When health minister Lord Ara Darzi first unveiled his plans for NICE to become involved in developing the quality framework, GPs voiced concern that its integrity would be damaged beyond repair.
Four months on and GPs are still fuming. Dr Terry McCormack, former chairman of the Primary Care Cardiovascular Society and a GP in North Yorkshire, warned it would be dangerous to link NICE, a body focused on cost, with the evidence-based quality framework.
Ironing out conflicts
But Professor Sir Michael Rawlins, chairman of NICE, is not put off by the criticism, and insists that the involvement of his organisation in developing the next quality framework will benefit GPs.
'There are crinkles between what is in the quality framework and what is in NICE guidance,' he says. 'We need to sort this out and NICE's involvement in the quality framework will help.'
The current situation, where quality indicators and NICE guidance conflict, places GPs in an impossible situation and is not good for patients, he says.
Sir Michael is quick to dismiss claims that NICE will damage the quality framework by shifting its focus from clinical effectiveness to cost.
'We have to look at the clinical effectiveness, as this is the most important thing. But if something is not clinically effective then it is not cost-effective either.'
One of NICE's main aims when it was set up in 1999 was to bring to an end the 'postcode lottery' of healthcare across England and Wales. Sir Michael says NICE has made major inroads, but more work is needed to eliminate these variations.
Including NICE indicators in the quality framework would ensure that all practices are following the same guidance and could bring this goal closer, he says. But he adds that local indicators could also feature in the framework.
'Some parts of the country have a bigger problem with smoking than others, for example, so an element of local variation seems to be very sensible.'
Sir Michael points out that primary care clinicians should not be criticised for not always implementing NICE guidance.
'We have not made it obvious or signposted the guidance relevant for primary care,' he admits. 'Quite a lot of our guidance spans across primary and secondary care, but we want to make sure that we tease out what is important for primary care.'
Sir Michael adds that although integrating NICE guidance with the quality framework will create strong incentives for GPs to follow it, the aim is not to force clinicians to stop using their own judgment. 'I want people to use NICE guidance because it is the best thing to do,' he says.
'I am particularly proud of the guidelines developed for mental health, in particular the guidance on schizophrenia.'
He points out that NICE advice has been adopted in parts of Europe and the US.
But to get more GPs to use NICE guidance, the organisation needs to become more user-friendly and engage GPs more effectively, he says.
A doubling of the money invested in NICE, announced as part of the Darzi review, will go some way to achieving this.
'The introduction of NICE fellows will help to implement NICE guidance,' says Sir Michael. He says that much of the change to NICE guidance is incremental and evolutionary, but these advisers will help clinicians adapt when a genuine step change occurs.
'They will be clinicians such as GPs, working part-time, who would help to engineer these big step changes.'
NICE has also been asked by the DoH to set up NHS Evidence, a one-stop shop for clinical advice. Drawing on local, national and international sources, it will provide information on primary research, summarised clinical evidence and prescribing advice.
Phase one of NHS Evidence is due to be launched in April 2009. 'If we can pull this off then it will make a huge difference for GPs,' Sir Michael says.
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