Evidence on the table for UK health professionals

The need for sound evidence to build a strong case is no longer confined to the courtroom. The move toward evidence-based healthcare in the UK has tremendous ramifications for medical and healthcare practitioners across the country, as well as the information managers who support them.

Evidence-based healthcare - a cornerstone of the Labour Government's 1997 White Paper Modern, Dependable - requires the best and most up-to-date evidence to be applied to improve the quality of decisions made by doctors and allied health professionals.

This has had tremendous consequences for the people and resources that members of the UK medical community rely on to furnish them with the information ? and hard evidence - they need to achieve 'clinical excellence'.

Bethan Adams, medical librarian at University College London's Institute of Orthopaedics library, believes there is an efficiency angle to evidence-based care.

"If you're doing the right things, in theory you shouldn't have anyone doing the wrong things - which is where advice and guidelines on treatments come in. Those things are based on evidence, which is in effect information, which is the stock-in-trade of libraries."

Her counterpart at the London-based Mental Health Trust library, which serves inpatient, outpatient and care centres across four London boroughs, Catherine Ebenezer, agrees.

"These days people have to think in terms of evidence - they can't just focus on one patient and a case-study," she says.

Which is why the libraries these women run are playing a more pivotal role in their users' professional lives than ever before.

The fact that Adams' library serves the NHS staff of the Royal National Orthopaedic Hospital in Stanmore, London, as well as the UCL community means she maintains a dual role as an academic and a clinical librarian.

"We serve all kinds of medical staff, from doctors through to plaster technicians through to managers, and we also have undergraduate, post-graduate and PhD students and lecturers," Adams says. "It sounds very grand but we're actually a small library."

But a series of mergers and amalgamations have had a significant impact on both Adams' and Ebenezer's libraries in the past decade.

This, coupled with the changing way information is viewed within the health service (as reflected in the Government's Information Strategy for the NHS 1998?2005, which recommended sweeping changes across the service), means adapting to constant cultural change.

It is not only the health facilities they serve but the libraries they run that have had to adopt a wider-ranging care brief. "It's not just about supporting study, but also supporting clinical practice," says Adams.

Users' shifting attitudes towards information - what they want, how they want it and what they want it for - mean both Adams' and Ebenezers' roles are constantly evolving.

"In the last three years we've seen an increase in the appreciation of the importance of information," says Adams. "Many more staff are asking about evidence and research. People are becoming more reflective about their practice, and acting in a more evidence-based way. I think it will become a natural part of what it is to practice healthcare."

Ebenezer observes not only that information has become more important, but also that people are keen to do different things with it.

"I get more 'service development' related searches to do than in the past. Recently I had to search mental health information for someone looking to start a cyber-caf‚ for the Trust's clients. I think there's a lot going on in mental health that people are having to react to," she says.

But certain traditions still have their place. "If you walk in the door of my library you would see, well, a library," says Adams. "However, that's obviously only one part of it. We have good orthopaedic journal and book collections, all of which support people in what they do day-to-day.

"The virtual part of what we do consists of lots of networked bibliographic databases such as MEDLINE, Embase, and the Cochrane library via the UCL network. The Trust library delivers databases - such as Cinahl, a nursing and allied health database, AMED, another allied health and complementary medicine database, and the British Nursing Index - over the hospital network.

"This doesn't mean the users of one network can't use the other. My undergraduate students can use some databases on the hospital network, even though they can't do anything else on the hospital network."

Managing daily issues around networks and funding sources takes up much of Adams' time, although the broader issue of how information is shared between NHS and educational institutions is currently a subject of national debate.

"There's one journal one group of staff have access to via the UCL network and another group of staff have access to via a North London consortium of NHS libraries," she says.

Most users have access to the same sources, but often get there in different ways. It is, Adams concedes, a cumbersome arrangement to manage, but concerns over NHS firewalls and security of patient data mean speedy resolution of licensing and networking arrangements is unlikely. "But," she says optimistically, "it will happen in time."

Tied in with this is where the money comes from to fund the networks and sources.

