Making use of guidelines in clinical practice.

Allen Hutchinson, Richard Baker (eds). (217 pages, £18.95.) Radcliffe Medical Press Ltd, 1999. ISBN 1-85775-088-8. Implementing clinical guidelines: A practical guide. Debra Humphris, Peter Littlejohns (eds). (195 pages, £18.95.) Radcliffe Medical Press Ltd, 1999. ISBN 1-85775-293-7. The growing hiatus between clinical guideline rhetoric and the reality of clinical practice is something that should concern all clinicians. It will be tragic both for clinician and patient alike if the ever-growing number of clinical guidelines and associated literature leads to ‘heart sink’ rather than, as it should do, a positive encouragement to more appropriate and more rational clinical practice. Making Use of Guidelines in Clinical Practice is a multi-authored book which attempts to place the current level of guideline understanding into some sort of coherent framework. It is an extremely detailed coverage of the subject. It comprehensively reviews the development, dissemination and implementation of guidelines. There is an emphasis on the theory and the literature underpinning the guideline process. The book ranges from the definition of guidelines through the development of the evidence base, the need for consensus and the assessment of the quality of the guideline produced. It has particular strength in the chapters relating to setting national guidelines into the local context and getting guidelines into evidence-based practice. For a multi-authored book it has a consistency of approach and presentation which is an undoubted tribute to its two editors. If one is considering developing guidelines from first principles, then this book should provide some assistance and support in what is an extremely difficult task. Yet it is not a book for a busy clinician waiting to improve his clinical care. If one is looking for practical help in the implementation of guidelines then I would recommend Implementing Clinical Guidelines: A Practical Guide as a much more useful and appropriate purchase. This book covers in some detail the Assisting Clinical Effectiveness programme in South Thames (ACE programme). It describes various projects that have been developed over the past 2 years on how to implement guidelines in clinical practice. The projects described involve both primary and secondary care in managing menorrhagia, schizophrenia, leg ulcers, asthma and breast lump referral. Some successes in implementation, especially in a multi-practice project in menorrhagia, appear significant. I think many readers will find the qualitative analysis of the evaluation of the projects controversial and open to interpretation, especially as GPs are seen as a blocking factor! The ACE programme clearly shows that ongoing education, training and support, user involvement, multi-professional collaboration and effective project management are necessary for effective guideline implementation. Unfortunately, these books do not show how the ordinary clinician, without the back-up of a well-resourced project team, might take forward guideline implementation in his or her own practice. The idea may be sound but, without extra resources, especially time, it is difficult to see how guidelines will be widely utilized and implemented. There is no doubt that this is an important subject at a time when clinical governance is becoming almost the dominant theme within the NHS. If guidelines are to be successful as a tool that can improve the quality of patient care, then the practising clinician will require resources in terms of both time and facilitation in order to make them part of his day to day practice. Both these books make a useful contribution to the growing volume of guideline literature, but all the answers will not lie on a library shelf.