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Does NICE listen to the views of GPs?

NICE has led the way in the transparency of its processes and has built in checks to ensure GP views are heard - but it has been let down by the failure of GP organisations to engage, says Dr Rubin Minhas. But Dr Simon Bradley argues NICE is a flawed organisation that panders to the interests of specialists and lacks the overarching, generalist perspective

NICE has led the way in the transparency of its processes and has built in checks to ensure GP views are heard - but it has been let down by the failure of GP organisations to engage, says Dr Rubin Minhas. But Dr Simon Bradley argues NICE is a flawed organisation that panders to the interests of specialists and lacks the overarching, generalist perspective

In recent years bodies such as NICE have pushed forward the boundaries of public participation in the deliberative process and shown a commitment to transparency. The way the QOF was developed had come to look anachronistic. So it was natural that the body responsible for setting clinical standards would be asked to develop indicators that measured the progress of those standards. Some might call that joined up policy - it was such a good idea that it had the quality of inevitability. The sceptics are in a minority and history has not been on their side.

NICE's experience in developing guidelines will be an asset. It was established to widen the net of engagement beyond the usual vested interest groups who, through the strategy of 'he who shouts loudest', were undermining the coherence of the NHS. The institute has reached beyond the specialist societies, the most mysterious and arcane elements of our profession. I recall being involved as a GP in submitting comments to a major guideline drawn up by a number of specialist societies and being told: 'this guideline is for real doctors'.

But I've worked extensively with NICE for six years and seen the commitment of its people first hand. It's probably one of the most challenging jobs in healthcare. NICE is a credit to the NHS and since the beginning it has been supported by GPs. People such as Dr John Robson, Dr Paramjit Gill, Professor Gene Feder and Dr Peter Brindle have been visible leaders for general practice.

NICE has won plaudits for producing practical guidance in the rarefied world of health policy. Unfortunately, the benefits of its guidance have not fully materialised for patients, and some of its better guidelines have been overshadowed by the more controversial ones. Even its uncontroversial guidelines have struggled to gain the attention of funders, with their status being regarded as worthy but not necessary. But now, with NICE taking responsibility for the QOF, there is an opportunity (and a motive) for all GPs to engage with the institute. The QOF cannot work if people find it unworkable. Traditionally, GPs have had little input into NICE as they tend to be focused on delivering care, regarding the institute's work as bureaucratic or academic. This has been compounded by

a lack of incentive for GPs to take part and the failure of PCTs to make GP involvement a priority. Consequently, clinical membership of NICE committees has been dominated by specialists, academics or public health doctors.

As someone involved in developing three separate NICE guidelines, I have seen how ineffective our GP organisations have been in providing feedback into consultations. Often, organisations such as the RCGP have not provided any comments at all, leaving the void to be filled by the vested interests.

There will be a steep learning curve before the new system operates satisfactorily, but under the design of the NICE model, GP feedback will be an important check and balance. The challenge for the small group of GPs who have taken on the unenviable task of putting the institute's QOF recommendations together is considerable.

Ultimately, GPs have a responsibility and a self-interest in making sure NICE gets it right. The job for NICE is simple: to listen and ensure that the success of the past six years is uninterrupted.

Dr Rubin Minhas is a GP in Gillingham, Kent and cardiology lead for Medway PCT

NICE is fundamentally flawed. Now don't get me wrong, if NICE didn't exist I would have to invent it. But it does exist and I would still reinvent it.

NICE is a SHA, a quango responsible to the health secretary. Its original purpose was to end the postcode lotteries that so embarrassed politicians. But over the 10 years since it was founded it has come to see itself as the sole source for NHS best practice guidelines. This creep in its scope has taken it from producing technology appraisals, assessing the cost-effectiveness of medical interventions, to providing benchmarking tools to measure, rate, and now reimburse, clinicians.

PCTs cannot see the guidance in the guidelines and seize NICE pronouncements as if from the one true God. Clinical practice becomes either the NICE way or the wrong way and individualised care is damaged by NICE fundamentalists who are unable to question its utterances.

That might just be OK if it the guidance had a breadth of perspective, recognised that 86% of patient management is undertaken in primary care, and represented us proportionately. The number of GPs in the NHS exceeds the combined number of specialists, so GPs should be at least equally represented within NICE committees. Nothing could be further from the case. NICE is specialist heavy from the top down.

Surely an organisation whose brief is to look at the whole of medical care from the use of donated human breast milk to spinal cord compression would be led by generalists? No. There is just one practising GP on the NICE board of 14.

So if not on the board, general practice must be represented elsewhere? What about the partnership board that oversees the NICE annual report? Sorry, no - nine consultant representatives and just one from the RCGP, who appears not to have attended since 2006! You would probably think the four guideline review panels would have at least one GP on each? No. There are just two GPs out of 16 members, leaving two panels with no GP input. But don't worry, because big pharmaceutical companies have four members, one on each panel. We can all rest easy.

The real work of NICE is done in the guideline development groups. NICE slices and dices the longitudinal care of people with undifferentiated needs and multiple illnesses. It drafts in experts on the segments and calls them a guideline development group. It then tells us what to do because the experts know best.

Let's look at the latest guidelines for antisocial personality disorder that specifically state they include the care of patients in general practice. One hundred and sixty-seven stakeholders are identified including the British Association of Art Therapists and the Association of Dance Movement Therapy but only one GP organisation, the RCGP. The guideline development group has 13 members, 10 of whom are secondary or tertiary care specialists and just one a GP - a GPSI in prison medicine.

What really makes me laugh fit to cry is the skewing that occurs when someone dedicates their life to a specialism that nourishes, clothes and houses them intellectually, professionally and physically. Seeing day in day out the pain and trauma of antisocial personality disorder on patients and their families, and the inadequacy of resources, cannot but make them evangelists for their cause and give them an over-inflated weighting of their specialism. Experts lack general context. Could we expect them then to energetically seek out and publish evidence that might show everything they have ever worked for is a sham? Being an expert in NICE almost inevitably means you are subject to a catastrophic conflict of interest. Maybe that explains why one of the recommended treatments in these guidelines acknowledges it is based on belief, or that no high-grade evidence exists.

Experts of course have a much greater pool of detailed data on patients with their condition and almost inevitably believe they are more able than the generalist to deliver care. But holistic GP care can deliver an outcome better than the sum of the expert's parts. This is recognised in the current NHS push to provide more care in the community, yet the expert-driven structure of NICE serves to drive more care in the opposite direction.

Nothing could more clearly demonstrate that GP generalists are desperately needed, in numbers, to put NICE guidelines into context and proportion. Without this, NICE will remain fundamentally flawed and unfit for purpose.

Dr Simon Bradley is chair of Avon LMC

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