Moan as we do about the National Institute for Clinical Excellence (NICE), which decides which drugs should be available on the NHS, the idea that there should be a rationale about rationing has been received rather differently across the Atlantic.

In the US $2,000bn is spent annually on healthcare, but only 0.1% of this is actually used to assess whether any of the money was spent wisely, the BMJ reports this week. Two Democratic senators have introduced a bill, which has been generally welcomed, to establish a NICE-like institution to evaluate what the most effective healthcare interventions are. 

The responses to the piece below about NICE’s proposal not to fund new drugs for renal cancer are, in disagreement, understandable. But the problem is that rationing healthcare interventions is inevitable. Even if we (rightly) save money by stopping inappropriate prescribing and other ineffective interventions, there are still going to be limits and hard judgment calls to make. These decisions should be made openly and as fairly as possible.

In general I think NICE are doing a hard job well but I think that there should be more questioning of what ‘cost-effectiveness’ means. If NICE decides an intervention is not cost effective then the intervention needs either to be made better, or cheaper, in order to compel us to prescribe it. 

Michael Rawlins, the chair of NICE, seems to agree. he is quoted today as saying that “we are told we are being mean all the time, but what nobody mentions is why the drugs are so expensive”. I think he’s absolutely right.  The research and development of pharmaceuticals is only one part of pharmaceutical budgeting. Especially when one considers that mere advertising of a drug can cost $161m, or that there are reportedly up to 8,000 ‘drug reps’ (pharmaceutical sales representatives) in the UK who are paid to encourage doctors to prescribe their products.

NICE should enable pharmaceuticals to stop all advertising and marketing. Its judgment should be the one that makes doctors put pen to prescription pad, which would mean more money for R&D and make drugs cheaper.