IN-SET
THE NEWSLETTER OF THE HEALTH LIBRARIES NETWORK
Extracts from IN-SET 39, April 1999
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IN-SETTHE NEWSLETTER OF THE HEALTH LIBRARIES NETWORKExtracts from IN-SET 39, April 1999 Reviews of Meetings & Courses, Selected Articles, Journal & Book Reviews |
Reviews of Meetings & Courses
THE WAY WE WERE, by Leslie Morton
I have been invited by Michael Carmel to describe some of the major changes in medical libraries that have taken place since I came on the scene in 1923, 75 years ago.
The most striking change is the greatly improved status of the medical librarian, who is now an important member of the medical team. I like to think that the two principal factors helping to bring this about are: classification schemes designed specifically for medical literature and information technology, both of which make it essential for the medical librarian to attain a considerable knowledge of medical terminology.
I first became acquainted with libraries as a schoolboy. I lived in North West London and used Chester Road Public Library. To get there I took a tram to Parliament Hill (so named after the non-event of 1605 when the Gun-Powder plotters went there to watch the blowing up of the Houses of Parliament). I went along Swain’s Lane, past Highgate Cemetery, whose residents include Karl Marx and George Eliot, to Chester Road.
In the library there was no open access. To get a book you filled in a slip with your name and the number for the book. You then consulted the Cotgreave Indicator. This was an enormous shop window behind which were thousand of numbers, blue or red. If your number was blue, the book was in; if red, the book was out. When a book was taken out the assistant simply turned round a slide bearing the number. I once made a mistake in the number and got a book on billiards. I had never seen a billiards table; I hadn’t a clue! You could not return a loan on the day you borrowed it so I had to take it home. The Cotgreave Indicator was the invention of Alfred Cotgreave, Librarian at West Ham Public Library. In 1893 he had opposed John Macalister’s suggestion that readers should be issued with a second ticket to allow them to borrow two books at a time. All those who profess and call themselves medical librarians will of course have read Shane Godbolt’s Incomparable Mac, the biography of Sir John Macalister, who re-founded the Royal Society of Medicine, of which he was Librarian and then Secretary.
I went to work at University College London in September 1923 in the new Medical Sciences Library at a salary of £52 a year. It had "own scheme" classification; a very broad grouping of books under general headings. There was a fixed shelf mark for each book. I went there 40 years later to see Osler’s book on medical incunabula; it had by then been moved to Foster Court, but still had the original shelf mark pencilled in by me in about 1924.
While working at UCL I was allowed to go part time to the School of Librarianship - the first in the country, established partly due to the efforts of Macalister. It was easier to become ALA then; you could take one or two papers a year at the School and when you had five passes you could qualify ALA at the LA. We learned the Dewey classification; popular in the public library but with disadvantages for the special library because it separates material dealing with the different aspects of a particular subject. It was introduced in 1876 and is now in its 21st edition. As you know, from it came UDC, a detailed expansion suitable for large collections.
In 1933 I went to the Royal Society of Medicine. Here again there was no recognised classification system, although it was the largest medical library in the then British Empire. It had its own simple grouping of books under main subjects. (In the main reading room the desks were furnished with overhead lights and a hanging pear switch). If a reader wanted a book, or some tea, he just pressed the switch. A red light came on over his head and a buzzer sounded in the issue room. An assistant turned off the buzzer, went to the table, turned off the red light and attended to the reader’s requirements). Before my time there was a devoted deputy librarian with years of practical experience, who knew where all the books were and managed practically everything, but had no formal training and was not receptive to new methods. When he left in 1933, everyone on the staff went up a step and I joined on the bottom rung of the ladder. He reminds me of Clifford Dobell, the eminent parasitologist, who earlier this century wrote of Mr White, librarian at the Royal Society of London: "He seemed to know all the volumes in the library and would stroll around when dealing with a query and seemingly intuitively locate the required item. He would refuse to lend a German work if the reader could not pronounce the title correctly". In other words, if you can’t pronounce it, you can’t read it! Dobell felt that White would close the library at night and then use one of the folio shelves for his bed.
