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GPs go forth

Guidelines exist to help, not hinder, GPs

Letter from Professor David Haslam, NICE chair

For over 350 years, science has progressed at an extraordinary rate.  This progress is based on challenging the status quo and questioning perceptions. So I was delighted to see Nigel Praities’ New Year editorial ('My vision for 2017? Let’s ditch guidelines for a start') calling for a year of 'no-holds barred discussion about where general practice is heading'.

We want them to be a source of support

Of course, we should continuously consider ways to improve, to do our jobs more effectively and efficiently. Open debate helps bring new ideas forward and creates opportunities to innovate and improve. And although I welcome the challenge to justify the use of guidelines in general practice, unlike Nigel, I believe they are essential to support doctors in their day-to-day work.

General practice is extraordinarily complex. It requires a depth and breadth of knowledge, an ability to synthesise and adapt to an ever changing world, and, of course, great resilience.

Having spent a working lifetime as a GP, I now chair NICE, the National Institute for Health and Care Excellence, one of whose central roles Nigel would like to abolish: guidelines.

NICE doesn’t produce guidelines to hamstring primary care. We want them to be a source of support. And if we didn’t produce them, either family doctors would have to read all the new research and evidence, or rely on someone else to do it. Every GP is focused on the quality of care for patients. But how can patients’ expectations be met without a credible and independent review of the evidence and conclusions drawn by experts? Our guidelines help GPs to offer safe and effective care.

To write them, we identify the issues the guideline is intended to address, pull together the best evidence from around the world, convene an independent committee of experts – including GPs and lay members – who deliberate on the evidence, synthesise it into practical recommendations, then we consult on the draft. It is an extremely thorough process – underpinned by evidence and expertise.

The final guideline is not the final word on how to treat someone. It is an important factor which should be taken into account with the preferences and values of the patient. But the responsibility for treating the particular patient and their particular circumstances must and does rest with the clinician.

Last year, we produced a wide range of important new guidelines and standards, and many of these cover the conditions and diseases GPs deal with day in, day out. Others were in areas where a GP may have referred a patient on but where they can find out what good care looks like for the person at the receiving end.

In September we published our much anticipated guideline on multimorbidity – which is rightly praised in Nigel’s editorial. The guideline cannot hope to detail every single combination of condition which a patient may present with. It sets out how we should put patients with complex health issues at the heart of decisions about their care, including how to decide between different medicines and treatments. 

We aim to have at least one GP on every guideline committee. They have helped to produce widely welcomed guidance on sepsis, managing menopause, end of life care (for both adults and children) to name a few.

GPs have played a key role in improving our draft guidance on asthma diagnosis and monitoring. When GPs raised concerns about the practicality of implementing this guidance in primary care we halted publication and began work on a new project to test the recommendations in question. The support from primary care teams in this project has been outstanding. Seven primary care sites across England, which use different asthma service delivery models, were recruited to the project and their findings will be considered before the guidance publishes in the summer.

Every year, GPs are involved in helping us to improve. They become a member of our independent committees. They comment on our draft guidance, join the NICE fellowship, take part in debates at our annual conference or public board meetings. I often hear how rewarding working with NICE is.

I would urge any GP to work more closely with us – creating guidance that will support family doctors, the people working with them in primary care, and most importantly helping to provide the best care to patients and their loved ones. You can visit our website to find out more.

Professor David Haslam is Chair of NICE. He is also past President and past Chairman of Council of the RCGP, and past President of the BMA

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Readers' comments (16)

  • Haslam, do you not realise that many such as NHS ENGLAND and others use "guidelines" to beat us over the head with.

    They "corrupt" guidelines.


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  • I'm sorry David.
    I can see that these guidelines may be produced with the 'best of intentions' and draw from 'the best evidence from around the world'.
    But we are not from 'around the world' we are fronting up the NHS which has very limited resources. There are unfortunately far too many of these guidelines. And far too many of them are poitless crap as applied to the real world. They are seen by many GPs to serve no other purpose than to make us cannon fodder for legal teams.
    There may be a need for some guideleines, but in the main I'm with Nigel on this one.

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  • Does anybody else remember Grange Hill and its character Janet St Clair who bleated to the portly kid "I'm only trying to help you Ro-laaand"?

