GPs denied clinical freedom by lack of accurate drug risk data

GPs cannot make an informed clinical judgment on whether to prescribe preventative treatments to patients unless NICE makes risk prevention data on drugs clearer, leading GPs have told the institute.

NICE chief executive Andrew Dillon

In a debate at the NICE annual conference on whether the institute is ‘working’ for general practice, senior GPs also stressed that guidance should be made simpler to help the profession find relevant information at a glance during busy 10-minute consultations.

NICE chief executive Sir Andrew Dillon said that NICE was looking for ways to make guidelines more ‘usable’ for GPs.

This could include simple, two-page PDF versions of guidelines and greater use of decision aids to make guidance clearer.

GP clinical judgment

Dr Julian Treadwell, vice chairman of the RCGP’s over-diagnosis group, added that NICE needs to make the specific risk reductions of recommended treatments clearer, otherwise it is ‘taking away [GPs’] clinical freedom’.

He pointed to three common preventative treatments recommended by NICE: steroid inhalers to reduce flare-ups in COPD patients, BP-lowering drugs to prevent strokes and osteoporosis drugs to prevent hip fractures.

‘Sometimes we wonder whether multiple drugs are the best option for our frail, elderly, multimorbid patients,’ he said. ‘Or we might be concerned about the possible risks and harms of the drug.

‘To make a good judgment here, we need to know how much of a preventative effect the treatment has, not just whether they prevent or don’t prevent the outcome.’

Risk prevention

Of the three preventative treatments, all have an absolute risk prevention of just 2% or lower after a number of years on the treatment, he said – meaning just a handful of patients taking the treatment will reap the benefits.

‘There is nothing inherently wrong about a 2% benefit, but we do need to know roughly what sort of a ballpark of effect size we’re in if we’re to give our patients a reasonable choice. And I think it’s fair to say that most GPs don’t have these sorts of statistics, and nor is it very easy to access them when you look.

‘This sort of evidence needs to be brought through to the guideline’s front page. If we have this sort of information, we’re able to make more nuanced, personalised recommendations.

‘If we don’t have this information, then the value judgment actually is being made in the guideline development group and we end up feeling like we’re practising with no clinical freedom and following a yes/no guideline.’

NICE guidance overload

Dr Alistair Blair, chief clinical officer at Northumberland CCG, added that GPs are struggling to keep up-to-date under a constant ‘steady drip of new guidelines’ and are struggling to keep up with the heap of demands and implications.

He said: ‘A lot of GPs love one-page, two-page guidelines, so they're not having to go down to page 20 to find the information they need. If you're in a consulting room, you want the snappy answers.’

NICE chairman Professor David Haslam said he understood how the release of guidance could be overwhelming for GPs. ‘I spent 36 years as a GP, so I'm completely aware that the number of topics you have to keep on top of is huge,’ he said.

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