Not NICE: a better way forward?

Although no politician will commit career suicide by admitting it, rationing of healthcare is inevitable, whatever the healthcare system, recession or no recession. Medicines, particularly biologicals, modern surgery and intensive care are pushing back the boundaries of what can be done to salvage seemingly hopeless situations, to give but three examples. The UK will never be able to pay for all possible medical care for all our citizens, irrespective of cost and benefi t. Thus, if medical rationing is inevitable then it should be as fair and transparent as possible, and conducted by experts not politicians. The National Institute for Health and Clinical Excellence (NICE) has the unenviable task of determining who can be prescribed expensive medications or treatments used in large numbers which form a signifi cant percentage of the drugs budget. At the same time, the 'elephant in the room' of rationing remains unacknowledged. Furthermore, Health Technology Assessments conducted by NICE project teams are unduly restricted by a rigid remit imposed externally, which precludes reasonable reviewing of indirect data which may be highly relevant to the topic under consideration. Notwithstanding these comments, their recent decision to deny 6–11-year-old children the anti-IgE monoclonal antibody omalizumab as a treatment for asthma, while allowing it for 12 year olds and above, is wrong, and importantly, highlights ways in which the current process is fl awed. Most asthmatic children are easily treated with low doses of inhaled corti-costeroids (ICS). Some need an add-on medication, usually a long-acting β-2 agonist or sometimes a leukotriene receptor antagonist. A very few have high levels of morbidity and deaths still occur, despite polypharmacy and high doses of ICS. The evaluation of such children, who have been referred as ' problematic, severe asthmatics' should be conducted by specialists. 1 When this is done, it is clear that many do not have 'severe, therapy resistant' asthma, requiring expensive and invasive medications, but the true problem is that the basics have not been adequately addressed. 2 – 4 Nurse led home visits in 71 children with problematic severe asthma revealed that more than 50% had potentially reversible factors, such as poor adherence and ongoing exposure to allergens or tobacco smoke in the home. 5 Thus, on a population basis, even in groups of children with apparently severe asthma, only a minority might be considered suitable for omalizumab. It is wrong, however, to extrapolate from populations to individuals—which is in …