Clinical guidelinesBMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39587.520833.CE (Published 31 May 2008) Cite this as: BMJ 2008;336:s189
- Ricky Banarsee, director of West London Research Network (WeLReN)1,
- Dennis Ougrin, Kraupl-Taylor research fellow2
- 1Department of Primary Care and Social Medicine, Imperial College London
- 2Department of Child and Adolescent Psychiatry, Institute of Psychiatry, King’s College London
Ricky Banarsee and Dennis Ougrin look at whether junior doctors can play a part setting guidelines and if so how
Guidelines are by no means a modern phenomenon. One of the first descriptions of guidelines can be found in King Hammurabi’s codex dating back to the 18th century BC.1 One of the surviving tablets, for example, states that sesame oil is to be used for postoperative wound care. Another describes penalties for not following guidelines: a doctor’s hand must be cut off for removing a slave’s mark and thus helping a slave to escape. The guidelines were created by the king himself in cooperation with his senior doctors. Thirty eight centuries later things are essentially unchanged. Most guidelines are still created by a tsar and senior doctors (plus or minus other professionals and service users) and are primarily for the junior doctors to comply with. It is exceedingly rare for juniors to participate in this process. In this article we consider whether clinical guidelines are any good. Would it be good for juniors to get involved? And how can you get involved if you think it is a good idea?
Who can produce clinical guidelines?
No guidelines on who can produce guidelines exist, so this could be done by almost anyone from a local clinical team to a government institution. Some guidelines start locally but acquire a regional and sometimes national status.23 The most important development in the field of clinical guidelines in the United Kingdom in the past decade has been the development of the National Institute for Health and Clinical Excellence (NICE).4 NICE is a unique body with links to both the Department of Health and clinicians that produces guidance on a number of topics across medical and allied specialties. The development of its clinical guidelines is facilitated by national collaborating centres, which are hosted primarily by royal colleges. The following seven centres are currently in operation:
Nursing and supportive care
Women’s and children’s health.
From the number of guidelines either published or in production, it appears that the national collaborating centre for cancer is the most active one.
Are guidelines any good?
The long history and increasing popularity of guidelines point to one fundamental property of guidelines—they reduce anxiety. This seems to hold true for all the parties concerned. Senior doctors feel they have done their best to summarise and communicate their expertise in managing patients. Juniors think they can rely on guidelines as a summary of the best evidence base and a step by step guide to clinical work. Both juniors and seniors hope that following guidelines will limit clinical negligence claims, although the role of guidelines in these cases remains minimal.5 Patients also feel that they get the best possible deal with an added advantage of being able to demand that their care meets guidelines’ recommendations. Service managers and commissioners could refer to the guidelines to evaluate, set up, or close services and to demand more money from the government.
Is this a win-win situation then? The answer is no for several reasons. Firstly, several stakeholders compete for limited financial resources during the development of guidelines. This leads to conflicts, as illustrated by the recent controversy of the NICE recommendation to limit the use of cholinesterase inhibitors in patients with Alzheimer’s disease.6 During the development process, stakeholders may face a dilemma: how to maximise their professional group’s control and influence on the one hand, and how to minimise potential for being held accountable on the other hand.7 This could make guidelines biased and perhaps even harmful. NICE collaboration is an attempt to alleviate this dilemma by subjecting NICE guidance to public consultation.
Secondly, as guidelines are not legal documents, following guidelines does not mean immunity from legal action, especially if different interpretations are possible.8
Thirdly, although guidelines usually draw on the current best evidence, there is limited evidence that generating guidelines necessarily improves patient care; however, there is no doubt that they can achieve it.910
The bottom line is that clinical guidelines could be an important factor in improving patients’ care but only if the following conditions are met:
Guidelines are based on the best current evidence base and there is a mechanism of updating the guidelines in line with the evidence base
Guidelines are specific, applicable to the population in question, comprehensive, and easy to understand
Guidelines allow sufficient flexibility
Guidelines are prepared in consultation with a range of stakeholders including service users and, crucially, the professionals who will be implementing the guidelines
There is a mechanism for implementation and feedback, including audit
Guidelines are tested with the target professional groups and their feedback is acted on
Sufficient resources are available to implement guidelines.
