Book Book

Making Use of Guidelines in Clinical Practice; Implementing Clinical Guidelines: A Practical Guide

BMJ 1999; 319 doi: (Published 16 October 1999) Cite this as: BMJ 1999;319:1078
  1. Andrew Wilson, senior lecturer
  1. Department of General Practice and Primary Health Care, University of Leicester

    Making Use of Guidelines in Clinical Practice

    Ed Allen Hutchinson, Richard Baker

    Radcliffe Medical Press, £18.95, pp 224

    ISBN 1 85775 088 8

    Implementing Clinical Guidelines: A Practical Guide

    Ed Debra Humphris, Peter Littlejohns

    Radcliffe Medical Press, £18.95, pp 200

    ISBN 1 85775 293 7

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    “When examining a patient with gastrointestinal symptoms, if you don't put your finger up [the rectum] you put your foot in it” was the first clinical guideline I was taught as a student in the 1970s.

    Since then, I have continued to receive guidelines at an increasing rate Most of these have been sent “cold” and have been variously binned, filed, or acted on. With so much emphasis put on the need for a strong evidence base in guidelines, it is ironic that the commonest method of implementation (unsupported dissemination), according to a recent review by the NHS Centre for Reviews and Dissemination, leads to “no statistically significant improvements in practice.”

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    From their titles, these two books about “making use of” and “implementing” guidelines, could be expected to address the neglected area of getting evidence into practice. Both are targeted at clinicians.

    Making Use of Guidelines in Clinical Practice is a multiauthor text whose editors have wide experience of guidelines, including the Royal College of General Practitioners' clinical guideline initiative. Its title is perhaps misleading, as the book provides an overview of the background, theory, and development of guidelines as well as their implementation in practice. “Making sense of guidelines in clinical practice” would be a more accurate description of the book's aims and contents.

    Clinicians like guidelines to be clear, authoritative, and succinct. This book shows how much work lies behind delivering such a product, starting with appraisal of the evidence and then the more difficult process of distilling this into clear recommendations. These issues are illustrated by reference to the Royal College of General Practitioners' Back Pain Guideline and the North of England Guideline Development Project. Other chapters discuss how to proceed when evidence is weak and the use of consensus methods. With the development of NICE, the book addresses the important topic of adapting national guidelines to local use and argues that the local contribution should be towards setting standards and implementation.

    The final chapters focus on the key issue of implementation, including the contribution of commissioning. The topical issue of involving patients and carers in implementation is discussed in detail and put in the broader context of decision making by patients and practitioners. The authors point out the potential conflict between patient autonomy and maximising clinical outcomes.

    This book provides an authoritative and readable account of the theoretical and practical issues around guidelines. It will help clinicians to consider the provenance of the guidelines they receive, how their quality can be assessed, and how they can be used to deliver clinical care.

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    Implementing Clinical Guidelines deals entirely with implementation. In their preface, the editors state: “this book is not intended to be read from cover to cover, but to act as a manual for … application of clinical guidelines.” After a brief introduction to the assessing clinical effectiveness (ACE) programme, it then presents case studies on how the implementation of six guidelines, ranging from schizophrenia to leg ulcers, was undertaken and evaluated with an uncontrolled, before and after design. The final section contains a chapter on lessons learnt, further developments of ACE, and a synopsis of the final report of the external evaluation.

    Although lessons emerged from the evaluation, especially the key role of facilitators and the need for advocates, these could have been predicted from previous literature, which is barely referenced. The book reads like a report to funding bodies, and, while it may be of use to project managers, it is insufficiently distilled for the editors' target audience of “busy clinicians and managers.”


    • Competing interests Richard Baker and some contributors to Making Use of Guidelines in Clinical Practice are members of my department.

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