"There's never enough money and any librarian who tells you otherwise wouldn't be doing their job," says Adams.

Some of the funding challenges she faces focus on the multiple funding streams through which public institutions such as hers get their financial lifeblood.

"In this library we receive funding from the Orthopaedics hospital itself and from University College, among others. The Royal National Orthopaedic Hospital library with which we're in partnership also receives funding from the Trust and South Bank University. Then there's external funding available to us for, say, courses run by the British Orthopaedics Association for Plaster Technicians.

"Marrying those funding streams into a single service so one person coming through the library doors doesn't necessarily feel he or she is getting a different service to the next person in the queue is quite a challenge."

Funding is clearly still the bugbear it has always been across the NHS.

Says Ebenezer: "There's never enough resources. I have to put in a bid for interim funding and I'm really going to push the boat out because we just need so much more than we're getting."

The way budget increases are tallied each year is, she believes, part of the problem. "NHS inflation sets our budget much lower than book and journal price inflation, and sometimes it's difficult to get this across to people."

So does she believe the resources are overpriced? "Some are definitely overpriced. There are some journals that are hideously expensive that we just can't live without, so we just have to try and find ways to afford them."

High on her to-do list is a journal survey ? something many librarians could surely relate to. "I need to determine what's key and what's peripheral," she says. "Some journals I'm sure are here because Dr X asked us to get them in 1994."

And, in the not-too-distant future, some journals may come to be on the shelves because patients ask for them. Both librarians - and their institutions ? are keen to allow patients to use their resources. There is, however, a virtual Pandora's box of issues they need to tackle before carte blanche access is offered.

"The potential for patients to use the library's resources is enormous," says Adams, "but it will have a huge impact on staffing, staff training and funding. Also, personally, I have concerns. Medical information can have an impact on how people feel about their treatment. This may be positive for some, but negative for others. There's a lot of data in this library that could be perceived as very frightening, so there would need to be training ? plus some development of the library space - to support that."

Ebenezer's library recently changed its policy, and more expansive changes are afoot. "Our regional consortium's policy regarding information for patients is that either we have to provide it or we must be able to refer people elsewhere, so we're looking now at how we'll implement that.

"We used to allow inpatients into the library with a member of staff, but now anybody can come and use us unaccompanied and by appointment. We've been quite restrictive about it for reasons of security, because we're just not trained to cope with lots of patient information enquiries. Although we don't want to withhold information from anybody, we're not really equipped to do it yet".

Both women see their roles changing considerably during the next few years, moving more from responding to search queries to training users.

Ebenezer will continue to concentrate on getting technical skills across the board to an acceptable baseline so her users can take better advantage of the electronic resources she's worked hard to mobilise.

"I've put a lot of effort into making electronic journals available, both free ones and electronic counterparts of our printed journals," she says. "I really do push it. Since I began doing this in January this year, the take-up and awareness of electronic journals has gone through the roof."

Two developments likely to represent a massive sea change for both librarians and their users are the March 2002 launch of the National Electronic Library for Health, and the Government's plans to offer desktop access to the internet to all NHS staff.

"The National Electronic Library for Health will have some really valuable content, so that will take some of the pressure off libraries to provide core content," says Ebenezer. It will also create, she believes, a need for them to justify their existence and add value locally.

One of the ways this value will be added, they believe, is by helping their communities decide what's hot and what's not in terms of the ever-increasing seas of information they have to wade through.

Says Adams: "A big part of my role will be helping people manage the information glut and appraise the quality of information. People aren't always good at differentiating between a good source and what's not so good. There's work happening here already but we'll be doing a lot more work around in this area."

Within a crowded information environment, Ebenezer says she will continue to help people balance the need they have for sound evidence with the pressures they face on their time and their attention.

"People will always want help with searching and evaluating. They're realising that, in the health service, information overload is a huge problem, and discriminating between sources can be difficult. Sometimes they have to be told which are the core journals, which are peripheral, how to spot redundancy, and why something's going to have less impact than something else."

All sound evidence that Ebenezer and Adams are likely to remain busy way beyond the birth of the brave new world of health information in the UK.

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