From the Frontline

NICE needs reform

BMJ 2011; 343 doi: (Published 7 December 2011)
Cite this as: BMJ 2011;343:d7945

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Displaying 1-8 out of 8 published

20 December 2011

What a delightful article to polarise responses!

Are some of NICE's practices questionable?


Are some of NICE's committee cumbersome?


Do the majority of committee's have old professors waxing lyrical about the good old days while taking back handers from drug firms?


I don't follow NICE guidance all the time and I am a champion of NICE guidance for children. I make independent decisions with the available evidence and the child who sits in front of me. When I decided that some of NICE guidance may not quite fit the bill I joined in - seemed a useful way for a working clinician to help this apparent 'intellectual terror"

Competing interests: NICE Scholar 2010-11 Member of NICE Feverish Illness in Children Guideline Development Group

Damian T Roland, Paediatric Emergency Medicine Research Fellow

Leicester University, PEMLA, C/O Elizabeth Cadman-Moore, Emergency Department, Leicester Royal Infirmary, LE1 5WW

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16 December 2011

Emperor’s NICE New Clothes

Des Spence is right: all doctors should challenge conventional wisdom in order to secure the best evidence based care for their patients (1). But attacking NICE is unlikely to achieve this. Far from being an ‘opaque’ bureaucracy, NICE publishes draft consultations of its guidelines - I count 20 on its website currently. In addition, reader-friendly versions of its guidance are freely available to the public, patients and carers.

NICE does not stifle debate – the reverse is true – as can be seen regarding Mark Welfare’s views on VTE prophylaxis in the very same issue of the BMJ (2).

Neither is NICE ‘closed to working clinicians’. Even a cursory look at NICE’s website(3) will reveal opportunities for front line staff to suggest future topics, become a member of a new working group, or influence everyday NHS practice by joining the NICE Fellows and Scholars Programme – now moving into its third year.

As for challenging orthodoxy, NICE has published over 100 ‘do not do’ evidence-based recommendations in my own field (4) (mental health) alone since 2007. Who is wearing the Emperor’s new clothes now?

1) Spence D. NICE needs Reform. From the Frontline. BMJ 2011;343:d7945

2) Welfare, M. NICE guidelines for VTE are not evidence- based. Personal View. BMJ 2011;343:d6452

3) Accessed 15 Dec 2011.

4) Accessed 15 Dec 2011.

Competing interests: Paul Blenkiron is a current 'NICE Fellow' - associated with, but not employed or paid by, NICE

Paul Blenkiron, Consultant Psychiatrist

Bootham Park Hospital, York North Yorkshire YO30 7BY

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14 December 2011

The Director of the NICE Centre for Clinical Parctice (sic) makes the extraordinary assertion that it is “understandable” that “someone who works north of the border” should be “spectacularly misinformed”.

Is this conceit endemic in his department or just the personal problem of someone called Fergus R Macbeth who works in an office in High Holburn?

Competing interests: None declared

Michael O'Donnell, Jouneyman writer

Loxhill GU8 4BD

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13 December 2011

Fergus R. MacBeth, asks in his reply to Dr Spence "so what evidence does he have that ‘no one dares go against them’?"

The answer to Dr MacBeth is carried in every day of 'every-day-medical-care.' I should add, given Dr MacBeth's doubt, that such does carry across the 'border' to those in the north.

There is ground between Dr Spence and Dr MacBeth. Perhaps this is that very border? It would be good to see this acknowledged.

Competing interests: None declared

Peter J. Gordon, Old Age Psychiatrist

NHS Forth Valley

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13 December 2011

Des Spence’s criticisms of NICE guidelines and their development (NICE needs reform. BMJ 2011;343:d7945) are spectacularly misinformed, surprising but perhaps understandable in someone who works north of the border.

It is very clear that our clinical guidelines are not in any way mandatory, and it is stated clearly at the beginning of each one, that they are aimed at helping ‘healthcare professionals and patients make informed choices’. So what evidence does he have that ‘no one dares go against them’?

Far from being ‘opaque’, all our methods are fully published and consulted on whenever we make substantial changes, and the decision-making is clearly laid out in the full version of each guideline. The guideline development groups (GDGs) do not ‘notionally legitimise’ the recommendations; they draft them in light of the evidence, modify them in response to consultation comments and then approve the final versions.

The GDG members are not ‘medical oligarchs’ and not all specialists; they are recruited openly and represent an appropriate range of different health professionals as well as patient and carer representatives. We are not ‘closed to working clinicians’: generalists as well as specialists and academics are recruited, and all actually work in the NHS, though getting real generalists, especially GPs, has sometimes been difficult. With around 15 members the groups are not ‘large and ponderous’ but need to include all relevant stakeholders without being unmanageable.

