Q Although I agree wholeheartedly with the RCP's national guidelines on stroke, we have very few of the recommended services in our district. I am concerned that all these guidelines will do is inform our patients that they are getting a second-class service. Should such guidelines have funding for implementation before they are made public?
A 'Idealists' feel that any guideline which does not propose the best available care institutionalises and legitimises poor care. They argue that if professionals and patients know clearly what should be provided and what is not available, there will be pressure for change, whereas 'pragmatists' argue that there is no point in proposing ideal standards of care as reality is imperfect. But it is possible to come some way towards reconciling these two points of view.
First, the purpose of any guideline should be clear, e.g. a 'guideline' that makes recommendations about an ideal service will be of use to different people in a different way from a 'guideline' that sets out minimum standards of care. The former will be used in discussions about commissioning services in the medium to longer term. The latter might imply urgent changes to the way that care is given and have immediate implications for clinicians' responsibility towards their patients if the best care that they can provide is unsafe.
Second, guidelines should where possible include minimum, reasonable, and ideal standards of care. It should be clear which standards are which. It is then possible to use a guideline for more than one purpose.
Third, guidelines should be based on the principles of continuous quality improvement: small improvements in care, repeated over a long period of time, will bring big rewards. Trying to get to best care in one leap is seldom successful: organisations and the people in them develop incrementally. It is possible both to keep the goal of ideal care in sight to ensure that effort is rightly directed in the medium to longer term, while focusing from day to day on making modest incremental changes.
Q What is the difference between a clinical guideline and an integrated care pathway?
A The National Pathways Association defines an integrated care pathway (ICP) as determining 'locally agreed, multidisciplinary practice based on guidelines and evidence where available, for a specific patient or client group. It forms all or part of the clinical record, documents the care given, and facilitates the evaluation of outcomes for continuous quality improvement.'
Clinical guidelines summarise the evidence for aspects of clinical management of patients. They are intended to help health professionals make clinical decisions on a more rigorous basis, to improve the clinical and/or cost-effectiveness of clinical practice.
While clinical guidelines focus on the (cost-)effective specific clinical decisions, ICPs are more focused on the cost-effectiveness of the care package. ICPs are intended to improve the seamlessness of care when a number of professionals are involved. They aim to coordinate the work of a clinical team and emphasise the organisational aspects as well as the clinical delivery of care.
Clinical guidelines outside ICPs are appropriate if the issues are uniprofessional, restricted to certain aspects of care, or detailed and technical. ICPs are more appropriate for multiprofessional care, and where the best way of improving care involves wider, organisational issues with clinical components as appropriate.
ICPs should be short enough to understand, to remember, and to practise. Both ICPs and clinical guidelines have a distinct history and purpose.