Brief Communications - Wiley Online Library

Brief Communications Brief Communications Continuing professional development in the NHSÐwhat is to be done? VERONICA FRASER NHS Library Advisor, Department of Health, Room 302 A, Skipton House, 80 London Road, London SE1 6LH, UK The drive to modernize and improve the quality of health care services in the United Kingdom has led to the publication of several strategic policy directives during the last 18 months. The earliest policies, published as Government White Papers, established broad overall targets for development. To achieve change within the NHS, the NHS Executive issues Health Service Circulars outlining individual and organizational responsibility for implementing specific policies. One key area that has been recently addressed is the need for ongoing professional development for all NHS staff.

Continuing professional development in the NHS The vision presented in `The new NHS'1 saw `Local delivery of high quality health care, through clinical governance underpinned by modernised professional self regulation and extended lifelong learning'. Health Service Circular 1999/154 `Continuing Professional Development: Quality in the New NHS'2 was published in July 1999 and sets out a long-term vision for Continuing Professional Development (CPD) and its role in supporting high standards of professional practice in the new NHS. The new CPD guidance aims to establish a new approach with the following core principles. CPD should be: . . . .

purposeful and patient centred, participative, educationally effective, cross boundary (professional and service),

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. designed to build on previous knowledge and skills, . part of a wider organisational development plan that supports local and national objectives. A key objective in the document suggests that CPD should involve local and national partnerships in order to develop innovative approaches to work-based learning, and should seek to align existing training funds in order to achieve greater equity among the different professions.

The position of library and information services Library services have been described as `the bedrock' of education and training, and NHS library services can expect greater demands on all their services as they support an increased emphasis on continual, selfdirected learning. The CPD guidance states that `library and IT strategies should provide a framework for ensuring equal access for all staff groups to the learning resources which support work based learning'. This factor alone will bring challenges and opportunities for librarians to take on the roles of knowledge managers and facilitators. In our efforts to assist NHS colleagues with their CPD it is important that we also remember our own CPD needs. Currently, CPD for NHS librarians is largely organized by Regional Library Units, or in regions where they do not exist, by regionally based, selforganized networks. The new policy, formalizing CPD for all, will require individual commitment as well as local, regional and national funding and activity if it is to be effective.

A wider skills base for librarians As user requirements become more sophisticated, and evolving information and communications technologies (ICT) offer new ways to communicate information, # 1999 Blackwell Science Ltd

Brief Communications librarians face exciting and demanding opportunities. Working within the complex structure of the NHS requires an ability and willingness to operate alongside other professions, including those responsible for implementing Local Implementation Strategies in response to Ìnformation for Health',3 and on the emerging National electronic Library for Health, yet also to continue to satisfy existing and new users. These factors will all impact on the services we provide and the skills we need in order to be at the centre of development rather than at the margins.

Librarian development programme In recognition of these challenges it is important to develop a national framework for librarian development. Earlier this year, an independent consultant with a long involvement with library education and training issues was invited to facilitate a brainstorm group brought together to discuss and draft a competency based development framework for NHS library staff. The group included representatives from Regional Library Units, Schools of Information Studies and Librarianship, colleagues from the higher education, research and private sectors, and a member of the Library and Information Commission's Training Panel. The various representatives were able to bring together current experience of librarian training and development alongside knowledge of developments under way within the People's Network, the higher education electronic libraries programme and work on competencies for knowledge management. The Librarian Development Programme (LDP) competencies were drawn from areas identified by the Medical Library Association, TFPL, The Library Association and others, and have strong links with the training needs identified for the People's Network for public libraries. The LDP therefore includes specialist health sector knowledge, ICT skills, competencies in business management and human resources,

learning and teaching skills, and recognition of the need to develop personal effectiveness. The next step will be to seek formal adoption by the NHS Executive and establish firm links between the Librarian Development Programme and related education, development and organization development programmes to ensure consistency and co-ordination. It is expected that formal adoption will release additional funding to help support the education and development needs of health service librarians. An initial project is already underway to conduct a national Training Needs Analysis of NHS library staff, which is due to be completed by the end of 1999. The Training Needs Analysis will identify existing qualifications and professional memberships and link these to job title, grade and salary in order to provide baseline data concerning current skills and experience. Librarians will also be asked to state their preferred learning methods in an attempt to recognize the need for, and encourage the provision of, a wider range of learning opportunities. Information will be collected and analysed by region. Further projects will be undertaken to compile a database of relevant learning opportunities and to explore accreditation of learning outcomes. A seminar series, planned jointly with the NHS Regional Librarians Group Continuing Professional Development Panel, will be run from Autumn 1999 into the new year, and will examine knowledge management, CPD issues and opportunities; best value and NHS Libraries; and negotiating skills. Funding will be available to enable a senior librarian to participate in the Kings Fund Senior Managers Programme in 2000, a crucial step if librarians are to be recognized as a key resource to support the development of clinical governance.4 Meanwhile what can be done locally? The new Guidance sets several very clear targets for immediate local action. These are: . an audit of current arrangements and investment in CPD,

# 1999 Blackwell Science Ltd, Health Libraries Review 16, 268±285

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Brief Communications . Personal Development Plans (PDPs) for all health service staff by April 2000, . more opportunities for multidisciplinary learning. The NHS CPD guidance could potentially link to the Library Association's CPD Framework and for many health librarians this could prove a useful and familiar framework within which to develop plans for ourselves and our colleagues over the coming years.

References 1 The new NHS: modern and dependable. Cm, 3807. London: The Stationery Office, 1997. 2 Continuing Professional Development: Quality in the New NHS. (HSC 1999/154). London: Department of Health, 1999. 3 Information for Health: an Information Strategy for the Modern NHS. (HSC 1998/168). London: Department of Health, 1998. 4 Clinical Governance: in the New NHS. (HSC 1999/065). London: Department of Health, 1999.

