Q I am a management consultant to the Trent Waiting List Task Force, and am involved in a number of demand management projects within Trent. The development of referral guidelines is a critical part of this work. I am keen to share information that ensures professionals do not waste time and effort reinventing wheels. However, for guidelines to work they have to be owned by the relevant clinicians. Can you offer any advice on balancing the need for ownership against the use of ready-made tools?
A 'Reinventing the wheel' often describes four quite different things. It can refer to the technical process of assembling evidence and making general recommendations. Assessing evidence and developing guidelines is a skilled and time-consuming process, and it seems pointless for 'core' work of this sort to be duplicated.
The phrase is also often used to describe the process of understanding and internalising information. The duplication involved is unavoidable if clinicians are to change their practice – we cannot learn for each other. The only way to bypass this activity is to issue guidelines as instructions, which is generally ineffective.
Third, a certain amount of reinvention may be necessary to tailor the general recommendations to the local situation. In some places, patients with chest pain may be admitted to A&E; in others they may go direct to a CCU. In some rural areas, consultants may provide limited outpatient facilities in health centres or community hospitals, whereas in others, these may not be available.
Personnel, record systems, and logistics vary from area to area, and practice to practice. Often, too, the evidence suggests that there are a number of equivalent options from which the local health community will need to make a choice.
Finally, there is the symbolism of involving local clinicians. The way a guideline 'feels' is important if people are to be willing to change.
It is important to be clear about the objective(s) of 'local' activity. I would try to avoid duplication of technical 'core' work on guidelines and agree with local key opinion leaders what needs to be done and why. Problems usually arise when there is no local involvement, or when local involvement is non-specific and unstructured.
Q Should we ultimately be aiming to audit our adherence to all the guidelines we adopt in practice?
A It is certainly important to ensure that the decision to adopt a guideline is followed through. Evidence from the literature, anecdotes, and our experience suggests that success is unlikely without:
- An identified individual being given responsibility for overseeing the implementation of each and every guideline
- Robust mechanisms, such as audit or academic detailing
- Involvement of all parties in understanding and adopting the guideline
- Commitment of all parties to making the guideline work
- Meaningful consequences for those involved who do, or do not, change their practice.
It is essential to know whether practice is consistent with a guideline that has been adopted. If, by 'clinical audit', you mean an organised comparison of current practice against desired practice, then the answer to your question is yes.
However, audit will not work if the other features listed above are absent. Audit need not be a quantitative analysis of key data collected on hundreds of patients manipulated in a huge spreadsheet. Good audits can be carried out by reading and discussing the last 10 cases, or by making a few observations on a small number of well-chosen cases as a 'litmus test' for the larger picture.
A classic audit of all guidelines would divert too much time and effort away from patient care. Adopting guidelines without follow-through is pointless, but implementation has to be balanced with other aspects of care.
Q We sometimes receive guidelines from hospital specialists on the management of specific conditions or on referrals in their specialty. These seldom seem to have involved primary care in their evolution, although they may well have evidence to support
A If a guideline is of concern only to hospital specialists, it shouldn't be sent to those working in primary care. If it deserves the attention of colleagues in primary care, it should have involved them in its development.
Assuming that the guideline is relevant to primary care, there are three possible problems if GPs and their primary care colleagues do not contribute to the guideline:
- The guideline may be impractical, e.g. it may assume staffing levels or facilities that do not normally exist in primary care.
- The guideline ® and the evidence on which it is based ® may be apply to a typical population of hospital patients but not to those in general practice, e.g. a guideline on back pain for orthopaedic outpatients or a guideline on diarrhoea for general medicine outpatients will be different from a guideline on these symptoms in general practice, because the likely diagnoses are different. Back pain or diarrhoea that is sufficiently bad for a GP to make a decision to refer a patient for a specialist opinion, and persistent enough to still warrant the appointment when the time arrives, is not typical of back pain or diarrhoea seen in the surgery.
- The guideline may not be adopted in primary care because it is seen as a product of old-fashioned secondary care imperialism.
I'd send guidelines like these back with a polite note pointing out which of the above problems apply in the specific case, and suggest that it makes no more sense for those in secondary care to give unilaterally generated guidelines to colleagues in primary care than the other way round.