Hopes are running dizzyingly high for the National Institute for Clinical Excellence. At the launch last week of NICE's first work programme, its aims were re-stated in simple terms: to end postcode prescribing, spread good value and new treatments through the NHS more quickly, and protect patients against outdated or inefficient treatments.

Not since the launch of the NHS itself has any health body been charged with so ambitious an agenda. Indeed, it is hard to resist the obvious implication that the service should have had something like NICE as an integral component for the past 50 years, primitive though it might initially have been.

The launch of NICE's laudable programme was attended with an amplified media fanfare which usually only the quietude of the silly season can guarantee. But given the high-profile nature of some of the therapies it has chosen for early examination, a repeat performance looks likely when NICE announces its first results. All the controversial treatments - except Viagra - which have hit the headlines in the past couple of years are there, from artificial hips and wisdom teeth extraction to keyhole surgery, beta interferon and drugs for breast cancer, Alzheimer's disease and obesity.

All are controversial because of doubts about their effectiveness and/or their high cost.

To crown the list is the most high-profile of all - Relenza, the treatment for flu, which is to be the first through NICE's fast-track investigative procedure so GPs have guidance in time to meet demands for the drug this winter. Whatever the guidance turns out to be, Relenza is destined to be the treatment which will firmly establish NICE in the public consciousness.

It could be that NICE may thwart many thousands of flu sufferers' expectations this winter if it does not recommend the drug be made widely available. NICE chair Professor Michael Rawlins hinted at one possible approach: Relenza could be restricted to 'certain categories' of patient who would benefit most, presumably elderly people or those with asthma or heart disease.

If this is the verdict, will patients accept it? Professor Rawlins may marshal and quote all the scientific evidence that exists, but it will be no guarantee that the public will accept his arguments.

Scepticism about expert scientific opinion has now reached epidemic proportions, and he will have to confront suspicions that his recommendations are not governed above all else by considerations of cost. That may not be easy to demonstrate; judging a treatment's cost effectiveness is as complex as gauging its clinical effectiveness, with the added complication that there are no universally agreed methods of doing so.

But full marks for grasping the nettle of a challenging programme, which enhances NICE's credibility - at the very least until it starts publishing its results. NICE said it consulted the NHS, the pharmaceutical industry, patients and professional bodies in drawing up its programme. No doubt ministers were another significant influence; did they pitchfork NICE into including so many controversial treatments so early in its work? More importantly, what influence will they have - behind the scenes - in shaping its guidance? A touch on the tiller here, a nod and a wink there, perhaps?

The big unanswered question for managers is what happens if a costly new treatment wins approval for widespread prescription? Will the money have to come from existing budgets, or will the government allow itself to be chivvied into disgorging a little more from the 'modernisation fund'? Maybe Professor Rawlins' gentle hints about appropriate usage and the importance of targeting treatments at those most likely to benefit imply that in the world of realpolitik , NICE's decisions will inevitably be cautious ones.

Finally, how readily will the medical profession adopt the guidance? It will not be compulsory, but failure to do so will be questioned and will have to be justified. The NHS's new enforcing arm, the Commission for Health Improvement, was conspicuous by its absence last week. It is currently recruiting commissioners. HSJ is aware of several prominent and eminently qualified people who have already been turned down. We eagerly await the announcement of CHI's membership.