Dr Mark Charny suggests ways of setting priorities to help GPs achieve the best results, in the third article in this series
The previous article in this series emphasised the need to be certain that you really do have a problem before you embark on a guidelines journey. Assuming that you feel that there are issues which deserve your attention, what do you do next?
Most of us don't have the time to make improvements in everything that isn't working as well as we would like. Setting priorities is important if you are to achieve the best results from your efforts. This article suggests some questions that may help you to identify the best opportunities.
1) Does the clinical care affect a lot of people?
Obviously, effort spent on something that occurs rarely is less worthwhile than working on an equivalent problem that occurs frequently.
2) Do the changes that you hope for offer patients the prospect of achieving a better outcome or avoiding a worse outcome?
It is not enough to choose areas of work because the condition is serious: you have to be satisfied that you can make a difference.
In general, importance to health equates to the percentage potentially realisable benefit or avoidable harm to each individual concerned multiplied by the number of individuals affected.
3) Does the change in care that might come about from introducing a guideline have significant resource implications?
This has two components:
- Is there a significant amount of resource (time, money, effort) not put to good use in terms of improving patient health?
- How much of the resource no longer used ineffectively can, in practice, be put to other uses?
For example, eliminating some follow-up blood tests that do not achieve anything significant for the patient may not allow you to refer more patients for physiotherapy, whereas eliminating some less useful prescriptions will easily allow you to prescribe other drugs for other patients, for which the budget might otherwise be insufficient.
In general, yield from your efforts equates to the percentage of resource currently used ineffectively multiplied by the ease of putting the liberated resource to more effective use.
4) If the care does not change, are you or the practice at risk of litigation, enquiry, or other forms of unwelcome attention?
5) Do changes in the care with which you are concerned offer possibilities for professional development?
6) Are changes in care likely to enhance your professional status or develop services more widely than just your practice?
7) Does the present situation risk the loss of patients to other practices?
8) Is the present pattern of care unsatisfactory to current members of staff, or does it make recruitment difficult? Does the new pattern of care offer possibilities for attracting and retaining the best staff?
9) Is there a recognised source of guidance on the subject?
For example, is there national guidance, through National Service Frameworks or the National Institute for Clinical Excellence (NICE), which started work on the 1 April 1999? Has a national professional organisation published recommendations? Are these guidelines evidence-based?
There will be times when guidelines are needed even though hard scientific evidence is not available, or the evidence that is available does not give clear answers. However, the less certain the evidence, the more difficult it is to be certain that there is a firm basis for local agreement about the way forward, and working on a subject about which there are legitimate differences in opinion is likely to be more difficult and less likely to lead to a successful result.
10) Are other people involved (partners, other members of the primary care team, staff of the local community trust or acute trust) on the same wavelength as you on this issue?
- Do they feel it is worth some effort?
- Do they see the issue broadly the same way as you do?
- Are they prepared to give it priority over other issues with which they are concerned (which may be different from the list that you have judged to be less important)?
11) Do you have a good relationship with other team members? Is there sufficient agreement on what should be achieved, and a supportive atmosphere in which departures from agreed patterns of care can be explored and changes made?
12) Does the situation suggest that you will be able to hold the interest and involvement of team members?
To some extent this is likely to be related to their idea of the importance of the topic. But remember that your colleagues – like you – aren't exclusively rational, and it may be hard work keeping people interested in a problem that, even if important, doesn't turn them on.
The above list outlines the sort of questions you might ask yourself before taking action. Spending time thinking through the problems and possibilities will pay handsome dividends: you will avoid wasted effort, and will make more of a success of those things you do take on.
Broadly, you need to be satisfied that:
- The issue is clinically significant
- Changes are feasible
- The evidence is sufficiently strong and clear to generate agreement among the group
- The issue is sufficiently important to your colleagues, or at least the majority of them, to encourage their efforts.