Implementing the National Programme for IT

BEST CURRENT EVIDENCE STRATEGY

CONSULTATION PAPER – MARCH 2006

Comments to J A Muir Gray

Version / Date / Prepared by
Version 1.0 / 21 March 2006 / J A Muir Gray, following a meeting with patient representatives.
Consultation period open until 31 May 2006

CONTENTS

  • Knowledge is the enemy of disease.
  • Best Current Evidence – concepts and plans
  • List of appendices
  • Appendix 1: Providing clean clear knowledge for busy clinicians and patients
  • Appendix 2: Decision Support Programme – knowledge support, computer-based clinical decision support systems, and patient decision aids
  • Appendix 3: National Library of Tools and Rules – project initiation document
  • Appendix 4: The 500 most common problems encountered in primary care

Knowledge is the enemy of disease

The application of what we know will have a bigger impact on health and disease than any single drug or technology likely to be introduced in the next decade. By putting knowledge into practice, we can prevent or minimise the seven universal problems of healthcare:

  • unknowing variation in clinical practice and service delivery;
  • errors of commission and omission;
  • waste;
  • failure to implement new knowledge and technology systematically and appropriately;
  • over-use and under-use – inappropriate care;
  • unsatisfactory patient experience;
  • poor quality clinical practice.

Evidence is one particular type of knowledge, namely the knowledge derived from research, and clinical practice and healthcare are evidence-based activities. Evidence is necessary but, of course, not sufficient; it has to be combined with the condition of the individual patient and the values of each patient, but without evidence it is impossible for patients, professionals, and those who manage resources to make good decisions, and we must ensure that patients, professionals, managers and public health professionals can base their decisions on best current evidence.

The National Knowledge Service has three main themes of work:

  • the Best Current Evidence Service, set out in more detail in this paper;
  • the National Library for Health, responsible for organising and mobilising the evidence;
  • the National Knowledge Infrastructure containing technical standards, tools and services.

Obviously Connecting for Health is only one contributor to the Best Current Evidence Service because it holds only a limited number of the relevant contracts and it is, of course, not a producer of evidence in the way that NICE or the Research and Development Programme or the Health Protection Agency are producers of evidence. Connecting for Health, therefore, has to work with knowledge partners and all of the key national knowledge partners are described in this paper which attempts to set the Connecting for Health resources in context.

A partner of particular importance is NHS Direct. The principle on which the National Library for Health has been developed is that patients should have full access to all the knowledge to which clinicians have access. This is for a number of simple and practical reasons, notably because many patients are at least as intelligent as clinicians but also because almost all patients have more time than clinicians, even if they have not had the basic biological training required to understand all of the terms used in all of the clinical documents.

This paper, however, is about the production and procurement of evidence primarily for clinicians; in parallel a Ministerial review is being undertaken on the basis of the White Paper to consider all the sources of evidence primarily for patients and how they should evolve.

This consultation takes place in a time of resource constraints. The case is being made to invest more resources in the production, procurement and mobilisation of evidence, but it is hard to justify more money until the publicly funded knowledge services have co-ordinated their production and procurement so weakly. This consultation paper focuses not only on the needs of the users but also on the needs of all those public agencies involved in the production and procurement of knowledge to work even more closely together.

This strategy consultation is part of the refresh of the strategy paper produced by the Service Implementation Directorate of Connecting for Health which set out the National Knowledge Service strategy and indicated that Connecting for Health had been given lead responsibility for the development of the National Library for Health.

