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New sheriff lays down law on NICE

The new Care Quality Commission is threatening to refuse GPs their mandatory registration if they don't follow CVD guidance. Will the regulator's heavy-handed tactics succeed in 'raising the bar' – or is it just throwing its weight around to show who's boss?

The new Care Quality Commission is threatening to refuse GPs their mandatory registration if they don't follow CVD guidance. Will the regulator's heavy-handed tactics succeed in 'raising the bar' – or is it just throwing its weight around to show who's boss?

There's no shortage of national bodies jostling to tell GPs what to do. The National Patient Safety Agency advises on safety issues, the National Prescribing Centre on use of drugs and the NHS Institute for Innovation and Improvement is keen to stick its oar in to promote efficiency and cost-effectiveness. And then of course there is NICE, the daddy of all the clinical advisory bodies, which not only gets to decide which drugs GPs use and how, but nowadays also has a say in how much GPs should be paid for using them, via its key role in shaping the QOF.

But now there's a new sheriff in town. The Care Quality Commission, the Government's health and social care regulator, has just issued its first report on the quality of care in general practice. It's not been the quietest of entrances, as tends to be the norm for the organisation's colourful chair, Baroness Young. The CQC, which has a remit to audit care and give a kick up the backside to those who are not up to scratch, seems to have adopted a specific role in ensuring NICE guidelines are implemented in full. Its new report, on cardiovascular disease, details a series of recommendations for how NICE should change the QOF to force its guidelines into practice, including raising payment thresholds for indicators on cholesterol management, introducing a range of indicators to support screening and reducing the length of time between cholesterol measurements.

All those suggestions have clinical merit, of course, and if GPs are to take part in a vascular screening programme, it will make sense to ensure they are properly reimbursed. But there are also enormous problems in terms of protocol with the CQC setting out such a specific programme for the future of the QOF, particularly with similar recommendations likely to follow in further disease areas.

NICE already has a detailed set of procedures to make sure any new QOF indicators it recommends are workable in practice and have the support of GPs. The institute recognises changing the QOF is enormously complicated and requires the framework to be examined as a whole – not one clinical area at a time. There are a huge number of potential indicators – each with its own cheerleaders – but the job of NICE is to sift through the evidence for each and make a final decision about what will bring most benefit for the money. And as for ramping up payment thresholds, all parties agree this is not a job for NICE at all, but to be negotiated between the GPC and NHS Employers.

The CQC's blunt demands for changes to cardiovascular care ride roughshod over this process. But they are likely to prove hard to ignore, as the CQC has made it clear it will be prepared to deny registration to practices that do not deliver on its newly identified priorities. If that happens, the era of compulsory NICE guidance will have arrived, and with it, a new level of restriction on GPs' clinical freedom.

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