Clinical guidelines are designed to help healthcare professionals (and patients) make decisions about treatment for a specific condition. It goes without saying that all guidelines should be used in conjunction with clinical decision making based on the patient’s individual circumstances and preferences. But what is it that makes a good guideline? Ultimately it is the combination of a range of different factors—a comprehensive review of the most up-to-date evidence; best-practice recommendations from experts in the field; real world patient outcomes data from national audits. For a guideline to have an impact it needs to be easy to implement. And in the cash-strapped NHS, it would be prudent to include some element of cost analysis—for NICE guidance, the guideline development groups make decisions based on both clinical and cost effectiveness, whereas independent bodies might aim for a ‘best-case scenario’ for the patient.

Since the early 2000s, asthma diagnosis and management in the UK has been guided by recommendations from the British Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN). Concerns about over-diagnosis and inappropriate prescribing of asthma inhalers prompted the development of a NICE guideline. BTS/SIGN reviewed clinical effectiveness and practical implementation studies to inform its recommendations. The recommendations made in the NICE guideline are based on evidence, but are also underpinned by a cost–benefit analysis of the different diagnostic and management strategies. Implementation of the NICE asthma guideline is not without its challenges.

In his article, Dr Kevin Gruffydd-Jones discusses these challenges and how they can be overcome. NICE recommends the use of objective tests to confirm a diagnosis, but input will be required from commissioners to ensure that these tests are accessible. The article includes algorithms detailing the management of chronic asthma in adults and children aged 5 and over. A checklist for implementing the guideline, and test and reflect multiple-choice questions (MCQs), are available in this issue. Consensus through a collaborative asthma guideline between NICE and BTS/SIGN is on the horizon, but the next update to BTS/SIGN asthma is due before then and it will be interesting to see how their recommendations change now that the NICE guideline is out.

New evidence is continually emerging so it is important that guidelines are regularly reviewed and updated accordingly. In July 2018, NICE published an updated guideline on the management of rheumatoid arthritis (RA) in adults following a review of the latest evidence. Dr Louise Warburton reviews the updated recommendations around diagnosis, treat-to-target strategy, pharmacological management, symptom control, and monitoring. The most important recommendation for GPs to be aware of relates to early referral of adults with suspected persistent synovitis, without waiting for test results. Some people with RA have negative test results and delaying diagnosis can lead to further joint damage and poor prognosis. Algorithms are used to outline the diagnostic pathway and how adults with active RA should be managed. Test your updated knowledge using the MCQs after reading the article.

The August issue of Guidelines in Practice included an article on integrating a pharmacist into the general practice team. In this issue, Shailen Rao and Anna Prescott explain how to embed the pharmacist and accelerate their development once they are on board. For most practices, having a pharmacist as part of the team is a relatively new concept. The authors summarise typical duties for prescribing and non-prescribing clinical pharmacists and provide tips for mentorship, training, and development.

This month’s top tips article explores the role of primary care clinicians in managing patients with breast cancer. Increasing and longer-term use of adjuvant therapies has improved survival rates; however, many treatments are associated with significant side-effects and issues, which are often managed in primary care. Dr Richard Simcock and Dr Nicola Harker discuss the different side-effects of treatment, including menopausal symptoms and bone loss, and the benefits (and risks) of extending endocrine therapy.

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Top tips: early and locally advanced breast cancer

Dr Richard Simcock and Dr Nicola Harker

Lastly, in this month’s View from the ground, Dr James Thambyrajah ponders the impact of Brexit on his role as GP. If you would like to share your views about how Brexit will affect you in your role as a primary care clinician or commissioner, then please do get in touch.

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Diagnosing Brexit

Dr James Thambyrajah