Q One of my patients has recently downloaded a set of American guidelines for her complaint from the internet. Unfortunately it gives a different suggested management from our local guidelines. How do you recommend tackling this problem?
A This situation is likely to become more and more common. First, you should look carefully at the differences between the guidelines your patient has downloaded and the local guidelines. Internet guidelines may not be based on evidence, or their provenance may not be clear. 2
If, as one would expect, the local guidelines were evidence based, you may advise your patient in this case that the local guidelines are a more secure basis for practice than the ones she has downloaded.
There may, of course, be other reasons why guidelines differ. For example:
- Certain drugs may not be licensed in the UK but are licensed in the USA, or vice versa
- Different regulations and laws, such as those permitting or preventing a professional group from engaging in an activity
- Different professional standards, such as those permitting acceptance of direct referrals
- Differences between healthcare systems, in which different payors and/or different total amount of resource available may influence 'real life' recommendations.
Any of these would be readily understandable to your patient, even if he or she did not like the result.
You could, of course, treat your patient according to the American guidelines (assuming that the recommendations did not fall foul of regulations or other factors in the UK context), but you should only do this if you feel satisfied yourself that the recommendations are sound and appropriate to the particular case. The patient may misinterpret guidelines, and they may not apply to his or her problem.
Finally, if you and the patient cannot agree what to do, you should always be prepared to give your patient the option of a second opinion.
Q A recently published research paper seems likely to change accepted practice and therefore national guidelines. Should we try to adopt the changes now or wait until a new set of guidelines is published?
A There is a tension between trying to make sure that guidelines are as up to date as possible in a world in which new information becomes available more and more rapidly, and making sure that the evidence on which the guidelines are based is carefully considered by acknowledged experts who develop evidence-based recommendations.
If you have good critical appraisal skills and can be sure that the new research paper is itself sound and the change proposed represents a significant benefit to the patient (or avoids significant harm to the patient), then you should probably change your practice accordingly.
You should not assume, however, that because a paper is published in a peer-reviewed journal that all is as it seems, and in addition it may not be easy to derive recommendations from 'raw' evidence.
If in any doubt, wait for the new guidelines. Whether or not you act before the new guidelines are published, you can do your bit to speed up the process of guideline development by bringing the new paper to the attention of the appropriate group or professional body and urging them to review the old guidelines as soon as possible.
Q The Standing Medical Advisory Committee advises the use of the Sheffield table for selecting patients with hypercholesterolaemia for primary prevention. We would like to use the New Zealand modified tables as recently published in the BMJ for this purpose. Will using different guidelines from the recommended ones cause us problems?
A You should think very carefully before developing guidelines that differ in any important respect from those recommended by a recognised national body. This may cause several problems: you may find that there are some highly technical reasons for choosing one basis for a set of guidelines rather than another, which are not immediately apparent.
New guidelines may not fit well with existing local arrangements (protocols for screening and referral, contractual arrangements in the local path lab etc.) based on older guidelines. However, this is all relative. If, in your judgment, the New Zealand modified tables are better than the Sheffield table, then you should base your practice on those.
You should be ready to explain your decisions to anyone with a legitimate interest and it is always a good idea to make sure that you take local colleagues along with you: key people here would be partners, physicians to whom you refer patients, and your local director of public health.
Before making up your mind you may find it useful to contact SMAC directly and get their views.
Q One of our local consultants is not managing patients in accordance with agreed primary/secondary care guidelines. Whose responsibility is it to tackle this? Who will be responsible in the event of a patient complaint?
A Before taking this any further, you must establish the reasons for the consultant's management. It may be, for example, that the consultant thinks rightly or wrongly that the patients concerned do not fall within the scope of the guidelines. Or, the information sent to you by the consultant may have left you with the false impression that the guidelines are not being followed. The easiest way to do this is to contact your secondary care colleague directly, preferably in person or by phone, and ask for information in a neutral way. Apart from clearing up any misunderstanding, you may find that even if the consultant is not following the locally agreed guidelines, he or she is quite willing to do so and the problem is solved.
