The reality of local policy lag
Every clinician knows the feeling. NICE publishes TA999 for a new anticoagulant, complete with clear efficacy data and a positive cost-effectiveness profile. Six months later, your Trust’s formulary remains unchanged. The local policy, last reviewed in 2018, still lists warfarin as the first-line option for the relevant cohort. This is not an anomaly; it is the standard operating procedure for many NHS organisations. The gap between national guidance issuance and local implementation is where clinical practice stagnates and risk accumulates.
The formulary fossil
Trust intranets are often museums of outdated clinical policy. I recently searched for our local guidelines on community-acquired pneumonia. The top result was a PDF dated 2012. It recommended a antibiotic regimen that would now be considered suboptimal based on resistance patterns and subsequent national guidance. The document was still marked as “active,” its review date long passed. This is a typical example of a policy fossil—a guideline that remains technically in force but is clinically obsolete.
These fossils create tangible problems. A junior doctor, following the local intranet, might prescribe the outdated regimen. A pharmacist, aware of newer national standards, may query it, leading to delays and confusion. The patient’s care is caught in a bureaucratic crossfire caused by a failure to decommission old rules. The administrative burden of reconciling old local policy with current evidence falls directly onto frontline staff during busy shifts.
Why local policies lag
The delay is rarely malicious. It is a systemic issue rooted in resource constraints and process complexity.
The committee bottleneck
Implementing a new NICE Technology Appraisal often requires approval from multiple committees: Drugs and Therapeutics, Finance, Clinical Governance. Each committee meets quarterly. If a submission misses the deadline for one cycle, implementation is delayed by three months. A contentious or expensive appraisal might be debated over multiple cycles. I have seen a straightforward NICE recommendation for a new biologic take over a year to clear local committees, during which time patients were denied a funded, evidence-based treatment.
The problem is compounded for non-drug interventions. A new NICE guideline on a diagnostic pathway or service model must be adopted by service leads, operational managers, and commissioning groups. This multi-stakeholder process lacks the formal structure of a drug appraisal, often leading to indefinite postponement or silent rejection.
Evidential ambiguity and the “not invented here” syndrome
Sometimes, lag is justified by claims of local context. A Trust might argue that its patient demographics or resource base are unique, therefore national guidance does not directly apply. While occasionally valid, this is often a smokescreen for inertia.
I recall a situation where NICE recommended a specific triage tool for early sepsis recognition in emergency departments. Our local policy group rejected it, citing a lack of “local validation.” No local validation study was ever commissioned. The result was three more years of an inconsistent, home-grown approach that lacked the robust evidence base of the NICE-endorsed tool. This “not invented here” bias prioritises unproven local custom over nationally validated evidence, to the detriment of patient safety.
The clinical consequences of misalignment
When local policies lag behind NICE, the impact is felt at the bedside. It creates a dissonance that clinicians are forced to navigate daily.
Moral distress and professional liability
Clinicians experience significant moral distress when compelled to follow an outdated local policy they know is inferior to the national standard. Do you follow the Trust’s protocol and provide care you believe is suboptimal, or do you deviate from local policy and risk governance repercussions? This is an untenable position.
From a liability perspective, the waters are muddied. In a clinical negligence case, which standard holds more weight: the outdated local policy or the current NICE guideline? While the GMC expects doctors to follow national guidelines where they exist, Trusts discipline staff for not following local protocols. This places the individual clinician in a legally precarious position, caught between their employer’s rules and their professional regulator’s expectations.
Inequity and postcode prescribing
Lag is not uniform across Trusts. One organisation might implement a new cancer drug within three months; a neighbouring Trust might take eighteen. This creates stark inequities. Patients with the same condition, separated only by a county border, have access to fundamentally different treatment options based solely on their GP’s postcode. This undermines the principle of a National Health Service.
We witnessed this with the rollout of direct oral anticoagulants (DOACs). Some Trusts rapidly updated formularies following NICE guidance, while others dragged their feet, maintaining restrictive criteria that effectively limited use. The variation in stroke and bleeding rates across regions during this period likely reflects this policy lag.
Case examples: When lag becomes dangerous
Antibiotic stewardship
A clear example is in antimicrobial resistance. NICE and Public Health England frequently update guidance based on evolving resistance data. A local antibiotic policy that is five years old is not just outdated; it is actively harmful. It may promote the use of antibiotics with now-high resistance rates, leading to treatment failure.
In my own practice, I admitted a patient with a urosepsis who had failed oral antibiotics prescribed by their GP according to a local CCG guideline that was years out of date. The causative organism was resistant to the recommended first-line agent. The delay in effective treatment contributed to a severe illness that required ICU admission. This was a direct consequence of a local policy lagging behind national surveillance data.
Mental health crisis care
NICE guidelines for the management of acute behavioural disturbance in mental health settings have evolved significantly to emphasise de-escalation and minimise physical restraint. Yet, many local trust policies still reflect an older, more physical intervention-heavy approach. Staff training is often based on these local documents, creating a culture and practice that is out of step with national best practice, increasing risk for both patients and staff.
Navigating the gap as a clinician
While systemic change is needed, clinicians cannot simply wait. We develop pragmatic strategies to bridge the gap, though these are not without risk.
- Documented Deviation: When deviating from a local policy to follow NICE, meticulous documentation is essential. The clinical notes should state: “NICE guideline CGXXX recommends X. Local policy has not yet been updated. Decision made to follow NICE guidance for the following reasons…” This creates an audit trail.
- Informal Advocacy: Raising the issue directly with clinical leads and governance teams. Sending an email with a link to the new NICE guidance and a polite query about the review timeline can sometimes catalyse action.
- Using Governance Systems: Submitting a clinical incident form citing “outdated policy” as a contributing factor to a near-miss or a delay in care. This forces the risk management system to acknowledge the problem formally.
These are workarounds, not solutions. They individualise a systemic problem, placing the burden of ensuring evidence-based practice on the individual clinician.
The path to better alignment
Solving policy lag requires a shift in how Trusts view guideline management. It must be seen as a core clinical safety function, not an administrative afterthought.
Proactive systems for local vs national alignment are crucial. This means automated alerts when national guidance is published, dedicated resources for rapid appraisal, and streamlined approval pathways for non-contentious updates. The goal should be to make alignment the default, and lag the exception.
Furthermore, all local policies should have mandatory, hard-coded review dates—and they must be allowed to expire if not reviewed. A policy fossil should not be accessible on the intranet as an “active” document. Sunsetting clauses would prevent the use of dangerously outdated guidance.
Acknowledgement and indexing
Trusts could improve transparency by openly acknowledging where local policy is under review or known to be behind national standards. A simple traffic-light system on the intranet—green for aligned, amber for under review, red for known lag—would at least inform clinicians of the situation.
For a broader perspective on the tensions and frameworks surrounding this issue, the resource at local vs national index provides a useful structural overview. Ultimately, closing the gap between NICE and the frontline is not just about efficiency; it is a fundamental component of patient safety and clinical governance. The current culture of tacit acceptance needs to be replaced by one of active accountability.