Professional development in a virtual learning community PHILIPPA LEVY Department of Information Studies, University of Sheffield, Sheffield S10 2TN, UK

Introduction The Internet offers an intriguing new environment for professional development in the library and information field. The use of email based discussion lists is already firmly embedded into the working practices of many staff, whether they are active participants orÐmore likelyÐamong a larger group who access and benefit from the debates and exchanges of information that take place but tend not to contribute frequently or at all. Membership of these listsÐor perhaps, `virtual communities'1Ðoffers excellent opportunities for on-going, informal professional updating

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and learning. At the same time, the Internet is becoming increasingly attractive as a means of offering cost-effective, flexible access to formal professional development activities. As the impact of the Internet increasingly makes itself felt in all areas of educational work, there is much to explore and understand about designing and facilitating learning events based on the use of information and communication technologies (ICTs). In this brief paper, I highlight some themes emerging from research in progress into the implementation of a distance learning, online professional development course which was hosted recently by NetLinkS,2 a training and awareness project funded by the Electronic Libraries (eLib) programme between 1995 and 1998. The course was based in part on the idea of participation in a virtual learning community, and in this paper I aim to give a sense of what was meant by this in terms of the design and facilitation of the course, and of how participantsÐall of whom were new to online learningÐexperienced involvement in such an initiative. An overall evaluation of the course is available in the Final Report3 of the NetLinkS Project, and further details about pedagogic and technology design are also available elsewhere.4

The course The course aimed to provide an opportunity for learner support staff in academic libraries and resource centres to explore issues related to their role in `networked learner support'5 and to work on a practical, work-based project of relevance to their own professional interests and circumstances. Information staff are increasingly involved in developing online help for both campus-based and distance users of information resources; examples of networked learner support from the library perspective include the development of Webbased information skills training materials, creation of online reference and enquiry services, delivery of `mixed-mode' or fully online courses in electronic information use


Brief Communications and, sometimes, participation in online conferencing to support the informationrelated dimensions of student project work. At the same time, learner support staff have a key role in academic liaison, aiming to promote the use of electronic information resources in teaching and research, and, often, to link information skills development activities more closely with the curriculum. Taking a proactive approach to developing networked learner support strategies and services can make a significant contribution to cultural change in institutions; it also entails a requirement for a new blend of professional knowledge and skills, in areas related to technology, pedagogy and organizational change as well as information resources. Based on research into relevant professional development needs,6 the course addressed: . the emerging educational role of information services in the networked learning environment, and current trends in networked approaches to information support; . current trends in networked learning and the potential of the Internet as an educational environment in terms of available technologies and varying pedagogic models; . directions for networked learner support in local contexts, and organizational issues in developing and managing innovation in this field. At the same time, the aim was to enable participants to gain direct, practical experience of the Internet as an environment for learning and to develop `process' knowledge and skills that are essential for the practice of active networked learning; these include skills in the areas of online group work, communication and technology use, as well as in reflective and self-managed learning. The course ran for a period of 17 weeks between September 1997 and February 1998, and comprised 36 staff from universities and colleges of higher education all over the UK; the group included a small number of

librarians in health fields. The course structure was based on a total of seven Units and participants were advised to spend between 6 and 8 hours per week on course activities, including at least twice-weekly access to the course Website. There were no face-to-face meetings, and most participants accessed the course solely from terminals at work. All facilities and resources were accessible via the Internet, except some suggested offline reading. Most tutoring and technical support was provided by a core of four NetLinkS team members, with the additional involvement of a number of other colleagues. An activity-based learning model was adopted, drawing on constructivist and experiential learning principles, and a good deal of emphasis was placed on opportunities for informationexchange (for instance, about relevant, innovative initiatives in participants' institutions), small-scale collaborative activities in groups (learning sets), and mutual support for individual project-work. The main discussion facility was a Web-based asynchronous conferencing system, with forums for each learning set, whole-group seminar discussions, discussions on technology and information issues, and a social space. A number of other communication options included e-mail and a MOO,7 which facilitated synchronous, textbased interaction in a `virtual suite' of seminar rooms; each learning set had its own `room' where meetings could be held. Participants' feedback about the course was generally very positive, confirming the overall relevance of the topics to this professional group. The technology design and facilities were judged to be easy to use and in general the standard of tutoring and technical support was perceived to be high, as was the quality of the course's information `resource base.' Encouragingly, the large majority enjoyed the experience and indicated that they would be happy to consider participating in an online course again. One of the most valued aspects of the course was its experiential element, in terms of the insight offered into the learners' perspective on online learning. Many commented that they felt far less isolated than


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Brief Communications they had expected to be, and two-thirds of the group experienced a strong sense of `community feeling' despite the lack of faceto-face meetings. The course was judged to be successful in providing a framework within which participants could pursue personal interests and learning needs whilst contributing to (and benefiting from) a collaborative learning community. There were many excellent discussions in both small groups and the large forum, and although participants did not usually complete their projects within the timescale of the course, it provided a stimulus for initiatives which participants continued to develop subsequently and were able to implement somewhat downstream of the course itself.

Issues in online professional development Alongside a good deal of enjoyment and achievement, there were also challenges and frustrations associated with participation on the course. Engaging with the demands of the online environment and of the learning approach involved a gradual process of acclimatization for most participants, and nearly all found some aspects of learning in this way difficult. The pace and length of the course were issues here; participants often commented that they were just getting into their strideÐdeveloping awareness, skills and confidence to work effectively in this wayÐtowards the end of the 4-month period. The following paragraphs highlight some key issues arising from participants' feedback about their experiences.