Clever newcomers to the RSM like myself would remark:
"What, no classification!" but no one took any notice of us until Donovan Richnell joined the staff. He had a Cambridge degree, the Diploma in Librarianship and the friendship of the secretary. When he said: "What, no classification!" something was done. The matter was discussed and it was decided to adopt UDC (at that time there was no Barnard and no NLM scheme). On enquiry it was found that only Geoffrey Hipkins, my immediate senior at the bottom of the staff ladder, and myself had any experience of UDC or Dewey so we were given the task of classifying the section on anatomy as a sample. By the way Geoffrey ended his working life here at Worthing at SmithKline Beecham. That’s how RSM got UDC. It is now using NLM for new books. Richnell ended his career at Senate House and then as Reference Librarian at the British Library, with a well deserved CBE.
In 1936 Cyril Barnard introduced his classification scheme, designed for the London School of Hygiene library. He revised it in 1955 for wider use in medical libraries. He was later commissioned to classify the library at WHO.
The Provisional NLM classification scheme was introduced in 1949 and the 1st edition in 1951. Like Barnard it allows for specific entry; unlike Barnard it has a great medical library to back it and experienced medical and lay workers to keep it up to date.
Schemes specially designed for medical literature make it essential for librarians to examine literature carefully and thus acquire more detailed knowledge of medical terminology.
The other great innovation since I came on the scene is Information Technology, about which I know nothing. I have Word Perfect ‘95 on my own computer, which I am able to work with the help and advice of my grandson and neighbours’ children.
Advances in information technology led to the introduction of MEDLARS in the early 60s, necessarily preceded in 1960 by the invaluable Medical Subject Headings, a subject headings authority list for the newly designed Index Medicus and the NLM Catalogue. It is a splendid piece of work that has guided many of us in the use of medical terminology.
I moved in 1959 to the MRC Library at the National Institute for Medical Research, where Barnard was in use. My deputy, and now successor at NIMR, Robert Moore reminds me that when MEDLARS became operative in the mid-60s I said to him: "You had better look after this; I am getting too old." In other words, give your colleagues every opportunity to investigate the more interesting developments in library/information services, even if you yourself end up with the more boring but vital activities.
I retired in 1972 but returned to work in 1973 as Regional Library Adviser, North East and North West Thames Regions, with John Mills in the South East and South West Regions. We were dealing mainly with the many postgraduate medical centre libraries that had sprung up, almost all in non-teaching hospitals. Apart from Roy Tabor in Wessex we were the only Regional Library organisations. We found an odd mixture; few of these small libraries had qualified or experienced librarians; books were classified by Dewey (very few), "own scheme" or none at all. In one centre the overworked secretary/librarian was against the appointment of a librarian because it might jeopardise the chances of her advancement. In another (in a mental hospital) a patient who had been a chronic alcoholic and a chronic smoker was eventually cured but had become institutionalised and feared to go back into the outer world, so they gave him living accommodation and put him in charge of the library!
Where possible, we recommended NLM classification. A most valuable contribution to the scene was the early introduction by John Mills of the co-operative centralised cataloguing scheme.
To sum up: I feel that over the past 70 years the introduction of medically orientated classification schemes and developments in information technology have profoundly influenced the exploitation of medical literature and have enhanced the status of the medical librarian. In this respect we owe a great debt to the NLM for its Catalog, for Index Medicus, and for MEDLARS. Medical librarians here have also played their part in the development of information technology and from where I sit the end is not yet in sight.
My warmest thanks for inviting me to your party and my very best wishes for the future of the South Thames Library and Information Service.
FIFTY YEARS OF THE NHS by David Wild
In 1953 when I was a new doctor, I worked in a small city centre hospital that had a large number of eminent consultants on its staff. It was the sort of hospital which was for the poor and its attitudes and practices were still the old ones. Patients were expected to be grateful, the hospital made the decisions, you waited in outpatients until you were seen, you did not expect too much information and the consultant was God. The Nurses lived in a Nurses’ home guarded by dragon sisters and the doctors were waited on hand and foot.
House doctors were paid very little before the NHS but now we got £350 plus board. Hours were much longer than they are now. I got one night off in three after 7.00 p.m. and one weekend off in three after midday Saturday.
