Royal Liverpool and Broadgreen University Hospital, Rheumatology & AMAU, Liverpool, UK. E-mail: TomDken{at}hotmail.com
Chair of SGAWG on behalf of the Working Group, which is a subcommittee of BSR's Clinical Affairs Committee.
Following the success of the report by the working party of the British Society for Rheumatology (BSR) on guidelines for prescribing TNF- blockers in adults with rheumatoid arthritis [1], the BSR decided to set up a committee to develop further standards and guidelines. The NHS, through a variety of bodies, including NICE and the National Service Frameworks, use the vehicle of guidelines and standards to improve the quality of care for patients with a number of different diseases, most noticeably myocardial infarction [2], stroke [3] and diabetes mellitus [4]. Audit is the tool by which the delivery of care can be best judged; examples are the myocardial infarction (MINAP) [5], asthma [6], COPD [7] and stroke [8] audits coordinated by the Royal College of Physicians. However, guidelines and standards do not supersede the need for careful clinical assessment and tailoring of treatment to the individual's requirement. As so aptly stated by Dr Watkins, Since the attitudes of patients range from total life-long obsession with illness at one end of the spectrum to complete indifference at the other, it is only within the medical consultation that the narrow confines of guidelines, which may introduce a spurious certainty, can be interpreted for the individual patient [9].
The Standards Guidelines and Audit Working group was set up (see Table 1 for membership) as a subcommittee of the Clinical Affairs Committee of the BSR in 2002. In its first year, it commissioned a number of guidelines (Table 2) and a standard of care for persons with rheumatoid arthritis.
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These tools have been developed to ensure that a rigorous approach has been used in the creation of the guideline. They assess the scope and purpose of the guideline, the involvement of the relevant stakeholders, including patients, user organizations and primary care, and the rigour of development, i.e. its basis in published evidence. The guideline itself should include eligibility and exclusion criteria, assessment and monitoring of the disease and treatment outcomes, including a practical audit tool. There should be a statement of cost implications and barriers to the introduction of the guideline and also an executive summary that includes a treatment algorithm. Once the Standards Guidelines and Audit Working Group have supported the guideline and reported back to the authors, the document is passed to the Clinical Affairs Committee for ratification and then to the Council of the BSR for endorsement. Finally the guideline is submitted to Rheumatology for publication; however, the guideline will be available on the BSR website once the BSR council has endorsed its publication (http://www.rheumatology.org.uk). All guideline development work is funded by the society itself, in line with BSR's working with industry policy, to ensure its independence from any pharmaceutical company interests.
What value do these guidelines have to the rheumatologist? They aim to provide an expert basis to improve the care of our patients with musculoskeletal disease. They should be viewed in conjunction with the ARMA standards of care projects [12], which are in the process of publication and have been developed by a multidisciplinary team to look at the needs of patients with musculoskeletal disease. The BSR guidelines will focus mainly on the treatment plans for specific diseases. The 20032004 guidelines concentrated mostly on the role of biological therapy in new indications and it is hoped that they can be used with service commissioners to encourage appropriately funded treatment. The BSR will use these documents to work closely with NICE to produce its guidance; however, until this is achieved, funding in England and Wales cannot be guaranteed for particular treatments. Finally, to try to state where guidelines fit within the evolving NHS, may I quote from Professor Hampton's paper [13] Guidelinesfor the obedience of fools and the guidance of wise men?, in which he states
Perhaps the last word should go to Lady Thatcher, who summed up her attitude to guidelines in the Inquiry into Arms to Iraq affair. The transcript of her evidence includes the following:Lady Thatcher: Guidelines are exactly what they say they are. They are guidelines. They are not the law.
QC: But do they have to be followed?
Lady Thatcher: Of course they have to be followed, but they are not strict law. That is why they are guidelines and not the law and, of course, they have to be applied according to circumstances.
The authors have declared no conflicts of interest.
References
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