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NICE has the resources and expertise to consider the clinical and cost effectiveness evidence about a treatment or care pathway. PCTs do not have these resources. Although there may be some issues about NICE it's ultimate aim is raise clinical standards and patient outcomes in the NHS to be on a par with other leading economies. PCTs that ignore NICE guidelines are certainly not delivering patient-centred care and compromise standards of health care delivery and patient outcomes. PCTs have little local accountability to patients and the public.

One must question how the PCTs rationing decisions and lack of compliance with NICE clinical guidelines are reached. It is unlilkely to be by even more careful consideration of the evidence than NICE. It is also unlikley to be by careful financial management comparing cost effectiveness. It certainly does not consider patients.

In our recent FOI survey of all English PCTs some were unable to tell us how many hysterectomies they purchased, even though this is one of the commonest operations, few had any mechanism for ensuring NICE guidleines were adhered to or that patients were properly informed about all the treatment options and some didn't commission a treatment for fibroids which was safer, less expensive for the NHS and patients and recommended by NICE - uterine artery/fibroid embolisation. This together with proper consideration of full treatment costs and outcomes of other newer medical technologies could have resulted in a considerable saving to NHS and patients, improved outcomes and greater patient choice.

From this evidence it would appear that there is considerable opportunity for improving NHS commissioning based on proper analysis of managment and clinical data and cost information, involving patients and clinicians and complying with NICE appraisals and clinical guidelines. It is very important that commissioning is improved and the greater local accountability and more clinical and patient involvment with CCGs will help.