National guidelines are more likely to be scientifically valid, but local guidelines are more likely to be valued and implemented. How do we resolve this dilemma?
Building on the strengths of both concepts, the Scottish solution has been constructed by the Scottish Intercollegiate Guidelines Network (SIGN). It has developed strong national guidelines with multidisciplinary participation to promote their translation into local guidelines and local implementation plans by local teams, e.g. primary healthcare team, LHCC/PCG or trust, taking into account local circumstances.
The SIGN guideline development methodology is described in SIGN guideline No 39. It requires multidisciplinary representation on the guideline group from across the country.
Wide consultation is encouraged throughout the process, including a national meeting to discuss the draft guideline and peer review. In this way a large number of healthcare professionals are involved in the development of each guideline. As more SIGN guidelines are discussed, published and used, there is increasing ownership of SIGN throughout Scotland.
Consideration of the national guideline by local multidisciplinary teams to examine key recommendations for best practice must take account of local circumstances and is a vital step in the process.
Implementation strategies require careful planning to ensure that the practicalities are supported and all the stakeholders are committed to making it work. Ownership can therefore be nurtured at both a national and a local level.
Commitment to guidelines is strongly influenced by the way a guideline is developed. Local teams are more likely to take time to consider for implementation guidelines developed by organisations they trust and which use well recognised methods of development.
The key features are:
|Well described systematic review of the literature|
Graded recommendations for best practice linked to the evidence.
Guidelines that fail to meet these criteria, especially advocacy guidelines, are likely to be of limited value. This has recently been reviewed and reported by Grilli et al in The Lancet.1 (See also News: Usefulness of specialist guidelines questioned, Guidelines in Practice, Jan/Feb 2000.)
Local ownership is essential for successful implementation of a guideline. However, the topic must first be of interest and concern to the local healthcare team. Sometimes there may be conflict of priorities between a practice, LHCC/ PCG or trust, which would have to be resolved. When there is agreement that a particular area of health or disease management could be improved, the group may look to see if there is a guideline available on this topic. This provides local ownership from the start.
An appropriate guideline, which the group values and is scientifically valid, can be selected and the key recommendations discussed. Again there needs to be local agreement on the objectives of implementation and the strategies to be employed to promote and sustain change.
This is further discussed by Dr Philip Cotton and colleagues in this issue of Guidelines in Practice (see Checklist facilitates move from guidelines to protocols).
Finally, local patients need to buy into this process and play their part in any implementation plans. We are at an early stage of understanding and supporting patient involvement in clinical guideline development and implementation. However, ownership does require a strong partnership between professionals and patients to achieve improved outcomes of care.
- Grilli R, Magrini N, Penna A et al. Practical guidelines developed by specialty societies: the need for a critical appraisal. Lancet 2000; 355: 103-6.