Q How do grassroots GPs feed back information about guidelines designed by experts designed which are not working well in general practice? Should the inclusion of a non-specialist GP on guideline design committees be mandatory?
A Anyone using a guideline should feel free to feed back his/her views to the author. The authorship of a guideline should always be clear and include contact details.
I hope that we are moving away from 'experts' to' expertise'. The experts in any situation are those who have lived through the situations covered by the guideline. Specialists have a unique contribution to make, but so too do GPs, other health professionals, and patients.
A good rule of thumb is 'horses for courses'. No guideline should be developed without input from representatives of all stakeholders.
A guideline on stroke rehabilitation developed solely by neurologists, for example, will rightly not influence physiotherapists, district nurses and GPs.
I doubt that anyone will mandate that GPs be part of guideline design committees: there are, after all, many subjects that do not involve GPs.
Two things are important here:
- The guideline should reflect the knowledge and expertise of all staff involved in providing care
- The guideline should be seen to reflect this knowledge, so that it is not rejected by those who are going to have to make it work.
Q Our practice is keen to embrace guideline usage and wishes to rationalise our treatment of hypertension. However, at a recent meeting each partner had found a different published guideline and we have now reached a stalemate over which to use. Are there moves to unify guidelines for major clinical areas?
A Unfortunately, this situation is not uncommon. There may be several reasons for this.
One is that we currently have no national system for registering guidelines. It is often so difficult to find out about guidelines developed elsewhere that people spend a lot of time developing their own. To this unhelpful proliferation is added haphazard circulation.
Another reason is the lack of central endorsement for one approach as representing best practice based on current knowledge. This is particularly important where there are gaps in the evidence, or the conclusions to be drawn from the evidence are not completely clear.
Although this should change now that the National Institute for Clinical Effectiveness (NICE) is up and running, the new system will take some time to cover even the most common conditions and situations.
Meanwhile, you and your partners should first of all examine the guidelines on hypertension and assess whether their recommendations are properly evidence based. You may find it helpful to use a checklist.1
There is a good deal of evidence about hypertension, but because evidence often supports more than one approach you may find that a number of different guidelines pass the appraisal test. Although choosing one of these may, to some extent, be arbitrary, it will make life much easier for everyone.
Q I am interested in the differences between guidelines and protocols. Can a protocol for a nurse be a guideline for a doctor? Does increasing clinical experience or seniority give more freedom to deviate from a guideline? Is this considered in guideline design where more than one professional is involved?
A Words such as 'protocol' and 'guideline' are used in different ways by different people.
You may find the definitions given below useful:
Guideline: Systematically developed statement that assists in decision making about appropriate healthcare for specific clinical conditions1
Protocol: An adaptation of a clinical guideline to meet local conditions and constraints1
(Definitions of other, related terms can be found in Q&As in the May issue of Guidelines in Practice).
Guidelines should make recommendations that reflect the clinical situation. Staff who are more experienced will tend to deal with more complex cases which involve a greater degree of judgment than simpler cases.
But in a given clinical situation, one would expect more experienced staff to follow the recommendations in the same way, and to the same degree, as less experienced staff, unless the recommendations clearly stated that they were applicable to staff with a particular level of training or experience.
Similar points can be made about different professions, e.g. a physiotherapist will take charge of certain aspects of the care of a patient with low back pain, and in these situations the recommendations would apply with equal force to a doctor who happened to be caring for someone in the relevant circumstances.
- Community Practitioners' and Health Visitors' Association. Clinical Effectiveness Information Pack. London: CPHVA, 1998.