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Asking the Right Questions

A recent thought-provoking and useful article - "Never mind solutions: what are the issues?" [1] - raises many points relevant to Bandolier readers. The paper provides an insight into practical ways to link research and practice. It includes work undertaken in North Thames and draws on lessons from outside the NHS.

To date much of the evidence-based medicine lobby has operated through the notion of "technology push". Bandolier's own imagery of 'bullets' of evidence is consistent with this model. Dawson [1] reminds us of the lessons that innovation in practice can only happen when 'technology push' is coupled with 'user-pull'. This is not a new idea, though it is often overlooked. It is consistent with the views of Stocking in 1985 [2] when she wrote about the "importance of research findings being perceived as relevant and applicable by clinicians if they are to have a hope of being translated into practice".

The development of Clinical Effectiveness Units (for instance at Kettering General Hospital and Derbyshire Royal Infirmary) are designed to address this gap in perception by engaging clinicians in a process of continuous feedback linking R&D and audit. In any healthcare setting clinicians need to be involved in defining and re-defining the problems as well as implementing the solutions. This is a key strength of locally produced, evidence-based guidelines.

If, as Oxman concluded [3], there are no "magic bullets" for improving the quality of care, then we must be very sure that clinicians are included as an integral part of the process of identifying the targets or we may find ourselves aiming at the wrong target! If, in addition, we want to avoid shooting ourselves in the foot, we must consider all clinically relevant issues (including the social and organisational contexts of practice).

Rules for defining the problem

Clinicians in primary and secondary care swiftly challenge researchers, purchasers and professional advisers (eg Health Authority medical and pharmaceutical advisers, and District Drug and Therapeutics Committees) who fail to ask the right questions in pursuit of 'better' patient care. So before offering an evidence-based solution, we must always follow the rules for defining the problem:
  1. Is it clear what issue is being addressed? (why have we chosen this target?)
  2. Is that issue clinically relevant? (is it the right target?)
  3. Have all the clinically relevant options been considered? (are there other means of achieving similar or greater benefits - other targets - and have these other means been properly explored in the problem definition?)

Sue Ashwell
Director of Pharmacy Services, Kettering General Hospital


  1. S Dawson. Never mind solutions: what are the issues? Lessons of industrial technology transfer for quality in health care. Quality in Health Care 1995 4:197-203.
  2. B Stocking. Initiatives and inertia: case studies in the NHS. London: Nuffield Provincial Hospitals Trust, 1985.
  3. AD Oxman. No magic bullets. A systematic review of interventions to improve the performance of health care professionals. London: North East Thames RHA, R&D Directorate, 1994.

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