We need to put the evidence to work

Could the current economic crisis be the making of evidence based medicine? Important though the past two decades have been for evolving its concepts, tools, and methods, I wonder if we have been only playing at putting evidence into practice. Perhaps it’s only now, in this harshest of financial climates, that we’ll really have to put the evidence to work

Speaking at the King’s Fund’s annual conference last week, John Appleby, the fund’s chief economist, left no doubt about the harshness of the financial climate or how cold it’s going to get. The King’s Fund and the Institute of Fiscal Studies’ three scenarios for future NHS funding start at “arctic” and warm up only to “tepid.” The middle scenario, “cold,” shows zero growth, something the NHS has never yet experienced. This scenario would still inflict a 3% cut on other government departments and leave a £19-20bn gap compared with what the 2007 Wanless report said we should be spending on health care (doi:10.1136/bmj.b5124).

Where will the money come from to even partly fill this gap? Appleby concluded with only two real options: increased taxation and “getting more bang for our NHS buck.” Mark Jennings, director of healthcare improvement at the King’s Fund, took us on from there, calling for a new healthcare paradigm in which quality care (effective, safe, and delivering a good patient experience) must also be efficient. This means eliminating “clinical waste”—not the stuff in the yellow bins but the unwarranted variations in what we do and how we do it. It’s in widely varying lengths of hospital stay and rates of prescribing generics that we have most scope to increase quality and reduce cost (doi:10.1136/bmj.b5075).

But are variations in practice always a bad thing? According to a surprising consensus reached at the end of last week’s BMJ/King’s Fund debate, the answer is no (doi:10.1136/bmj.b5071). Variations are only bad where there is strong evidence for a specific course of action. Delegates agreed that in such cases we should strive to eliminate unwarranted variation. But where there’s no strong evidence, eliminating such variation would drive out essential innovation, argued Robert Lechler. Since more interventions in health care lack an evidence base than have one, there’s huge scope for experimentation. But it has to be tied to proper evaluation and reliable comparative local data on what’s actually happening, which are badly lacking at the moment (doi:10.1136/bmj.b5181)

Good data can change things, especially when combined with good clinical leadership, as several speakers demonstrated. This is also the message of a report from Rwanda in the BMJ this week (doi:10.1136/bmj.b3488) The BMJ Group is working on both fronts, developing evidence based performance metrics and launching soon a modular online leadership programme in partnership with the Open University (http://group.bmj.com/products/learning/clinical-leadership).

It’s easy to ignore data that make us look bad, as individuals or as organisations. Mark Jennings presented some common reactions. (1) The data are wrong. (2) The data are right, but it’s not a real problem. (3) The data are right, and it’s a real problem, but it’s not my problem. (4) The data are right, it’s a real problem, and it’s my problem—but I don’t need to do anything about it. What’s changed? It’s the economy, stupid.