Self-managed learning Throughout the course our aim was to support participants in their development of strategies and skills for managing their own learning. We brought the learning model to the fore early on, and built in ongoing opportunities for reflection and discussion on `learning to learn' issues. We suggested that participants keep reflective learning

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journals and many did so (although few kept them consistently). However, for a variety of reasons managing personal learning in this environment was not always straightforward, and those who were very familiar with the concepts of active and independent learning in theory were not necessarily well-prepared to adopt such an approach in practice, especially within a new (online) context. Few, for instance, were familiar with concepts associated with `reflective practice'8 in professional development. Managing time and flexibility also posed problems; there were a variety of arrangements with employers regarding time spent on the course, so that some were able to devote 6 working hours per week to it, whilst others' involvement was wholly in their own time. Whatever the nature of arrangements, however, finding time for the course was a common difficulty and many did not spend as much time as initially planned. This was partly a matter of difficulties in gaining sustained periods for network access, personal study and reflection at the workplace, combined with lack of Internet access from home. However, many also encountered difficulties in establishing a pattern of participation suitable for the mode of study, with the need to take into account the differing temporal dimensions and rhythms of asynchronous discussion, realtime online meetings, and personal study.

Computer-mediated and group-work

communication

(CMC)

Although all participants were familiar with the use of e-mail and some had experience of news groups and other forms of conferencing, using CMC to support formal learning activities was a new experience for everyone. Issues related to the logistics and dynamics of CMC loomed large for many; it was not a straightforward matter to develop effective communication routines, to use text to initiate and weave discussion in large and small-group forums, to exchange critical feedback online, to network with others across a large


Brief Communications community, or to establish satisfying social relationships. Despite the advantages afforded by different media and the opportunity to communicate independently of time and place, learners often experienced both synchronous and asynchronous connectivity as inhibiting or disorienting, or were frustrated when it proved difficult to stimulate the type of debate they wanted. Few were active `people-networkers' outside their own learning sets despite the technical opportunities and the information available about mutual interests in the wider group. Many were infrequent contributors to online discussions, whether in small or large forums, although the value (and pleasures) of `lurking'Ðlistening without respondingÐwere emphasized. There was also a need to develop an understanding of the merits of different technologies in relation to different purposes and learning activities, and of the ways in which they could be used to complement each other. The fact that the course offered a combination of asynchronous and synchronous discussion facilities proved successful, and many were happy to sacrifice personal flexibility for the chance to meet others in real time on a regular basis; punctuating the course with real-time sessions was found to be helpful for structuring personal participation and time-management. However, working in online learning sets was often a particular challenge. Whereas some sets developed successful approaches to collaborative and co-operative work, others were frustrated by difficulties encountered in cementing group relationships early on and establishing effective strategies for coordinating discussions and collaborative work within fairly tight timescales. It became clear that more emphasis on facilitating small-group work early on in the course would have been beneficial.

Conclusions It has not been possible in this short paper to do more than indicate the diversity and

complexity of participants' experiences of becoming involved in a virtual learning community, or to examine the pedagogic and other issues involved. Work continues as an in-depth case study analysis of the initiative. However, this brief overview does serve to suggest some considerations for other educators and trainers in the LIS field who are adopting networked methods for continuing professional development (CPD) and training. As a pilot for future implementations, the course provided a rich source of insights into the attitudes, experiences and support needs of participants, and has particular implications for the design and facilitation of `process support' for active networked learning and for the nature of the employer's contribution to supporting staff to engage in flexible, networked CPD.

References 1 Levy, P. Virtual communities and information services: an overview. Vine 1999, 109, 3±9. 2 NetLinkS. Web Site: http://www.netways.shef.ac. uk 3 Levy, P., Wilson, T.D., Bowskill, N., Goodier, C. & Ashton, S. NetLinkS: Final Report to JISC. 1998. http://www.netways.shef.ac.uk 4 Levy, P. An example of Internet-based continuing professional development: perspectives on course design and participation. Education for Information 1999, 17(1), 45±58. 5 Fowell, S.P. & Levy, P. Developing a new professional practice: a model for networked learner support in higher education. Journal of Documentation 1995, 51(3), 271±280. http://www. aslib.co.uk/jdoc/1995/sep/4.html 6 Levy, P. Continuing professional development for networked learner support: progress review of research and curriculum design. International Journal of Electronic Library Research 1997, 1(3), 267± 84. 7 For an explanation of MOO environments in education see. Cook, N. & Stanley, T. MUD/ MOO environments in the delivery of user support and training. Vine 1999, 109, 53±8. 8 Schon, D. The Reflective Practitioner. New York: Basic Books, 1983.


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Brief Communications Reflections on evidence-based practice training* JOHN BLENKINSOPP Medical Library, North Tees General Hospital, Stockton on Tees TS19 8PE, UK

Introduction In the National Health Service it is accepted that medical treatment should not be based upon muddling through elegantly as a paradigm for treatment, but on the evidence that has been published. Evidence-based practice (EBP), clinical effectiveness and clinical governance have become important issues for all clinicians. This change has helped to stimulate increased demand for medical library resources and user education. According to Glanville et al.,1 `There is an increasing pressure on healthcare professionals to ensure that their practice is based on evidence from good quality research'. A recognition of this increasing pressure led North Tees Health NHS Health Trust to formulate an Evidence-based Healthcare Training Programme that could be made available to all clinical staff in the Trust.

Background Evidence-based medicine has been described by Rosenberg and Donald as `The process of systematically finding, appraising and using contemporaneous research findings as a basis for clinical decisions'.2 EBP has dominated so much of the medical literature in recent years that practitioners are in danger of being overwhelmed by the sheer quantity of references. The information profession, and Medical Libraries in particular, have recognized the challenge and importance of this issue by providing resources and expertise to help users find appropriate and relevant information. The Medical Library at North Tees General Hospital and the Clinical Development Unit *This paper was first submitted for the UHSL New Writing Award.

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in the Trust have worked together to develop an instructional programme of information skills required to support EBP. This article discusses how this programme was set up. It also looks at the results of the course, reports the responses from the participants and uses these findings to make some predictions for future development. The course included library resource orientation, a workshop in computer searching, the identification of relevant information resources, the structure of information, the development of search strategies in support of evidence-based medicine, and the identification and evaluation of qualitative journal literature.

