Conflicting guidelines on same topics cause doctors confusion, say MPs

BMJ 2007; 335 doi: (Published 15 November 2007) Cite this as: BMJ 2007;335:1012
  1. Lisa Hitchen
  1. London

    Clinicians in England and Wales are confused when different sets of guidelines are published at the same time on the same topic, a parliamentary committee heard at an inquiry into the National Institute for Health and Clinical Excellence (NICE).

    Richard Taylor, MP, health select committee member, said that for two topics NICE and the Department of Health had recently published recommendations one soon after the other. One was about venous thromboembolism and the other on the use of alcohol in pregnancy.

    NICE's clinical guidelines on the prevention of venous thromboembolism in patients having orthopaedic surgery and the Department of Health's report of the independent expert working group on the prevention of venous thromboembolism in patients admitted to hospital were both published in April.

    “What clinicians are bothered about is when they get two substantially different bits of advice,” said Dr Taylor.

    Michael Rawlins, chairman of NICE, said that the department's guidance was an interim document and that NICE produced full guidance on venous thromboembolism.

    But the department's report was delayed by nine months, noted Dr Taylor, and its interim status was never made clear.

    Dawn Primarolo, minister for public health, agreed that the process of simultaneously publishing guidance from the Department of Health and NICE needed to be handled with “care and clarity.” “This is a really complex area, and I can say that the Department of Health is looking very carefully at how they manage that,” she said.

    On the use of alcohol in pregnancy, updated health guidance for pregnant women came from the department in May telling women who are pregnant or trying to conceive that they should abstain from alcohol altogether.

    NICE's draft clinical guideline on antenatal care followed in September and is to be published as final guidance in March 2008. Its draft recommendation is that pregnant women should limit their alcohol intake to less than 1.5 units per day.

    Ms Primarolo said that NICE's final guidance, when it comes out next year, should be accepted as the definitive advice.

    Sandra Gidley, MP, wanted to know if NICE could work faster, as the Scottish Medicines Consortium seemed to do.

    Andrew Dillon, chief executive of NICE, explained that NICE could only reach its decisions more quickly if it dropped its consultation and appeals processes. “About 30% of our technology appraisals go to appeal and this adds further time,” he said.

    Identifying which new drugs to look at and which patient groups they are useful for also differentiated NICE from the Scottish consortium, he said. “We have a very different process and are producing a different product.”

    She asked what would happen if NICE focused on more useful products and disinvested its time in treatments that were known to be ineffective.

    NICE had attempted to do this using Cochrane reviews, replied Mr Dillon. “The health service does not indulge in things that are not working to an extent. What we have found in some circumstances is some things that are being overused, and we could stop some of these.”

    What was needed was more selective use, added Professor Rawlins. “A lot of it is not saying we should never give an antibiotic for a short time, it is defining the circumstances much more precisely.”

    NICE is currently examining the most effective use of grommets using such an approach, he said, and the Medical Research Council's trial on tonsillectomy will inform NICE recommendations on the most appropriate use of this operation, he added.


    • The oral evidence to the House of Commons' Health Select Committee is available at

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