Online Delphi survey
Twenty-eight GPs agreed to take part in the Delphi panel, of whom 10 were recruited through national and 18 through regional approaches. Of these GPs, 25 out of 28 (89%) completed the first round and 21 out of 25 (84%) completed the second round. The participants represented a broad range of experience in general practice, with most being service GPs (80%, n = 20), with no experience of guideline development (88%, n = 22) (Table 1).
Table 1. Characteristics of participants undertaking the Delphi survey
Recommendation ratings for applicability to primary care patients
Mean ratings for the recommendations’ applicability to primary care patients were lower after presentation of evidence for those recommendations where the summary disclosed that fewer than half of the studies were applicable to primary care populations. Mean ratings remained the same or increased for recommendations where most cited publications were applicable to primary care populations (Table 2). While most responders altered their ratings modestly (raising or lowering by 1 or 2 points) after reading the evidence summary, few responders did not change their initial ratings. Ratings did not change substantially in the second round and are not given here.
Table 2. Delphi ratings for the recommendations’ applicability to primary care patients, before and after reading a summary of relevance of the evidence base to primary care patients
Participants’ free-text comments included that the wording of some recommendations was complex or not clearly defined, and that a GP ‘user’ perspective should be included at all stages of guideline development. Some were concerned about the UK applicability of the studies, and not just primary care applicability. Many responders considered that having some evidence is better than having no evidence, and others commented on the importance of clinical experience when implementing guidelines:
‘Overall it appears that I am less critical [than other responders to the Delphi] of guidelines that do not originate specifically from primary care — but my reasons for this are “ laissez-faire” rather than believing other sources are more important. Overall, I considered whether the guideline was in keeping with what, for other reasons, I believe to be good practice, and/or whether it complies with the old adage “first, do no harm”. Most of the recommendations considered met these criteria (for example, prescription of thiamine): if the guidelines were suggesting radical change to practice or invasive treatments I would be much less likely to give them credence without rigorous evidence.’
(GP, Delphi)
Attributes affecting guideline use
GPs rated nearly all 16 factors as likely to encourage guideline use, including ‘Study outcomes used are relevant and important to primary care population’ (Table 3). The notable exception was ‘Evidence underpinning recommendation comes from secondary care population’, which was the only attribute with a mean score of less than 3 out of 5. Attributes relating to guideline accessibility, such as clarity, brevity, and accessible format, scored highly. Scores did not change in the second round.
Table 3. Scores for attributes affecting guideline use
Focus groups
Ten GPs and 10 primary care practice nurses agreed to take part, and six GPs (three male and three female) and 10 nurses (all female), all from different practices, attended. Four themes were identified: guideline use, evidence base, barriers to use, and pay for performance.
Overall, NICE guidelines were viewed favourably as a major source of practice guidance. Participants commented on the large numbers of guidelines, their need for concise summaries, the advantages of user-friendly web-based versions, and the need to identify relevant guidelines quickly when uncertainty drove usage. The groups felt they had to trust the process of derivation and the comprehensive uploading of relevant guidelines, as they had little time to check either background or the availability of guidance. There was considerable evidence of individuals and practice teams trying to be systematic about updating local protocols and templates in line with new guidance, but with concern about the time and feasibility of this given the pressures of work and numbers of guidelines. Streamlining of local protocols across the team, between practices, and with secondary care, and the requirement to meet multiple guidelines as well as QOF indicators all presented additional challenges.
Guideline use
Primary care practitioners in general, and nurses in particular, were positive about guidelines and used them where there was clinical uncertainty, often in short formats:
‘When you want to find something out or you’re unsure of something, you might go in retrospect and then look at the guidelines and see what you perhaps should have done but to learn from the guideline.’
(GP)
‘I actually no longer read what NICE has got to say about it, I go to one of those ... digest websites which condenses it into one screen and I can read it off of there and if I detect anything that I would do differently, then I go back and I will expose myself to the whole guideline which is otherwise too hard work to read.’
(GP)
‘... just use the quick reference. And we get e-mail alerts with the new guidance that’s come out or been updated and we usually see if there’s anything relevant ... if there’s anything I need to use, I go and have a look at it then.’
