NICE and EBM
The Editor of the BMJ writes of the "[corruption] of evidence-based
medicine" (1). This corruption or, more correctly, misrepresentation is
not exclusively the preserve of NICE, although that organisation sadly
typifies the intellectual sloppiness and lack of imagination in the
establishment's response to evidence-based medicine. When the founding of
NICE was announced (along with the inclusion of evidence-based practice in
clinical governance) (2) I (perhaps naively) imagined that the practice of
evidence-based medicine would now be encouraged among front line
clinicians. This has not happened. What has happened is that the
centralised, bureaucratic systems that have hamstrung the NHS for decades,
with all their traditional panoply of expert committees and top-down
implementation of guidelines have claimed extra legitimacy by invoking the
mantra of "EBM".
Far from encouraging clinicians to practice EBM, NICE imposes a "one
size fits all" population view. This is undoubtedly more comfortable for
the Department of Health, the NHSE and Health Services' management in
general than the potential anarchy (from their point of view) that could
result from empowering clinicians and patients to make their own decisions
that are informed both by evidence and by patients' values and
expectations, a process which follows from the "[application of]
epidemiological principles...to the beliefs, judgements and intuitions
that comprise the art of medicine" which is the basis of EBM (3). EBM
challenges the legitimacy (and the power and influence) of expert groups
such as NICE to make decisions about management, which are instead taken
by individual clinicians and (if the clinicians have thoroughly
assimilated both the skills and philosophy of EBM) shared with their
The way NICE functions therefore sits uneasily with the practice of
EBM at an individual clinician/patient level. The current lack of EBM
skills (or even the wish to acquire them) among ordinary clinicians (5)
means that NICE faces no serious challenge to its authority at present.
However this may well be an issue in the future, as it is impossible for a
single national committee (or even local implementation initiatives) to
tackle more than a small fraction of the questions that patients and
doctors need answering (6). If subversives such as myself are successful
(through workshops and other means) in encouraging others to engage in the
process of EBM, managers and expert groups will sooner or later find that
they are consistently behind ordinary clinicians in the understanding and
application of evidence in clinical practice. What legitimacy or authority
would NICE have in those circumstances?
1. Smith R. The failings of NICE. BMJ 2000;321(7273):1363-1364.
2. Secretary of State for Health. The new NHS, modern, dependable. In:.
London: HMSO; 1997.
3. Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical epidemiology: a
basic science for clinical medicine. 2nd ed. Boston: Little, Brown; 1991.
4. Lipman T. Power and influence in clinical effectiveness and evidence-
based medicine. Family Practice 2000 (in press)
5. McColl A, Smith H, White P, Field J. General practitioner's perceptions
of the route to evidence based medicine: a questionnaire survey. Bmj
6. Lipman T. Discrepancies exist between general practitioners' clinical
work and a guidelines implementation programme [letter]. Bmj
Competing interests: No competing interests