How are you off for guidelines? I've got loads - more than I can cope with - so allow me to share a few. First up is a lime-green book for amnesiac GPs called Guidelines - and it's packed full of them. There are even two guidelines on the use of guidelines: "Guidelines are systematic statements to assist decisions about appropriate health care" and: "Guidelines should be firmly based on reliable evidence of clinical and cost effectiveness." Gripping stuff, eh? But the point is well meant. In medicine, good guidelines reflect good science and good financial management. Unfortunately, a lot of the ones doctors use reflect out-of-date opinions or the profit margin of the pharmaceutical company that devised them. So it's nice to have a book that collects all the latest independent ones, even if it is peppered with irritating drug ads.

My copy fell open on "Real Women, Real Pain" - an ad for evening primrose oil featuring a model in white pants with "ouch" written across her breasts. On the opposite page is a guideline summary for cyclical breast pain. "Mild mastalgia requires examination and reassurance. For moderate or severe mastalgia, examine, reassure and assess with a breast pain chart." (I've no idea what it is either). "If pain is for more than seven days/month and interfering with life, give gamolenic acid (eg. evening primrose oil) 40mg, 6-8 tablets daily in divided doses." There's plenty more, but you can see the problem. What about six days of pain? Or five? Or four? Just gimme the tablets.

When I shared the guideline with a patient, she found it very useful - until she read the page heading of "malignant disease". Cyclical breast pain is very rarely malignant, but the compilers had tacked it on the end of the breast cancer section. So mass panic and lots of explaining all round. The consultation took 40 minutes and left me half an hour behind with a full waiting room of tetchy punters. Thanks a lot, Guidelines*.

Not all guidelines are as controversial. In June, St James's and Seacraft University Hospitals trust (Jimmy's to you) disseminated a guide on plant maintenance. "Due to the economic situation, the decision has been made to terminate the contract with Urban Planters Interior Landscaping Ltd." Now the trust staff have been responsible for maintaining "the 138 live displays on site" - as if they hadn't got enough to do. Highlights of the guidelines include:

"Remove all dead foliage on a weekly basis with sharp scissors. Discoloration of the leaf can be cut out but ensure the shape of the leaf is followed."

"Use your fingers to check soil moisture. The top surface may appear dry, but it could be very wet an inch below."

"In A&E (which has dim artificial lighting, making it difficult to read by) only water twice a month."

"Signs of over-watering - brown tips, yellow leaves, stagnant smell, heavy container."


The author of these guidelines - Keith Atkinson, Estates Officer (Building) - hasn't provided references, so it's hard to assess their scientific validity. However, I can confirm that since they were sent to me two months ago, I've tried them on my own plants and they work beautifully. There are, however, a few unanswered questions. Should a hospital spend money on 138 live plant displays rather than, say, 138 bags of plasma? Has the rise of plant displays been in proportion to the television exposure? Was the money used to pay for them ring-fenced for foliage? How many yuccas are loitering in managerial offices, out of public view? And is there evidence that the environment of a hospital can improve the mood of the users?

Studies have shown that patients who have a view of the rose garden feel better than those with a view of the mortuary - and require less pain relief. Roland Rivron was once admitted to the ophthalmology ward at St Thomas's, which had a very uplifting view of the Thames and Westminster. "At least it would have been uplifting if I didn't have patches over both my eyes."

Alas, I've been unable to track down a study directly comparing the mood- enhancing qualities of live plants versus bags of plasma, but isn't it just possible that we could decorate hospital corridors with creative arrangements of essential supplies that could satisfy both artistic and biological needs? I phoned Keith to discuss this with him but he wasn't available. Probably working on some more guidelines

*Available on subscription. Phone 01442 876100

Next week: Guidelines on ward round behaviour and how to respond to a hospital bomb threat