Opinion  

But, with 'value for money' a mantra at every level in every Whitehall department, it was only a matter of time before cost became part of the equation. And, unsurprisingly, this means a role for NICE.

Lord Darzi's Next Stage Review, published earlier this month, had already proposed change, saying the quality framework should shift its focus to incorporate more preventive work and hinting at the end of a UK-wide deal in favour of local frameworks reflecting local need.

The latest plans go further and would see NICE redesigning the framework around cost-effective disease areas that have the greatest impact on the health of the nation (which, in this case, means England as Lord Darzi's review has no impact on policy in Scotland, Wales and Northern Ireland).

So it seems we are heading towards different frameworks for each country. But should cost play a role in deciding priorities?

In a tax-funded system, of course the cost of treatments and interventions should be considered, it would be irresponsible if they were not. However, surely the quality of care, in other words the evidence base that supports clinical decisions, and the resulting outcomes should be most important factors.

NICE guidance is supposed to be just that - guidance. It provides an analysis of evidence and the costs involved. Making it an intrinsic part of the quality framework means that practices would be financially penalised for not adhering to it. Is this not just taking away GPs' clinical decision making abilities?

What happens if a recommendation from NICE runs contrary to the latest evidence? The current debate around the institute's recommendation of Framingham to assess cardiovascular risk, when research suggests QRISK2 performs better (GP, 27 June), shows that this can, and does, happen.

Any amendments NICE decides to make to the quality framework would have to be negotiated by NHS Employers and the GPC, but Lord Darzi has said there will be no extra quality points, so this means something will have to be dropped to make way for additions.

It remains to be seen which clinical areas NICE will choose to prioritise, but it seems certain that practices will have to work harder if they are to achieve maximum points. There is also likely to be conflict between what NICE believes practices should prioritise and what GPs think they should concentrate on.