Q Our PCG wishes to disseminate a set of guidelines on diabetes care to all its members. We took these from the NHSnet. We will acknowledge the authors but should we formally request permission before using the guidelines in this way?

A There are two aspects to consider: legal and practical.

The legal position is simple in theory. On NHSnet, as in any other medium, it should be clear who owns the copyright of the material and what the owner is prepared to let others do with it and under what conditions. Examples of copyright conditions might be:

  • Anyone (or perhaps only those working in the NHS) are allowed to copy and distribute material, but not to sell it
  • Use of material is permitted provided the authorship is acknowledged
  • Prior permission of the copyright owner is required before copying is permitted.

However, copyright and intellectual property law are not always crystal clear. Copyright exists even without a © symbol, which is only a claim to copyright, not a definitive legal statement about the status of the material.

It is generally assumed that the person or organisation who created the material is the owner of that material and can decide what is and is not permitted in relation to it.

However, a guideline usually draws on material from elsewhere, such as papers in published journals or conference proceedings, and ownership of the material may not be straightforward. Also, as with other material, the way in which the copyright owner has allowed it to be used in the past may allow people to claim that, even where there is no explicit permission to use material, there is an implicit permission to do this.

You should always abide by the conditions laid down by the copyright owner, if these are clear. If you are not sure whether the use you want to make of material is permitted, you should contact the copyright owner, explain your proposed use, and ask for permission.

If you want to use material in a way that is not covered by any specific permission, you should assume that you are not entitled to use it without permission and should seek the copyright owner's agreement. In other words, if in doubt, ask.

From the practical point of view, it is obviously important to acknowledge the authors. If the guideline is a good one, and the authors are respected in their field, referencing will give added strength to the recommendations, and it will be easier to ge people to pay attention to them.

In the non-commercial circumstances you describe, it is very likely that if the copyright owner is unhappy about your proposed use of the guideline, this will be for very good reasons.

In general, copyright owners are happy to allow use of their material, provided they do not think that this exploits them. Most professional bodies generating guidelines do so because they want them to be used.

Q A local consultant sends back referrals if they do not comply with clinical guidelines. Is he within his rights to do this?

The short answer to your question is yes, in the sense that there is no obligation on a consultant to see a patient simply because the patient is referred to him. But if he did not see a patient referred to him, and that patient subsequently came to harm as a result, then he might have a problem both with the GMC and the civil courts. Along with the right to make independent judgments about referrals comes the duty of care.

However, your question implies one or more serious problems. GPs and consultants should be working together for the benefit of patients.

If the guideline to which he refers has been agreed locally, GPs should not be sending him patients outside the guideline without very good reason. This is a matter for GPs to address.

If there are good reasons, and the consultant knows about them, then there must be differences of view between the consultant and the GP about some aspects of the guideline. In this case, GPs should get together with the consultant and consider these aspects and agree a line to take.

If the consultant is simply turning away patients on the basis of a guideline that has not been agreed locally, this suggests poor communication between him and local GPs, and the problem may be related to the individual. This needs a different approach.

Whichever situation it is, it sounds as if a meeting between the consultant and GPs is needed. One approach that might be helpful is a primary/secondary care interface audit, in which a sample of patients is looked at both in the community and in the hospital setting, and jointly peer reviewed.

Q Many guidelines are good for patients with a single disease, but difficult to apply to those with multiple pathology. Multiple pathology is increasingly the norm in our ageing population. Studies are often criticised for having non-representative patient populations – should guideline design take account of this?

A To some extent, any guideline will need to simplify the issues it deals with in order to handle them properly. Trying to cope with all possible combinations of condition, even the major ones, would make it very difficult to make recommendations.

On the other hand, it is not helpful to have a guideline that does not seem to apply to the patient in front of you, leaving you with the problem of deciding which recommendations, if any, to follow.

There is no easy answer. Computers offer some prospect of bridging the gap: by entering information about the patient, it is possible to generate a version of the guideline that is more tailored to the circumstances.

Guidelines in Practice, January 2001, Volume 4(1)
© 2001 MGP Ltd
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