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At the heart of general practice since 1960

Crude attempt to force NICE on GPs

There was a time when regulation of GPs' clinical performance was supposed to be light-touch.

There was a time when regulation of GPs' clinical performance was supposed to be light-touch.

GPs would be interviewed about their QOF achievement, sure. They would be expected to demonstrate they had met the standards agreed in the contract. But the default assumption would be that they were hard-working doctors attempting to deliver good quality care for their patients.

PCTs had already begun to undermine those hopes with an increasingly crude approach to the performance management of GPs, from toughened annual QOF reviews to investigations into exception reporting outliers. Now we learn that the light touch is to be swept aside by a great clunking fist, with the news that adherence to NICE guidance is to become effectively compulsory.

NICE has long wanted the power to enforce its guidance, but it could surely never have expected quite this much power. GPs will have to endure special reviews every year to ensure they are sticking to the institute's rules - and the consequences for those who don't will be straight out of 1984. Miscreant GPs will not be able to register with the new Care Quality Commission, which could spell the end of their careers. But that's just the start - they could also face legal action and the prospect of tough financial penalties. There's a powerful incentive to keep Big Brother happy.

Medicine by numbers

Except that this would mean capitulation to a world of medicine by numbers, with the clinical freedom that GPs have trained for years to earn just a cherished memory. The Bolam principle has established that debate is part of medicine, and that doctors cannot be found negligent if they have followed a practice accepted by a body of medical opinion, even if other doctors disagree with it.

Making NICE guidance essentially compulsory fails to recognise this important principle - and the 50 years of case law that have followed it - and could leave GPs more vulnerable to negligence claims. The increasingly powerful NICE will get to decide precisely how doctors are practising, however much others disagree.

And disagree they will. In the past few weeks alone, NICE has been forced to reverse decisions on drugs for kidney cancer and rheumatoid arthritis, and has come under fierce fire for its guidance on osteoporosis.

NICE judgments will always be controversial - it's the nature of medicine that decisions are rarely clear-cut. But the institute's U-turns and climbdowns serve to illustrate just how dangerous it would be to remove from doctors the right to use their discretion, to treat guidance as just guidance, and to treat the patient in front of them as they see fit.

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