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P Whitty, M Eccles, Eds. Oxford: Radcliffe Press, 2004, £24.95, ISBN 1 85775 837 4.
There is something missing from this book. As I understand the intentions of the authors, they want their book to be read by working mental health professionals, those involved in Primary Care Trusts who commission and provide mental health care, and people who use mental health services. It is strange, then, that they fail to really address the issues that have kept many of us busy for quite a while since the publication of the National Service Framework for Mental Health five years ago. It’s all very well designing guidelines, protocols and care pathways, but how do you get then fully implemented? How do you persuade the doctors who didn’t participate in any way in the production of your local depression protocol to get the folder out of the in-tray and read it?
Paradoxically, if you haven’t succeeded in achieving this in your organisation, this book can be quite reassuring. As Steven Woolf and his colleagues in a chapter entitled “Potential benefits, limitations and harms of clinical practice guidelines” say: “Too often advocates view guidelines as a ‘magic bullet’ for healthcare problems and ignore more effective solutions. Clinical practice guidelines make sense when practitioners are unclear about appropriate practice and when scientific evidence can provide an answer. They are a poor remedy in other settings” (page 10).
Also comforting for clinicians is a quote from Sir Michaels Rawlins, Chairman of NICE: “No guideline can cover 100 percent, because people vary. It’s up to the doctor or other health professional to decide when the guideline is no longer acceptable and what to do in its place” (page 45). This presupposes that an adequate clinical governance mechanism is in place to map the clinical process, compare existing practice against guidelines, agree where implementation is or is not appropriate, and audit the impact on clinical outcomes. Where mental health is concerned—both in specialist trusts and in primary care—these systems are still fairly rudimentary. The section by Roger Paxton and his team from Morpeth on implementation of a NICE informed schizophrenia guideline through an integrated care pathway is one of the few that offers a real practical insight into these complex matters.
More than half of the book is generic in content and of interest to anyone concerned with what has happened in the field of guidelines and protocols over the last decade. I learned about the way in which NICE works and what the National Collaborating Centres actually are. But the experts were mostly telling us what they thought we ought to know about the interesting things they had been doing rather than engaging in the sticky issues we face on the ground. The Department of Health tells us to produce local protocols, wants boxes ticked, and issues guidelines. Ultimately, I began to wonder how much this knowledge has actually informed (or not) the unseen ones who send out the instructions and who still, despite the fine words of Louis Appleby in the foreword, think that is all they need to do.