Guidelines, guidelines. My desktop, bookshelves and floor are covered with them. Advising on everything from diabetes to incontinence, they come from multiple agencies in increasing sizes and scope.

Some guidelines are excellent; they save doctors from a long trawl through the evidence and give directions in shorthand that everyone can understand. But Baroness Young, chair of England’s new health regulator, the Care Quality Commission, seems to have an unnerving faith in guidelines. Under her aegis, the CQC seems to have general practices in its firing line, and sees adherence to guidelines as a proxy for GP quality. This is alarming.

There are several issues the baroness might not be aware of – she does not have a healthcare background, after all. First, guidelines are a guide, not a formula. If guidelines for a generic population could be applied to everyone, why bother with anything but a computer and automated prescriptions? Individuals have different preferences, concerns, histories and views. The day I start ignoring the variability of people to enforce homogenous guidelines will be, I hope, the day that I lay my stethoscope down and do something else instead.

Second, I fear the baroness sees all evidence as equal when the truth is more sordid. Some evidence is rubbish, or overstates the effect of an intervention, or does not look for important side-effects. Many guidelines make vigorous attempts to distinguish good evidence from bad, but all evidence comes with provisos and, in terms of doing harm, the unthinking reliance on evidence may be just as bad as relying on no evidence at all.

A recent issue of the British Medical Journal carried a piece of research examining how GPs treat depression. The GP contract stipulates that people diagnosed with depression must have their symptoms scored, with the total of points used to suggest whether treatment is required. Personally, I find that most helpful information comes from a discussion rather than a series of yes/no answers. Indeed, the study found that the various scoring systems used by GPs were inconsistent in grading depression and it was thus a good thing that doctors relied more on a holistic discussion.

As the National Institute for Health and Clinical Excellence says: “Guidelines are not a substitute for professional knowledge and clinical judgment … guidelines can be limited in their usefulness and applicability by a number of different factors … [a] guideline does not, therefore, override the individual responsibility of healthcare professionals to make appropriate decisions in the circumstances of the individual patient, in consultation with the patient and/or carer.” Perhaps Baroness Young should read this last set of guidelines, in full.

Margaret McCartney is a GP in Glasgow.
margaret.mccartney@ft.com
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