One of the problems of being a medical generalist is that every specialist knows more about his/her area of clinical interest than a GP. A tidy-minded specialist wants to see things within his own ambit managed properly, and the temptation to offer doctors guidelines on how to do this is often irresistible.
The same temptation can be too much for health planners, medical educators, Royal Colleges, special interest groups and commercial organisations, all of whom generate documents that are presented to GPs as the best – if not the only – way to manage a particular problem.
Over the last few years the trickle of such 'guidance' has become a steady stream that threatens to become a torrent. But so variable is the quality that most are relegated to the bin, a few are filed and forgotten, and just one or two become accepted practice.
During the summer of 1999 Somerset LMC became concerned that many guideline documents for primary care were clearly being written without the involvement of representative GPs. The advice was often badly thought out and presented, attributed disproportionate importance to the problem being addressed, and would have huge resource implications if implemented.
We felt that only by formally rejecting such inappropriate guidelines could GPs regain control over their clinical practice. Also, agreed rejection at this stage would help protect them if legal action followed as a consequence of a doctor's failure to adhere to a particular recommendation.
In discussion the Somerset LMC identified six key criteria by which guidelines should be judged. It was agreed that any guideline which failed to fulfil all of these criteria should be rejected and returned to the issuer.
1. Has the guidance been drawn up with the participation of representative GPs? This would include GPC, LMC or PCG appointed GPs.
2. Is the guidance based on robust evidence of clinical effectiveness and efficiency? One randomised control trial will not do. Ideally the guidance should be based on something like a Cochrane review. There should be evidence of true cost benefit to support any proposed change in practice.
3. Is the guidance phrased in a way that is useful to general practice? Recommendations must be clear without being didactic and should allow the clinician to retain some independent judgment.
4. Has the guidance considered the workload impact on primary care, and have resources been identified to support any new work proposed? General practice has no capacity for unresourced new work. If a guideline issuer is adamant that something new has to be done, then they must identify what work should be abandoned to make room for it.
5. Has the guidance been endorsed by a national or local body that considers clinical effectiveness and been considered by the PCG/PCT and weighted according to local priorities? GPs have neither the time nor the skills to decide which guidelines take precedence. This is a matter for national decision and local implementation.
6. Have any ethical questions that may be raised been properly addressed? Have patient groups been consulted? How does this guidance fit with the requirements of clinical governance?
At a time when NHS resources are stretched ever more thinly, and the service is undergoing a change more radical than any in the last 50 years, it is clear that alterations to clinical practice must be based on objective decisions. We hope that these criteria will help GPs to do just that.