Professor David Haslam: ‘We are not in cloud cuckoo land’
At Pulse Live in April, Pulse editor Nigel Praities grilled NICE chair Professor David Haslam on the institute’s proposals for statin treatment, his hopes for the QOF and fears over GPs’ increasing workload
There has been a lot of debate around NICE’s proposals to halve the primary prevention threshold for statin treatment. Will you reverse your final decision if the feedback is not supportive?
NICE genuinely takes on board all consultation responses and the views that are fed back to us will back final decisions. We have to strike a balance and look at what the question was that we were asked to consider. With the particular issue of lipids it is about looking at the cost-effectiveness and whether the risks and benefits have changed.
Do you look at the implications for practice workload when drawing up guidelines? For example, when recommending to halve the primary prevention threshold?
The committee certainly looks at the impact. In terms of the specific GP workload, to be honest with you, I simply don’t know [for the lipid modification guideline]. But this is not cloud cuckoo land – completely separated from the real world of the busy doctor. Otherwise, why would we want to do the job?
But cost-effectiveness does not necessarily mean it is practical. Is that part of NICE’s remit?
If we look at the QOF, NICE’s role is very clear; to look at what the academic evidence is for any given activity, to look at other metrics that are measurable and whether it is worth doing. What we have done in the past is produce a nebula of things that the GPC and NHS Employers can negotiate in terms of the impact on general practice. What we are producing is the evidence base for the negotiators to work their way through.
Do you see a role for NICE to also come up with lists of things that GPs shouldn’t do?
Yes, absolutely. Everybody involved in the NHS at the moment is struggling with the fact that there is too much to do, too little time to do it in. There needs to be more of a shift towards encouraging self-care among patients and more of a genuine partnership between doctors and patients in terms of sharing the options, benefits and risks. We certainly know with things like cataract surgery and a lot of orthopaedic surgery that if you really go through what the benefits are of the operation, around a third of people choose not to have it. There is a huge bunch of stuff that is done and does not need to be done.
Is this something that NICE is looking at?
Yes very much so. In fact, on our website there is a list of ‘do nots’ and we are trying to focus on these as much as possible. I think it’s an important area. The critical thing is taking the public along with you.
What will NICE’s role be in relation to the QOF this year?
That discussion is yet to be had. Our role is the academic role – looking at the evidence, the benefits, the risks, the opportunities and where it will be in the future.
‘I see the QOF as something that has been fundamentally a good thing, but like most drugs, it has side-effects’
What do you think about practices in Somerset preparing to drop the QOF completely?
The QOF has certainly had a massive beneficial impact both on patient care and on GPs. The question is whether it has also affected the whole way that general practice is done, with it not always being as helpful as it could be. There is no doubt that points mean prizes and there are boxes to be ticked.
What bothers me is when the patient’s agenda gets contracted to the time available to it because people are concentrating on the QOF. So I see the QOF as something that has been fundamentally a good thing, but like most drugs that are introduced to bring in a benefit, it has side-effects. Sometimes you don’t get the side-effects until years later and you have to balance the benefits and the risks and work out which is the best way forward.
Are you worried about GP workload in general? Do you think we are reaching a tipping point?
I’m not close enough to answer the tipping point question. But I know most of the GPs that I meet are struggling – they are drowning in work. It is that feeling of being in control, or out of control, which is one of the drivers for burnout.
So I am really bothered by the number of doctors who seem to be drowning in work and we have to find a way of supporting them, of ensuring that patients get the best quality care. It drives me absolutely mad when I see newspapers criticising GPs for access issues, which are a real problem for patients, without accepting that the reason that access is poor is because doctors are working frequently 12 hours a day. It is not that they are twiddling their thumbs and counting the vast amount of money some newspapers claim they are making.
Is there a way of changing that?
Yes there is – through the leadership of general practice, particularly Dr Chaand Nagpaul [GPC chair] and Dr Maureen Baker [RCGP chair]. I believe that the secretary of state understands this as well. Having talked to Jeremy Hunt, I believe he is genuinely a fan of general practice.
I have also stressed throughout my career to every politician I have worked with that without the quality of general practice, the NHS cannot survive. So it is critical to get politicians to understand our extraordinary ability to absorb the uncertainty and to focus on the things that need focusing on.
Will NICE recommend more indicators to remove from QOF?
I don’t know where those negotiations have got to. Dr Colin Hunter [chair of NICE’s QOF advisory committee] presented to the board last month about the history of QOF, so the board was au fait with the impact that it has.
Should the price of drugs be printed on prescriptions?
No. I don’t want to worsen health inequalities and I believe it would frighten off the wrong people. If my 93-year-old mother-in-law knew the cost of her pills she would stop taking them and say it’s not fair on the system.
Should doctors see NICE guidelines before the public?
No. Unless you want us to email every doctor on a secure server before everything goes public. I understand the frustration, but I think the way forward is openness and for patients and doctors to work together.
Should politicians avoid promising too much?
You can’t take the politics out of something that consumes nearly 10% of the UK’s gross domestic product. I think it behoves medical leaders to point out that we can do whatever they want, but they must tell us what we should stop doing.