Sir, I am not surprised that patients are being denied access to drugs recommended by the National Institute for Clinical Excellence (NICE) (report, September 8).

Certainly, NICE should produce greater consistency throughout the NHS, and patients fortunate enough to be prescribed NICE-approved treatment have a right to receive it. But health authorities work within fixed budgets. The guarantee of treatment for some may be at the cost of patients whose treatment has not received NICE approval.

Some health authorities have been reluctant to “disinvest” from treatments that do not have NICE approval. This is a difficult and delicate issue. How should such disinvestment take place, and which treatments should be discontinued? Yet health authorities receive no guidance.

NICE should do more to assist health authorities to identify the savings necessary to meet the costs of its guidance. For example, if NICE worked within a “fantasy” budget of its own, it too would recognise the cost implications of its guidance and be able to propose where savings could be made.

NICE may create winners and losers in the NHS. Let us not ignore those patients whose treatment may be affected because it is not approved by NICE.

CHRISTOPHER NEWDICK
(Author, Who Should We Treat? — Rights, Rationing and Resources in the NHS, Oxford University Press, 2005).
c.newdick@reading.ac.uk

From the President of the British Association of Endocrine Surgeons

Sir, We must be very wary of the assumption that all NICE’s recommendations must be implemented and that trusts which do not comply “should have this reflected in their annual performance ratings”.

NICE is a governmentsponsored organisation that reflects a zeal for homogeneity and diktat. Its recommendations, whilst usually sound, need always to be compared to other available clinical guidance and undergo a clinical and financial “reality check”. For example, its recent recommendations about the conduct of thyroid surgery will require hugely disruptive and expensive changes for little or no clinical benefit.

There can be no guidelines that are always right, always achievable and always appropriate. Those of NICE are no exception.

ANTHONY E. YOUNG
anthony.young@gstt.nhs.uk

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