Views & Reviews From the Frontline

NICE needs reform

BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d7945 (Published 07 December 2011) Cite this as: BMJ 2011;343:d7945
  1. Des Spence, general practitioner, Glasgow
  1. destwo{at}yahoo.co.uk

Change is difficult for professionals—no one wants to have to unlearn all the certainties they spent years ramming into their memory. But David Sackett changed medicine. He came from the streets and rapped on its corners about evidence based medicine. He swept away the conventions of medical classicism. But like all controversial ideas, in time it became the orthodoxy. Profit is a great motivator and medical corporations quickly adapted to the new order.

Now evidence based medicine is today’s conservatism. Representatives clasp research sponsored by drug companies and steelily say, “You can’t go against the evidence.” Research is today’s weapon of medical repression against dissent.

Likewise, the National Institute for Health and Clinical Excellence (NICE) was once a radical new movement, standardising care and sweeping away the sludge of unofficial guidelines that clogged the arteries of clinical practice. But medical power is now disproportionally concentrated at NICE, and it has become the unchallengeable leader and an intellectual terror. No one dares go against the guidelines.

NICE is opaque and bureaucratic. Its large, ponderous stakeholder “guideline development groups” notionally legitimise the final guidelines. These committees are awash with an intimidating array of academics and experts, with more professors than the opening day of a corduroy jacket and bow-tie sale. But large committees never work and are usually dominated by a vocal few specialists, because of the scourge that is deference. Some guidelines run to 600 pages and contain many hundreds of references. This seals the guidelines’ unquestionable authority. But as a rule of thumb, the number of references in a document is inversely proportional to the credibility of the conclusions. Indeed, most specialties are lucky to have 10 current relevant seminal papers. The medical profession’s prevailing construct—that specialists understand the research better than others—is fallacy.

Medical experts are politicians, with a biased agenda. The tripartite motto is always “underdiagnosed, undertreated, under-resourced.” I have read many NICE guidelines and find they overstate the evidence, are unrealistic, emotive, and have little insight into the potential consequences of their advice. Worse still, a high proportion of NICE’s medical oligarchs are paid advisers and speakers for drug companies. This is simply not acceptable. NICE guidelines are big money. AstraZeneca admits that when it paid for the implementation of guidelines on chronic obstructive pulmonary disease, drug prescribing increased (BMJ 2011;343:d7713, doi:10.1136/bmj.d7713).

NICE seems closed to working clinicians—a waste of experience and intellect. With communication technologies and online forums, the process could and should be much more democratic. It would make sense for the guidelines to be controlled by technocrats, unsullied by the conflicts of interests of the medical expert. David Sackett wrote, “Progress towards the truth is impaired by the presence of an expert” (BMJ 2000;320:1, doi:10.1136/bmj.320.7244.1283).

It’s time for a rethink at NICE.

Notes

Cite this as: BMJ 2011;343:d7945