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Revealed: trusts block GPs' choice over BP drugs

GPs are being barred a choice of first-line treatments for hypertension by cash-strapped primary care organisations in a direct challenge to new NICE guidelines.

A Pulse investigation reveals 55 per cent of PCOs aim to restrict GPs to use of diuretics as main first-line drugs – even though NICE gives calcium channel blockers equal billing.

A third of these have released local guidance giving the impression of being in line with NICE while omitting calcium channel blockers as a first-line option.

The move ridicules the institute's attempts to end postcode lotteries in use of drugs and threatens to leave patients exposed to an unnecessary risk of diabetes.

It reflects widespread alarm among PCOs over the cost of implementing the hypertension guidance, with 73 per cent expressing concern that increased use of calcium channel blockers would send costs spiralling (see chart, right).

Hypertension experts insisted any local divergence from NICE had to be clearly marked.

Professor Bryan Williams, professor of medicine at the University of Leicester and member of the NICE hypertension guideline group, said: 'Local guidance should make it absolutely clear what represents the official output from NICE or the BHS and what is local interpretation.

'There are examples where this has been done very well and others where the distinction has been less clear.'

Professor Williams added that NICE had found calcium channel blockers and diuretics were equally cost-effective in the long-term because of the increased risk of diabetes with diuretics.

Of 44 PCOs surveyed by Pulse, 24 had issued, or were planning to issue, local guidance recommending diuretics first-line for white patients over the age of 55.

In many cases, local bulletins reported that NICE advised diuretics first-line without mentioning calcium channel blockers were also recommended (see box, left).

Other bulletins appeared to reproduce the NICE treatment algorithm – but with calcium channel blockers removed.

But PCOs denied accusations they had misrepresented NICE.

Andy Hutchinson, head of medicines management at South Leeds PCT, which claimed NICE listed calcium channel blockers as an 'alternative' to diuretics, said: 'Our local interpretation is clearly marked.'

pulse@cmpmedica.com

How PCOs are distorting guidance

What nice says

'In hypertensive patients aged 55 and over, or black patients of any age, first choice of initial therapy should be either a calcium channel blocker or a thiazide-type diuretic.'

How PCOs describe the advice

Leeds

'NICE and BHS recommend thiazides as first-choice treatment in most people with hypertension. Calcium channel blockers are an alternative.'

Denbighshire

'NICE June 2006 recommends a thiazide for newly diagnosed hypertensive patients over 55 years of age.'

Caerphilly

'Thiazide diuretics are endorsed by NICE and BHS as first-line treatment option for most patients.'

Bedfordshire and Hertfordshire

Algorithm under headline

'Extract from the Nice Clinical Guideline' has thiazide diuretics first-line and calcium channel blockers as third choice where there is risk of new-onset diabetes.

South Derbyshire

A page headed 'NICE Guidance

34 on Hypertension' features an algorithm identical to the institute's – except for the omission of calcium channel blockers as a first-line option.

GPs angered by drug restrictions

GP reaction

GPs have strongly criticised moves by PCOs to attempt to restrict hypertension drugs choice.

Dr Pravin Shah, CHD lead for South Stoke PCT, said some local guidelines were clearly misleading. 'PCTs are narrowing the field in so many areas. It is wrong and a misrepresentation of NICE guidance. Calcium channel blockers are effective and cost-effective.'

Dr Ahmet Fuat, a GP in Darlington and deputy chair of the primary care cardiovascular society, said: 'PCTs should make it clear what are NICE recommendations and what is their interpretation. To a certain extent by leaving out calcium channel blockers they are doing a disservice to patients. The choice is there for a reason.'

Dr David Bailey, a GP in Caerphilly, where the local health board is pushing GPs towards diuretics, said he would ignore the local guidance. 'If there is any suspicion trusts are driven by their wallets rather than patient care, GPs will stick to the national recommendations.'

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