Dr Philip Cotton, Dr Patricia Donald and Anne Farquharson outline an initiative to raise awareness of SIGN guidelines and aid implementation
Evidence-based guidelines covering a wide range of clinical topics are being developed by the Scottish Intercollegiate Guideline Network (SIGN). More than 20 of these guidelines have been disseminated to health boards and hospital trusts for further dissemination, and ultimately for adaptation and implementation in local practice.1
Each guideline is produced as a complete referenced document with a quick reference guide. Central funding has been made available to health boards to facilitate implementation.
A survey of the 15 health boards by the RCGP Guidelines Coordinator at the end of 1996 showed that all of the 13 boards who had guideline steering groups spanning primary and secondary care required information on implementation.
A further survey2 revealed that most members of primary care teams were feeling overwhelmed by the number of guidelines and were seeking help in how to prioritise guidelines for implementation.
In response, the RCGP in Scotland held a conference on guideline implementation and produced a video and literature on this subject3 which were distributed to primary care teams.
Furthermore, in collaboration with the National Board for Nursing, Midwifery and Health Visiting in Scotland (NBS) and the Scottish Centre for Post-Qualification Pharmaceutical Education (SCPPE), the RCGP Scottish Council Clinical Guidelines Working Group planned a series of multidisciplinary educational meetings. The aim of these meetings was to share experiences of implementation and deal with uncertainties and to plan support and educational initiatives for the future.
Six evening meetings were held in Inverness, Glasgow, Dundee, Stirling, the Borders and Aberdeen. Invitations were sent to all GPs and practice managers and to all primary care practitioners working on SIGN development groups. Fliers advertising 'The Roadshows: A Team Approach to Guidelines' also appeared in general practice, nursing and pharmacy newsletters.
The chairperson, speakers (local opinion leaders), panel members and worshop facilitators were invited from medicine, nursing and pharmacy in each of the six geographical areas.
PGEA approval was given. The project was funded by a consortium of pharmaceutical companies and attendance was free. The programme for each evening was standard (Table 1, below).
|Table 1: Programme for meeting|
|19:10||An overview of SIGN|
|19:25||Local examples of implementation|
Some 762 people applied for the 600 places. A total of 573 delegates attended the roadshows. Of these, 43% were from the nursing profession, 25% were GPs and 9% were pharmacists; the remainder were from a range of disciplines including public health, professions allied to medicine, local health council members and NHS trust members.
The workshop groups were put together from the delegate lists to try to represent the main disciplines. Each group was given the option of addressing up to three questions, and discussions were summarised by the facilitators. The three questions were:
|What are the current implications for primary care surrounding the implementation of clinical guidelines?|
|List the steps that you would need to take in order to implement either of the two guidelines presented in the early part of the evening|
Discuss your experiences of implementing guidelines in the past and the possible reasons why some were successful whereas others failed.
At the end of each meeting, delegates were asked to complete evaluation forms which addressed satisfaction with the evening and explored ongoing education needs and issues raised by guideline implementation. Reports were also prepared by facilitators of discussions in the workshops and plenaries.
Delegate evaluation forms
Evaluation forms were returned by 280 (49%) delegates. Of these, 42% felt that the roadshows fulfilled their stated aim, 43% were neutral and 15% did not feel that the aim was met.
Specifically, delegates felt that they needed to develop the following skills:
|Translation of a national guideline into a local one (26%)|
|Implementation in general (15%)|
|Prioritisation of guidelines (13%)|
|Team building (12%).|
Other skill areas were management of change, information technology (IT) and critical appraisal.
The preferred styles for training were training courses/workshops (57%), the use of local facilitators (26%), and a distance learning pack (16%). The most popular setting was in-house multidisciplinary training using relevant practical examples.
Eighty-five per cent of respondents felt that primary care summary sheets would be a useful addition to the guidelines.
Free text comments were received from 158 delegates. The main themes were:
Raising awareness of SIGN evidence-based guidelines:
"...some insight into how they are formed. More confident in their use."
Distribution of guidelines
"I only found out at the meeting that the practice nurse did not receive guidelines."
"…has highlighted the need for good communication throughout the team."
Implementation of guidelines
"It has been a very stimulating learning process and I hope to take back some ideas into practice."
Feedback from workshops and plenary sessions
Session facilitators provided written reports of their workshops. Several recurring themes emerged from the workshops, which were echoed in the plenary sessions.
This was discussed by every group. Some nursing and managerial staff had never seen or heard of SIGN guidelines, although in several cases nurses were aware of the existence of the guidelines but had not had the opportunity to see them. Several delegates had not made a distinction between SIGN and other guideline-producing agencies, but added that they hadn't realised the rigour of SIGN guidelines.
It was considered that there were too many guidelines being sent to practitioners, and some thought that this was the case even from SIGN alone.
The groups felt that implementation of guidelines demanded additional time and resources from what they considered to be a stretched service.
Many comments regarding guidelines originated from what delegates described as the heterogeneity of primary care: variation in care, practices being at different stages in the management of conditions, and having different priorities. The delegates felt unclear about the medico-legal consequences of failure to comply with guidelines and the mechanism for updating recommendations.
Several groups felt that incentives should be provided to encourage and reward implementation. However, there was a feeling that practitioners have a moral responsibility to embrace guidelines for good practice.
When informed of the implementation money awarded to health boards, groups questioned where it was and for what it had been used.
There were many comments regarding problems – real and anticipated – at the interface between the different providers and agencies.
