Clinical guidelines: Must we follow them?

Controversy about clinical guidelines is not new. Hurwitz (1999)1 described how, in the fourth century BC, Plato explored the difference between skills grounded in practical expertise and those based solely on following instructions or obeying rules. Plato was of the opinion that flexible responsiveness and ‘improvisatory ability’ were endangered by the use of guidelines. Plato’s view was that the ritual following of guidelines debased medical practice because guidelines presuppose an average patient rather than the particular patient that the doctor is treating. He also believed that the knowledge/analysis that goes into the development of guidelines is not with the treating clinician, but with guideline developers distant from the clinical situation. The legal profession seem to like guidelines and protocols; it gives them something to judge us by. The question we need to ask in clinical practice is, how do we stand legally if we don’t follow NICE guidelines or hospital/departmental protocols? Is it a mandatory requirement that we do so? If not, why have they been drafted in the first place? Gupta and Warner2 helpfully summarise the rubric of the NICE guidelines, pointing out that NICE concede that they are not a replacement for clinical knowledge and judgement, and do not take the place of the individual responsibility of healthcare professionals to make appropriate decisions. NICE itself indicates that clinical guidelines recommend the ways in which healthcare professionals should care for people with specific conditionsand encourage best practice. However, Tingle3 describes how, in 1996, the Department of Health4 indicated that the guidelines should be constructed in such a way that permits deviation and initiative, which has the potential to result in improvements. The point is also made by Tingle that clinical guidelines are not a cookery book and clinical judgement is not suspended when they are …