In their otherwise excellent review Dr Samanta and his colleagues (March
2003
JRSM1)
assert that ‘clinical guidelines are systematically developed,
evidence-based, clinically workable statements that aim to provide consistent
and high quality care for patients’, and that because ‘guidelines
from NICE... may be seen as the
crème de la crème of
authoritative bodies' it follows that their pronouncements are increasingly
likely to inform the standard of care in negligence’. This is a
dangerously illogical assumption to make: for all the diversity of lay and
medical expertise available to NICE, the content of their guidelines is
becoming increasingly proscriptive, and, in some cases, advocates a radical
departure from pragmatic medical practice. The recent furore over the use of
ultrasound locating devices for placing central venous catheters is a case in
point.
2,
3,
4 There are any number of
criticisms that could be made of this document and its practical
implementation,
5 but
with regard to the quasilegal nature of the guidelines, several important
questions arise. Who owes the duty of informing doctors of new guidelines? Who
is responsible for their execution—the hospital, the doctor, or both?
Who is responsible for failing to follow the guidelines—the doctor, the
hospital (either primarily, or vicariously), or both? Does obtaining specific
consent from the patient vitiate the pseudo-legal requirement to follow the
guideline? What is the legal recourse open to doctors who do not accept that
the guidelines are ‘systematically developed, evidence-based or
clinically workable’? Finally, should the courts be asked in every case
to determine whether the guidelines are reasonable and rational before relying
on them as the standard of acceptable medical practice?
NICE and CHAI are valuable agencies for improving the quality of care in
the NHS, but their authority depends on the soundness of their decrees. It is
ultimately for the courts to decide, case by case, whether such
decrees should inform the standard of care in negligence. Guidelines should
continue to inform, rather than prescribe, medical practice.