Ten years ago, in a paper called Britain’s Gift, the editor of the BMJ at the time and the director of the UK Cochrane Centre outlined a vision of medicine for the 21st century: easy access to good quality reviews of clinical evidence, and the streamlined recruitment of patients into randomised trials as a matter of routine whenever there is uncertainty about choice of treatment.

“For example,” they explained: “we still do not know which treatments are useful for acute stroke, but if every patient in the world experiencing a stroke were admitted to trials we would have enough patients within 24 hours to answer many of these questions.”1

The first goal of easy access to good quality reviews of evidence is on its way to being realised. Trials, however, remain exceptional in everyday clinical care, and sometimes address comparisons that are irrelevant to doctors and patients because they compare new treatments with placebo rather than with the best treatments currently available. Furthermore, trials are often conducted in idealised or unrepresentative patient groups.2 Because of these problems, randomised trials commonly fail to inform decisions in everyday clinical care: they address the abstract question of an intervention’s efficacy under ideal conditions, rather than its effectiveness when used in usual clinical practice, on outcomes that are important to patients.3 4

Here we describe a UK project to implement randomised trials as unobtrusively as possible in the everyday clinical work of general practitioners (GPs), comparing treatments that are already in common use, and using …