Comments to Muir Gray by 31 May 2006

BEST CURRENT EVIDENCE

CONCEPTS AND PLANS

J A Muir Gray

March 2006

EXECUTIVE SUMMARY

  • Best current evidence needs to be produced and procured as a basis for a National Knowledge Service. This consultation paper focuses primarily on knowledge for professionals. A separate Ministerial review of knowledge for patients is underway.
  • Evidence is knowledge produced by research; it needs to be linked to the knowledge produced from data analysis, sometimes called statistics, and knowledge from the experience of clinicians and patients.
  • Ignorance is a type of knowledge, and a Database of Uncertainties about the Effects of Treatments needs to be developed to complement the database of evidence.
  • Evidence is generalisable and relevant across the country and often internationally. To be useful it needs to relate to a particular patient and a particular service; the National Care Record Service allows the former, the Map of Medicine, mobilised through NHS Broadband, NHS e-mail and Internet, will allow the latter.
  • Studies: a wide range of journals are currently procured; the peer review system is so unreliable that these are not suitable for busy clinicians and patients unless the journals conform to very strict protocols. Steps are being taken to promote and facilitate the introduction of such protocols.
  • This strategy is based on the Four S approach developed in McMasterUniversity – Study reports, Systematic reviews and guidelines, Synopses, and Systems.
  • This strategy is based on studies of the needs of end users.
  • Systematic reviews and guidelines: these are the most valid source of knowledge, for example the Cochrane Database of Systematic Reviews and NICE guidelines, but they are not always easy to use in their current form.
  • Synopses: these are readable documents produced from systematic reviews and guidelines.
  • Systems: the introduction of the Care Record Service allows the incorporation of knowledge in systems. A National Library of Pathways is being developed and will be launched in 2006. In addition a National Library of Tools and Rules is being developed. These will complement the National Library for Guidelines and all of the documents reporting research findings and systematic reviews already in the National Library for Health.
  • Knowledge support is simple and effective; clinicians and patients should be offered knowledge just in time, where and when they need it.
  • A set of quality assured pathways, tools and rules will be provided to all information system providers as a National Clinical Decision Support Service.
  • More complicated computer-based decision support has not been shown to be effective except for a few conditions. Further work will be done with NICE to develop criteria and systems to appraise decision support systems.
  • Patient decision aids are of vital importance.
  • Work will be done with all the national agencies producing knowledge to make all of their knowledge available through a search engine in a consistent form. The procurement of an NHS-wide search engine will allow all of these sources to be searched through a one stop shop.
  • The seven sources of synopses currently procured by the Department of Health or the NHS will be more closely related to one another and when current contracts run out the procurement, the business case for which was approved in September 2005, will be for an integrated Clinical Synopsis Service.
  • A National Library for Medicines will be created; all advertising will be removed from NHS computers.
  • Steps will be taken to procure sources of study reports which have filters in addition to peer review to reduce the number of articles which clinicians have to search and provide them with assurance that these articles are valid, relevant and new.
  • The knowledge for common problems will be co-ordinated and presented in National Knowledge Weeks, for example the Breast Cancer Knowledge Week.
  • Open access to the Cochrane Library will be provided.
  • The Map of Medicine will be used to allow best current evidence to be represented in the form of national care pathway templates. The Map of Medicine will also be used to provide localised versions of the national care pathway templates, allowing generablisable knowledge to be set in the context of local constraints and opportunities.
  • The Best Current Evidence Service will cover both the 50 biggest health problems and the 500 conditions most commonly seen in primary care and walk-in centres.
  • Rare diseases will receive separate consideration and a National Library for Rare Diseases will be prepared.
  • The Best Current Evidence Service will be developed in partnership with the National Library for Health to create a National Knowledge Service, based on a common technical infrastructure and using to the full the skills of librarians and their local services.

1.Developing a National Knowledge Service

The mission of the National Knowledge Service is to provide best current evidence where and when it is needed for patients, clinicians, and for those who manage resources.

The benefits that will result from this will be not only an improvement in the health of the population but also a dramatic change in the quality of the health service and the value derived from the resources invested in health care. The application of what we know from research, from the analysis of routinely collected audit data, and from experience will have a bigger impact on health and disease than any other single drug or technology likely to be introduced in the next decade and contribute significantly to the reduction of the seven most common problems in health care:

  • unknowing variation in clinical practice and service delivery;
  • errors of commission and omission;
  • waste;
  • failure to implement new knowledge and technology systematically and appropriately;
  • over-use and under-use – inappropriate care;
  • unsatisfactory patient experience;
  • poor quality clinical practice.

The components of the National Knowledge Service are shown in the diagram below (Figure 1).


Figure 1

The mission of the Best Current Evidence Service is to ensure that best current evidence is produced or procured for organisation, mobilisation and, the end goal, utilisation by patients, clinicians, and those who make decisions about health care. This paper focuses on the evidence that is primarily written for clinicians, although the aim is for it to be open to patients also.

2.Three types of generalisable knowledge

There are many definitions of knowledge and within the National Knowledge Service three different types of generalisable knowledge are distinguished:

  • knowledge from research, sometimes called evidence;
  • knowledge from the analysis of routinely collected and audit data, sometimes called statistics; and
  • knowledge from the experience of clinicians and patients.

The priority of the National Knowledge Service is to provide easy access to evidence, namely to knowledge derived from research. Working in partnership with organisations such as the Public Health Observatory and Dr Foster, the Information Centre for health and Social Care , we will be identifying ways in which direct links can be made to relevant statistics. Knowledge from the experience of clinicians and patients, either presented as guidelines from a professional association or as patient experience, for example through the Database of Individual Patient Experience (DIPEX), will also be made available, but the main focus of this paper is on evidence.

2.1Ignorance as a type of knowledge

It is important to emphasise that it is often important to clinicians and patients to be certain that there is no answer to a particular question. One of the benefits of the National Library for Health will be to help the person who asks the question to find the best available answer, and to be clear whether or not there is an answer. For this reason a Database of Uncertainties about the Effects of Treatment (DUETS) is being developed in partnership with the Department of Health and the Medical Research Council. The lead organisation in this work is the James Lind Library and the work is being done in partnership with the Medical Research Council and the R&D Directorate of DH. In future, therefore, when there are uncertainties about effects, these will be made explicit.

