Q How do we know whether to use guidelines to manage new presenting cases of a condition, or to search out existing sufferers to modify their management? Finding existing patients with a disease and reviewing their management against guideline ideals is likely to be costly in terms of both time and the need for more treatment. Will money for audit time and the proper management of patient populations be built into national guidelines? Will practices be informed which clinical areas will take preference when large-scale audits to apply guidelines are needed?
A Searching for unmet need is a difficult practical issue, whether or not it is considered in the context of a guideline. Despite policy pronouncements to the contrary, governments rely to some extent on not having to find the resources to deal with everyone who could benefit from treatment.
In the case of coronary heart disease, for example, there is good evidence that a more interventionist approach will reduce mortality and morbidity. Despite the National Service Framework, the costs of better care will for the most part have to be found by the NHS itself under an implicit policy of 'robbing Peter to pay Paul'.
In the end, we all need to consider what is best for our patients, on the basis of good clinical practice and, within the limits of the resources available to us, including our own time, go as far as we can towards achieving it.
It is not helpful if doctors use the problems of the NHS to score political points, but neither is it appropriate for clinicians to collude with the Government against patients\to fudge the issue of insufficient resources and unacceptably low standards of treatment.
We should all try to use resources responsibly and recognise that no patient will get a Rolls Royce service without denying another the opportunity to ride in a Mini, but there are minimum standards below which ethics determine that cooperation is connivance.
The problem is that different people have different views on what constitutes a minimum standard, and the most appropriate response to these awkward situations, in which the patient may ultimately be even more disadvantaged by knowing that possibilities for treatment exist but are not available.
Q The Babycheck booklet has been shown not to change frequency of health service use in infants 6 months of age. Is there any evidence that issuing guidelines to patients aids early diagnosis or helps to regulate demand for medical care?
A Changing human behaviour in health care is not well understood. Studies have shown that if you show patients with benign prostatic hypertrophy a video setting out side-effects of the operation, nearly half of them will decide not to proceed to operation. On the other hand, the evidence that NHS Direct is reducing demand on health services is not clear.
Experience with clinicians suggests that simply handing out information is not likely to change behaviour. Written information is often less effective than other sources such as television or local opinion leaders.
Where written information is used, it has to be supplemented by other approaches. Very often, written information is a useful source of reference, e.g. when a child has a fever the mother may be able to access advice .
In general, changes in systems work better than personal intervention, and interactive information sources are more effective than passive information.
Q Our practice was recently shown guidelines for prostatism by a pharmaceutical representative, which specified the preferred order of branded drugs. Not surprisingly the representative's product was favoured by the guideline, which had not been issued by our own health authority. Are there any restraints on the pharmaceutical industry's involvement in guidelines?
A When considering any guideline, you should ask yourself a number of questions about its origins.
First, the authors:
- Who are the authors?
- Which organisations do they work for or represent?
- Do the authors have an independently recognised expertise, demonstrated, for example, by published papers or membership of expert groups convened by professional associations or government?
- Are all professional interests relevant to the subject included?
If you are satisfied that the views expressed are likely to be professionally sound, you then need to consider the factors that brought the guideline into being:
- Who triggered the guideline?
- Has any organisation provided financial or non-financial sponsorship?
In short, who is expecting to get what out of it? This is true of both financial and non-financial sponsorship. It is also true of direct and indirect sponsorship, e.g. pharmaceutical company research grants may encourage individuals from an institution to participate in activities which, in other circumstances, they might not agree to.
It is important to be sceptical, but avoid undue cynicism. Pharmaceutical company sponsorship does not always mean that the resulting information is biased. The company may, for example, wish to associate itself with high quality independent work to enhance its image generally rather than promote a particular product. On the other hand, a non-commercial organisation may produce biased information to advance a political cause.
The key point is to satisfy yourself that you understand the motivation of those involved in developing a guideline and judge that you can nevertheless act responsibly on the resulting information.