For some time I've been harbouring secret misgivings about NICE.
They seem to have grown and sprawled to the size of a small country. I can't bear to think about the size of their budget �70m-ish. They do everything from telling us to take the stairs and not the lift to taking this pill and not that one.
I remember when Frank Dobson, the then Secretary of State, invented the organisation. About that time a whole stream of expensive drugs was emerging. Some commissioners used them, others didn't. The phrase 'post-code lottery' was invented.
I thought at the time, 'a political solution to a resource management problem'. Give it time and it will come unstuck.
It's taken longer than I thought. NICE weathered the storm of disapproval from Pharma, doctors, patient organisations and have become as much part of the landscape of care as car parking charges.
Now, it looks like they've hit the buffers. Caught between the rock of common sense and the hard place of Simon Stevens' relentless quest for �30bn savings.
We have to ask; what is the point of an organisation obliging the NHS to buy drugs it recommends, knowing, full well, the service can't afford them. Formularies are melting. However good, however needed, however desirable... someone has to find a way of saying enough is enough. Are the NICE days are over?
NICE have their own way of doing things; calculations based on a QUALY, and value for money assessments. Extraordinarily, affordability is not considered.
Tarzan has stepped in. Not before time. A new "budget impact threshold" is set to be introduced that will be "triggered" if a new drug is projected to cost the NHS more than �20m in any of the first three financial years following its introduction.
Pull the trigger and a whole palaver kicks-off; negotiations with the manufacturer to talk the price down. If this arrangement was in place last year, one in five treatments would have been caught up in the fandango.
It's complicated and the HSJ has the best explanation. There is a fast track process for cheaper drugs. About time too. The Scottish equivalent of NICE is quicker and cheaper.
I wonder what the 'budget impact' means? Diagnostics, imaging, staffing? Who knows? Expect new rows with Big-Pharma and patient's groups. De-ja-vu.
Pharma will argue it will slow the NHS' already glacial adoption of new drugs.
Patients will say... well, we know what patients will say. Put yourself in the position of someone denied treatment.
This is not good news for anyone. MPs can expect burgeoning postbags from campaigners and expensive lobbying from Big-Pharma.
Why make the changes? It's obvious and we should spell it out. There's not enough money in healthcare and this is an austerity measure... end of.
If you can't get the drug you want, if the NHS decides not to buy it, don't hassle the health service. Hassle your MP. Politicians make the decisions about budget allocations. The NHS is left trying to make one pound do the job of two.
There is another logic. If the NHS doesn't want to buy a drug why do we need such an expensive complex process to say no? There is a European requirement for a state healthcare provider to be transparent in its decision making and have a meaningful process for appeal.
Brexit might see that off and let the NHS decide on its formulary and that's that.
Where does it leave patients? Already there is a facility for cancer patients to buy non-NHS formulary drugs and have them administered in the NHS. It is an exception.
Patients' organisations have a choice to make. Push for more exceptions or push to close down the budget-impact-threshold idea entirely. Or, push for more money in the NHS.
Big-Pharma could decide to launch new products elsewhere. Although the NHS is a prestigious customer, England is a small market. Or, they could run for their lawyers.
Frankly, given the constraints, I don't know what else Tarzan and NICE can do. If you don't like it, you know who to complain to.
Next year the money will get even tighter and the decisions more difficult, plunging us into more moral and ethical dilemma; the trade off between utility, rights and justice.
This is not going to be easy.