What happens if the consultant concerned will not follow the guidelines. One simple remedy is not to refer your patients to that consultant, but this always seems an unfair way to deal with a colleague who is not making a contribution, because it puts an additional strain on others.
Once formal clinical governance arrangements are in place, the responsibility for dealing with the situation you outline will be clearer in theory, at least.
Meanwhile, you could speak to the trust's medical director, or the appropriate clinical director, and share your concerns. Depending on the circumstances and the local situation, you may find that the local director of public health or a public health consultant may be able to clarify the issues and perhaps take the matter up on your behalf.
Who carries the can in the event of a complaint by the patient depends very much on the details of the situation. In general, you are not responsible for the consultant's decisions and actions. However, if you continue to refer to this consultant knowing that his or her practice is bad, the patient might reasonably argue that you bear some responsibility.
If the consultant is simply not following the guidelines and the patient does not come to any harm, a complaint is unlikely to be made and, if made, is unlikely to succeed.
Q We are interested in designing guidelines. Who should we contact for advice?
A Designing guidelines is a combination of common sense and technical skill. There are a number of groups that specialise in various aspects of developing and appraising guidelines, including:
- The Oxford Guidelines Project
- The Health Care Evaluation Unit
- North of England Evidence Based Guidelines Project
- School of Health and Related Research (ScHARR)
- Royal College of General Practitioners Clinical Guidelines Initiative
- Royal College of Surgeons of England
- Scottish Intercollegiate Guidelines Network (SIGN)
- Health Services Research Unit
You may also find it useful to search on the World Wide Web. One site that is particularly interesting is the Agency for Health Care Policy and Research site which describes the National Guidelines Clearinghouse being set up* in the United States: http://www.ahcpr.gov:80/clinic/ (*This has now been developed and is at www.guideline.gov)
Finally, there is a wide range of books:
Guidelines summarising clinical guidelines for primary care. Berkhamsted: Medendium, 1998.
Agency for Health Care Policy and Research. Using clinical practice guidelines to evaluate quality of care. U S Department of Health and Human Services, 1995.
Agency for Health Care Policy and Research. Using practice guidelines to evaluate quality of care, volume 2: methods. Agency for Health Care Policy and Research, 1995.
British Medical Association. Clinical Audit Committee. Guidance notes for clinical guidelines. London: BMA, 1996.
Cluzeau F, Littlejohns P, Grimshaw J, Feder G. Appraisal instrument for clinical guidelines (version 1). London & University of Aberdeen: Queen Mary and Westfield College, 1998.
Group Health Association of America. Introduction to clinical practice guidelines in health maintenance organizations. Washington, DC: Group Health Association of America, 1995.
Hurwitz, B. Clinical guidelines and the law: negligence, discretion and judgement. Oxon: Radcliffe Medical Press Ltd, 1998.
Maclean D. Clinical guidelines: a report by a working group set up by the Clinical Resource and Audit Group. Edinburgh: Scottish Office, 1993.
Mann T. Clinical guidelines: using clinical guidelines to improve patient care within the NHS. Leeds: NHS Executive, 1996.
Marek KD. Manual to develop guidelines. Washington, DC: American Nurses' Association, 1995.
McCormick KA, Moore SR, Siegel R. Clinical practice guideline development. Rockville, Md: US Department of Health and Human Services, 1993.
Mozena JP, Emerick CE, Black SC. Clinical guideline development : an algorithm approach. Gaithersburg, Md: Aspen, 1996.
Royal College of Nursing, Dynamic Quality Improvement Programme. Directory of national clinical guidelines 1997. Royal College of Nursing, 1997.
Royal College of General Practitioners. Clinical Guidelines Working Group. The development and implementation of clinical guidelines. Report of the Clinical Guidelines Working Group. Exeter: RCGP, 1995.
University of Leeds. Effective healthcare implementing clinical practice guidelines. University of Leeds, 1994.
- Information for Health. Leeds: NHS Executive, 1998.
- McLellan F. "Like hunger, like thirst": patients, journals, and the internet. Lancet 1998; 352 Suppl 2: 3.