Shared learning database

Croydon Borough Team, NHS South West London
Published date:
December 2012

The existing local Primary Care Protocol for Depression Croydon, a local guideline for treating depression in adults, was 10 years old. This submission describes the process undertaken to review the guideline in line with the latest evidence to ensure it supported current prescribing and referral practice in Croydon.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

The general aim of the project was to bring the local guideline in line with the latest evidence to support general practitioners in the diagnosis, treatment and management of depression in adults.

The two main objectives of the project were to:

- Ensure the local guideline was evidence based by using the stepped care framework of the NICE Clinical Guidelines on depression (CG90) and depression with a chronic physical health problem (CG91).
- Ensure the guideline was user friendly and provided up to date information on local services available for GPs to refer patients on to where appropriate.

Reasons for implementing your project

The existing Croydon local guideline for treating depression was 10 years old. This needed to be reviewed to bring it in line with the latest evidence and ensure it supports current prescribing and referral recommendations in Croydon.

A baseline assessment based on local prescribing and other data relating to the treatment of depression demonstrated variation in practice between some GP practices.

A working group led the review of the guideline. Involvement of stakeholders, including service users, was achieved through discussion of aspects of the guidance during focussed meetings and obtaining comments on the draft guideline at several stages of the project.

The main benefits sought were:
- Improving early diagnosis of depression
- Reduce variation in the treatment & management of depression including appropriate prescribing of antidepressants

How did you implement the project

A working group led the review of the local guideline. The content and format of the guideline was developed in collaboration with local GP's, specialist mental health services, Croydon prescribing team, commissioners, service users and local service providers.

The stages of the project were:
- Development of a project plan
- Identification of the stakeholders who should be involved
- Review of the evidence available
- Identification of local services and at what stage they should be referred to
- Agreement on the format and design of the guideline
- Consultation on the guideline drafts
- Approval through the governance process
- Launch of the guidance to GP practices

A small sub working group of GP's was consulted to ensure that their views and concerns were heard and taken into account. GP's were aware of variation in practice through prescribing data and with the development of clinical commissioning, were keen to promote an evidence based, cost effective approach. The current local guideline was ten years old so the lead GP's supported the review in light of recent NICE guidance and the need to improve consistency in prescribing in particular.

The main challenge was to ensure the guideline was user friendly and easily available for use by all GP's.

To this end the guideline was designed to be available on the desktop at the point of consultation between the patient and GP and focussed on the following:
- Simplifying a complex pathway as much as possible.
- Placing the right emphasis on the recommended treatments/interventions and their place in therapy at each stage e.g. general advice on lifestyle and self-help interventions, consideration of the underlying causes of depression, psychological therapies and prescribing antidepressants.
- Ease of access to information on services available and information for patients.
- Ease of access for information on how to refer to other services e.g. direct links to self populating referral forms.
- Highlighting monitoring requirements and risk management for individual patients.

The project did not incur any direct costs but did require the time and energy of the working group over a period of 12-18 months and of course the input from stakeholders. The guideline was approved by Croydon Prescribing Committee in November 2011 and disseminated to all GP's in December 2011.

Key findings

The evaluation process is important to assess how the guideline has supported GP's to effectively diagnose and manage people with symptoms of depression. Audit was recommended to measure progress after the guideline had been in use for at least a year using data from existing sources.

Early anecdotal evidence from GPs using the guideline indicates a change in practice in relation to antidepressant prescribing in particular.

Early prescribing data shows there has been a very slight increase in the percentage prescribing of the first choice antidepressants recommended in the guideline. (Citalopram, sertraline & fluoxetine). Using the NHS Business Service Authority Toolkit data shows the following:

In Quarter 2 (July- Sept) 2011-12 63.78%
In Quarter 2 (July- Sept) 2012-13 64.828%

Once prescribing data is further reviewed an analysis will be carried out to assess any reduction in prescribing of dosulepin and reboxetine, taking into consideration that not all dosulepin prescribing is for depression.

Key learning points

The key learning points were:
- To ensure that the key stakeholders are identified at an early stage in the project and used effectively to ensure they were engaged at the right time and focussed on areas where their expertise could be most effective.
- The first stage of the project should be to think how the end product would on a practical level be used for the maximum benefit of patient. In this case the guideline needed to be available for the GP to access at the point of the patient consultation. Establishing this first will save time and duplication when designing the final product.
- Alongside the development of the guideline it was important to identify how the impact of the guideline would be evaluated by suggesting indicators that could be used in the evaluation process and the sources of data to be used.

Contact details

Tracy Steadman
Evidence Based Practice Lead
Croydon Borough Team, NHS South West London

Primary care
Is the example industry-sponsored in any way?