To review published evidence and clinical experience of the perceived barriers to insulin initiation and intensification and to develop solutions for patient management. Literature review and workshop discussions. Many patients with diabetes fail to achieve targets for glycaemic control because of inappropriate use of insulin. Patients and health care professionals face many potential barriers to insulin initiation and intensification in primary care. These can be categorised as low motivation, lack of familiarity or experience and time constraints. Solutions should be tailored to different health care settings. Strategies include improving education and training, providing prescribing aids and increasing the efficiency of collaborative working and communications.