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Correspondence |
I note with interest the letter from Prof Paul Goddard recently published in the British Journal of Radiology [1] on the subject of guidelines, and would like to make the following observations.
Since publication of the fourth edition of "Making the best use of a Department of Clinical Radiology: Guidelines for Doctors," in 1998, the Royal College of Radiologists' and its Guideline Development Group have maintained a commitment to periodically producing referral guidelines for the use of clinicians.
Indeed the "little red book" was appropriately adopted by the European Commission with minor modifications, and published in 2000 in similar booklet form as "Referral Guidelines for Imaging". This publication can be accessed through the Europa server (http://europa.eu.int) and specifically addresses article 6(2) of The Revised Medical Exposure Directive (97/43/Euratom) requiring Member States to ensure that recommendations concerning referral criteria for medical exposure are available to the prescribers of medical exposure.
In the "little red book", attempts to underpin guideline statements with strength of evidence following limited literature searching were made. As the Guideline Steering Group for the fifth edition work towards completion of their task, they have sought to strengthen the methodological approach to assuring the evidence base (where present) to the guidance. A managed, systematic process of Special Interest Group involvement with cascade responsibility to appropriate individual radiologists, offered training in literature searching, systematic review in critical appraisal, was instituted.
The guidelines continue to move away from GOBSAT (Good Old Boys Sat Around Table) and towards best evidence base.
Nevertheless, it is clearly stated in the European referral guidelines for imaging that "these referral guidelines are not binding on Member States, and form part of a number of technical guides drawn up to facilitate implementation of the medical exposure directives. Local variations may be required according to health care practice and provision". Prof Goddard's interpretation of the "large private hospital group" transforming guidelines into directives seems an unusual interpretation of the specific incident cited. They simply appear to be attempting to implement a guideline, in a way that any other organisation, profit making or not, could and arguably should do. I think there is a clear distinction that needs to be made here between appropriate guideline implementation and transforming guidelines into rules and directives.
Indeed I wholeheartedly support Prof Goddard's injunction "use [of guidelines] as a directive is an abuse".
Whether appropriate implementation of methodologically sound guidelines is a form of rationing or rationalization could be debated. It will clearly contribute to a more effective Health Service.
Yours etc.,
Postgraduate Centre, Medical School, Foresterhill, Aberdeen AB25 2ZD, UK
References
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