Good quality primary health care is the essential foundation for effective and efficient national health systems. This inescapable fact explains why health services in developed countries around the world continue to devise and test novel ways of structuring or managing primary care. But amidst all the new policies, primary care practitioners may sometimes feel powerless and confused, although the quality of primary care depends on their energy and initiative. The tension between an increasingly managed service and the practitioner who seeks to provide care tailored to the individual seems to grow with each new policy, and clinical practice guidelines and the methods used to implement them can often appear to practitioners as the embodiment of this problem.,¹ Yet guidelines could be part of the solution.

The first step in making guidelines a solution rather than a problem is for practitioners themselves to take the lead in guideline development and authorisation. Whilst this does not preclude involvement of managers and patients – indeed, their involvement should be seen as mandatory – it does mean that practitioners must take a leading role in the institutions established to develop guidelines. Standing back and complaining is not an option. Guidelines contain, primarily, recommendations for health practitioners, and practitioners must take responsibility (in partnership with others) for developing those recommendations. In addition to ensuring that guideline recommendations take account of routine clinical practice, practitioners through leadership of guideline development can help to make sure of the quality of the guidelines. Good quality guidelines promote the use of the findings of best research evidence in clinical practice, and therefore represent a key feature of professionalism. Professional bodies can play a role in the authorisation of guidelines, drawing on established tools for assessing guideline quality.² Practitioners are likely to welcome professional leadership in deciding which guidelines are suitable for local use.

The second step is for practitioners to claim leadership in the implementation of guidelines in clinical practice. The factors that hinder or promote the uptake of guidelines are various, and differ from one setting to another. They may include issues relating to practitioners themselves such as training, confidence or attitudes, matters of concern to patients such as costs, time or convenience, and problems in the health system more widely such as lack of services or administrative blocks to referral. An understanding of factors that make uptake more or less likely is essential, and should be followed by development of a plan that takes these factors into account.³

The design of guidelines and their implementation should therefore take note of local needs and context, and involve real practitioner involvement. In Hong Kong , this means empowering practitioners to help bridge the gap between research and practice. Using the model of “knowledge translation”,⁴ practitioners could potentially contribute from awareness, agreement, adoption, to adherence with evidence- based practice. However, a survey of Hong Kong doctors showed a suboptimal level of knowledge in electronic searching,⁵ while the skills in appraising evidence, or assessing guideline quality, have not been systematically taught in the medical undergraduate curriculum until recently. For practitioners to claim a leading role, they must first be enabled to grasp a new set of knowledge and skills, and then be provided a platform for application of these skills in the local primary care setting.

The 2010-2011 Financial Budget announces the establishment of a Primary Care Office in the Department of Health to support the Working Group on Primary Care of the HMDAC, for the “overall co-ordination of long-term development of primary care.”⁶ While it is encouraging to see the government’s investment of resources and effort, it is crucial to note that 85% of Hong Kong ’s primary care is provided by the private sector, mostly as solo practitioners. Involving private practitioners will be, as discussed above, essential to relieving the tension between the administrators and clinicians when guidelines are to be implemented in routine practice. This public private partnership has been highlighted in the Hospital Authority’s suggestion to the government regarding the development of clinical guidelines for quality assurance.⁷

Since 2004, annual Clinical Guideline Development Workshops have been co-organized by the Professional Development and Quality Assurance, Department of Health and international institutions – such as The Clinical Governance Research and Development Unit of the University of Leicester, New Zealand Guidelines Group (NZGG) and Scottish Intercollegiate Guidelines Network (SIGN) – culminating to a few authorized clinical guidelines for local use.⁸ This represents a model for boosting the confidence and enhancing the leadership of primary care practitioners in guideline development. Professional bodies, such as the Hong Kong College of Family Physicians, are well placed to extend this model across sectors, so that real practitioner involvement can be elicited from different walks of practice.

Participating in training, writing or implementation of clinical guidelines demands time, energy and dedication from practitioners. Tangible support including incentives to allow protected time, information technology backup and academic accreditation will be conducive to facilitating practitioners’ involvement. Ideally, a culture is to be nurtured such that a primary care practitioner would regard it an honour to be involved in guideline development and implementation, thus contributing on a wider scale to improve the health of the population.