All I said was "How are you Mr Basham and he got out of bed, hit me, broke off my front tooth and said, that’ll teach you to starve me you little bugger". Everyone in the ward laughed, which was, I thought, unkind as I stood there, gap toothed and humiliated. However Sister Rose Douglas had the situation in hand at once. "Phone for a taxi Nurse Moore and bring Mr Basham’s clothes", she said and to Mr Basham "get up, get dressed and go home." Mr Basham was in for observation. I am still not clear what we were observing. Mr Basham had blackouts of unknown origin. Maybe observation might have revealed something if he could have behaved himself, but unfortunately he rendered himself unfit for receipt of what was seen as charity by noble nurses and doctors.
Patient compliance is unsatisfactory. These attitudes still linger even today.
In 1950 medicine was not exactly medieval. Pathology was well advanced and patterns of infection understood. Antibiotics were in their infancy; we did not know the dose of penicillin. Auto-immune disease was beginning to be recognised. Renal disease was beginning to be elucidated. Heart disease was becoming treatable. Therapy was not advanced. The idea that therapy is good for you is a new concept. Patients died of therapy. Bed rest was important, on the basis of very little evidence. Surgeons still did procedures based on the principle that all bad should be cut out, but science was stirring.
In midwifery mothers were precious, babies a by-product. Infant delivered and set aside. Enter the paediatrician and infant monitoring. Real judgement began to be overtaken by the technical imperative. "I’ve been trained to use this equipment". Now I am retired I can be truthful. Medicine is for the philosopher, surgery is a haven for the reactionary. Physicians know everything and do nothing, surgeons know nothing and do everything, psychiatrists know nothing and do nothing, pathologists know everything and do everything but late.
This is not a criticism. Surgeons have a very difficult job and have to make their own decisions, on the basis of their knowledge and experience.
POLITICS
The NHS is labour property but has actually been defended by every Government. Mrs Thatcher had to retreat. Using tax as a basis makes for a lot of problems and has some bad effects. However it is the political prominence of the NHS that ensures its safety as a public service, guarantees its funding and creates a national service which can research its activities (a lot better than it does). Fashionable words such as AUDIT can rock the boat and be very persistent especially if politically driven.
Currently waiting lists have great political status. It appears that they are one measurable factor that can be represented to the public as politically manageable. In fact they distort practice and create endless bureaucracy. A colleague of mine wrote a paper showing clearly the factors most affecting waiting lists, none of which had anything to do with the realities of clinical work.
The waiting list. The urgent waiting list. The very urgent waiting list. The special waiting list. Those who actually got into hospital were never on a waiting list, just like some of those jobs we see advertised but mysteriously filled in advance.
In all my years in the NHS communication was a problem. In out of the dark and back into the dark.
EDUCATION
For my first ten years or more, postgraduate education was a rare thing offered only in the teaching hospitals. Its growth into an overall service was no overnight thing but took a lot of hard work and had to endure much criticism. Its pioneers, some of whom I knew, left a wonderful legacy.
I have already mentioned science and it is in this field that the great changes have taken place. Medicine is now a mix of biochemistry, physics. mathematics (principally statistics) and pharmacology. Medical journals used to contain a great deal of "Clinical Findings and Observations". They now contain statistical tables and epidemiological commentaries. Pleased as I am to find my primary discipline elevated to its rightful place, I sometimes wonder if something is not missing. Good doctors learn the proper way to practice their trade, from example and experience, although some do not.
For my first twenty years as a doctor I used to study one new topic a year. Neurological presentations, aspects of hormonal disorder, new bacteriological findings in food poisoning. The year after I had read all about thyroid disease it all changed so I gave up and concentrated on my own speciality. The necessity of continuing education makes up to date information vital.
FUTURE
I think that the NHS is here to stay. Some form of rationing will continue. Postgraduate education is perhaps the most important of all medical activities (AND MAY EVEN TEACH SOME PEOPLE).
NOW THERE IS HOPE by Freda Knight
This was the motto of the forerunner of the Royal Earlswood Hospital. For when this pioneering institution was founded 150 years ago, there was no hope for the feeble-minded or idiot as he was then described. They were either kept at home if they were lucky, or when relatives could no longer cope, they were either sent to the poor house or the asylum for the mentally ill. No distinction was made, no help given.
