As for its third mandate, eliminating the dreaded postcode lottery, it has not come close to succeeding—not by a long shot. Even though its rulings are supposed to be mandatory, the drugs it approves can take some time to come into widespread use in the NHS, as primary care trusts cite budgetary constraints to delay implementing its guidelines or to introduce extra restrictions of their own. And even when its rulings are adhered to, that can mean other, less high-profile, treatments lose out. Treatments for mental illness and learning disabilities, all the things nobody lobbies for, get cut back to balance the books.

 

As for whether NICE is saving money, well, that was always a moving target. Its brief but eventful life has coincided with the growing trend of patients using the Internet to diagnose their own ailments as well as the use of expensive drugs like statins by large numbers. It has, however, had some success in driving hard bargains for the NHS, as with Lucentis for wet AMD. Another example is Velcade, a treatment for multiple myeloma. An initially negative assessment from NICE has been relaxed because of an agreement brokered by the manufacturer, Janssen-Cilag, under which the NHS will pay for four rounds of treatment for all suitable patients. After this, the patient’s level of serum M-protein, a marker for the disease, will be measured, and if it has fallen by half or more, the NHS will continue treatment; if not, the NHS will be reimbursed for what it has already spent.

 

And these are not the only examples of manufacturers giving ground in order to get on the right side of NICE. In December, Genentech wrote to oncologists to offer a price-capping arrangement for Avastin: they can apply for a refund for any patient who spends more then £14,000 a year on the drug, for any approved indication. Such innovative pricing is a way for manufacturers to keep up their list prices in order to stop parallel exports, but to still offer sufficiently good value that they are not shut out of the U.K. market.

 

More subtly, NICE has moved the question of healthcare costs into the open in a country that has long allowed its citizens to remain startlingly ignorant on the subject. In 2005 Andrew Dilnot, an economist at Oxford University, made a television program about the future of the NHS as a taxpayer-funded service, for which he followed the treatment of a truck driver who had been badly injured in a crash. The man spent many weeks in hospital, at first in intensive care and then, after numerous operations, undergoing intensive physiotherapy. None of it cost him a penny. Toward the end of the program Dilnot asked him how much he thought his treatment had cost the taxpayer. His answer underestimated the trust cost (£130,000) by almost an order of magnitude. “The NHS was set up to be ‘universal, comprehensive, and free,’” says Dilnot, “a charming idea, but naïve. There are decisions being made all the time about what treatments to offer. NICE has made it more obvious that this is going on.”