How NICE plans to reshape general practice

Professor David Haslam, the new chairman of NICE, believes technology is the key to integration. Stephen Robinson reports.

'I'm passionate that NICE's work should become much more relevant to GPs,' Professor David Haslam told the institute's annual conference this month.

The vow from the new NICE chairman and former GP is one of several changes to how NICE works that will affect primary care over the coming years. With GPs increasingly expected to practise what NICE prescribes, these changes will mould the evolution of general practice.

The institute, now recategorised as a non-departmental government body, has been given the task of replicating its evidence-based advice on healthcare for England's social care system and integrating the two systems, along with public health guidance.

Add in quality standards, value-based pricing, CCG performance targets and the QOF, and it is clear the recent exponential growth in published advice and recommendations is likely to continue.

This prediction may make GPs cringe: many already see the sheer quantity of NICE guidance for primary care as overwhelming.

Spearheading change

Professor Haslam, formerly chairman of the RCGP, was appointed in April to spearhead these changes. Speaking to GP at NICE's conference in Birmingham, he acknowledges that digesting the guidance must be made easier for busy GPs.

Professor Haslam believes technology is the answer. 'As far as NICE is concerned, I think the quality of our products is exceptional; the rigour they've gone through,' he says. 'But I'm also aware that in a brief consultation, it's vital that we work out a better way of integrating guidance with GP computer systems.

'Now, what that doesn't mean is a bunch of templates that you have to fill in. But it does mean real-time support for doctors at the time they are faced with the patient, where they can be linked with what best practice is at the time. We have to take on board the use of technology to address this, otherwise, there's too much information.'

The recent growth of NICE's public health advice raises the spectre of reams of extra guidelines for general practice to follow - unpalatable at a time of workload strain.

Professor Haslam says greater GP involvement in wider public health work is inevitable, but insists NICE will do its part to make sure the profession is not burdened with recommendations. 'GPs at the moment feel they are almost overwhelmed by the amount of work they are doing, so simply adding more tasks is not something many practices are going to welcome,' he says.

Delivering healthcare

'But I am aware we're at the beginning of a real change in the way healthcare is delivered. I think the boundaries between primary care, secondary care and public health are going to change really quite dramatically,' he says.

'The whole public health remit and where that fits into the world of local authorities, CCGs, and health and wellbeing boards, again, it's all to play for at the moment. I don't know how this is going to fit, but I don't want GPs to feel this is yet another thing to add to an already over-busy day. We have to work out a better way of getting this all joined up.'

His colleague, NICE deputy chief executive Professor Gillian Leng, also a former GP, says in future, NICE's health guidance for GPs will be far more integrated with other areas such as social care, on which NICE has been asked to provide advice.

'Hopefully, GPs will get a more integrated set of guidance, as GPs are crucial to integration. We are aiming to integrate our health and social care work to make it look more seamless,' she says. 'But it's about making sure it's framed in language that meets the requirements of GPs and the social care setting.'

Professor Leng says NICE's early work has uncovered medicines management in care homes as an example of an area that needs better ties between health and social care. Here, there is often confusion about who is responsible for prescribing.

'A lot seems to relate to the fact that people in care homes are on a large number of medicines,' she says. 'There's clearly an issue about reviewing what those individuals are taking, and reviewing whether these are administered appropriately.'

Social care

Designing social care for patients recovering from a stroke, for example, may not directly require input from GPs, but it is 'important they see the big picture', she says.

What all this means for everyday GP work is unclear and the profession cautiously awaits the first social care guidelines, due by early 2014.

Multimorbidity is one of the key challenges posed by the ageing population, and this formed a cornerstone of Professor Haslam's opening speech to the NICE conference.

In it, he explained: 'The spectacular demographic changes this country is facing ... inevitably means multimorbidity is the norm, and generalism becomes ever more important.'

Professor Haslam admits that NICE faces a challenge to accommodate this complexity in its guidance, but says this is essential if guidance is to become more meaningful to primary care. 'I've talked many times about patients with heart disease, kidney disease, arthritis, depression, where working out what is good for that individual is quite complex.

'You have to work out a way of not just adding guidelines and guidance together, because you end up with something that is almost certainly the wrong answer for an individual.

'But how we're going to come up with that answer, I don't know. I'm committed to doing it, because I know it's what GPs need from us and what patients need from us.'


Profile - Professor David Haslam

'I realised a long time ago,' says former GP Professor David Haslam, 'that having a meeting with a minister or a senior civil servant was exactly the same as holding a consultation at a practice.'

Professor Haslam believes his time in general practice was perfect preparation for his newest challenge as the chairman of NICE.

He believes there are clear parallels between dealing with patients and with politicians. 'You have to explore their ideas, concerns, expectations. In general practice, talking to someone where it really matters is the most remarkable training for a role like this.'

Professor Haslam was once a GP in Cambridgeshire, but now is perhaps best known for his roles as RCGP chairman in 2001-4, college president in 2006-9 and BMA president from 2011 to 2012.

He currently advises the government through his position on the National Quality Board, and is a visiting professor in primary healthcare at De Montfort University in Leicester. Author of 13 books, mainly on health, he was awarded the CBE in 2004 for services to medicine and healthcare.

In April, he took over the helm of NICE from Professor Sir Michael Rawlins, who has won acclaim for steering the institute for the 14 years since its inception in 1999. Professor Haslam says Sir Michael gave him 'a lot of advice' and was 'extremely supportive' during the handover. 'He'd been in the role as chairman for 14 years and I could not praise him more, he's done a remarkable job,' he says.

He describes his first six weeks in the role as 'fascinating' and says it is 'very interesting' that NICE appointed a former GP to the post. 'It's a measure of the centrality of primary care in so much of what's going on in healthcare delivery and policy,' he says.

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