Q We are faced with an ever-increasing number of areas covered by guidelines and protocols, and the state of knowledge moves on rapidly. How do we ensure that our guidelines stay up to date?

A There is unfortunately no simple answer to this question. All guidelines should have review dates written into them, and many already do.

If the review date has passed and the practice has not received a new copy of the guideline, you should contact the authors or the organisation that produced the guidelines.

Good housekeeping is essential:

Throw away the old version of the guideline when a new one arises.
Update pages as necessary, including confirmation that the review date has been extended.

Have a 'bring-forward' system so that you automatically take action on the review date if you have not heard by then.

Developments in IT look set to make guidelines more accessible. Information for Health (the IT strategy published by the NHS Executive in October 1998) sets out plans for a National Electronic Library, accessible via the NHSnet. This will include up-to-date copies of guidelines.

Modern electronic technology makes it possible for even small organisationsXto distribute updates automatically to large numbers of registered users economically.

If the guideline you are using does not have a review date, you should contact the originating organisation or authors and ask for clarification as to the status of the evidence on which the guidelines are based.

Finally, if the authorship of a guideline is not clear, you should take steps to review the guideline formally as soon as possible.

As discussed in 'How to draw up your own guidelines' (Guidelines in Practice, July 1999, p.59), an individual clinician or practice should be very wary of reviewing a guideline.

The work of assessing and distilling evidence may require skills that are not available in a practice, and the labour involved may not be justified if the results are to be used only by one practice. This is where it would be wise to consider working with other practices in a PCG, or with other PCGs, or even through a national body.

If you do wish to review a guideline yourself, possible sources of information include:

  • Your PGMC library or the BMA library, carrying out periodic literature searches on MEDLINE
  • The internet
  • Royal College guidelines units (although they may have a variety of names)
  • Specialist associations
  • National Institute for Clinical Excellence (NICE).

Q In view of consumer and governmental pressure to abide by evidence-based guidelines, and the rapidly increasing array of these, is it likely that we will move towards merely accepting national or international good management guidelines 'off the shelf', as to do anything else would be too time-consuming?

A Continued growth in the number of guidelines is inevitable as part of efforts throughout the developed world to improve quality and contain costs.

There is not enough time for every clinician or every practice, or even every PCG, to work through the original published material and derive sound recommendations.

To a great extent, guidelines will have to be taken on trust. Hence the importance of endorsement of guidelines by recognised bodies, which allows you to follow the recommendations with a high degree of confidence.

However, this does not mean that guidelines will be taken 'off the shelf'. Even a sound guideline will need local work to tailor the general advice to the local situation.

There are five reasons why this may be necessary:

  • Developing a sense of ownership. Local ownership of a guideline depends on giving clinicians the opportunity to discuss a national guideline, question it, consider what it means for their practice, and how best to implement change.
  • The guideline may suggest options that are not available locally (e.g. certain equipment or investigations).
  • The guideline may not apply to local circumstances (e.g. the optimum response to acute chest pain in a very rural community may be different from that in an inner-city area).
  • Developing more precise specifications. Here, it may be useful, for example, to have local agreement on the degree of back pain that qualifies for referral to open access physiotherapy or to an orthopaedic outpatient clinic.
  • There is also a need to ensure that the details in the local guideline reflect the way in which local care is organised. If a guideline is to be a useful tool to support clinical care, it should refer to the appropriate forms, procedures, people, telephone numbers, times, places, etc.

Finally, it is worth reiterating that a guideline can never be a substitute for clinical judgment about the patient's particular circumstances. For that reason a clinician's decisions will never be taken 'off the shelf'.

Q With increasing need to spend time on guideline development and updating, audit, and other aspects of clinical governance, how do we balance the time needed to carry out these tasks with the competing demands of our family and patient-contact time?

A It is important that the time spent on improving quality is balanced with the time spent on delivering a service – and on hobbies and family. Most of the care we give can be improved and made more efficient and effective by streamlining the systems on which it is based.

There is, of course, the problem of how to escape from the vicious circle of not having enough time because of inefficiencies in care to improve things, so that they continue to be less well organised than they should be, and as a result they remain as they are.

However, provided that you can find a way of overcoming this initial problem, it is better to think of clinical governance work as an investment of time that will be repaid by savings later, rather than something that needs to be done in addition to all the things we are doing already.

To achieve this, you need to choose with care the topics on which you focus your efforts.

Key criteria for this choice include:

  • Whether the topic is considered important
  • Whether work on this topic will substitute for work that would otherwise need to be done (e.g. as part of a Health Improvement Programme or part of a national service framework)
  • Whether there is local agreement that there is a problem
  • Whether there is local agreement that there is a solution
  • Whether there is the prospect of eliminating duplicated effort, clarifying responsibilities etc.

With the right choice, you may be able to 'tick the box', improve care for patients, and have more time for the family!

Guidelines in Practice, November 1999, Volume 2
© 1999 MGP Ltd
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