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NICE guidance must pass the ‘10-minute test’



I recently watched a wonderful presentation by former RCGP president Dr Iona Heath on how ‘less is more’ in medicine. She made a powerful case that intervening less is often better for patients and doctors and I was reminded of this maxim when I came to write this editorial.

Less is most definitely more in the case of clinical guidelines, but this is a message the brains at NICE have yet to understand.

Today we look at the increasingly bizarre and impractical recommendations emerging from the institute. We make the bold claim that recent guidelines risk turning NICE into a ‘laughing stock’, rather than a respected source of tools for GPs to use in daily practice.

While the world around it tries to make life simpler and easier to navigate, NICE seems intent on making its guidelines more complex, less grounded in reality and – at times – almost comically out of touch.

Take the recent draft guidelines on diabetes, cancer and asthma. NICE’s decision to recommend repaglinide as an alternative to metformin was described as ‘bonkers’ by one prominent diabetes GPSI. The recent draft cancer guideline is hopelessly complicated, with table after table of symptoms and recommended actions for GPs. The latest guidance on asthma urges GPs to use a battery of tests to diagnose asthma – not all of which are routinely available in either primary or secondary care.

These are major clinical areas for primary care, and adherence to NICE guidance is a yardstick by which practices are measured, but the institute is issuing advice that is neither sensible nor practical.

Most patients do not have a neat single diagnosis, yet despite promises that NICE will address the issue of multimorbidity, GPs now have even more guidelines with reams of flow charts and bulleted lists to follow for individual disease areas.

Of course, NICE has always pushed boundaries and some of its recommendations will inevitably cause a stir. It has tried to include more GPs on guideline groups and its job is to look at the evidence and make recommendations; implementation is not its remit.

But NICE must consider the effect of its work on practices, particularly at a time when they are under such strain. What use is a guideline if it just ends up on a dusty shelf, rather than becoming an instrument for improving patient care?

NICE needs only to look to Scotland to see how to do it. SIGN has managed to chart a course between robustness and pragmatism that means its guidance is hardly ever met with the heated controversy so often seen south of the border.

There need to be far better incentives to ensure that more GPs are involved in forming guidelines. There should be a ‘rationalisation stage’ where a panel of GPs has the chance to go through a guideline and ensure any batty proposals are removed and that the whole thing passes the ‘10-minute consultation test’.

GPs’ views must be heeded at the consultation stage. The furore over the recent halving of the primary prevention threshold for statin treatment barely made a dent in the final guideline.

At that time, my predecessor invited NICE to come down from its ‘ivory tower’, but if anything, the institute has disappeared further up it.

I urge NICE to listen to GPs. Guidelines should be a help, not a hindrance, and NICE risks becoming a bad joke unless it revamps the advice is it giving.

Nigel Praities is editor of Pulse