Implementing clinical guidelines

Current situation

  • Clinical guidelines have increasingly become a familiar part of practice.
  • It is important to be aware of the level of evidence on which a guideline is based.
  • Authors of guidelines should take into consideration the available resources needed for them to be implemented successfully.
  • Guidelines have to be evidence based, up-to-date, realistic and reliable. They should also be easily accessible to all practitioners and should ideally be adapted to suit the local target population.

What is the evidence?

  • The total number of national guidelines for UK doctors is at least 300 (BMJ 2006; 332: 1,160).
  • Ample evidence exists to support the argument that the most simple and cost-effective intervention to increase the implementation of guidelines is rewriting guidelines in behaviourally-specific terms (BMJ 2004; 328: 343-5).
  • One problem with guidelines is knowing which ones to use in clinical practice, as often different guidelines for the same condition have conflicting advice in them. This was made apparent with the British Hypertension Society guidelines. Although they recommend tailoring antihypertensive drug choice according to a patient's ethnic group and age (the ABCD approach), NICE guidelines for hypertension initially conflicted this. However, NICE reviewed and altered their guidelines in 2006.
  • A study has shown many clinical guidelines in the US are actually influenced by the pharmaceutical industry and special interest groups, which may also be a problem in the UK (NEJM 2007; 356: 331-3).

Implications for practice

  • NICE was established to advise the NHS in England and Wales not only on the quality of care individual patients could expect (in terms of appropriateness and effectiveness) but also to address the other important dimensions of health care quality (equity, fairness and efficiency) society expects. It develops guidance through advice from professionals and the public.
  • However, one in six NHS trusts is not adhering to NICE guidance or does not know whether it is or not, according to the preliminary results from the new annual health check scheme (BMJ 2006; 333: 170).
  • The cost effectiveness of guidelines should be taken into account before comparing with other, potentially more cost effective, approaches (BMJ 2006; 332: 793).

Useful website - NICE - Scottish Intercollegiate Guidelines Network

Dr Louise Newson is a GP in the West Midlands and author of 'Hot Topics for MRCGP and General Practitioners' PasTest 2006.

Key points

  • Guidelines should be easy to use.
  • Conflicting guidelines exist.
  • Cost effectiveness of guidelines need to be considered.
  • Many trusts are still not adhering to NICE guidelines.


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