Intended for healthcare professionals

Education And Debate

Clinical guidelines—the hidden costs

BMJ 1999; 318 doi: (Published 06 February 1999) Cite this as: BMJ 1999;318:391
  1. Alan Haycox, senior research fellow (,
  2. Adrian Bagust, senior research fellow,
  3. Tom Walley, director
  1. Prescribing Research Group, Pharmacology and Therapeutics, University of Liverpool, Liverpool L69 3GF
  1. Correspondence to: Dr Haycox
  • Accepted 6 April 1998

The publication of guidelines for statin treatment in the United Kingdom attracted criticism, particularly that no attempt had been made to assess the implications for resources associated with the guidelines. 1 2 The need to evaluate cost and clinical effectiveness in real terms before the widespread use of a treatment is frequently acknowledged.3 Unfortunately, these issues are rarely addressed in clinical guidelines, and there is little evidence that cost effectiveness in practice is considered in drawing up guidelines. 4 5

Surprisingly little consideration has been given to the role of guidelines in a healthcare system in which resources are constrained. 6 7 Cholesterol lowering drugs epitomise the problems that affect clinical guidelines in many areas. We consider here some unintended consequences from the development of guidelines (whether regulatory or … supposedly … advisory) that arise for those funding health care, doctors, and patients.

Summary points

Implementation of evidence based guidelines may limit doctors' discretion and the autonomy of local commissioners

Guidelines allow narrow interest groups to impose their priorities on the health service

Implications for resources and the real effects of proposals must be evaluated thoroughly if guidelines are to be of value

Failure to do this may distort decision making in health care; this, in turn, can lead to unbalanced structures that do not serve the best interests of patients

Nature and role of guidelines

All clinical guidelines aim to promote “best practices” that improve the outcomes of treatment.8 This rests on two assumptions—firstly, that outcomes identified in clinical trials are reproducible in normal practice and, secondly, that rapid and universal adoption of an effective treatment leads to optimal treatment for the whole population. Guidelines place most weight on evidence generated in randomised controlled trials. Unfortunately, real life clinical practice, where resources are more restricted, patient compliance …

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