NICE at 20

All healthcare systems ration care. The creation of the NHS in 1948 as a universal tax- funded system, largely free at the point of use, was an explicit rejection of rationing based on price and the ability to pay. But the need to decide between competing demands on a limited budget remained.

For half a century, the NHS grappled with this rationing dilemma through a combination of, as Rudolf Klein has characterised it, delay, dilution, deterrence, denial, and deflection.1 This solved the problem after a fashion, but inconsistently and opaquely. The creation in 1999 of what is now the National Institute for Health and Care Excellence (NICE) was an attempt to tackle that through a systematic, evidence based, and economic approach.2

The essential question it was set up to answer is whether new technologies are not just clinically effective—in the case of medicines, they have to be to get a licence—but cost effective.

NICE has bucked the trend by surviving two decades without the …