As expected when comparing GPs in two relatively similar national health care systems, perceptions of clinical guidelines did not differ much between the GPs in the Norwegian and the Danish studies. This also confirms the meta-study of focus group studies from 2007 which did not find any systematic variation in attitudes to clinical guidelines between countries [6
]. The common issues found in both groups of interviews here have all been reported in earlier studies and reviews of GPs' attitudes to guidelines [1
Nevertheless, we also noted a clear cross-national difference: While the Norwegian GPs in this study appear rather sceptical to economic evaluations incorporated in clinical guidelines, and do not see such clinical guidelines as part of a greater scheme for priority setting, the Danish GPs seem able to combine the need for rationing with their professional identity as holistic generalists. Some of the Danish participants explicitly state that economic evaluations need to be included for the benefit of the public. GPs' concerns about economic vs. clinical standards in guidelines have been noted in a few earlier qualitative studies [17
On the one hand, the similarities are important findings to report because they support the knowledge base, and they are easier to explain than the diverging findings. It is more difficult to explain the dissimilarities, which could for example be results of atypical study samples. However, striking differences merit attention and are interesting because they may lead to new hypotheses about explanations that inspire further studies.
If we for example presume that GPs' attitudes reflect organisational features in the national health care systems, it is relevant to ask whether the difference in attitudes between the two groups of GPs in this study represents stages in an international development of general practice. Whereas Norwegian health care has recently started a process of incorporating economic considerations in government guidelines, Danish GPs are accustomed to applying priority setting. Hence, the Norwegian GPs could be voicing preoccupations about a new situations and how it will form clinical practice, while the Danish GPs have internalised the rationale behind using clinical guidelines for rationing. Thus while the Danish GPs do have to negotiate with patients to follow clinical guidelines and still sometimes end up with acceding to patients' requests, they are not themselves opposed to the motivation implicit in the guidelines.
It follows from this line of argument that as rationing through clinical guidelines is increasingly imposed on GPs, they gradually become more positive to such guidelines as they internalise the ideas behind rationing of health care, or perhaps adapt to a situation they cannot change. The development of primary care in UK would be an interesting case for testing this theory. The British primary care system has in many ways inspired reforms and development of the Danish and Norwegian primary care sectors: The British system is well advanced with a central authoritative guideline source (The National Institute for Health and Clinical Excellence), which produces a steady stream of clinical guidelines. In contrast, Norwegian doctors seem to relate to no more than a dozen clinical guidelines and seem confused about which sources to trust [8
]. Also with regard to government regulation vs. professional autonomy, the countries differ; British GPs are more closely monitored, and have long experiences with rationing health services because of budget responsibility, especially after the new GP contract of 2004 which implies that GPs' payment partly depends on whether evidence based guidelines are followed. Denmark seems to be in a middle position in this alleged development, both with respect to the range of government guidelines and in terms of regulation of professional discretion. If the theory holds, British GPs should be even more positive to rationing than Danish GPs, but this remains to be tested.
A team of British researchers who have studied how British GPs' manage their clinical practices and professional identity explains the development of British general practice thus [21
]: From the late 19th
Century the biomedical model based on hospital practice became prevalent and GPs gradually attempted to associate themselves with this model to maintain status. From the 1960s an anti-biomedical wave grew, partly spurred by patient empowerment, and led to the development of a holistic and patient centred approach in general practice. However, in later years, health authorities have increased the evidence based standardisation and regulation of general practice. Interestingly, the empirical results from this qualitative study indicate that even though British GPs currently are practicing according to the biomedical model, the GPs for the time being seem to be upholding their holistic identity i.e. the participants in this study claimed to be practicing holistically in spite of the apparent incongruity with their actual practice. Earlier UK studies suggest the opposite, e.g. in an interview study preceding the 2004 contract Charles-Jones et al found that British GPs were re-adopting a biomedical view on medicine, specialising to increase efficiency and that the holistic approach was being marginalised [22
]. Summing up, it is fair to say that, according to current knowledge in the field, there is no unambiguous evidence that British GPs are welcoming rationing and standardisation through clinical guidelines.
Still, scepticism and concerns about future changes in work situation is a well-known psychological phenomenon [23
] and fits well with current discourse in the medical literature, e.g. voiced in a comment in Current Surgery
which recognises the controversies concerning guidelines for cost-control but still argues pro-guidelines as long as guidelines do not become the "demanded standards" of practice enforced by health authorities [24
]. However, given that there is a relationship between increased economic considerations and GPs' attitudes to clinical guidelines, it need not be linear. Also, there may be alternative explanations for why different interview studies convey different attitudes among GPs. In depth studies are normally not suitable for generalising because the context in terms of interview questions, terminology, setting, relationship between interviewer and interviewees etc vary between studies. Hence, the differences noted across studies may be related to a range of other factors besides the organisation of the health care systems. Adding to the inevitable contextual differences between interview studies, a review of studies applying focus interviews in primary care research warns that the variation in how the methodology is conducted is tremendous [25
The great advantage of focus groups is the rich and comprehensive material they yield, which in this case indicates that the differences and similarities noted here are well-founded. Adding to the validity of the study is the researchers' impression that the interviewees seemed relaxed and honest during the group interviews; humour and laughs were frequent, as were enthusiastic discussion. Also, we registered no comments indicating scepticism towards the researchers' or their role in this project.
On the other hand it is difficult to assess the representativeness of the participating GPs, i.e. the study sample. According to the limited data we have, the samples are similar to the average of the GP populations in both countries according to a few background characteristics, but bias according to unobservable factors such as attitudes and personality types remains unknown. Thus we cannot ignore the possibility that the difference in attitudes between the Norwegian and the Danish groups could be the result of peculiarities in the samples. However, the group by group analysis did not indicate marked differences between groups within each country, which indicates that unless there have been very different mechanisms influencing the group leaders' decision to participate in the two countries, the groups at least can be expected to represent the same type of GPs in both countries.
Finally, it is relevant to underline that interviews, whether they are quantitative or qualitative, are fallible as measures of people's behaviour. Hence, attitudes to guidelines are not necessarily a good measure, or even explanation of guideline adherence in practice. Studies frequently report that respondents, both in surveys and interview studies, are notoriously inaccurate when predicting or reporting own behaviour [26
]. Indeed, a multi-method international study of adherence to clinical guidelines in Norway, the Netherlands and Sweden found that less then 17% of the variation in practice was explained by the attitudes appearing in an included survey [3