Welsh health minister Edwina Hart has angered some local health boards - and stepped further into NHS decision making - by ordering managers to pay for four unapproved drugs for advanced kidney cancer.
She made the unexpected announcement last week that patients should be given sunitinib, bevacizumab, sorafenib and temsirolimus where the request was backed by two specialists.
The National Institute for Health and Clinical Excellence is expected to approve the drugs next month following a change of criteria for end-of-life drugs earlier this month, though its decision would not usually apply immediately.
Ms Hart said the decision, which will apply until new NICE guidance is in place, would "allay the anxiety felt by patients and their relatives during this interim period".
The All Wales Medicines Strategy Group, which issues drugs guidance for Wales in addition to NICE, has not approved the drugs either.
One local health board pharmaceutical manager told HSJ the shock decision meant it would exceed planned budgets. "It was very much our view that we were following national guidance," he said. "This throws our planning out. We have received an allocation on the basis of the guidance that has been published."
The manager said it was a step further in Ms Hart's interventions in NHS decision making.
Welsh Institute for Health and Social Care director Marcus Longley said: "She has seen the way the wind is blowing and wants to make sure Wales gets the benefit as soon as possible.
"It does put considerable pressure on NICE and emphasise the independence of policy making in Wales. It is difficult for local health boards [and] the revenue consequences in a year could be really quite significant."
Andrea Hague, cancer services director at specialist provider Velindre trust, said the decision was a surprise. The trust is now looking at how the drugs and related treatment should be provided in practice.
Ms Hart has also been forced to defend a decision not to close a neurosurgery unit at Morriston Hospital in Swansea after it emerged she had ignored clinical and policy advice to centralise at Cardiff's University Hospital of Wales.
Ms Hart, who is an Assembly member for Gower, near the Morriston Hospital, said: "My view is that what people want is two sites, and you've got to look at what the patients want as well as to what's required."
She said: "At the end of the day, decisions lie with me as a politician."