In a pressured environment, realising that NICE guidelines do not have to be followed to the letter can be quite freeing - and also better for the patient - argues Margaret Stubbs
There are a variety of guidelines recognized in the UK to help us in our practice, but at times they can become restrictive if we do not use them as that, guidelines. Some years ago, at a meeting of those providing diabetes care in the locality where I then worked, a secondary care diabetes consultant reminded us that guidelines such as those provided by NICE or SIGN are here to help us, but if from our clinical understanding we decide to do something different with our patients, that is not wrong, as long as we are able to adequately support such a decision.
I found that quite releasing at the time, and since then have used the same advice for colleagues, who feel duty bound to follow the NICE guidelines to the absolute letter. Maybe you have felt that way until now?
However, do you constantly have your local clinical commissioning group (CCG) telling you that you need to reduce your budget in this area by changing certain drugs or use different blood glucose meters that use cheaper test strips to try and reduce the drug budget? Over recent months, since management of primary care has been taken over by CCGs, CQUINs have appeared. In my locality, it has meant pressure on us as nurses (and GPs) to reduce spending on our drug budget. Alongside this, some manufacturers have interpreted these CCG guidelines as an opportunity to push the use of their meters, and are frequently phoning and asking if we need any more of their meters. Some have even just delivered a boxful to the surgery, without checking if we are going to use them.
We are being asked to constantly review various medications, and whether we are using them as advised, fulfilling the appropriate criteria. While it is good practice to review medications regularly (annually at least), are we given the time in practice nursing to do that more frequently, with the view that we may need to change the blood glucose device to one with more economically priced test strips, or swap a drug to a lower priced one, and then have to rerun various blood tests to confirm suitability? The truth is, as most of us are aware that the most expensive drug is the one not taken by the patient.
Patients with diabetes are often taking numerous drugs, one or more for their cholesterol, maybe two for their blood glucose control, perhaps two for their hypertension, and that is a total of 5, assuming they have nothing else they need medications for. I wonder how cost effective it is to keep trying to reduce drug budgets by trying to persuade patients to take the less expensive options and keep changing their medications.
In a previous blog, I spoke of the need to use NPH insulin instead of going straight for the analogue varieties. I think in diabetes care we do need to think carefully before prescribing, but we are also being urged to “individualise” our patient care. Each patient may respond differently to a certain medication, for some, metformin is great and causes no problems even at 1g twice daily; on the other hand there are those who cannot even tolerate 500mg M/R a day. We must use our clinical knowledge and experience to guide us, as well as using NICE and SIGN guidelines as a starting point for prescribing decisions.
We must work in partnership with our patients, so that they can more confidently choose which is the most effective treatment pathway for them and we can support them in doing so.
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