Guidelines provide reasoned advice on the management of a problem. If they are to be of any value, all those involved need to be convinced of their relevance and committed to their use. This is the difficult part of developing any set of guidelines. The adherence to treatments and approaches supported by strong evidence helps achieve agreement, but even in the face of evidence, it may be difficult to change long-held beliefs and practices.
Back pain is a very common reason for medical consultations. In 1993, there were around 14 million GP consultations in the UK for back pain. It is also a major cause of time off work and long-term disability. Up until the early nineties there were no clearly defined guidelines on the management of back pain in use in the UK. In 1992 the DoH set up a committee, under the aegis of the Clinical Standards Advisory Group, to look at NHS provision for the management of back pain.
This committee felt that it was necessary to judge such provision against a standard, and therefore took the opportunity of establishing some consensus and evidence-based guidelines.1These were very widely accepted and welcomed, but, although the CSAG had started the ball rolling, it was not its official role to produce guidelines. A subsequent set of national guidelines was therefore produced by the RCGP in 1996,2 which also took into account further evidence that had appeared in the intervening years.
With both sets of guidelines the aim was to involve as many stakeholders as possible in their formation and development, as well as using evidence-based practice. The reason for this was to produce something that these groups would subsequently actually use in practice. National guidelines are all very well, however, if the grassroots do not identify with them they will not be used. Local circumstances, historical practices, geography and facilities vary, and it is thus wise, indeed important, to develop local guidelines in order to address these differences. The development process itself is a very important learning process and is very likely to influence practice even if the guidelines produced are not always fully adhered to.
The RCGP Clinical Guidelines for the Management of Acute Low Back Pain form a very good basis for local discussion, as they put the evidence, along with an objective weighting score for that evidence, beside the committee's recommendation which derives from it. Thus, at a local level, decisions can be made in a more informed way. If the evidence for a recommendation is weak, then there is more latitude for local variation than where the evidence is strong.
The RCGP guidelines use a star rating system to give an idea, at a glance, of the weight which can be given to the assertions made. The meanings of these ratings are shown in table 1. The features looked for in an acceptable study are summarised in table 2, and an example of a recommendation, along with the evidence and the strength of that evidence, is given in table 3.
In order to set up local or even practice guidelines, it is essential to include all possible players in the development. It is likely that, in the present state of the NHS, larger groups eg health authorities, hospital trusts, PCGs and out-of-hours cooperatives, will instigate the development of guidelines. At a local level, within the practice, guidelines can be agreed, but may be limited by attitudes and service availability in the area.
It is impossible merely to emulate the national guidelines as local circumstances may differ, and what suits one area may be totally impractical in another. On the whole it must be better to instigate new guidelines either from within the practice or a primary care setting.
It is likely that primary care groups will develop guidelines in order to encourage some uniformity of practice with the aim of producing uniformity of quality and cost. In the case of back pain the national guidelines are so well researched and documented that in would be folly to start from scratch, and the evidence-weighting system encourages local variation.
It is important to include local consultants, physiotherapists, and probably chiropractors and osteopaths in your deliberations, as they could certainly prove confounding factors otherwise. It may also be wise to include at least one patient.
Though there may be members of the group who are practising in ways which are not supported by the evidence it is to be hoped that discussion in this sort of a forum, along with a review of the literature, might gently inform their future practice. Everybody involved in this sort of process finds it educational.
As a group it is possible to plan the most effective use of manpower and resources which may lead to changes in practice for most of those involved.
It is impossible to abide by guidelines consistently, without involving the whole primary healthcare team in the decision. Thus not only the decision, but also the nuts and bolts practice approach to their implementation need to be worked through as a team. We all know that this is rather time-consuming, but usually yields benefits, as often unexpected innovations and improvements come from the team approach.
In our practice we have regular clinical meetings at which we discuss such things as guidelines, the practice formulary etc., and these enable everybody to voice their opinions. We hope that, as a result, the outcome is more likely to be accepted and applied by the team as a whole.
Having developed guidelines, it is important to print them and have them accessible throughout the practice, preferably in a similar format, e.g. in a ring binder of the same colour in every room, or on the computer system. Thus the patient is likely to get the same advice from the practice nurse, the registrar, the assistants, the locums and the partners. It is also wise to revisit them now and again to audit their use, and remind people of their details.
If your out-of-hours cover is provided by a cooperative then it may be that this group of doctors will provide the driving force behind the development of guidelines. Otherwise most of the doctors are likely to be included in a PCG approach. It is, however, important to consider out-of-hours care when designing guidelines and if cover is provided by a deputising service they should also be involved in the development of the guidelines.
The typical patient with back pain is often a middle-aged man with an unhappy marriage. He is no longer able to keep up the pace at his physical job which may be on the line. He does not want to be told that he should try to stay at work if possible, but is hoping for a respectable sick certificate. Naturally the GP has to take the whole picture into consideration. Perhaps in such instances, the guidelines help us to get to the real reason for the consultation.
The local physiotherapy department may have a long waiting list, making it impossible to arrange early treatment for back pain, but after discussion, it may be possible to arrange a change which allows for more accessibility e.g. by agreeing that patients with back pain of longer than 12 weeks' duration will not have acute back physiotherapy offered to them (there is little evidence that this is useful) but that this group will be offered exercise regimens, which are less therapist intensive, thus freeing up therapists for the acute cases.
However many people, specialties and organisations are involved in the development of guidelines, there will always be people who do not wish to be dictated to, and others who are rather slow to change their practice. In the case of back pain the very discussion of guidelines brings to the fore the importance of staying active, while avoiding aggravating factors. This in itself is of value. Gentle encouragement along with strong evidence from the literature may eventually persuade those who are sceptical about the guidelines to comply too.
The RCGP Clinical Guidelines for the Management of Acute Low Back Pain can be seen, in summary form, in Guidelines. The full version is available, on request, from the RCGP, but may also easily be accessed on the World Wide Web at: http://www.rcgp.org.uk/rcgp/clinspec/guidelines/backpain/index.asp
- Back Pain Report of a Clinical Standards Advisory Group Committee on Back Pain, Chaired by Professor M. Rosen. HMSO. May 1994.
- Clinical Guidelines for the management of Acute Low Back Pain, RCGP, 1996. (Waddell G, Feder G, McIntosh A, Lewis M, Hutchinson A. (1996) Low Back Pain Evidence Review London: Royal College of General Practitioners.)