Searching for evidence-based health care information In early 1998, as part of the Clinical Development Strategy in the North Tees NHS Trust, it was felt that there was a need for a training initiative to support clinicians from all health care professions to meet the opportunities and challenges presented by the introduction of clinical governance. An Evidence-based Healthcare Training Programme was devised entitled Èvidencebased Health Care Training for Medical Staff, Nurses and the Professions Allied to Medicine'. The programme was available to candidates as five òne off' sessions each of which covered a specific evidence-based health care topic, these were: Èvidence-based HealthcareÐan Overview', `Searching for Evidence-based Healthcare Information', Ùnderstanding Statistics', `Critical Appraisal Skills' and `Developing Evidence-based Health Care Guidelines'. Staff were given the flexibility to choose which session(s) to attend, depending on their needs. The second of these five 3 hour courses, and the subject of this paper, was called `Searching for Evidence-based Health Care Information'. This course aimed to introduce electronic information sources in the form of Internet resources, printed library resources and CD-ROMs, as well as providing advice


Brief Communications in the planning of search strategies and the basic principles of conducting a computerbased search. Part of the Internet teaching included advice in evaluating various Internet Web pages as there was a concern that practitioners who were using the Web were not always critically appraising the resources that they were obtaining. The course was aimed to last no more than 3 hours in totalÐand to make it as stimulating as possible, it was intended that there would be less `chalk and talk' and more `hands-on' experience to allow candidates to have a `taster' session to introduce them to available resources. The course was intended to be a simplified introduction to information resources in EBP in order to appeal to users at all levels and to enable candidates to be aware of sources of specialist help both in the Trust and elsewhere.

The candidates The candidates on the course were a mixture of GPs, consultants and nursesÐthe course was made available to anyone in the Trust. Nominations were not processed on first come first served basis as there was an aim to have a good multi-professional and crossdivisional balance on all parts of the training programme. No attempt was made to discover the range of candidates' information skills before the courseÐit was assumed that those expressing a need to learn would have few IT skills.

Structure and planning The library input was to introduce EBP by way of hard copy resources as well as providing electronic resource demonstrations, suggesting useful Websites and providing advice in their evaluation. The information skills aspect of the course was over-subscribed and it was decided that to provide a worthwhile course, numbers would be restricted to a maximum of 20 participants in each session. A waiting list was kept for

possible future courses. Based on previous experience of teaching user education to students in the University sector, we felt that `hands-on' practical experience would be a more useful form of learning. Initially, a plan for the course was formulated by the two facilitators, and then further developed using existing experience of user education. One of the facilitators was a clinical practitioner who was able to bring her own perspective of user needs into designing the programme. A pre-course planning meeting was organized and it was agreed to split the course into four distinct parts, which gave both facilitators a break between each. In the first part, after a short introduction, the services that were available in the Medical Library were described, and hard copy and electronic EBP resources currently available from the library were demonstrated. These included a selection of books, journals and, for demonstration purposes, a printout of the term Èvidencebased' on CINAHL and MEDLINE was provided to help emphasize the range and quantity of materials available on EBP. The second session introduced the concept of EBP and showed how it had risen as the accepted form of researchÐseveral journal article references were made available as further reading. There was a discussion about the various print and electronic resources available to practitioners. The third session involved a lengthy workshop using EBP Websites, which were introduced and demonstratedÐparticipants had also been asked in advance of the course to bring their own subjects of interest to research. The candidates were each given a list of useful Websites to take away so that they could then try out sites that were relevant to them in their own time. To emphasize the dangers of accepting Internet resources blindly, candidates were advised on how to prepare a strategy for finding and filtering information available over the Internet, how to search and navigate the Internet effectively and how to evaluate Websites for relevance and quality of evidence. A number of apparently academic


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Brief Communications papers available on the Internet were demonstrated and candidates invited to draw conclusions as to their quality based on a set of quality criteria given to evaluate the papers. In the final session, core resources such as the Cochrane Library and the National Resource Register were discussed in detail and the concepts involved in structuring detailed search strategies for users who were contemplating a systematic review or who were simply reviewing the literature of a subject were described.

Putting planning into practiceÐ perceptions and feedback Verbal feedback from the `Searching for Evidence-based Health Care Information' course was positive. The library tour appeared to be useful to the candidatesÐ especially as it became apparent that many had `slipped the net' and had not had a library induction previously. This had the added advantage to the medical library of publicizing available resources and even registering new members. The completed evaluations gave the facilitators plenty to think about, although the demand for the course (it was over-subscribed with a waiting list) meant that there was enough interest to enable the planning of future sessions. Many of the candidates followed up the course by requesting one-toone teaching sessions with library staff using the Internet and the databases. Following the first two sessions, a formal meeting was held within the Trust to discuss the success or otherwise of the various areas of the course. Each of the participants completed an evaluation form. In general, the feedback was good, although 14% of the candidates felt that the level of information provided in the course was too low. During the first running of the course it had become immediately apparent to the facilitators that there was a wider range of abilities amongst the candidates than had been expected and that changes would have to be made. Some candidates were using

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library and Internet resources on a regular basis during their working life. Others were unfamiliar with what we considered to be the basic IT conceptsÐindeed some had little or no keyboard skills. The course was considered to have been delivered in an ùnderstandable' format by all candidates and most (96%) of the candidates felt that the content fulfilled their expectations. All of the participants felt that they could use some aspect of the course in their clinical practice and that they would recommend the session to a colleague. A selection of some of the comments are listed below: `Very re-assuring presentation so I didn't feel too stupid if I got things wrong. Very useful to have hands-on sessions' `Need to structure session for experienced IT users and non/inexperienced users' `The whole ``computer'' scene is new to me. I feel . . . that it has stimulated a huge urge to go and find information to backup clinical practice' `Well designed sessions which gives a good overview of what is available with the back-up that when you want to use the facilities there are staff (medical library staff ) at hand for a refresher session as and when. Found it useful!'