Finally he claims that a ‘high proportion’ of GDG members have financial links to drug companies. Indeed some (mainly medical) GDG members do declare such interests but NICE has a very clear and public policy on managing conflicts of interest both when people apply for an advisory committee and during meetings. These are rigorously followed.

Perhaps Dr Spence should apply to join one of our GDGs. We would welcome his generalist perspective and he would learn at first hand how we actually do things rather than snipe inaccurately from afar.

Competing interests: FM has been involved in the development of clinical guidelines for NICE since 2004 and is currently Director of the Centre for Clinical Practice and responsible for the programme

Fergus R MACBETH, Director

Centre for Clinical Parctice, NICE, MidCity Place, 71 High Holborn, London WC1V 6NA

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Try being the front line.  The NICE guidelines are tight evidence based handcuffs.
Please don’t think I didn’t do any research before I wrote this piece . I did.
I have trawled  through the committees and I suggest that you do likewise. hypertension ( Group of 24 – 3 GPs , 4 COI ), Diabetes ( Group of 33 , 1 GPs , 8 COI)   ADHD  ( Group of 30 , 1 GP , 11 COI – check them out they make interesting reading !) , Lipids ( Group 19 , 3 GPs, 7 COI ), COPD ( Group of 25 , 2 GPs, 9 COI ) –…. I could go on.  Are these important  CDG really representative ?
These committees seem dominated by a small group of often well known specialists. I want experts who have no COI,  not merely ones that declare them. GP are difficult because most of us run our own practices so find it difficult to take time out. Use other outlets to engage with opinion - GP magazines and the Internet
If NICE are doing review of the Pharma Industry  and COI, count me in.
I am working on something constructive to add to this with a proposal to change how these committees are structured looking at models from elsewhere like Canada.

Competing interests: None declared

Des Spence, GP

General Practice, Glasgow G20 9DR

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12 December 2011

In reading Des Spence, allbeit from his 'frontline' I find that he does not always write nicely.

Whilst I am certainly less attacking in nature, I somehow find that his frontline challenges of wisdoms-boxed, and often NICE'ly wrapped, more than festively necessary.

I cannot talk with authority upon NICE guidelines most generally. However Dr Spence covers from his frontline concerns that I share specifically for the NICE guidelines on Dementia (and indeed the Scottish equivalent, SIGN guidelines on Dementia).

My concern with both guidelines is that they:
(1) do NOT define 'Alzheimer's disease'
(2) include little ethical perspective
(3) conclude from evidence that is scientifically robust but not in itself absolute enough to provide rounded guidance.
(4) and may be incorrectly employed in approaching dementia in its pre-dementia phase (a most difficult area)

I ask readers to compare the NICE guidelines on Dementia (and indeed the SIGN guidelines) with the Nuffield Biothics report on Dementia (1). This I think is a box worth unwrapping.

(1) Nuffield Council on Bioethics, Dementia: ethical issues 28 Bedford Square, London WC1B 3JS. 2008

Competing interests: None declared

Peter J. Gordon, Old Age Psychiatrist

NHS Forth Valley

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8 December 2011

Having followed the quality control procedure, I agree with Spence (BMJ 2011;343:d7945) that NICE needs reform.

From a purely scientific perspective, I still fail to understand why factual errors were not corrected when they were brought to their attention. Surely, correcting factual errors is part and parcel of the scientific process? One can not make informed decisions based on selective, let alone, inaccurate information.

Having failed to correct about ten errors, NICE subsequently refused to tweak the guidelines for chronic fatigue syndrome (CFS) on the basis that the errors were not of clinical significance. This position is hard to justify. Infact, had the errors been corrected and with the additional information I had provided, it would have been clear that there was a fourth approach that now met their own criteria for recommendation.

A small amendment would have provided doctors with an additional therapeutic option often referred to as pacing [1]. This is a cheap, safe and acceptable approach to energy management for people with CFS and myalgic encephalomyelitis. It's evidence-based, pragmatic and has been judged as one of the most useful approaches in all surveys carried out to date. I can only presume that the cleaner was in charge of quality control that day.

1. Goudsmit EM, Jason LA, Nijs J, Wallman KE. Pacing as a strategy to improve energy management in myalgic encephalomyelitis/chronic fatigue syndrome: a consensus document. Disab Rehabil 2011. In Press. doi: 10.3109/09638288.2011.635746.

Competing interests: None declared

Ellen M Goudsmit, Psychologist

UEL, London, E15 4LZ

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