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Clinical becomes political

It’s a good job that only sticks and stones break bones, or NICE would be lying in bed covered in bandages by now.

It's a good job that only sticks and stones break bones, or NICE would be lying in bed covered in bandages by now.

Few health organisations seem so regularly to crash the front pages of our national newspapers, and fewer still manage to attract such resolutely negative press.

Sir Mike Rawlins, chair of NICE, must have developed rhinoceros-thick skin in his near-decade in charge.

NICE of course has a near-impossible job. It is hard to stay popular while juggling the conflicting interests of individuals and the health service as a whole, denying patients access to treatments and drug companies to profits, and attempting to tell trained medical professionals how to do their job. And it is notable that for all the criticism overall, NICE has retained the support of politicians in general and the current Government in particular.

Indeed NICE retains such support that, far from seeing its power leach away, it is to be fortified with a new array of roles and responsibilities. Most controversially, the institute is to be asked to shape the QOF in its own image, conducting a review of current indicators, selecting new ones on the basis of cost-effectiveness and bringing the whole scheme into line with its own guidance.

Questions raised
The idea that cost should be factored directly into a doctor's clinical decisions is one that is bound to send shivers down a few spines. And the move raises questions too – why bother employing NICE to review the evidence for QOF indicators, when just such an evaluation is conducted every couple of years by a panel of independent primary care experts?

Draft guidance released by NICE last month provides a clue – handing GPs a key role in getting patients off long-term incapacity benefit and back into work. It forms part of the institute's public health programme, but it could have rolled straight out of the Department of Work and Pensions.

It's all in sharp contrast to the conclusions of the QOF expert panel, which in 2005 rejected two of the Government's proposed indicators on worklessness. Where indicators were once selected for their clinical benefit, it looks likely that they will increasingly be chosen by political priority. That's not the contract GPs voted for.

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