There was a fair amount of uncertainty over the response of the secondary care sector to guidelines. It was predicted that access to tests, both hospital and practice-based, was likely to prove difficult, given the experiences of some practitioners.
There were also problems among peers who were indifferent or hostile. While some delegates regarded guidelines as 'doctor business', others were confused by GPs who failed to adhere to guideline recommendations endorsed by their practices. Groups expressed the need to involve patients.
There was concern over the need to standardise data recording and data collection.
Several recommendations arose from the meeting (see Table 2, below).
|Table 2: Recommendations|
Targeted dissemination including mailing to practice nurses and community pharmacists
The production of primary care summaries/quick reference guides
Implementation focused on locally prioritised guidelines
The development of patient versions of guidelines
Greater multidisciplinary collaboration
|Development of IT to integrate guidelines into consultations|
Half of the delegates gave feedback regarding the roadshows, and these were generally positive. The audience was largely self-selected and may have been converted to a certain degree. Secondary care was not represented and several of the discussion groups were less multidisciplinary than had been planned, mainly because some people failed to attend.
Pre-workshop preparation was welcomed by some, with suggestions that working examples could be used to illustrate implementation. Others felt that the subject area was too wide to be covered in an evening meeting.
The most popular choice for future educational initiatives was to have more task-oriented programmes held locally.
Dissemination may predispose professionals to consider modifying their practice but does not effect rapid change.4 However, it is clear that guidelines are not reaching those professionals most likely to use them, in particular practice nurses and community pharmacists.
The most appropriate method of dissemination for primary care teams may be to send the guidelines exclusively to practice managers, who could then coordinate their circulation to doctors and nurses. In addition, there could be some form of pre-dissemination consultation to target guideline mailings appropriately to interested 'ndividuals and specialists not reached in any other way.
It is important to raise the profile of the SIGN guidelines in order that practitioners appreciate the rigorous methodology underpinning the guidelines and thus have confidence in their use.
Although the development process involves several stages of consultation,"there has been very limited post-dissemination consultation apart from occasional surveys. Such consultation achieves the purposes of dealing with difficulties and anticipating problems and encourages ownership. The delegates themselves regarded primary care as heterogeneous and found it useful to share experiences and ideas for guideline implementation.
Several developments have taken place since the roadshows, some in direct response to the meetings and others in response to earlier consultation exercises (see Table 3, below).
Table 3: Recent developments
|A Conference hosted by the Medical and Dental Defence Union of Scotland (MDDUS) on guidelines and the law was held in November 1997. Proceedings are now available.5|
|Dissemination to nurses and pharmacists is being discussed and an information pack on guidelines has been sent to practice managers.|
|A pilot project has been started in one health board employing local facilitators to help implement SIGN guidelines.|
PGEA for practice-based multidisciplinary educational projects is being discussed.
|The development of a distance learning implementation pack is under discussion.|
|Work has now begun on developing patient information. An RCGP website is being developed for guideline information. Primary care summaries will be available on this site.|
|Website training has been made available throughout Scotland with PGEA approval. Furthermore, discussions are taking place between software developers and the IT strategy groups at the Scottish Office.|
|One further roadshow has been requested and others may be held.|
|Production of a video and a research project on implementation of the SIGN primary care asthma guideline.|
The format and presentation of guidelines may affect their acceptance in practice, and delegates were supportive of straightforward one-off publications with clear statements about areas of uncertainty. Specific primary care summaries/quick reference guides may encourage primary healthcare teams to consider implementation. An option to request the full document could then be made available.
Patient versions of guidelines and educational material on the philosophy behind guidelines and their development need to be produced.
Endorsement of local practice-based priorities for implementation focusing on a limited number of guidelines seems essential.
Guideline software should be developed as part of a national strategy for IT. Work shows that this should most usefully be patient specific at the time of a consultation.
Training needs identified include critical appraisal and information retrieval, which is essential if we are to involve more people in guideline development and implementation. SIGN currently provides this training for members of guideline development groups.
The gap between evidence and practice may be bridged, and fears over the misuse of guidelines reduced, through:
|Greater collaboration between primary and secondary care and public health|
|Credible guideline development bodies|
|Audit and research and development agencies|
|Greater involvement of patients.|
There was widespread support for the appropriate involvement of patients in the guideline process.
Creating the proper environment for collaboration and teamwork in primary care may require the nomination of a lead professional.
Opportunities for multidisciplinary learning should also be developed. Continuing professional development programmes and multidisciplinary meetings could be established around guideline implementation. Practice-based training should be available from facilitators, and a trouble-shooting telephone help-line could be established.
There are many opportunities for multidisciplinary collaborative work with the implementation of guidelines, and more work is needed to examine and describe the most effective ways of breaking down professional barriers and modifying the practice and delivery of healthcare across the primary-secondary care interface.
- Acknowledgements: Drs Jim Beattie, Clare Campbell, Alan Merry, John Reid, Alex Watson, Keith Wycliffe-Jones, Rose Marie Parr of SCPPE and Shona Monfries of NBS.
- Petrie J, Harlen J. SIGN comes of age: but what next? Health Bulletin 1997; 55(6) 362-4.
- Health Board Survey Results. Edinburgh: SIGN, November 1996.
- Getting National Guidelines into Local Practice. Edinburgh: SIGN, 1997.
- Grimshaw JM, Russell IT. Achieving health gain through clinical guidelines II: ensuring guidelines change medical practice. Quality in Healthcare 1994; 3: 45-52. 1994.
- Buckley G, West B. A safe path or a legal minefield? Health Bulletin 1998; 56(6): 848-50.