Objective: To explain recent rapid audited change in the uptake of locally implemented, evidence-based clinical guidelines for asthma and angina in primary care.
Methods: A case study of primary care in two matched, adjacent districts in Northern England, focusing on a stratified random sample of 49 general practitioners (GPs) from eight primary care groups. Data were collected from three cycles of mainly qualitative interviews carried out at six-monthly intervals, before and after the dissemination of local guidelines and after audit data were gathered. Interviews examined attitudes, awareness and impact of locally disseminated asthma and angina guidelines and the subsequent audit. Audit data on guideline uptake were also available from a parallel study.
Results: The rapid increase in guideline uptake observed in both intervention and control groups was not explained by individual practitioners or practice factors. The findings are attributed to GPs' awareness of policies for evidence-based medicine, of new health service institutions and of the clinical governance activities of primary care groups. Behaviour change reflects GPs' decisions about what to record in case notes as well as their clinical decisions, so that findings may reflect changing perceptions about accountability rather than about preferred treatment regimes.
Conclusions: Guideline production and dissemination is best seen in the broader context of policy change. Studies of guideline implementation should report before and after data and incorporate significant qualitative components in order to identify important contextual factors.