Conclusion The `hands-on' approach to teaching EBP was successful. However, we were rather too optimistic in thinking that IT searching abilities would be fairly standard amongst the candidates when we were in the planning stage. As a result, before running the course again, it was decided that candidates should be split into two groups for the last session. Those who were more competent would spend the time learning how to develop detailed search strategies while the others would be able to spend more time undertaking basic CD-ROM and Internet searches. All users were given an opportunity to play and practice with the machines and to


Meeting Report make and learn from their mistakes, thus helping them build up confidence in searching techniques. It had become clear in conversation that this was something that they had been unable to do during their normal working week. The opportunity to request help where it was needed during the course and to have the ability to request further help at a future time when they wished to further develop their interests was appreciated. To reiterate, many of the candidates are reinforcing the knowledge developed during the courses by booking additional library training in searching techniques. It is worth emphasizing that the last half-hour of the course was designed to allow candidates to `do their own thing' with the facilitators on hand to provide help and advice where needed. When the course was run the second time, candidates were so enthusiastic the course lasted an extra hour!

References 1 Glanville, J., Haines, M. & Auston, I. Sources of information on clinical effectiveness and methods of dissemination. In: A Haines & A Donald (eds). Getting Research Findings into Practice. London: BMJ Books, 1998. 2 Rosenberg, W. & Donald, A. Evidence-based medicine: an approach to clinical-problem solving. British Medical Journal 1995, 310, 112±26.

Meeting Report Consumer Health InformationÐ New Directions Consumer Health Information Study Day. St Thomas' Hospital, London, 13 April 1999 HILARY HAMES, Information Services, Essex Libraries, PO Box 882, Market Road, Chelmsford, Essex, UK In the late 1990s there has been an explosion of interest in consumer health information;

this workshop explored recent change stemming from the government's Ìnformation for Health' strategy which will put IT at the heart of the NHS. By 2005 there will be electronic transfer of patient records all over the country and smartcards will record every detail of our healthcare journey from the cradle to the grave. The information strategy also proposes a National Electronic Library for Health (NeLH) which will provide easy access to best current knowledge on various `knowledge floors' for both clinicians and patients. The workshop concentrated on the quality of health information for consumers and its delivery. David Gilbert of the Office of Public Management set the scene by describing work done by the Kings Fund with patient focus groups to investigate availability and quality of patient information using 10 common health problems as a sample. Information was often found to be patronizing, out-of-date and not evidence based. Frequently the problems associated with treatments were glossed over and the success rates of interventions not considered. The Centre for Health Information Quality (CHiQ), which is based at the Help for Health Trust, provided the next speaker. Working closely with NHS bodies and patient support groups, CHiQ aims to improve patient information by developing appraisal tools and offering training materials for the writing/assessing of health information. Recently the role of the Centre has been strengthened to enable it to provide the `patient floor' of NeLH which will be a gateway, using high-quality filters, to patient information on the Internet. NHS Online, as it will be called, will be a distinct Website from autumn 1999. Technical information such as clinical guidelines will be included, rewritten to be comprehensible to patients and carers. Sweden has a highly developed consumer health information service. Torbjorn Persson of Spri, the national resource library for health, gave an impressive account of their Internet databases. Ninety per cent of requests for documents are supplied within the same day. Health and social care is an integrated function


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Research of the county councils in Sweden and 41 consumer helplines cover the country. Jackie Chapman described the setting up in Nottingham of one of the first NHS Direct pilot projects. This government funded nurseled telephone advice service, has been enthusiastically received by the public and will be rolled out over the entire country by the end of the year. During the year 2000 the lesser known NHS Health Information Service (0800 665544) will be fully integrated with NHS Direct and extensively publicised. It may not be a freephone service, but we will all have 24 h telephone access to advice on dealing with illness and emergencies plus information on conditions and treatment and details of patient support groups. In the future, some enquirers might well go direct to NHS Direct but libraries can still expect to be used for in-depth information. The NeLH strategy document paints a picture of many public libraries having a less than reasonable collection of medical texts. As NHS On-line develops and as more health information providers, particularly the major patient support groups, adopt CHiQ guidelines for writing their publications, the service we all provide in health information can only be enhanced. The last speaker was Roger Stewart from the Telephone Helplines Association (THA). He is the Quality Development Manager for the Association. The THA exists to promote the highest possible standards for helplines. It has a members' support unit, a quality unit and a training unit. The Association produces a leaflet on setting up a new helpline for providers and a leaflet for the public on confidentiality. There is also a complaints procedure for callers who feel that they received an unsatisfactory service from a member helpline. The phone number of the Telephone Helplines Association is 0171 2483388. ChiQ NeLH THA

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http://www.centreforhiq.demon.co. uk http://www.nelh.nhs.uk http://www.helplines.org.uk

Research Evidence-based health service management JANE FARMER* and DOROTHY WILLIAMSy, *Department of General Practice and Primary Care, Aberdeen University, Foresterhill Health Centre, Aberdeen and ySchool of Information and Media, Robert Gordon University, Aberdeen The tidal wave of the evidence-based movement has brought an understanding of the factors affecting the uptake of research findings by clinicians. Less is known about the use of evidence by managers in the health service. Clinicians' obligations to use evidence are acknowledged, but what are the obligations of managers and how can evidence be actioned within management processes? Research findings are beginning to appear that shed light on the mysterious processes by which managers make decisions and the information they use In 1995 Stocking set out to explain `Why research findings are not used by commissions and what can be done about it'.1 This column will look at three research papers exploring different aspects of this issue. While the findings discussed belong to the years of the internal market, they still provide relevant insights.

