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Acting on the evidence


"Acting on the evidence" is the title of a superb research paper from Kieran Walshe and Chris Ham of the Health Services Management Centre at the University of Birmingham. It presents the findings of a study to assess the progress of evidence-based health care in the NHS and to identify innovations and approaches which might serve as models of good practice. Bandolier thinks they have done a good job. There are some thoughtful words which should be read by those responsible for management of Health Authorities and Trusts, and by policy makers. While primary care was not a subject of the research, many of the conclusions and suggestions are immediately applicable to primary care.

Making it happen

Perhaps the most important issue facing the health service is not how it should be organised or financed, but whether the care it provides actually works. This applies not only to particular interventions, but to whole packages of care, and one of the features of the evidence-based approach - systematic review - has been to starkly demonstrate that what we think , or what we believe we know , falls flat when it comes to proof .

The problem is one of handling the tidal wave of knowledge coming our way. High quality evidence is increasingly available, not just through the Cochrane Collaboration, NHS Centre for Reviews and Dissemination, or Health Technology Evaluation (all parts of the NHS R&D initiative), but through the efforts of researchers all over the world producing systematic reviews published in academic medical journals.

Impact and impact factors

Walshe & Ham point to the "curious dissociation between the research and development process and the world of clinical practice". If research agendas are being set by academics and funding bodies, we should not be surprised. Academics (or at least those who make their living in Universities) live and die by academic brownie points - which come from individuals and departments publishing results of research in journals with the highest "impact factors", and whether or not they change practice is irrelevant.

The fact that most practitioners, let alone managers, will never see the journal is neither here nor there - impact (by which we mean the information getting to the largest number of potential users) will be subordinated to the next grant application, and driven by publishing in the BMJ, Lancet, JAMA, Annals or New England Journal. The whole raison d'être of Bandolier is to be a signpost to good quality information, published where you might not find it.

Managing knowledge

We need a few new developments. It seems to Bandolier that health authorities and trusts are going to need knowledge officers to handle the tidal wave and to direct knowledge at a local level. Nationally we need an information exchange - so that some of the excellent implementation examples described by Walshe & Ham, or coming from the King's Fund PACE programme, or being developed locally in many health authorities and Trusts don't need to be re-invented.

And where's the beef?

In his foreword to the second edition of the Bandolier Annual, Professor Richard Lilford takes Bandolier to task for not making more effort to cover modelling, patient preference issues, and issues of cost utility and decision or process analysis. Other readers make the same criticism. We agree with that, and would love to see more information on costs and economics based on sound evidence. Perhaps Bandolier is looking in the wrong places, but we don't find much available to fill information and implementation gaps.

Filling the implementation gap

Walshe & Ham point to a gap between the production of knowledge and its implementation. Bandolier agrees that such a gap exists, and has pointed out the irony of spending large amounts of money on technology assessment, for instance, and then printing only 100 copies of reports at £50 a time ( Bandolier 37 ). But the gap will not be filled by researchers whose prime interests lie elsewhere, and it is inefficient to expect every gap to be filled in each locality.

We need a national implementation programme which can create task forces to do the work to bridge the gap. These task forces should include researchers, health economists, specialists, GPs, public health doctors and managers, and would aim to fill the implementation gap by summarising the evidence on effectiveness, exploring the heath economic arguments, and examining the process of delivering the highest quality effective healthcare with pro-forma guidelines which can be adapted to local needs. Such implementation task forces could not only look at existing services or treatments, but also should be expected to examine emerging trends (like viral load tests and protease inhibitors for HIV, for instance).

We should thank Walshe & Ham for concentrating our minds on how we deliver a better standard of effective service. Bandolier recommends reading their monograph, which is available from the NHS Confederation Publications office (Fax +44 (0) 121 414 1120).



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