Why is it difficult or impossible to obtain some treatments on the NHS? Why are some kinds of evidence accepted by professionals more readily than other kinds? Why, when Internet sources or contacts have recommended something, is it often dismissed by those providing services? And how can parents and carers evaluate the information available in order to make decisions? Evidence based practice is part of the answer to these questions.
What is evidence based practice?
The idea of evidence based practice is well established in "Evidence Based Medicine" (EBM)1. It also features in other health professions, social care and social science, education, technology and policy. Many organisations, including Cerebra, have it as one of their working principles. It is defined as the conscientious use of the best, latest evidence in making decisions. As well as professionals, families and others making decisions about the care of a child, can find it a useful approach.
An evidence based way of working means combining experience and judgement with the best available research results. Research can be formal or informal, and can be done in any part of the world but it varies in quality, so it is important to know how much a piece of research can be relied upon as evidence. It is also important to consider how much knowledge can be brought to researching the information and making use of it. Organisations issuing evidence-based guidelines generally bring together panels of people who each have expertise in some aspect of the subject concerned.
This way of working is not yet universal in the UK, yet it already profoundly affects the advice that you are given by professionals, the type of research that is carried out and the services that are made available to you and your children. Various other names are used for it, such as "best evidence"and "best practice". In medicine, organisations like the Cochrane Collaboration, www.cochrane.org work to gather together all studies that have been done on particular topics, evaluate how reliable they are and decide what knowledge can safely and effectively be taken from them ("Systematic Reviews")2. The National Institute for Health and Clinical Excellence (NICE) issues guidelines on
medicines and treatments, which can be seen on their web site www.nice.org.uk. These guidelines do not have the absolute force of law (for example, when they recommend cognitive behavioural therapy for children, this will not oblige an NHS Trust to provide it, but it will help to make this possible).
Best available evidence
According to Prof. David Sackett3, in medicine "best available evidence" should mean clinically relevant research of the highest standards (particularly "randomised controlled" studies). These may be drawn from the basic sciences that support medicine (e.g. molecular biology, physics, pharmacology). Especially valued is patient-centred clinical research. Topics covered by such research will include:
- the accuracy and precision of diagnostic tests/clinical examinations;
- how accurately something can predict future progress (a "prognostic marker");
- efficacy and safety of therapeutic, rehabilitative and preventive interventions.
Research also carries more weight if it is independent of those who have an interest in the results. For example, a therapy centre’s research on its own therapy would not carry as much weight as research independent of the centre.
Such external evidence can alter previously long-held or accepted procedures and replace them with new validated ones. Evidence from high-quality research may also validate and develop existing practices, renewing confidence in them.
In social care the Joseph Rowntree Foundation, based in York, www.jrf.org.uk, is an evidence-based research centre going right back to the early 20th century. Studies have also been conducted elsewhere in the world since the 1930s on the welfare of service users and carers. Related fields include psychology, sociology, social policy and health. Whether to use this research, in order to make decisions, is up to the individual.
In social care and education, evidence can be more difficult to define but is still "a set of processes, procedures and principles that, when implemented, have been shown to reliably produce a measurable and sustainable improvement in productivity, efficiency, or effectiveness"4. It should guide choices about what is done, as well as how new projects and ideas should be carried out and evaluated. It should be possible to show that the approach can lead to a similar outcome in different settings (called "replication" in research).
If there is a certain amount of good evidence, but not the best possible, it is regarded as "model" or "promising" evidence.
Negative reactions?
This approach has its professional critics who say it is impossible to read enough to keep up with the best evidence, or that it is "academic" rather than real, an excuse to cut costs or a threat to professional freedom. It can also be hard for a family to understand when, for example, many people say that a technique or a medicine has been good for other children but they are told that the evidence for it is not good enough.
However, reviews of evidence can help to address the variation in standards of care and rates of intervention in UK practice. There are now journals, courses and websites to help busy practitioners to identify and apply the safest, most effective and most efficient approaches. For families, the Internet makes it easier to access the evidence, and understand something of the basis upon which professional judgements have been made. It is useful to realize that knowledge about a condition or situation is often incomplete or controversial, and that professionals can still disagree with each other about what to do.
A good example of evidence-based decision-making is when considering "alternative" approaches. There is often not much evidence available and decisions must be made using other criteria as well. The first principle is to remove any doubts about the safety of the approach. For example, in a Primary Care Trust wishing to improve the quality of life of cancer patients, an "alternative" approach was used on the basis that "A member of staff thought these aims might be achieved by using [these] methods" and "Three focus groups attended by patients, carers and health professionals, were held to influence the early stages of the project". These two types of evidence do not rank as highly as randomised and other scientific studies, but the project is held up as an example of good NHS practice.5 If the approach is seen as safe, meeting the aims of all those involved, non-invasive, inexpensive, applied by qualified, accountable people and perhaps also addressing a need that is not easily met by other methods, then the research behind it does not have to meet such strict criteria.
References
- Evidence-Based Medicine: what it is and what it isn’t. British Medical Journal vol. 312, 13 January 1996, pages 71-72
- The Cochrane Database of Systematic Reviews, Cochrane Collaboration, PO Box 777, Oxford OX3 7LF, UK. (Or BMJ Publishing Group, tel. 0171 383 6185).
- Sackett D.L., Haynes B.R. On the need for Evidence-Based Medicine. Evidence-Based Medicine, vol. 1(1), Nov. 1995, pages 5-6
*Professor David L. Sackett, NHS Research and Development Centre for Evidence-Based Medicine, Oxford Radcliffe NHS Trust.
- Oregon Commission on Children and Families, 2003. Guide to Evidence-based Practice.
- Department of Health, Dec. 2005. Now I Feel Tall: What a patient-led NHS feels like.
More information, including links to other major sites on evidence based practice: University of Sheffield, Netting the Evidence: A ScHARR Introduction to evidence based practice on the Internet. www.shef.ac.uk/scharr/ir/netting/