I would like to support Dr Matthew Lockyer's point about the difficulty in applying guidelines to individual patients in day-to-day clinical practice (October 1998).
The best examples of this arise with preventive medication which can cause adverse reactions, and where the balance of risk vs benefit can be difficult to judge for an individual patient.
The patient has no symptoms and therefore sees little benefit in continuing to take a drug that makes him or her feel ill.
There is good evidence to support the use of etidronate in preventing steroid-induced osteoporosis. However, in my experience many patients suffer gastrointestinal side-effects, particularly from the calcium supplements, and stop taking the drug.
With clinical governance looming, prescribing rates of preventive drugs such as these may be seen as a measure of 'good practice'.
Doctors may be unfairly seen as failing these objectives, without considering the patient's input into the prescribing decision.
Dr Lockyer's other point about the difference between research populations and our patients is another important one to do with excluding certain patients from trials. An example of this is seen in the use of warfarin for prevention of stroke in atrial fibrillation.
The original trials had very strict inclusion criteria, and for our patients who do not fulfil these criteria, we cannot be sure that warfarin will have the same overall benefit.
Finally, there is the old problem of statistical vs individual benefit. The use of NNT (numbers needed to treat) has been very useful in highlighting the difference.
This can be helpful to patients and doctors alike in deciding whether to embark on a preventive treatment for their own personal benefit. I'm all for evidence-based medicine, but we have to accept that the evidence will never encompass every clinical situation we will meet, and that is when judgments based on uncertainty have to be made, involving the patient as well.
Dr Carol Blow, GP, Surrey
Your readers may be interested to hear of our experience at Birmingham Heartlands Hospital with the distribution of guidelines to clinical areas using internet technology.
Guidelines are submitted to the Guidelines Committee and are assessed for their evidence base.
Once approved for use throughout the hospital they are published on the guidelines intranet site, which can be accessed using any PC attached to the hospital network (though not as yet from outside the hospital).
Access is very rapid (almost instantaneous) and it is possible to find guidelines by title, author, specialty and a full text search.
There are links to other intranet and internet sites and a facility for feedback by e-mail. It is also possible to review all guidelines added or updated within a user-defined time period. The database includes review dates and warns if a guideline has expired.
Guidelines are related by hypertext links, and source materials and references are included either as pages on the web site or links to the articles on the internet.
Guidelines can be printed locally. The system ensures that approved guidelines are easily available and always up to date.
Dr Steve Smith, Director of Renal Services, Birmingham Heartlands Hospital
I would like to say thank you to Dr Charles Sears for a useful and informative article on setting up back pain guidelines (October 1998).
It mirrors my experience in East Sussex, both for East Sussex Health Authority and the local district general hospital. Involving everybody is, I am sure, the key.
In Eastbourne we have set up a rapid access physiotherapy service for acute backs (<6 weeks' duration of symptoms).
This works well, and built into the system is a 'direct line' to the consultant orthopaedic surgeons for epidurals and/or further investigation or surgery.
Thus, by following the guidelines and treating appropriately, we hope to minimise the onset of chronic back pain.
Dr Rob M Wicks, GP, Eastbourne
Congratulations on producing a very useful magazine.
Guidelines can be a bugbear; for example, Lambeth Southwark & Lewisham HA guidelines for head lice give expert opinion on chemicals that can be used, while guidelines from Manchester HA place head lice lotions as a last resort.
We are in danger of paying too much attention to guidelines, and forgetting that clinical guidelines are no substitute for professional judgment and accountability for action.
Carl Curtis, Nurse Practitioner, London
I have just received the first copy of Guidelines in Practice and look forward to future editions.
I am working on a research project at Sheffield University's Institute of General Practice and Primary Care. For the past 18 months, we have been investigating how to deliver health informatics training to primary care professionals, using web-based resources and tutorials and facilitated e-mail discussion lists. The project home page is at:
and provides access to a library, an archive of the discussion lists, a series of evidence-based practice tutorials and a growing collection of clinical situations.
We do not have the resources or the remit to develop regional guidelines from scratch, but we are interested in locating, appraising and discussing them.
Dr Alan O'Rourke, WISDOM Project Information Officer, Northern General Hospital, Sheffield
I was interested to see the first edition of Guidelines in Practice. I think it may help to demystify guidelines for GPs.
I would like to see an article about the medicolegal implications of guidelines. This seems to be one of the main anxieties and concerns expressed by the GPs that I come across in Wales.
An article from SIGN (Scottish Intercollegiate Guidelines Network) on their work would also be useful.
Dr Fergus Macbeth, Director, Clinical Effectiveness Support Unit (Wales), Glamorgan
- We plan to run an article on the medicolegal aspects of guidelines in the next issue of Guidelines in Practice.