Nice is turning nasty - and not before time. Under attack, the National Institute for Health and Clinical Excellence, which decides what treatments and drugs are good enough value for the NHS, is fighting back. Another assault by tabloids, television and political opportunists is trying to force Nice to approve drugs by popular outcry. But its latest press release gives a vigorous riposte over the drug Velcade, for treating multiple myeloma. "We are extremely concerned about misleading coverage," it says.
Disgracefully, Andrew Lansley, the shadow health secretary, claimed at the weekend that he would prescribe the drug, adding an absurd promise that he would also "renegotiate" its price with the manufacturers. As if.
Paying no attention to Nice's rebuttal, ITV's The Sunday Edition paraded three patients with bone-marrow cancer desperately seeking the drug, understandably anxious for any shred of extra hope. Who wouldn't be? The presenter opened the item thus: "Now, how would you feel if you were denied a drug which might add seven years to your life because of an accident of geography? For three Yorkshirewomen ... that's the reality." Except it wasn't - nothing like it.
Nice refutes all the charges. No, the drug is not as effective as some people suggest. Its manufacturer claims only that it extends life on average by less than a year, compared to other treatments. No, there is no postcode lottery for this drug, as Scotland has approved it for only a tiny number of patients in the last weeks of life. No, Nice doesn't reject cancer drugs that work. Of the 26 cancer drugs it has appraised so far, it has recommended 25 for NHS use - but you wouldn't know that from the coverage.
The most sinister charge against Nice is that it is not truly independent. Many people suspect drug companies of stirring up understandably eager patient groups to undermine its authority. But Nice independence has been hard-won. Founded in 1999, it is one of the best things Labour has done for the NHS. Here is an entirely open and transparent system to manage the rationing that is an inevitable part of every health system, publicly funded or privately insured.
Its first trial of strength with the drug companies was its defining moment. When Nice said no to the flu drug Relenza (except for exceptional conditions), Glaxo threatened to pull out of Britain in revenge. Nice held firm, Glaxo stayed. The latest battle has been over Alzheimer's drugs, where again anecdote trumps evidence in the press. Yet often Nice battles to make doctors prescribe new drugs, such as those for schizophrenia with fewer horrible side-effects.
Decisions are made by panels of 30 people - including doctors, scientists, NHS managers, nurses and patients - who examine the research evidence in scrupulous detail. Any outsider can give an opinion and all evidence appears on the internet: they take time to get it right (known in the drugs trade as "Nice blight"). Already the established world authority, its work is used by many other health services. Any system is fallible, but no politicians, drug companies or patient pressure groups can interfere with Nice deliberations - it would be obvious if any decision it took was not based on its own published evidence.
But it isn't as simple as that. Faced with patients clinging to any last straw, the big questions remain. What is a life worth? How good a quality of life should be saved, at what price, for how long? Nice has a rule of thumb using QALYs, or quality-adjusted life years. A year of life in a reasonable condition is worth £20,000-£25,000. Anything over £30,000 needs to be an exceptional case: that's not personal circumstance but a rare condition with absolutely no other treatment. Nice has to consider what better treatments could be bought for how many others for the cost of holding off death for a few more painful months? Never easy, it will always depend on how much cash there is in the pot. And politicians need to ask if an NHS pound really buys more wellbeing than other services?
But at a cost of £30m, Nice is one of Labour's best ideas - though like so much else of value in the NHS it doesn't add to "productivity", which only measures how many patients are treated per extra pound spent. Andrew Dillon, its chief executive, has pondered these dilemmas all his working life in the NHS, where value for money is hard to assess. How do you measure the "productivity" of the greatly enhanced quality of life given to arthritics from new drugs that Nice recommends? As they don't save lives, on paper it's a dead loss. Measuring NHS productivity financially is an unresolved argument, Dillon says. "To me, the extra NHS money feels like rain after a long drought, taking a long time to sink in before you see it on the surface."
New anti-NHS pressure from the right now uses Nice's decisions as proof that rationing is unacceptable in a world of individual choice. (They ignore the strict rationing applied by US private health insurers, which use a tariff limit on hospital days, so it's too bad if you get complications.) Professor Karol Sikora and the rightwing group Doctors for Reform call "the current socialist model" of the NHS "dogma". Instead they want patients to get basic NHS-standard treatments as approved by Nice, with the option to buy unapproved treatments by paying extra or buying top-up insurance. Sikora, writing in the Mail, compares it to private opticians letting people choose glasses to suit their purse, but the state ensuring no one goes without.
NHS provision is unequal now, but this would create an instant class divide, far greater than the 11% who currently use some private medicine. It would herald the end of a universal NHS altogether, but then perhaps it is the logical next step in the "choice" agenda. It's alarming how Tony Blair and some of his ministers listen to Sikora's market vision with intense interest.
All kinds of agendas are at work in the attacks on Nice decisions. The drug companies push for a yet fatter slice of NHS spending. Patient groups understandably want everything for their sufferers. But a political groundswell rippling all around the Tory party is more sinister. They see Nice as a battering ram to break public support for the NHS. In the old days rationing was opaque, but now that it is transparent, can rational argument prevail with voters over rightwing tabloid agendas? Almost certainly it can. People know that there are always spending limits, and the NHS remains a great emblem of national solidarity.
