The government's plans to limit prescribing of Viagra have raised questions about the powers of the new National Institute for Clinical Excellence, writes Kaye McIntosh

Rationing is the worst-kept secret in the NHS. Politicians have always denied it exists, dumping unpopular decisions on health authorities.

So many in the NHS saw health secretary Frank Dobson's proposal to curb prescribing of the anti-impotence drug Viagra as a refreshing change. At last a minister was prepared to state publicly that the NHS could not afford to fund unlimited treatments for the human condition.

This latest round of the rationing debate was sparked by so-called 'lifestyle' drugs such as Orlistat (for obesity) and Seroxat (for anxiety) as well as Viagra.

But it will move on to drugs which unquestionably aim to deal with serious illness. As Mr Dobson announced his proposals, news emerged that the licence for beta interferon-1b could be extended to cover 40 per cent of multiple sclerosis sufferers in the UK.

The public consultation on Mr Dobson's plans for Viagra ends in March, less than a month before the National Institute for Clinical Excellence begins the job of judging which treatments are both cost-effective and clinically effective.

But does the health secretary's handling of the Viagra debate provide a model for NICE? Or is it a story of incompetence and missed opportunities?

Ruth Chambers, professor of healthcare commissioning at Staffordshire University, says Mr Dobson fell at the first hurdle, because 'if rationing is to be effective you have to carry the medical profession with you'.

Instead, British Medical Association GP committee chair John Chisholm described Mr Dobson's proposals as 'unethical and cruel'.

Professor Chambers blames this reaction on Mr Dobson's 'procrastination' since Viagra was licensed in September. Mr Dobson advised doctors not to prescribe it until further notice, but GPs argued that their terms of service meant they could not refuse patients a drug that was not officially blacklisted.

Dr Chisholm, while welcoming the opportunity for public debate, is 'deeply critical of the way Frank Dobson reached his rationing decision'. Mr Dobson 'ignored' a 'rational consideration' of need, clinical and cost-effectiveness and instead made a decision 'on solely financial grounds', he claims.

The guidance limits treatment to men in five categories, from those who have had radical pelvic surgery to those with diabetes. It suggests 'one treatment per week' for these men, and 'in exceptional circumstances', those in 'severe distress' from impotence, after specialist assessment.

NHS Confederation chief executive Stephen Thornton finds the decision 'reasonable' and the decision-making process 'a model' for future judgements on new therapies.

He does not expect much change after NICE starts running. Its job 'will be to advise the secretary of state about cost and clinical effectiveness, not to make decisions about availability on the NHS'.

That is not quite how Sir Michael Rawlins, chair of NICE, sees it. He says the Department of Health will 'give us a shopping list' of therapies to consider. But decisions about the availability of treatments will be the result of 'dialogue between the department and NICE', not political diktat.

'NICE cannot commit the NHS to large expenditure without having got the NHS to agree that this is what it wants to spend money on, ' he says.

On the other hand, he says NICE will sometimes be 'an advocate for a form of treatment', persuading the health secretary 'that it does offer value for money and squeeze the resources out of him'.

Sir Michael denies that NICE will actually be involved in rationing.

Instead, it will 'propose priorities' where cost-effectiveness varies between patient types - for a drug where 'the benefit is slender in redhaired Welshmen but marked in greyhaired Geordies', for example. 'But that is not the same as rationing'.