Introducing the evidence Dixon, Booth & Perrett2 explored commissioning managers' priority setting processes. They aimed to examine how research findings were actually used in making decisions, and whether introducing evidence into the process affected the outcome. In the District Health Authority (DHA) that they investigated, priority setting had five stages: an initial invitation to providers to submit proposals; an evaluation of the proposals received against criteria of health gain, equity,


Research contribution to priorities and `quality'; a weighting and ranking of the scores for each proposal; a multi-professional meeting to rank the priorities among the scored proposals; and final adjustments made later. While proposers submitted evidence in support of their proposals, the researchers also searched for evidence to feed into the evaluation process. The five `best' pieces of literature retrieved (determined by the quality of research design) were used to give a `strength of recommendation' score. Quality research evidence identified by the researchers was compared with the èvidence' used by the proposers in support of their bids. Only 7% of the items used by proposers were also chosen as `best available evidence' by researchers. Looking at the priority setting process, the results suggested that evidence probably had an influence when assessing health gain, but no relationship was found between research evidence input and the eventual priority order of proposals in the DHA purchasing plan. The researchers concluded that formal decisions were made without due consideration of the evidence and that, in any case, many decisions probably `bypassed' formal priority setting. They suggested that a more interactive approach between researchers/evidence inputs and commissioners might prove more successful, but effective means of implementing such a system would need to be identified.

A question of structure Dixon, Booth & Perrett concentrated on the stage at which research evidence is formally introduced into the decision process. They queried whether stages later in the process might somehow erode the influence of evidence. McCarthy looked at the influences at work in the contracting round,3 and his article provided details of several of the factors that may intervene to reduce the influence of research evidence in management decisions. McCarthy's overall impression was that financial considerations, in particular the

formal policy structures related to budgeting and contracting, had a strong influence on commissioning decisions. Public Health advice emerged as only one factor in the process, introduced early in strategic planning, and tending to be dissipated by budget consider-ations and the format of final decision-making. While the strategic and priority setting stages of the process were made on a disease or health-issue basis, the final stage was conducted by the provider not by programme. Therefore, the way funds were allocated fitted better with specific provider contracts than it did with provision for specific health problems. This suggests not so much that research evidence is a weak link in a `chain' of decision-making, but that the `chain' does not exist, i.e. management decision-making is not a single, linear, process. Early stages of the commissioning process may invite and consider research evidence, but eventual decisions are made on a different basis, which tends to discount research evidence in favour of factors arising from operational matters. McCarthy's study observed an event that highlights this issue. The Health Authority members in his study played a simulation game in which they prioritized health care on the basis of disease prevalence, treatment effectiveness and equity. The priorities arrived at in the game were compared with the actual budget allocations for each area, and were found to be very different. So it is not simply a matter of making the evidence available to decision-makers in a robust and appropriate way: both of the studies we have looked at so far raise the question of the interactions and relationships between evidence and managers as the decisionmaking process unfolds.

A matter of trust The interface between managers and the research they commission was the subject of an exploration by Harries, Elliott & Higgins.4 Examining nine case studies of the


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Book Reviews commissioning process, they found that health service managers and researchers often have different models of the role of research evidence, and a variety of local relationships emerged as a consequence. They found that research appeared to influence the process of decision-making in a nonlinear, iterative way, with the researcher or team influencing the managers in a developing relationship of trust, rather than the decision being made on the basis of an item of evidence introduced at a particular stage. They concluded that developing these relationships between research and management may be more important than formal structures in actioning evidence within decision-making. They suggest that it may be a mistake to concentrate only on disseminating items of evidence and that the influence of research is an ongoing, interactive, interpersonal issue involving factors such as trust and having information available at the crucial time. If, as they suggest, change is the only real certainty for the NHS in the near future, then how and when research findings are introduced into the process may be as important to the outcomes of decisions as the quality and content of evidence. In all three of these studies, different barriers hindering the influence of evidence within management decision processes were examined. Research evidence may not be available, it may not be considered, or its impact may be dissipated by the over-riding influence of other factors. So returning to Stocking's 1995 title, evidence is beginning to accumulate about why research findings are not used by commissioners (and managers generally). We know there are barriers to its uptake, but what can be done about it? This is a question that needs to be tackled if evidence-based health care is to include the effective use of evidence by all staff groups. Much has been written, research conducted and projects developed to improve the use of evidence by doctors. It is now time to look at the role of health service managers in evidence-based health care.

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References 1 Stocking, B. Why research findings are not used by commissions and what can be done about it. Journal of Public Health Medicine 1995, 17(4), 380±2. 2 Dixon, S., Booth, A. & Perrett, K. The application of evidence-based priority setting in a District Health Authority. Journal of Public Health Medicine 1997, 19(3), 307±12. 3 McCarthy, M. The contracting round: achieving health gain or financial balance? Journal of Public Health Medicine 1998, 20(4), 409±13. 4 Harries, U., Elliott, H. & Higgins, A. Evidence-based policy-making in the NHS. Exploring the interface between research and the commissioning process. Journal of Public Health Medicine 1999, 21(1), 29±36.

Book Reviews Evidence-Based Health Care Workbook including the Evidence-Based Health Care CD-ROM. Oxford: Update Software Ltd, 1999. ISBN 1±901868±01-X. 76 pp. (plus cd-rom). £35. As we enter the new millennium all of us will become de facto librarians of the 21st Century. However, will we have acquired the essential skills of critical appraisal required for effective management of research literature, and of small group teaching, necessitated by increasing demands for user education? If your answer falls anywhere short of a resounding `Yes' then this exciting product is for you. The EBHC Workbook and cd-rom, as befits their Oxford pedigree, capture the state of the art of current practice in both finding and appraising the evidence. Taking the user through Àsking the Question', `Finding the Evidence', Àppraising a Randomised Controlled Trial' and Àppraising a Review' the course provides an individual with a seamless alternative to an activity otherwise best practised in groups. Furthermore, helpful supporting tools such as a glossary


