed those hopes. Behind the scenes a risk sharing scheme was designed that would provide access to the drugs but without compromising the NICE decision. This threw down a gauntlet to the drug companies: demonstrate a cost per quality adjusted life year (QALY) of £36 000 (€42 000; $53 000) or reduce your prices.1

The first report on 3686 patients (86% of those recruited) with relapsing-remitting multiple sclerosis in the scheme showed that patients did less well on the licensed therapies than expected from the natural course of multiple sclerosis.2 Several reasons were given why this …