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Implementing the evidence Sarah Taylor explains why what works is not always what's done For a long time there has been ample evidence that variable standards of practice fail significant numbers of patients. Furthermore, even dramatically positive results from rigorous clinical studies can remain largely unapplied.1 However, we live in a world where there is increasing political and patient pressure to show the effectiveness of what we do as doctors, and standardising clinical practice is becoming everybody's business. We might agree that the practice of medicine is not reducible to a mechanistic, fault free system, however, health professionals owe it to patients to apply the most effective practice. The situation must change With the emergence of clinical governance, 2 there are now systems in place to govern the quality of care. In reality this generates an industry for the development of clinical guidelines and protocols, and concern to measure the extent to which practice follows these standardised pathways. Cochrane's promotion of randomised controlled trials (RCTs) made the science of the evidence base common currency. 3 Guidelines are now produced on a wide range of topics in order to turn the evidence into practice, or to drive practice in more standardised directions. Where there is conflicting or complicated evidence, the profession has resorted to the consensus approach to determine best practice. 4 More recently, the rise of evidence based medicine in a culture of lifelong learning has offered a more sophisticated approach to fill the gaps between research evidence and clinical practice. 5 What has made this vision more urgent is firstly the call for external validation of professionally determined standards, and secondly policing of practice against the agreed standards. 6 We also continue to debate the proportion of clinical decision making that is evidence based. Some studies show that about 80% of practice in some circumstances is justified if scientific rationale is used as a criteria alongside the evidence of RCTs. 7 Changing practice takes time So why do clinicians not behave in line with the evidence of effective practice, and what can we do to change this? Some of the theories come from the wider principles of the social sciences, or of management theory developed in the commercial sector applied to the field of health care. 8 The quality assurance approach, applied, for instance, to screening programmes, focuses on the need to pay scrupulous attention to detail to avoid practice drifting, and the importance of feedback loops in processes to alert practitioners to deviation from the protocol. But most health care does not have the structured bureaucracy of systems that would allow us to apply this, nor would it be practical to do so in many areas of medical practice where the interaction with the patient is complex. In addition, the circumstances in which "80% evidence based practice" occurs are rather different from the common experience of many parts of health services. For instance, the nature of inner city general practice is often of high demands of very needy patients placed on poorly resourced and unsupported general practitioners. For a doctor who qualified from a traditional medical school 20 or more years ago, keeping up to date is inevitably a challenge, and the change in culture required to develop evidence based practice and meaningful continuing professional development requires a lot of support. Keeping pace with the amassing evidence of what works and doesn't work in medicine often feels incompatible with the demands of our everyday lives. The challenge for the future There is evidence that training in lifelong, self directed, evidence based learning produces doctors who are more up to date for longer in practice than traditional medical training. 9 This should encourage doctors and other practitioners to use best available knowledge for solving problems. It often does, presumably on the incentives of habit, professional satisfaction, and removing obstacles in practice. We have gone far in the past decade on developing easy to use packages and routes to access the effectiveness literature - for example, the BMJ online library facilities. Increasingly, examples of effective behaviour change are being seen.10 In its publication of national service frameworks (NSFs) the government is clearly directing the NHS as an organisation, as well as individual clinicians, to the specific actions that will have direct patient health benefit. This leaves a challenge for the next few years and indeed for the next generation of doctors. In a field that combines art, sociology, mythology, and pastoral care they must learn how to keep up to date with new technologies and new evidence on effective practice. At the same time they must put into effect the practices already in the system that, if properly applied, could save lives and improve our patients' health.
Sarah Taylor director of public health Shetlands
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