Book Reviews and a `statistics made simple' section are on hand to ease the progression up the otherwise steep learning curve. In truth the creative input has been focused on the cd-rom with the book being primarily a repository for offprints and checklists for the appraisal process. Nevertheless I am sure that the two-page handout on Building Questions which we have already incorporated into virtually all our teaching sessions is destined to figure in similar instruction across the country. It is quite simply the most clear and concise presentation on this topic I have as yet encountered. Installation of the cd-rom is very straightforward as one might expect from a company that has cut its teeth on the Cochrane Library software, and this might help to make this a product as much for the ward-based workstation as for a cd-rom stack in the hospital library. If one was to wish to gild this otherwise perfectly acceptable lily then it would stem from the feeling that this package captures, rather than extends, existing practice. This is, however, the rather world-weary view of someone who has been practising critical appraisal for the last 5 years and probably bears little relation to the acknowledged needs of a novitiate spent at the cutting edge. In fact this package fills a significant niche in a market that necessitates a conservative rather than a radical approach and the entrepreneurial spirit that we have come to associate with its two partner producers is seen in its chosen delivery medium rather than its content. Top of my list of selling points for the cd-rom comes its bold and imaginative use of icons and the intuitive feel of the interface. Materials have been selected to appeal to the widest possible multidisciplinary audience. In short this will prove a useful addition to any health care environment and can serve as either an endproduct in its own right or as an invaluable support tool for local critical appraisal teaching. In a domain increasingly populated by teaching packages such as the West Midlands Project Apple initiative (http://library.hsrc.org.uk/ projectapple/) and, dare I mention, the

ScHARR South and West libraries RES&WRCE (http://www.shef.ac.uk/~scharr/ reswce/reswce.htm), this seems destined to set the gold standard to which the rest of us must aspire. ANDREW BOOTH SCHOOL OF HEALTH AND RELATED RESEARCH UNIVERSITY OF SHEFFIELD Copyright: interpreting the law for libraries, archives and information services. 3rd edn. GRAHAM P. CORNISH. London: Library Association Publishing, 1999. ISBN 1±85604±344±4. iv, 188 pp. £19.95. Copyright in health libraries. 3rd edn. SANDY NORMAN. London: Library Association Publishing, 1999, ISBN 1± 85604±323±1. viii, 84 pp. £9.95. The increasing speed of change in the copyright field, especially with respect to electronic copyright and other developments arising from EU directives, is reflected by the publication pattern of these two books. Both were first published in 1990, with a second edition in 1996 (Norman) and 1997 (Cornish), followed rapidly by the present third editions. Graham Cornish's book is set out in the form of about 600 questions and answers. It is intended to serve as a practical work of reference for library staff at all levels and in all types of library, providing simple answers to the most common types of copyright query. Most of the answers are stated baldly, without specific reference to the legislation or code of practice on which they are based. The strength of this book undoubtedly lies in the definite nature of the answers given, in a field where much advice tends necessarily to be qualified and ambiguous. The book is divided into chapters dealing with the different types of copyright material (literary, dramatic and musical works, artistic


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Book Reviews works, sound recordings, films and videos, etc.). It is generally easy to establish quickly whether or not the book contains an answer to any particular query either by scanning the relevant chapter or by consulting the index, which is helpful but perhaps rather short. Since the second edition, the chapter on `Databases and electronic materials' has been substantially rewritten to incorporate the new concept of `Database Right' which was introduced into UK law in 1997. Other changes seem to be fairly minor. Sandy Norman's Copyright in Health Libraries is an introductory guide to UK copyright law for librarians, aimed specifically at those working in nonprofit health libraries. Librarians working in profit-based sectors such as pharmaceutical companies are referred to Copyright in Industrial and Commercial Libraries, another volume in the series of Library Association copyright guides of which this book forms part. The law and the various codes of practice that lie behind the bald questions and answers in Cornish's book are clearly described in Norman's guide, so the two books complement each other very well. Also included are a summary of legislative changes since the 1988 Act and a selection of case law, the most recent dating from November 1998, most of which I have not seen collected together in one place before. There is thus a good balance between basic information about photocopying limits on the one hand, and discussion of current developments on the other. Future editions would need to appear even more frequently in order to maintain this degree of currency. Most of the material in this book would be relevant to any nonprofit library. Apart from brief discussions of journal clubs and of the relationship (or lack of one) between the Copyright Licensing Agency and the NHS, I could find little in it specific to the health sector. None of the other volumes in the Library Association series of copyright guides are subject-specific, and it might be questioned whether the health sector really requires its own guide.

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Those needing a lot of detail might find Ray Wall's optimistically titled Copyright Made Easier (2nd edn, Aslib, 1998), or the loose-leaf Aslib Guide to Copyright, more useful, but taken together these two Library Association books form an excellent source of advice and information about copyright. The preface to Norman's book says that it is intended not just to describe the law, but `to promote respect and understanding of copyright'. Certainly neither of these publications shy away from giving definite advice and recommendations, which I am sure is what many librarians will be seeking. STEPHEN DALE CAMBRIDGE UNIVERSITY LIBRARY SCIENTIFIC PERIODICALS LIBRARY Exploring the contexts of information behaviour. Proceedings of the 2nd International Conference on Research in Information Needs, Seeking and Use in Different Contexts, 13/15 August 1998, Sheffield, UK. Edited by T. D. Wilson and D. K. Allen. London: Taylor Graham, 1999. ISBN 0947568 75 1. 625pp. £65.00 [paperback]. This volume contains papers from the Second Conference on Information Seeking In Context (ISIC2). The conference attracted participants from 17 countries, drawn predominantly from schools of library and information science. As with ISIC1,1 the proceedings place an emphasis on research presentations that demonstrate rigorous methodology and conceptual modelling. The 42 papers included five keynote addresses and 37 contributed reports grouped together into broad categories. One of these, `The Health Services Context', contains six papersÐfour from the USA and one each from Spain and the UK. They describe studies into the information-seeking needs and practices, or `human information behaviour', of physicians, community nurses


Book Reviews and medical students, discussing how appropriate methodologies can be developed and applied to suit specific areas of investigation, and reporting the results of surveys that employed those methods. Readers of Health Libraries Review may instinctively gravitate first towards this section, but the proceedings as a whole merit further study for the lessons that can be learnt about the research process. While some papers are undoubtedly more theoretical than others, there is much here that is potentially valuable for those involved in, or contemplating, operational library and information research, and who wish to ensure that their operational investigations are founded on good methodologyÐà sign of maturity in the field', as the editors put it.

