Although no politician will commit career suicide by admitting it, rationing of healthcare is inevitable, whatever the healthcare system, recession or no recession. Medicines, particularly biologicals, modern surgery and intensive care are pushing back the boundaries of what can be done to salvage seemingly hopeless situations, to give but three examples. The UK will never be able to pay for all possible medical care for all our citizens, irrespective of cost and benefit. Thus, if medical rationing is inevitable then it should be as fair and transparent as possible, and conducted by experts not politicians. The National Institute for Health and Clinical Excellence (NICE) has the unenviable task of determining who can be prescribed expensive medications or treatments used in large numbers which form a significant percentage of the drugs budget. At the same time, the ‘elephant in the room’ of rationing remains unacknowledged. Furthermore, Health Technology Assessments conducted by NICE project teams are unduly restricted by a rigid remit imposed externally, which precludes reasonable reviewing of indirect data which may be highly relevant to the topic under consideration. Notwithstanding these comments, their recent decision to deny 6–11-year-old children the anti-IgE monoclonal antibody omalizumab as a treatment for asthma, while allowing it for 12 year olds and above, is wrong, and importantly, highlights ways in which the current process is flawed.

Most asthmatic children are easily treated with low doses of inhaled corticosteroids (ICS). Some need an add-on medication, usually a long-acting β-2 agonist or sometimes a leukotriene receptor antagonist. A very few have high levels of morbidity and deaths still occur, despite polypharmacy and high doses of ICS. The evaluation of such children, who have been referred as ‘problematic, severe asthmatics’ should be conducted by specialists.1 When this is done, it is clear that many do not have …