(Nurse)
Evidence base
Primary care practitioners rarely looked at the evidence behind the recommendations unless the recommendation seemed very different from their normal practice:
‘So where there is evidence, I’m sure they do a fab job and I don’t need to read the evidence myself to believe them.’
(GP)
‘I’ve looked once at the ... behind the guidance, I think it was for cardiovascular risk screening and I have to say I really wouldn’t look forward to doing it again because there were 382 pages to trawl through and it pulled every aspect of each screening tool to bits.’
(GP)
‘Well you might do, that’s a point ... if it was something completely different, you might just want to look at the evidence base I think. If it was quite a different way of treating somebody I think I would have a look at the evidence base then.’
(Nurse)
Few had detailed understanding of guidelines formulation with regard to wording and how it’s used to reflect strength of evidence:
‘I think as time goes on and more research is done in primary care that that evidence needs to contribute towards the guidelines so it’s not just secondary care.’
(Nurse)
‘I’ve been happy to rely on the NICE guidelines for the evidence that they’ve reviewed. And I’m sure they did a great job of reviewing that with the best-available methods to rate evidence but what you can’t see is the gap, which bit is the bit that they just picked out of thin air because they have to cover that area because there is no evidence? And if there is no evidence, then they can say whatever they think is necessary, which is no better than what I can say on the subject.’
(GP)
Participants were aware of the need to interpret research findings for primary care and were pragmatic about this, and hopeful that future guidelines would have more primary care evidence and greater clarity about inevitable gaps in evidence. There was support for clearer labelling of primary care-based evidence:
‘Certainly where you’re using NICE guidance, it would be nice to know that they’ve been done with the thought of general practice in mind.’
(GP)
Some participants argued that good evidence from secondary care could not be realistically implemented in a primary care population:
‘ ... think if you’re doing it, again depending on the subject area, if you did look at all the evidence you’d not find much ... it’s so skewed towards what’s being done in secondary and tertiary centres and not again what’s happening in the real world with GP patients and what’s ... like say the number of patients that are not taking their [drug name], I mean how many people have probably done little audits on that? But there’s probably not a research paper out there that NICE would be able to get their hands on to say “Well look, the evidence there” but people don’t take ... if they haven’t got the evidence, they can’t do ...’
(GP)
‘I was the only GP on that guideline. And the problem that we’d got, we had with the guideline, was that NICE were brilliant at looking at all of the evidence but a lot of the evidence was from America, a lot of the evidence was from various European countries. There was very, very little research from the UK and even less of any research from primary care populations. So there was no evidence to base a primary care guideline on. So we had to go with what was available and had to keep adapting. But you were only there as the one GP trying to bring it back to the real world, well actually you know, what’s realistic and what sounds realistic and what they think is an ideal and what is actually realistic is very different.’
(GP)
Barriers to use
Participants saw the number of guidelines, time available, and limits of evidence as constraints on their practical use and appraisal of guidelines. They highlighted that guidelines mostly addressed the management of specific conditions post-diagnosis, while primary care practitioners predominantly deal with comorbidities and symptoms pre-diagnosis. They wanted guidelines to be short and clear:
‘I think there’s just too many for us to follow any more than just 1% if you like.’
(GP)
‘So you wouldn’t ever go to the guideline unless you’d had that diagnosis in your head.’
(GP)
‘I think the problem is if you’ve got somebody who’s got several comorbidities and you’re trying to do one but it doesn’t sit well with another one maybe.’
(Nurse)
‘And also keeping it to sort of one sheet of A4 format or a flow chart, a flow chart with a patient pathway.’
(GP)
‘I don’t think it’s dealt with by NICE particularly. I don’t think it’s dealt with by NICE, comorbidity.’
(Nurse)
Pay for performance
The UK’s national primary care pay-for-performance scheme or QOF was identified as a key driver for compliance with guideline recommendations, although some concerns were expressed about the impacts of this on professional practice and the associated opportunity cost. Limited resources may impede on primary care practitioners’ ability to explore aspects of clinical care beyond QOF-incentivised practice, and this could be a hindrance to implementation of non-QOF guidelines:
‘With the diabetes you know, the NICE recommendations on ACE inhibitors and statins and things like this, GPs have tended to go to do because they have their QOF box to tick that they’ve done these things.’
(GP)
‘I think to be fair, a lot of it’s targeted towards QOF when you’re writing a template.’
(Nurse)