References 1

Vakkari, P., Savolainen, R. & Dervin, B. Information seeking in context. Proceedings of an International Conference on Research in Information Needs, Seeking and Use in Different Contexts, 14±16 August 1996, Tampere, Finland. London: Taylor Graham, 1997.

PETER MORGAN CAMBRIDGE UNIVERSITY MEDICAL LIBRARY ADDENBROOKE'S HOSPITAL CAMBRIDGE The new review of information and library research. Edited by P. BROPHY, Vol. 4. London: Taylor Graham, 1998. ISSN 1361±455X. £65.00 [paperback]. The fourth volume of this annual publication, which until 1994 was known as the International Journal of Information and Library Research, marks a change of editor, Peter Brophy taking over from Stephen Roberts, and a change of direction. It contains a selection of papers from the December 1998 conference Ìntegrate, Cooperate, Innovate' held in London by the UK's Electronic Libraries Programme (eLib). The conference marked the start of eLib Phase 3, which is devoted to research into hybrid libraries, clumps (large scale resource

discovery systems), digital preservation, and the development of Phase 1 and 2 projects into services. This volume concentrates on the hybrid library concept, with an introductory paper and 13 presentations of research projects. All the projects are based within the UK higher education sector, reflecting eLib's primary remit. Their significance though, as with earlier eLib projects like OMNI (http://omni.ac.uk/), is far wider. They have begun to explore issues central to the hybrid libraryÐissues such as resource description; user authentication and authorization; standards and interoperability; scalability and sustainability; and accessibility. All are issues that also confront those working outside the higher education sector on the development of information services, whether national in scope like the National electronic Library for Health (NeLH) (http://www.nelh. nhs.uk/) or more localized, that seek to integrate conventional library resources with networked information resources; and in any case, sectoral boundaries become increasingly irrelevant in the world of hybrid libraries. Similarly, while the reports in this volume are not specifically concerned with health-care information, the underlying principles for the technical models they describe, the collaborative structures they employ and the user needs they analyse are all relevant to health-care information strategies. PETER MORGAN CAMBRIDGE UNIVERSITY MEDICAL LIBRARY ADDENBROOKE'S HOSPITAL CAMBRIDGE Health and British magazines in the nineteenth century. E. M. PALMEGIANO. Lanham, Md. & London: Scarecrow Press, 1998. ISBN 081083486 3. 296pp. $59.50 This book is an annotated bibliography of articles on health published in the popular British periodical press during the nineteenth century. The author, Eugenia Palmegiano, is


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Book Reviews Professor of History at Saint Peter's College in New Jersey, and President of the American Journalism Historians Association. Professor Palmegiano defines her scope as `wellness as science and society understood it at the time'. She has selected 48 magazines from those included in The Wellesley Index to Victorian Periodicals or Poole's Index to Periodical Literature, all of them notable for the regularity of their writings on the subject of health. While acknowledging that these magazines would have a bias towards readers and writers of the middle and upper classes, she argues that their personal and social perspectives were sufficiently varied and changing to ensure a broad-based presentation of health issues. After an introductory essay, the bibliography is arranged alphabetically by magazine, and under each magazine articles are listed chronologically with a brief descriptive annotation. Each list is prefaced by a succinct description of the magazine's essential character: thus The London Quarterly Review, `backed by Methodists but not bound to religious texts. . .inspected especially epidemics and the evolution of women's role in community vigor'. Many of the topics coveredÐdrug abuse, vivisection, exercise, for exampleÐhave a late twentieth century ring to them; others less so, like the Temple Bar article of 1866±7 on `Hippophagy and Onophagy' which advertised the nutritiousness of horse and ass meat. Running throughout these lists is a strong feeling of political activity, of a popular press committed to campaigning for improvements in living and working conditions as the essential precursor to improved public health. (It comes as no surprise to learn that both Dickens and Trollope edited magazines included here.) As a source of material for social and medical historians, and for students of nineteenth century literature, this bibliography offers rich rewards. PETER MORGAN CAMBRIDGE UNIVERSITY MEDICAL LIBRARY ADDENBROOKE'S HOSPITAL CAMBRIDGE

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Catalogue of the pre-twentieth century holdings in the library of the Reading Pathological Society in the Royal Berkshire Hospital. Compiled by D. T. O'ROURKE. Reading: Reading Pathological Society, 1999. ISBN 09536090 0 6. x, 93 pp. £6.00 [paperback]. In the days before postgraduate medical centres and libraries became a standard feature of educational and professional life, their role as meeting places and providers of study resources was largely filled by medical societies. The great national societies and their libraries are still a familiar and highly valued part of the scene. Less well-known are the many local societies that flourished around the country and that in many cases are still active. One such is the Reading Pathological Society, founded in 1841, later amalgamated with the Reading Medico-Chirurgical Society, and closely associated throughout its existence with the Royal Berkshire Hospital. For many years the Society's collection served as the hospital library until a new postgraduate centre, incorporating a modern library, was built in 1974. Following refurbishment of the Òld Library' in 1992, the historical collection has been recatalogued by Diarmuid O'RourkeÐformerly of Reading University Library, where he worked with the Cole Library of Early Medicine and AnatomyÐand this volume is one result. It records 735 books and manuscripts and 34 journals published (with a few exceptions) before 1901. The entries generally follow Anglo-American cataloguing rules and are arranged alphabetically by author, with a separate title list for journals. There are indexes of authors and contributors, provenance and subjects, and some wellchosen illustrations. The devoted historical bibliographer may regret the absence of pagination and other physical descriptors, but will welcome the annotations on provenance. Although there is a scattering of earlier works, the greater part of the collection consists of nineteenth century publications.


Book Reviews It has continued to grow through a number of significant twentieth century donations, but most volumes were presented to the Society by its members in its early years. The catalogue thus provides the social historian of medicine with a valuable picture of the

learning resources used century medical practice.

by

nineteenth

PETER MORGAN CAMBRIDGE UNIVERSITY MEDICAL LIBRARY ADDENBROOKE'S HOSPITAL CAMBRIDGE


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