It is a long time since clinical guidelines were seen as cookbook medicine and a threat to professional autonomy. Nowadays, evidence based guidelines are considered one of the major efforts to improve patient care. Development of guidelines has progressed enormously, with many organisations (including the National Institute for Health and Clinical Excellence in the UK) using validated methods such as the AGREE instrument.1 Clinical guidelines are valid if they are developed in a rigorous way, independently of vested interests of their developers, and if they support decision making in practice and affect actual care. But are current guidelines meeting these criteria? I have concerns.

For guidelines to have an impact on actual care, they need to be integrated with other quality improvement initiatives, such as performance measurement and quality improvement programmes. This requires intensive collaboration between the organisations responsible for these tasks,2 which is lacking in most countries. Expert guideline developers, usually clinicians and epidemiologists, often have …