Editorials

Is clinical effectiveness a management issue?

Action on clinical effectiveness is showing that success in implementing evidence based practice is achieved only when there are real local partnerships between clinicians and managers. The challenge is not to turn clinicians into managers but to recognise that some aspects of the task are the direct responsibility of managers. The recent white paper on the NHS, with its emphasis on quality and concept of clinical governance,¹ has given added impetus to the creation of these partnerships. The requirement for chief executives of trusts to make "appropriate local arrangements" may make little progress unless doctors and managers reach a shared understanding of their distinct contributions to the development of evidence based practice and generate enthusiasm for the approach in organisations.

Progress may be contentious because some clinicians are sceptical about the interest of managers in clinical effectiveness and evidence based practice.² Clinicians are usually interested—and excited—by discussions about research, but their interest wanes when those discussions progress to questions about the routine use of research findings. Interest in implementation is often viewed as yet another means of influencing clinical decisions or, more cynically, as a means of reducing resources.

Improved access to research evidence has stimulated interest in implementing evidence based practice³ in order to improve the quality of health care, reduce variations in the delivery of health care, secure a better return on the extensive investment in research, and minimise clinical risk. Early examples of implementation projects included the use of corticosteroids in preterm delivery in Oxford⁴ and the use of aspirin in secondary prevention of cardiovascular disease in Sheffield.⁵ More recently several other projects have been launched, including a programme involving all health authorities in the North Thames region and a major national programme, Promoting Action on Clinical Effectiveness (PACE), which was launched in 1995 and is based at the King's Fund.

The programme includes 16 projects working on a range of 10 clinical conditions. These projects are showing that a focus on a clinical topic can encourage changes in clinical behaviour. For example, the Bradford project is aiming to change clinicians' prescribing practice in order to eradicate Helicobacter pylori, the Chase Farm project to improve the management of pressure sores, and the North Derbyshire project to improve the treatment of cardiac disease.⁶ Project work also identifies areas where local partnerships and clarity about the roles and responsibilities of clinicians and managers are important.

In fact, clarity about responsibilities is a prerequisite for success. Clinicians need to review local practice against available evidence and help determine priorities for change—a subsequent task to be handled jointly by clinicians and managers. The Bromley project has shown that discussions about respsonsibilities can promote understanding about the overall task. Managers can help ensure adequate resources and bring project management skills to the task. This is important because coordinating the work may be time consuming: many projects need to work in both primary and secondary care and involve a wide range of disciplines. The Royal Berkshire project has shown that communications are an essential shared responsibility so that all those likely to be affected by a change are kept in touch. It is essential that staff are equipped with the relevant skills, such as critical appraisal, change management, and appropriate research skills. Both clinicians and managers need to be involved in developing and delivering training programmes and staff must be encouraged to attend. The Oxfordshire project has illustrated problems in releasing staff to attend national training sessions.

Parallel efforts are needed to secure changes to services.⁶ There is no point in encouraging general practitioners to change their referral practice if the service cannot meet an increased demand. For example, the Southern Derbyshire project has emphasised the need for early access to physiotherapy services to improve services for patients with low back pain. These resource issues cannot be resolved solely by clinicians.

But good projects are only part of the story. Clinicians and managers must work together—again with a clear understanding of relative roles and responsibilities—to create organisations, in both primary and secondary care, which support rather than stifle the delivery of evidence based practice. These are organisations that foster an inquisitive culture, where clinicians are encouraged to ask, "Am I doing things right?" Essential elements of these organisations include information and library services to help clinicians keep up to date; audit programmes to assess local practice and the need for change; education programmes to support clinicians who need to change their practice; information services to support the monitoring of practice and service delivery; and joint training to facilitate improved understanding between clinicians and managers.

Work in St Helens has earlier provided a salutary lesson in showing how large is the amount of resources already devoted to all these local systems. It is difficul to measure the return on this investment. Responsibility for many of these systems rests with managers,⁷ and better alignment and integration of these systems is one of the major challenges facing the NHS. Clarity about the respective roles and responsibilities of clinicians and managers will be an essential precursor to progress—and success. The proposals for quality and clinical governance in the white paper may rest or fall on success with such developments.

Michael Dunning, Programme manager,^a Myriam Lugon, Medical director,^b John MacDonald, Chief executive ^c

^a PACE programme, King's Fund, London W1AM 0AN, ^b Forest Healthcare NHS Trust, PO Box 13, Woodford Green, Essex IG8 8DB, ^c Oxford Radcliffe Hospital NHS Trust, Oxford OX3 9DU

1. Secretary of State for Health. The new NHS. London: Department of Health, 1997.
2. Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. BMJ 1996;312:71-2. [Free Full Text]
3. Grol R. Beliefs and evidence in changing clinical practice. BMJ 1997:315:418-21.
4. Dopson S E, Gabbay J. Getting research into practice and purchasing (GriPP): issues and lessons from the four counties. Southampton: Wessex Institute of Public Health Medicine and Templeton College, Oxford, 1996.
5. Eve R, Golton I, Hodgkin P, Munro J, Musson G. Learning from FACTS: lessons from the Framework for Appropriate Care Throughout Sheffield (FACTS) project. Sheffield: ScHARR, University of Sheffield, 1997.
6. Dunning M, Abi-Aad G, Gilbert D, Gillam S, Livett, H. Turning evidence into everyday practice. London: King's Fund, 1997.
7. Murphy M, Dunning M. Implementing clinical effectiveness: is it time for a change of gear? Br J Health Care Management 1997;3:23-6.