Appraising clinical guidelines: towards a "which" guide for purchasers.

All health care services are attempting to control escalating costs in the face of increasing patient needs, expectations, and healthcare interventions. In the United Kingdom the government has responded in two ways: by introducing a competitive health market to provide incentives for efficiency and an emphasis on providing only those services that have been shown to be clinically effective. The latter approach has concentrated on changing professional behaviour through the introduction of a national audit programme' and a research and development strategy.2 Clinical guidelines are proposed as the logical link between these initiatives, with purchasers being encouraged to include evidence based guidelines in their contracts as a method of increasing clinical effectiveness.3 Simply put, the research and development initiative will define appropriate practice, which will be translated into statements of good care (guidelines), and clinical audit will monitor adherence to the guidelines.4 The potential benefits are enormous: an increase in appropriate practice and hence reduced morbidity and mortality; improved efficiency by controlling professional excess; and cost containment by targeting finite resources on effective interventions.