Patients in England still face a postcode lottery on drugs and treatment guidance, five years after a system designed to end such patchy provision was introduced.
Checks on the extent to which local NHS trusts are following national advice have revealed that implementation is "less comprehensive and less timely than desired", a report prepared by the Audit Commission and the National Institute for Health and Clinical Excellence (Nice) revealed last night.
It confirmed complaints from professional bodies, charities and patients that guidance is not universally followed. Areas of concern have included access to IVF and treatments and expensive but effective drugs to treat rheumatism.
The full extent of how tardy local primary care trusts and hospitals are in meeting guidance will not become evident until next year when the Healthcare Commission, the NHS watchdog for overall standards, publishes its annual health checks on individual trusts.
The Department of Health gave no indication last night, however, that it would crack down heavily on trusts which do not comply.
Nice is charged with determining the clinical efficacy and cost-effectiveness of individual drugs and treatments, and with issuing guidelines for the management of certain conditions.
Local trusts are directed by the health secretary to find the funding for most individual drugs within three months of final recommendations for their use being published. But implementation of broader guidance might take years of reorganisation and it is far more difficult for the Department of Health to insist it is followed.
Most trusts surveyed by the Audit Commission and Nice said cost was a major barrier to implementing guidance. But the report concluded far more could be achieved with better financial planning at grassroots level.
Approval of drugs, medical devices , diagnostic techniques and surgical procedures alone is thought likely to cost the NHS £800m a year. The costs of broader guidelines are more difficult to estimate - but those for fertility treatments will cost around £84m a year and managing depression a further £58m.
The research for the report involved questionnaire responses from 71 NHS bodies, more than one in 10 nationally, and visits to 16 sites for in-depth interviews.
Among those sites visited, only four could verify they were implementing Nice appraisals of drugs and treatments within three months. One trust said that in one case it had taken closer to three years to achieve full implementation.
On the broader clinical guidelines, for conditions such as heart failure or diabetes, the survey found implementation "ranged from full to nil compliance".
More than 80% of trusts said funds available to implement guidance on individual appraisals were insufficient, citing particularly the cost of arthritis treatments.
Joanne Rule, the chief executive of CancerBacup, said: "We welcome the recommendation that non-compliance with Nice guidance will impact on performance assessment. It is vital the guidance has teeth."
David Isenberg, the president of the British Society for Rheumatology, said a third of doctors were still unable to provide treatment to all patients suitable for the arthritis drugs, despite Nice guidance on them being published more than two years ago. "It is a thoroughly unsatisfactory situation."
The NHS Confederation, which represents most trusts, said Nice guidance on drugs accounted for just 10% of the £8bn total cost of drugs to the NHS last year, a 46% rise on the bill for 2000.
"Extra investment in the NHS is growing by an average of 7.4% a year in real terms but drug costs are rising even faster."
The Department of Health said in a statement: "NHS bodies must make their own decisions about whether or not to fund new drugs based on all the available evidence.
"Some of these treatments cost thousands of pounds, so NHS bodies must find the difficult balance between funding expensive drugs for a limited number of patients and providing services and treatments that will benefit many other people."
