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The NHS Plus evidence-based guideline project
Over the past decade, evidence-based clinical guidelines (EBGs) have become an increasingly familiar part of medicine. The subsequent incorporation of evidence-based health care into every day practice has resulted in improvements in clinical effectiveness [1] as well as efficient allocation and utilization of health resources [2]. When NHS Plus was established in 2001, there appeared to be few EBGs for use in occupational health (OH) practice. A search of guideline databases revealed only five guidelines relevant to OH practice, and only one of these, the OH management of low pain back pain, produced by the British Occupational Health Research Foundation had involved occupational physicians in its development. Factors that were thought to have prevented the development of EBGs in OH included lack of funding, a perceived lack of research base and a perception that OH practice differs from other medical specialities in the type of guideline required.However, an EBG programme in OH had been established by Nederlandse Vereniging voor Arbeids—en Bedrijfsgeneeskunde in the Netherlands [3] and the British Occupational Health Research Foundation had produced several evidence-based reviews [4]. Verbeek et al. [5] had established that the evidence base relevant to OH was sufficiently extensive to practise evidence-based OH in a clinical setting. It was with this background that the NHS Plus evidence-based guideline project commenced in 2003.
The EBG project has two principle aims:
- (i) To review and collate existing guidelines relevant to OH practice in the UK.
- (ii) To develop new EBGs to assist OH units in raising the evidence base and quality and consistency of their work.
- (ii) To develop new EBGs to assist OH units in raising the evidence base and quality and consistency of their work.
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A range of OH professionals submitted proposals for new guidelines and six were selected for funding and development directly by NHS Plus and the Occupational Health Clinical Effectiveness Unit is developing a further two.
Topics were selected for new guideline development using the following criteria:
- (i) Evidence of variation in practice, which affects management or clinical outcomes.
- (ii) A strong research base providing evidence of effective practice.
- (iii) The potential benefit to employees/employers must be sufficient to justify the resources invested in the development and implementation of the guidelines.
- (ii) A strong research base providing evidence of effective practice.
The seven guidelines currently under development are listed in Table 3.
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The methodology used by the NHS Plus EBG project to develop the new guidelines is described elsewhere in this journal.
EBGs in general are not without their limitations [6]. Guideline development groups may misinterpret some of the evidence available or may miss a vital piece of research especially if it is in the grey literature. Furthermore, it has been argued that guidelines developed at a national or regional level may not reflect the needs of local practitioners. With regard to OH guidelines, there are few randomized controlled trials exploring the effectiveness of interventions in the workplace; therefore, OH guidelines are usually based on observational studies, the evaluation of which can be complex and subtle. Within the guidelines being developed by NHS Plus, we have found that there are few studies on interventions effective in facilitating return to work. This has also been found by others undertaking systematic reviews in OH (Jos Verbeek, personal correspondence). Often recommendations can only be based on general evidence for return to work interventions, such as are detailed in Concepts of Rehabilitation for the Management of Common Health Problems [7].
In developing the NHS Plus guidelines, we have tried to ensure that the guideline development groups were comprised of multidisciplinary groups of professionals, with representation from a wide geographical area. All the guidelines are reviewed by external assessors with an in-depth knowledge of the topic under review.
The production of guidelines per se does not lead to an improvement in quality of practice. It is imperative that guidelines are distributed as widely as possible, especially to workers and managers who are generally harder to target than health professionals. Therefore, NHS Plus has a multi-pronged dissemination plan for each guideline. Guidelines and accompanying leaflets are distributed by direct mailing and electronic bulletins to a variety of professional groups and are freely available on the NHS Plus website [8]. Lectures and seminars on the individual guideline topics are planned for the future. Implementation of clinical guidelines involves changing the behaviour of health professionals, which is not an easy task. Grol et al. [9] found that the main factors associated with the successful implementation of a guideline or protocol in general practice were the practitioners' perception that it was uncontroversial, evidence-based, contained explicit recommendations and required no change to existing routines. Furthermore, the optimum implementation strategies are those based on the integration of guideline and audit findings into problem-based educational programmes [10]. All the NHS Plus EBGs contain suggestions for further research and suggested audit criteria. At least one region has incorporated the audit criteria for the implementation of the chronic fatigue syndrome guideline into their local policy (Alison Rimmer, personal correspondence).
The Occupational Health Clinical Effectiveness Unit in partnership with the Royal College of Physicians and the Faculty of Occupational Medicine will oversee the completion of the current guidelines under development, develop further guidelines and a national audit programme to ensure the implementation of the guidelines. The onus is now upon OH professionals to embrace evidence-based OH practice, to become involved in the national audit projects and to initiate research projects to fill the gaps in the evidence base of OH clinical practice.
e-mail: ira.madan{at}kcl.ac.uk
References
- Pearson M, Ingham J. Audit, assessment or performance management? Clin Med (2005) 5:7–11.[ISI][Medline]
- Maynard A. Evidence-based medicine: an incomplete method for informing treatment choices. Lancet (1997) 349:126–128.[CrossRef][ISI][Medline]
- Nederlandse Vereniging voor Arbeids—en Bedrijfsgeneeskunde. http://www.nvab-online.nl/.
- British Occupational Health Research Foundation. http://www.bohrf.org.uk.
- Verbeek JHJ, van Dijk FJ, Malmivaara A, et al. Evidence-based medicine for occupational health. Scand J Work Environ Health (2004) 30:164–168.[ISI][Medline]
- Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Potential benefits, limitations and harms of clinical guidelines. Br Med J (1999) 318:527–530.
[Free Full Text] - Waddell G, Burton K. Concepts of rehabilitation for the management of common health problems. London: TSO.
- NHS Plus. http://www.nhsplus.nhs.uk.
- Grol R, Dalhuijsen J, et al. Attributes of clinical guidelines that influence use of guidelines in general practice: observational study. BMJ (1998) 317:858–861.
[Abstract/Free Full Text] - Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients' care. Lancet (2003) 362:1225–1230.[CrossRef][ISI][Medline]
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