If you think it is a difficult task to achieve all of these goals, there is only one thing you can do: rise to the challenge and get involved.
Why should I get involved?
If you don’t get involved others will be telling you what to do (lack of sense of control).
Being part of a guidelines development committee is good for your CV and career.
You will learn more and feel more confident.
You might help more people by doing your job properly.
How do I get involved?
Development of guidelines follows several logical steps, and each step provides an opportunity for juniors to get involved.
This could be driven by a myriad of factors ranging from a critical incident in your department to a shift in government policy. NICE provides transparent opportunities for all interested to suggest a topic. Suggestions can be made on-line11 and are assessed using transparent criteria.12 Topic suggestions are assessed by one of the seven topic specific consideration panels. The panels are chaired by experts in each topic, and each panel includes other experts in the topic area, as well as generalists and two lay members. The final decision about whether to refer a topic to NICE is taken by health ministers.
Any professional or lay person (in theory) can apply to become a member of a topic consideration panel, but it would take an exceptional junior to make it through. There are no junior doctors among the members of the NICE topic selection committees at present.
Things are much less formal when it comes to selecting topics for guidelines at local level. Here is a challenge: speak to your senior about developing guidelines on a topic relevant to your department and where no guidelines exist. Prognosis: the answer will be yes. Side effects: you might be nominated to do a lot of work in your own time.
Becoming a member of a guidelines development committee
The ease of getting selected for a guidelines committee is inversely proportional to the level of the committee. There should be little impediment to your participation in the local guidelines development process. At regional and national level, things are more complicated. This is especially true for NICE guidelines—the Holy Grail of the guidelines business. Representation on a NICE guidelines development group is not restricted to “experts.” The person specifications state that professional members should have an interest in and experience of the guideline topic, preferably gained while treating patients on a day to day basis in the NHS. Indeed, anyone can get involved in developing NICE guidance by responding to a guidance consultation, although NICE does recommend that individuals do so via the registered stakeholder organisation that most closely represents their interests. It goes without saying, then, that any engagement with NICE is easier if your trust is a registered stakeholder. A list of registered stakeholders for each guideline is published on the NICE website (www.nice.org.uk).
Doing a literature search
This is a crucial step in the development of guidelines. A comprehensive literature search is universal irrespective of the level of guidelines. Few people will be keen to do literature searches, but for a junior it might have an extra benefit—you could potentially publish them. The Cochrane library is an excellent source of up to date systematic reviews.13 Do literature reviews in the format of a journal article—this will save you time if you decide to submit your review for publication. It is worth studying the style of your preferred journal carefully and reading the instructions to authors before you start.
Guidelines are notoriously difficult to implement. Doctors have been trying novel and challenging implementation strategies with variable success.14 The bottom line is that good guidelines are easier to implement and bad guidelines are more likely to cause resistance. NICE recognised implementation as a key area of the development guidelines and has set up specialist panels to provide an independent and impartial view on the implementation tools NICE develops to support its guidance. Clinicians of all training grades who have experience relevant to the guidance topic are encouraged to apply. In addition, many trusts will have local arrangements to facilitate implementation of guidelines, and juniors are usually welcome to participate.
Engaging in evaluation
Trusts are usually interested in demonstrating adherence to guidelines, in particular NICE guidelines. A trust’s performance depends partly on being able to demonstrate adherence to NICE guidelines. Audit could be a useful way of increasing adherence.15 Juniors are required to do audit and are entitled to use up to two hours a week to audit their practice.16 If you can show that your audit resulted in increased adherence to guidelines, this then becomes a publishable piece. NICE is keen on receiving feedback and has set up a specific feedback mechanism to capture comments from those concerned with implementing its guidance.17
Guidelines could improve clinical practice but only if done properly. Guidelines are here to stay, and they are almost always developed by experts for the use of juniors. Recent developments, and NICE collaboration in particular, provide unique (although little known) opportunities for juniors to join in almost any stage of the process. The benefits of getting involved probably outweigh the effort required.
This work was supported by the Psychiatry Research Trust.