Q Our guidelines for secondary prevention of heart disease threaten to bankrupt our PCG drugs budget, especially with increased pressure from the recent rise in generic costs. Should guidelines for ideal practice be costed before they are released for use?
A This is a very difficult issue. There are those who feel strongly that for practical reasons guidelines should be based on minimum standards, and others who feel equally strongly that for ethical reasons guidelines should be based on ideal standards.
The problem you highlight may lie behind the delays in the publication of the National Service Framework for Coronary Heart Disease. It is impossible to envisage proper care of patients with CHD within the existing drug budgets for the relevant groups, and very difficult to envisage keeping overall spending within the current budget by scaling back enough on other drugs to meet the increase.
As unified budgets take hold, it will become easier for people to spend more on pharmaceuticals in order to save expenditure (outpatient visits, hospital admissions, investigations etc.) elsewhere.
Once PCGs are more developed, it will also be possible to identify expenditure that does not significantly benefit patients (e.g. duplicated tests, unnecessary follow-up out-patient consultations) and this may also help.
In the end, however, ideal care cannot be offered to everyone within existing resources. As a society, we will have to decide on the best balance between the cost of the NHS and the services it can offer.
On this basis, ideal practice may not be achievable and guidelines about ideal care may not be relevant. If guidelines do recommend ideal practice, they should certainly be costed before they are disseminated and those who produce the advice should take responsibility for the knock-on consequences on other services from which resources may need to be moved.
Q Somerset LMC has recently advised GPs to return unwelcome or unrealistic guidelines to the authors. It has produced a set of criteria to help GPs assess new guidelines. Would it be worth making this a nationwide policy?
A It is important to assess any guideline from elsewhere if you want to use it locally. This involves technical assessment (is it based on evidence, what are the strengths of the recommendations?), tone (who produced it and why?), usability (is it phrased appropriately, does it fit in with local patterns of care?), and is it a priority? Simply because a guideline arrives in your in-tray is no reason to assess it, far less use it.
It is helpful to have a locally agreed system for dealing with guidelines: this activity should not be left to chance, or to the goodwill of one person.
No system should be too inclusive (giving every guideline – no matter how commercial or cranky – careful consideration), or too exclusive (only accepting guidelines that are government-endorsed and based on rock-solid evidence). The objective should be to endorse and disseminate a modest number of guidelines, consistent with local priorities and the way in which local clinicians work.
Guidelines should be assessed as described in 'Is this guideline right for your patients?' (Guidelines in Practice, June 1999) In addition, the work of assessing guidelines should be spread around a number of individuals, and perhaps shared between neighbouring PCGs.
Criteria for determining which guidelines to assess, and an 'abbreviated assessment' to rule out unsuitable guidelines at an early stage, will help to keep the work manageable.