It is essential to help the clinician or patient find out if nobody knows the answer to a question; this then allows the patient to make a decision on the basis of their values.

3.Generalisable knowledge and particular knowledge

Best current generalisable knowledge needs to be related to knowledge about:

  • this particular patient, and
  • this particular service.

The integration of the National Library for Health with the National Care Record Service will allow the former link to be easily and automatically made.

However, with increasing reliance on agency and locum staff in the NHS, together with more rapid turnover of staff, it is necessary to link generalisable knowledge to information about the particular service with which the clinician and the patient are engaging. This will be greatly facilitated by N3, the system which will ensure that 18,000 healthcare locations have Broadband connection, and Contact, the NHS e-mail system. The use of the Map of Medicine software will not only allow evidence to be related to local constraints and opportunities but will also set out explicitly how evidence-based care is delivered both nationally and within each health community. This consultation is linked to the Integrated Service Implementation Programme.

4.The four S approach

In a landmark article, Brian Haynes, who has contributed so much to knowledge management research, proposes a simple classification of knowledge into four types:

  • studies – research reports which appear in journals, paper or digital;
  • systematic reviews and guidelines – summaries of syntheses of studies;
  • synopses - brief readable chunks of knowledge prepared primarily for ease of use while notlosingaccuracy, specifically for busy end users who are not familiar with the research literature and its deficiencies;
  • systems – ways in which knowledge can be incorporated into the electronic patient record or into the many documents that clinicians and patients receive, for example appointment letters, radiology request forms, or laboratory reports.

A diagram illustrating the relationship between these four types of source is set out below (Figure 2).

Figure 2

5.The needs of the end user

A number of studies have been conducted on end user needs. Obviously clinicians are learners and researchers as well as practitioners, but the main focus of the Best Current EvidenceService is to provide evidence for clinicians to help them with patient care.

Primary responsibility for the provision of knowledge for patients rests with NHS Direct, a special health authority responsible not only for the telephone support service but also for NHS Direct New Media, including NHS Direct Online. This work is being done in close partnership with NHS Direct which is currently involved with the Department of Health in undertaking a major review of all information for patients and the public, stimulated by the White Paper Our Health, Our Care, Our Say.

There are about a hundred different professional groups within the National Health Service, in addition to those people primarily responsible for education and those involved in research, and the main groups identified as a focus for the production and procurement of evidence are listed below:

  • nurses;
  • midwives;
  • district nurses;
  • practice nurses;
  • mental health professionals;
  • learning disability professionals;
  • allied health professions;
  • healthcare scientists;
  • Foundation Year doctors;
  • clinicians in specialist training;
  • GP registrars;
  • general practitioners;
  • consultants;
  • managers.

User needs have been evaluated systematically and work will continue with the National Advisory Group of the National Clinical Leads of Connecting for Health to ensure continuing involvement of users in providing feedback to those who produce and procure evidence for decision-making.

A user group has been set up and will be expanded in consultation with the National Advisory Groups of Connecting for Health.

6.Relevance of the four types of knowledge to healthcare professionals

6.1Studies

Professional education rightly emphasises the important contribution that research has made and continues to make to patient care and health care management. The development of peer reviewed scientific literature has made a major contribution to the evolution of clinical practice and health care in the last fifty years. However, research into the peer review process, and the scientific literature, has revealed a number of very important weaknesses. The introduction of peer review undoubtedly improved the editing of scientific journals but it is a system whose limitations, both in terms of scope and execution, are now well documented (Appendix 1). There is good evidence, for example, that:

  • journals are more likely to publish articles with positive findings – “positive publication bias”;
  • information about harm is less well presented than information about benefit;
  • unless abstracts conform to CONSORT and QUORUM criteria, they tend to reinforce the positive effects of publication bias by emphasising the positive and beneficial results within studies;
  • peer reviewers and editors fail to spot methodological and statistical mistakes;
  • there is a failure to base both the research and the reporting of the research on a synthesis of pre-existing knowledge; the articles by Iain Chalmers, Mike Clarke and Phil Alderson, cited in Appendix 1, make powerful reading;
  • the way in which journal articles are published often makes it impossible for the busy clinician or patient, or even research worker, reading the article to spot the deficiencies;
  • sometimes it is easy to identify the weaknesses in published trials, and Chalmers, Clarke and Alderson report a study that was brilliant in its conception but relatively simple in its execution. In contrast Chan and colleagues report a study, cited in Appendix 1, (which was also brilliant in its conception but very time-consuming and difficult to carry out), which demonstrates how researchers selectively forget the results that are less impressive or less interesting.

For all these reasons journal articles, even those peer-reviewed and published in “good” journals, must be treated with great circumspection and should not be brought to the attention of the busy clinician or patient without careful appraisal and a health warning.