Gordon Brown's Big NHS Speech, to which HSJ gave front-page treatment last week, was full of virtuous declaration about what needs to be done to manage rising - and costly - demand in healthcare systems around the world.

Good stuff, even if Peter Hain's deputy leadership funding problems (I could have told him not to waste his time: he came fifth out of six) overshadowed most of the government's week.

Alan Johnson also shed some fresh light on ministerial thinking. The health secretary told The Guardian that, contrary to what you may have read in our more expensive newspapers, there is no difference between him and Patricia Hewitt on NHS competition and the private sector's role.

Glad to have sorted that out. But by the weekend I was engrossed in the Commons health select committee's latest report on the performance of the National Institute for Health and Clinical Excellence.

That was Hained a bit, too - a shame because it is good stuff, not least because it was quite difficult to get my head around the issues that have circled NICE since its inception in 1999.

As you may know, problems identified by the committee include slowness to evaluate new medical technologies and procedures, insufficient attention to "wider benefits of treatment to society" (eg carers), inadequate use of experts and available information, the need for better guidance to primary care trusts, etc. It's basically a success story, but MPs looked to Canada, France and Scotland for ways of doing things better.

What caught my attention was the limit it uses to decide whether a treatment is cost-effective and the differing views of the committee's expert witnesses on whether the quality-adjusted life years cost threshold used by NICE is too high or too low.

NICE pitches its cost-effective QALY threshold at£20,000-£30,000 a year, ie what the NHS should be prepared to spend to keep a patient alive and in reasonably good shape.

That range has not changed since 1999. But hang on, there has been the usual NHS-specific inflation, which should adjust it to£28,000-£42,000, says one camp. What's more, the NHS budget has more than doubled since 1999. Doesn't that count, too?

The result of a "low" cost-effective threshold is that some good new technologies, drugs, equipment and procedures never get approval, which is a loss to patients and a cause of high-profile litigation against NICE, as we often read in the media.

Yet PCTs themselves seem to use even lower QALY thresholds when budgeting -£13,000 per patient for cancer and£8,000 for heart disease. But hang on again. The other camp warned MPs against raising the NICE threshold because it only piles fresh burdens on already hard-pressed PCTs.

Why so? Because a higher threshold, especially alongside streamlined NICE evaluation procedures which the MPs also suggest, would let more drugs on stream as mandatory for PCTs to start sanctioning within three months of NICE approval.

But they are already struggling to implement the institute's rulings; a higher threshold would only add to their budgetary burdens.

The select committee does not think itself competent to adjudicate a higher/lower threshold for NICE, but thinks a separate body should, with all the warring interested parties represented.

The committee's other cherished complaint is that NICE does not spend enough time examining older drugs which are in use but no longer should be because they are costly and/or not very good. "Disinvestment" in such products, as the MPs call it, would free up cash for better use.

Reading all this made me realise what was missing from Gordon's Big Speech. He covered most of the waterfront, including the need to use new technologies more effectively, which I take to include the above. But he shied away from the NHS's R-word.

In his Treasury days, R stood for "Redistributing" taxes to the poor, which he did on the sly. In the NHS it stands for Rationing treatments and drugs.

How do we prioritise? A debate is needed, MPs were told.