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Views & Reviews No Holds Barred

Margaret McCartney: Have we given guidelines too much power?

BMJ 2014; 349 doi: (Published 06 October 2014) Cite this as: BMJ 2014;349:g6027
  1. Margaret McCartney, general practitioner, Glasgow
  1. margaret{at}

“Guidelines, not tramlines,” said David Haslam, chair of the National Institute for Health and Care Excellence (NICE), at its conference this year. Amen to that, but for those of us in primary care, how well do guidelines fit our patients?

Guidelines should be a good idea. It’s impossible to keep on top of all new research, to assess its relevance, outcomes, and biases, and to systematically review and meta-analyse it. We require experts to pull research together and then pick it apart. But is the end result reliable?

Researchers from Norwich Medical School assessed the 22 pieces of NICE guidance in 2011-12 that were relevant to primary care (from a total of 45). These contained 495 recommendations for primary care, based on research findings from 1573 publications. However, only 38% of these were based on patients typical of those managed in the community.1 In other words: the guidelines we use in general practice every day are not backed by research from this population. They are based, in the main, on findings from a different group—patients who are likely to be more unwell and to be in the care of hospital specialists rather than GPs.

In 2012 comorbidity—the new normal—was found to be inconsistently accounted for in NICE guidance.2 This is no surprise, as the most frail and elderly people are under-represented in clinical trials, even though they are most liable to problems from the polypharmacy3 that we routinely prescribe. We ride a sea of uncertainty.

How will we know when guidelines, applied wrongly, cause harm? For instance, the risk of acute kidney injury has risen in association with an increase in prescribing of ACE inhibitors—as per the guidance—for people with chronic kidney disease and proteinuria.4 Are we doing more good than harm? How would we know?

This should be an opportunity. NICE should make the most of “only in research” recommendations: this is vital in ensuring that research is done where needed and in involving the complex, older patients who are often missed out. Whenever there is significant uncertainty, let there be a trial. We need to know, easily, the relevance and relative uncertainty of recommendations.

The Scottish Intercollegiate Guidelines Network (SIGN) places a grade of evidence quality in the margin beside statements. This is good, but we need more: we need to have the uncertainties of each statement in the guidance spelt out. And, to be fair, we should have guidance on when to stop prescriptions and when to drop out of using them altogether.

Or perhaps not. Perhaps the problem is that we have given guidelines too much power, when we need professional, careful, individual judgment and discussion instead.


Cite this as: BMJ 2014;349:g6027


  • Competing interests: I have read and understood the BMJ policy on declaration of interests and declare the following interests: I’m an NHS GP partner, with income partly dependent on Quality and Outcomes Framework (QOF) points. I’m a part time undergraduate tutor at the University of Glasgow. I’ve written a book and earned from broadcast and written freelance journalism. I’m an unpaid patron of Healthwatch. I make a monthly donation to Keep Our NHS Public. I’m a member of Medact. I’m occasionally paid for time, travel, and accommodation to give talks or have locum fees paid to allow me to give talks but never for any drug or public relations company. I was elected to the national council of the Royal College of General Practitioners in 2013.

  • Research news: Guidelines are often based on evidence not relevant to primary care, study finds (BMJ 2014;349:g5914, doi:10.1136/bmj.g5914)

  • Provenance and peer review: Commissioned; not externally peer reviewed.

  • Follow Margaret McCartney on Twitter, @mgtmccartney


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