Q While welcoming the new guidelines on rhinitis (produced by BSACI and reviewed in Guidelines in Practice, July 2000), I was dismayed to see the inclusion of patch testing and the comments on delegation of this to practice nurses, who would need specialised training. Should new guidelines from specialist fields take account of funding issues and workload resulting from their recommendations?
A The BSACI guidelines suggest that patch testing could be the province of the practice nurse – not that it must be. Extra training is available from the National Asthma and Respiratory Training Centre, but could also be obtained from other, local, sources.
Nurses cannot undertake procedures for which they are not properly trained, but the exact form of training is not prescribed. It is up to the individual GP, as the practice nurse's employer, to be satisfied that this task can be delegated and to be sure that the practice nurse feels comfortable with taking on that delegated task.
Whether patch testing should be carried out by the practice nurse depends not only on those concerned agreeing that it is professionally appropriate – the GP will also need to consider whether the cost of training the practice nurse is justified by the work that can be delegated. This will depend on the number of patients with rhinitis, the personal preferences of those in the practice, and the way in which the practice is organised.
The important thing about the guidelines is the care that patients should receive. How that is delivered will vary from practice to practice.
Q I sit on a committee that designed local guidelines for atrial fibrillation. These have been successful and some members wish to put them on the intranet. What issues should we consider before doing this?
A There are two sets of issues to consider. The first concerns local guideline development itself. It is important to ensure that this is soundly based in terms of evidence, tailoring recommendations to local circumstances, and involves local clinical staff so that they both understand and 'own' the work.
The second issue concerns publishing and communicating the guidelines. It is important to remember that technology, however clever, is only a means to an end. In deciding whether to put guidelines on an intranet or the internet, you have to assess the degree to which local clinicians will be both able and willing to access material in this way.
The advantages of web-based publishing are that it is easier to keep material up to date, and the costs of distributing and updating information are low.
The disadvantage is that many people do not feel comfortable browsing for information in this way because they have not been properly trained or they prefer to use other media.
In short, you need to make sure that in putting guidelines on an intranet you are not making unwarranted assumptions about the behaviour of local clinicians. Particularly important is that you should not see this as an easy way of communicating (rather than distributing) the information.
Successful implementation is about much more than simply sending out information – and this applies as much to web-based media as to traditional paper-based publications.
You need to ensure that clinicians know:
- that there is a guideline
- where it has come from
- why it has been produced
- what it means for their practice.
The principles of implementation, which are now well established, apply as much to publication on an intranet or the internet as they do to paper-based publication. The technology may change very rapidly, but human behaviour changes slowly, if at all.
Q Will allocation of extra clinical funding under the NHS Plan be influenced by clinical guidelines? Guidelines for best practice often have a bottleneck (e.g. exercise testing and echocardiography) and judicious application of resources could ease these.
A In a rational world there would be a close connection between allocation of funds and evidence-based recommendations for achieving health outcomes.
Unfortunately, policy making about evidence-based clinical practice is seldom itself evidence-based, and we can expect the allocation of funds under the NHS Plan to be determined by a number of factors, most of which are non-rational, such as visibility, current media interest, ease of measurement, and novelty value.
We can hope that local decisions on the allocation of resources will be influenced – even if they are not determined – by proven ways of achieving the targets set out in the NHS Plan and the Performance Assessment Framework.
Echocardiography, for example, is an essential investigation in the diagnosis of heart failure. As the National Service Framework on Coronary Heart Disease notes, heart failure is underdiagnosed as well as inadequately treated in many patients. Echocardiography is not uniformly available, and it is unreasonable to expect those working in areas where it is less available to meet the same standards in the treatment of heart failure as those in areas where there is greater provision of echocardiography.
Even allowing for non-rational factors, we can reasonably expect a more even provision of echocardiography across the country in the future. Just don't hold your breath for too close a link between evidence-based guidelines and national policy: you are likely to be disappointed.