Lack of resources. Lack of resources re-emerged as a major barrier to following guideline recommendations. Problems of patient referral included having no specialist to refer them to, patients being misled about specialists’ qualifications, and patient confidentiality issues. Several GPs reported that by the time patients received appointments, they reported their problems had disappeared and they no longer wanted appointments.
…a guideline might come through and I’ve followed the protocol … and arranged a referral … then the reply has come back from the hospital that they don’t have the resources for this at the moment. So it [the guideline] has fallen flat on its face and that is extremely disappointing when we in primary care are trying our best. (GP2)
Waiting times reported were between 2 to 26 weeks for psychiatrists or community psychiatric nurses and 9 to 12 months for psychologists. Perceived delays or deficiencies in specialist services may partially explain GPs’ tendency to over prescribe relative to recommendations.12
Increasing guideline use
For guideline use to increase, GPs in this study thought that more resources needed to be put in place (particularly mental health professionals); the number of guidelines issued should be reduced; and guidelines should be produced and sent from a central body with a multidisciplinary team including some GPs, to reduce problems of perceived unrealistic assumptions. Incorporation of guideline recommendations onto computer systems with prompts and flow charts was also suggested by several GPs as method to promote guideline use. The majority of interviewed GPs also said they would like some form of audit and feedback.
We really need some kind of measure.… We’re all meant to audit our work, but again its time and we audit what we have to. If someone could demonstrate that I’m not managing depression well, then I might sit up and think I need that guideline there. We need all the feedback we can get really. (GP9)
Discussion
In this study, GPs perceived barriers to implementation of current depression guidelines matched other research findings on this subject—eg, lack of time,22 lack of resources,17 variability among patients,19-21 lack of awareness,22,23,27 lack of agreement with guideline recommendations,28 and poor accessibility to guidelines.11
The relatively small group of participants in this study cannot be generalized to all GPs. Additionally, there are always difficulties with self-reporting—participants may not do what they say they do. However, “purposive” sampling is consistent with qualitative approaches and allows a wide range of GPs’ views to be explored in depth. This study could be replicated elsewhere to assess how representative these views are.
Interviewed GPs did not always agree with depression guidelines. To address disagreement, some sort of educational intervention may be useful. Previous research has shown educational interventions to enable guideline implementation: an educational program was reportedly one of the most important elements in the successful implementation of cervical screening guidelines28 ; and large group meetings were effective in modifying drug use in coronary artery disease.29
An important theme in this study was the issue of referring patients and the availability of specialist services. GPs disagreed with the recommendations about referring, and saw lack of mental health professionals as a main barrier to following depression guidelines. This problem needs to be addressed, and interviewed GPs believed certain recommendations would be followed if resources were put into place. Their views have important implications for clinical guideline development. Resources must be considered before recommendations are made. Alternatively, those involved in guideline production may be demonstrating the case for more mental health professionals.
The volume of guidelines and lack of time and accessibility to guidelines were also perceived barriers. Both barriers could be addressed by introducing computerized decision support systems. Indeed, several GPs suggested the incorporation of guidelines onto computer systems as a way of promoting guideline use. However, the effect of computerized evidence-based guidelines has been variable,1,30 and further study is needed.
The GPs thought depression guidelines were insufficiently flexible to use with the spectrum of depressed patients they see. However, some expected this, believing there would always be certain patients to whom guidelines do not apply. Greater involvement of GPs in guideline development was seen as a means to addressing this problem as well as reducing unrealistic assumptions made about general practice.
Audit and feedback emerged as a potential method for assessing and improving compliance. This matches the evidence. A review of 12 studies using audit and feedback as implementation strategies concluded these activities change behavior modestly, but all studies reported improvements in the process of care.1