Implementing guidelines in general practice care.

care.' Despite efforts to set standards, guidelines, or protocols implementing them in practice has generally received little attention. Guidelines are not self implementing.2 It is well known that new and valuable information; new scientific results; and, in particular, new consensus guidelines or protocols reach only part of the target group.35 Even if doctors are well informed about what to do, they often do not perform according to their knowledge or skills,3 6-9 and the relation between their attitude towards certain expected behaviour and actual performance is generally weak. Ideas about implementing guidelines and standards in general practice tend to be naive. The interventions or strategies are often restricted in circulation to publication in (scientific) journals and to continuing medical education by means of lectures or group discussions. Many general practitioners (GPs) do not read this information. Only half of them will attend meetings for continuing medical education, and only those on topics considered as interesting to them. Often only reinforcement of existing ideas is achieved. Research usually shows that the effect of continuing medical education on actual performance in practice is marginal.6 7 10-12 Classic approaches to implementing new information fail because, firstly, too little attention is given to the specific barriers to change in certain groups of doctors and practices. Also too much effort is spent on improving knowledge and attitudes and too little on improving skills and actual behaviour; too little is known about interventions and programmes that are really effective in changing GPs' performance. In this paper I shall explore the current views and research on implementing guidelines and suggest some recommendations on methods and approaches to quality improvement in general practice. I shall discuss in more detail some of the general principles of promoting change in clinical care highlighted by Stocking in this journal.'3