If there is a quintessential British value, it is surely a belief in fair play. In the national psyche, queue-jumping ranks alongside major crimes, and it sometimes seems that variations in schooling, healthcare, and other local services are less acceptable than a poor service for all. There is even a special phrase, “postcode lottery” (postcode is the U.K. equivalent of zip code), to describe the outrage people feel when, for no reason other than where they live, some win and some lose.

 

It was outrage over postcode lotteries in healthcare that in 1999 gave rise to NICE, the National Institute for Clinical Excellence. Renamed the National Institute for Health and Clinical Excellence when the job of evaluating public health measures was added to its portfolio, this agency was assigned a task worthy of Solomon: to decide which medical treatments the National Health Service (NHS) should pay for—and which ones patients should be denied. Nominally, the new agency had three equally important jobs: to keep a lid on costs, to promote innovation in healthcare, and to ensure equity by standardizing decision-making across England and Wales (Scotland has its own agency). In reality, though, the political necessity of the last goal—equity—has become paramount.

 

Now, after almost a decade, how has it fared? What can other countries learn from the NICE experience? The verdict, in a word, is mixed. Professor Peter Smith, the director of the University of York’s Centre for Health Economics, says NICE has done pretty well with modest resources—and blazed a trail for health technology assessment—but suffers from several problems as well. “Whatever country I speak in, they have all heard of NICE,” he says. “Rationing, however you want to try it, is an issue for all countries.” But the agency is too slow, he says, and spends too little of its time evaluating old healthcare technologies to see which ones are obsolete. Both problems are the result of its limited staff and budget. He would like to see it take a more imaginative approach, with quick approval for obvious wins, or for companies willing to offer their products cheaply until more evidence of the benefits is available.

 

He cautions, though, that creating an independent agency like NICE cannot absolve politicians from the duty to make painful choices. Healthcare budgets are finite, so decisions to spend in one area inevitably mean cutbacks in another, however much politicians wish that were not the case.

 

These tensions could have been predicted from the start. In 1999, then-Health Secretary Alan Milburn faced questions about the case of a Sussex resident who suffered from motor-neurone disease, for which his doctor wanted to prescribe riluzole (Rilutek). If he had lived in neighboring Norfolk or Essex, he would have received it free, but in Suffolk the drug was not covered. NICE, said Milburn, would end such anomalies. What he did not say, though, was whether riluzole would become available everywhere, or nowhere. Nor, if the former, did he say which other treatments would be denied to balance the books.