Q The advent of PCGs will give doctors the chance, maybe the obligation, to draw up locality-based guidelines for referral or treatment of a range of conditions. How should we tackle this? Our concern is to make everyone feel involved and that they own the guidelines, without them being too woolly or taking too long to draw up.
A First, don't spend your energy doing work that has already been done. Look around for national or regional guidelines or guidance. You may have to search quite hard, because some of the material has not been made widely available.
NICE and other initiatives may help by creating a national database of guidelines that can be accessed by PCGs. However, some relevant work is not even described or presented as guideline material: for example, many regional development and evaluation Committees (DECs) have carried out reviews of evidence. Once again, NICE may provide a central point for accessing this information, as it gradually takes over the role of DECs.
Other under-used resources are guidelines that have been drawn up by other local groups. These are not always as rigorous as national guidelines, but may provide relief from a lot of the groundwork that is needed if you start from a greenfield site. These guidelines may be made available in a national database in due course.
Meanwhile, you might find it helpful to contact the Oxford Guidelines Project (for further details, contact Dr Nicholas Hicks, Institute of Health Sciences, University of Oxford), the National Centre for Clinical Audit or the Eli Lilly National Clinical Audit Centre.
Medendium's Guidelines is a good source of reference. There are also books, such as Guide to the Guidelines (Peter Smith, Radcliffe Medical Press). And if you can't find the material you need, you might consider sharing out the work on a number of guidelines between local PCGs and even others a little further away.
There are no easy answers to developing guidelines in a way that involves everyone, promotes ownership, is reasonably quick and doesn't fudge the issues.
Your best starting point is to talk to those with experience:
- St George's Health Care Evaluation Unit
- The North of England Evidence-Based Guidelines Project
- ScHARR (University of Sheffield School of Health and Related Research)
- The Eli Lilly National Clinical Audit Centre
- The Oxford Guidelines Project.
Q We have often felt the urge to 'tweak' national guidelines and wonder whether this is a good idea.
A Where national guidelines have been agreed you should consider very carefully whether to start locally from scratch. Not only is it difficult to find the time to draw up a good guideline, it also involves skills in assessing and appraising evidence.
Even when a national guideline exists and is relevant to the clinical situation of interest to you, it is unusual just to accept the guideline.
First, there is the issue of local ownership. Success depends on helping everyone involved to understand what the guideline says, what it is based on, and what the implications are for his/her clinical decisions and practice organisation. The best way to do this is not simply to print and distribute guidelines and to stipulate that they must be used. Local clinicians may need to discuss the guideline and express it in their own words so that it becomes theirs and feels that way.
Second, guidelines often contain options. It may be helpful to focus on a preferred option, sometimes because it is simpler if everyone who works in a team follows similar routes and sometimes because an option may not be available locally.
Finally, some guidelines may not apply locally without amendment. The way in which, for example, the objective of reducing pain-to-needle time is achieved in a very rural area may not be the same as the way in which we might go about it in an inner-city area.
So, provided that you don't alter the national guideline so much that you leave the evidence behind, feel free to go ahead and 'tweak'.
Q There seems to be a huge unexplored area in the relationship between primary and secondary care guidance, e.g. glue ear referrals and radiology requests. Do you feel that this is a useful area to explore, and if so where should we start?
A It is surprising that more work has not been done on this important area. Perhaps it is because primary and secondary care are still so distinct. Different forms of budgeting, management structures and traditions reinforce this separation.
From the patient's point of view, it is important to focus on the totality of care. In drawing up a guideline, it will be helpful to use the patient's perspective to define the issues. You will need to involve secondary care colleagues: it is good to start with a subject that allows you to work with those with whom you have a good working relationship and who have a good understanding of primary care.
You need to be careful that your guideline is dealing with the same group of patients. For example, a hospital physician's intuitive understanding of diarrhoea is not the same as that of a GP: by the time the physician gets to see the patient, self-limiting illnesses and obvious explanations have already been ruled out.
I suggest that you start by thinking of a group of patients, say all those who present in adult life with wheeze, and construct the guideline so that it follows the care of this group through to a conclusion. In this way, you and your hospital colleague can talk the same language, but retain a perspective appropriate to your differing roles.