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  • Dear David, a valiant attempt to justify NICE's role, if you truly believe what you write, you need also to tell the world, and embed into every guideline that THESE ARE GUIDELINES NOT TRAMLINES, regards

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  • The advertised principles of NICE are indeed noble, to guide clinicians, including GPs, through the wealth of evidence, highlighting nuggets of important information. The ideal of 'guidelines' guiding generalists through the maze of specialist data to help them make decisions is all very well, but the majority of people understand the term by its dictionary meaning- "Guideline=a general rule, principle, or piece of advice" (Oxford English Dictionary)

    There is a fine line between a guideline and a protocol. Indeed it is easier to compare decisions made to guidelines than it is to try to assess the complexities of an individual situation and environment to judge a clinician's actions. We see this far too often in GMC FTP and court judgements against GPs, where 'guidelines' are treated as protocols and standards of care.

    Guidelines may be intended as helpful pointers to aid decisions, but the all too real, though unintended, consequences are top-down control of decision-making, loss of autonomy, and impaired ability to use judgement for fear of vilification and punishment. And as young GPs come through training, such an emphasis on guidelines is detracting from them developing the skills needed to make complex judgements in individual situations.

    My suggestion is to get away from the directive term 'Guideline', and instead label them as the treatment 'suggestions' they are intended to be, making it clear to all that judgement in individual situations is imperative to how they are used.

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  • Dear David,

    Here is an example of what I went through:

    I was reported to the Ombudsman for failing to refer a patient to Dermatology. I sucessfully treated the condition, but this patient had a relative that had a history of recurring complaints to all services. She checked on line guidance and reported me. I went through two years of hell. By the time the Ombudsman reached his decision the complaint was upheld even though by then the NICE guidelines had changed and under the new guidelines had a similar condition been seen I would have been following NICE guidelines! I do have a lot of experience in Dermatology.

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  • We were subjected to 14 months of investigation by NHSE following a malicious referral - the outcome being that 'there was no evidence of poor practice and numerous examples of very good practice.
    Of note, the Terms of Reference for the investigation stated that the practice was expected to be 'NICE compliant'.
    Assessment of NICE compliance was a major part of this process, with investigators seizing on any supposed deviation from guidance.
    In one case I was criticized for treating an 82 year old nursing home resident with a chest infection with antibiotics, as guidance supposedly recommended 'watch and wait'. In fact, the patient had been admitted with pneumonia within the last year, so my action fortunately could be shown to have complied with guidance.
    In another case, I was criticized for arranging blood tests for a patient with symptoms of fatigue, as NICE guidance on the management of fatigue in adults recommends waiting a month before investigation. We pointed out that NICE guidelines on the management of chronic fatigue syndrome do not apply to an 80 year woman with a history of ovarian cancer and hypothyroidism.
    I could provide several more examples of over-zealous application of NICE guidelines.
    The point is that compliance with NICE guidance was obviously considered mandatory, and any deviation from the guidance was evidence to be used against the practice and individual GPs.
    So thank you Professor Haslam, in the real world there is a very significant hazard to all GPs from this misapplication of NICE guidance, and I would consider that in this respect at least it significantly hinders rather than helps your colleagues.

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  • I can also see the current trend towards a 'Guideline Culture' in medicine creating even more problems for the government and NHS with redesigning service and reducing unnecessary work and costs. Reducing A+E attendences, acute admissions and outpatient referrals will require a strong base of GPs to enable management quicker and closer to home. The GPs are already very knowledgeable and skilled, and perhaps GPs with Enhanced skills and knowledge in, for instance Dermatology (such as Tony). But they need to be empowered, trusted to want to take on and develop such roles, and supported by the RCGP, professional bodies (GMC), the law and courts,government,society and the other bodies whose actions and publications impact on the work we do, including NICE. Keep on piling on more guidelines thinly pained as advisory but treated by higher bodies as protocols on to GPs, and those aims of shifting the balance of healthcare closer to home will never be met. Youve set up a no-win situation

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  • Of course GPs need guidance. But we need GP guidance. Guidance made by GPs for GPs. The GPs who sit on NICE committees go "native". I know because I am a CVD Lead for the CCG and I know that GPSIs can occasionally become detached from grass roots general practice.

    The problem with NICE is that it is quoted by every lawyer, every complaints authority and every external agency under the sun and they form part of the prosecution case against a doctor.

    What can be done about this?

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