More details in the form of a full paper are available on the BMJ’s website.	Germany, Italy, and Spain—Guidelines are on the rise in Germany and Italy, where a guidelines database is being developed to support national healthcare reform. In Spain, the Catalan Agency for Health Technology Assessment has begun preparing guidelines and teaches methods of guideline development. Consensus guidelines figure prominently in Catalonian healthcare reform.
Europe	North America
United Kingdom—Guidelines have existed in England for decades; recent years have heightened interest in guidelines as a tool for implementing health care based on proof of effectiveness. Professional bodies, encouraged by the NHS, are producing guidelines for use by providers to improve care and by purchasers to guide contracting and commissioning decisions. The NHS is now using a critical appraisal instrument to determine which guidelines to commend to health authorities. Although historically most British guidelines have derived from consensus conferences or expert opinion, there is growing interest in using explicit methods to develop evidence based guidelines. The Scottish Intercollegiate Guideline Network uses a systematic multidisciplinary approach to prepare evidence based guidelines. National guidelines are converted at the local level into formats that encourage adoption in practice.	Guidelines, protocols, and care pathways developed by professional societies and other groups are common in American hospitals and health plans, where they are used for quality improvement and cost control. Although some evidence based guidelines produced by government panels and medical societies have received prominent attention, many healthcare organisations purchase commercially produced guidelines that emphasise shortened lengths of stay and other resource savings. Canadian health care is largely state funded, but a similar proportion of organisations as in the United States use guidelines. The massive guideline industry in America has created special problems such as information overload. Directories and newsletters have become necessary to monitor the hundreds of guideline topics and sponsoring organisations. Americans have articulated evidence based methods in manuals and other reports. This expertise has not always found its way into actual guidelines—most of which remain rooted in consensus or opinion.
The Netherlands—In the Netherlands, the Dutch College of General Practitioners has produced guidelines since 1987, issuing more than 70 guidelines at a rate of 8-10 topics per year. A rigorous procedure involves an analysis of the scientific literature, combined with consensus discussions among ordinary general practitioners and content experts. A systematic implementation programme follows guideline development. Updating of the guidelines has recently begun. Guidelines figure prominently in Dutch health policy.	Australia and New Zealand
Finland and Sweden—In Finland, national and local bodies have issued more than 700 guidelines since 1989. A programme for evidence based guideline development has been started recently. Guidelines in Sweden appear in reports by the Swedish Council on Technology Assessment in Health Care, an internationally consulted technology assessment agency, and in recommendations from other government bodies.	Guidelines in Australia date to the late 1970s, when the state health authority began endorsing guideline booklets,2 and they continue on a large scale today. There is an increasing emphasis on the need for evidence based methods.
France—In France, the Agence Nationale de l’Accréditation et d’Évaluation en Santé has published over 100 guidelines based on consensus conferences or modified guidelines from other countries. It has also developed more than 140 références médicales, guidelines on procedural indications for use in setting coverage policy. The guidelines are disseminated through networks of general practitioners, and their effectiveness is evaluated through local audits.	Guidelines in New Zealand emanate directly from national health policy. New Zealand’s choosing to restrict services at the point of service through guidelines received international attention in debates about rationing. One guideline on hypertension and a subsequent cholesterol guideline from the New Zealand National Heart Foundation broke new ground methodologically by linking recommendations to patients’ absolute risk probabilities rather than to generic treatment criteria .