The Royal Earlswood story begins with a certain Mrs Plumbe who became increasingly concerned about the plight of these people and sought advice from medical men of her acquaintance, including Dr John Connolly of the Hanwell Asylum, who became famous for the abolition of mechanical restraint there. She also consulted the Rev Dr Andrew Reed, a well- known philanthropist of the day who had already founded several orphanages in the London area. He had himself been thinking along the same lines for some time, so Mrs Plumbe’s approach could be said to have acted as a catalyst. They both felt that if only some education and training could be offered, the condition of these neglected people could be improved.
In the spring of 1847 Andrew Reed set off on a fact-finding mission, travelling to France, Germany and Switzerland where institutions had already been founded. He came back with much information, and was determined to tackle the problem in this country.
After careful preparation and advance publicity, a meeting was called at the Kings Head Tavern, Poultry in July 1847, where it was resolved to found an institution for the remedial care and education of the feeble minded. At a second public meeting at the London Tavern in October of the same year, with the Lord Mayor in the Chair, it was resolved to proceed with the project "The Asylum for Idiots" and that ‘it should be forthwith begun’. Various famous men such as Lord Palmerston, Baron Rothschild and Lord Ashley became officers of the charity.
By 1848, Park House Highgate had been acquired and 54 boys and 12 girls were admitted for training. It was the first institution of its kind in Britain.
Conditions soon became overcrowded but in 1850 this problem was partially solved by transferring 19 children to Essex Hall Colchester, an asylum developed by Samuel Peto. However it soon became apparent that larger premises must be found to cope with the demand and late in 1850 an 88 acre site at Earlswood was acquired. A public appeal was launched for the building of ‘The Asylum for Idiots’ and a competition was held for the design of the building. Eventually the design of a Mr Moffat was chosen and a builders tender for £29,400 was accepted. The builder was Mr Jay who had built the Houses of Parliament.
The building was entirely financed by public subscription and Queen Victoria subscribed 250 guineas in the name of Edward Prince of Wales, who became a life member. Albert, Prince Consort took a special interest from the beginning. He laid the foundation stone in June 1853 and opened the Asylum in June 1855. In 1862 the Queen conferred a Royal Charter on the asylum.
Although not completed, patients began to be admitted in 1855 and children transferred from Park House and Essex Hall. Soon there were 300 patients in residence.
The first Medical Supt. at Earlswood was Dr John Langdon Down. He was a compassionate man, with radical views for the time, and during his 10 years at Earlswood developed a new model of care for the patients and was responsible for improving conditions and management of the asylum. Whilst working at Earlswood, he identified the condition he described as Mongolism, now known as Down Syndrome. He left Earlswood in 1868 to open Normansfield at Teddington, an establishment for the training of mentally subnormal children of the wealthier classes.
It soon became obvious that the building needed to be enlarged, such was the demand for admission. So a further appeal was launched and on the 28th June 1869, the foundation stone for the extension was laid by Prince Edward and Princess Alexandra. It was completed in 1872.
Admission to the asylum was by a novel system of Election. Each subscriber had the power of one vote for each half guinea subscribed. Candidates for admission who came from all over the country, supplied details of their condition and circumstances for consideration. If a candidate was unsuccessful at the first election, votes could be carried forward to the next election. If after 6 elections he remained unsuccessful no further attempts were allowed.
Fee-paying patients were accepted without election and these patients often had their own apartments and their own attendants. Three categories of patient were admitted, 25% very improvable, 50% less improvable, and 25% scarcely or wholly unimprovable. Patients were usually admitted for 5 years. If after that time it was felt further improvement was likely they could be re-elected for a further period, otherwise they would be discharged.
Children were educated as far as possible and then trained in a variety of trades e.g. carpentry, brush-making, printing, shoe-making, tailoring, laundry and domestic work and work in farm and garden. Patients were treated kindly and fed well. Order and routine was established in their lives, daily exercise and leisure pursuits encouraged.
Of the many success stories of the system of education and training at Earlswood that of James Henry Pullen is the most outstanding. He became famous in his day as The Idiot Genius of the Earlswood Asylum. The Prince of Wales became his patron - Friend Wales - and when he died, aged 81, his obituary appeared in the Daily Telegraph.
He was born at Dalston, Hackney in 1835 into a respectable artisan family, one of 13 children, most of whom died in childhood. He appeared at first to be virtually deaf and dumb but did gradually learn to speak, write and spell a few words. His sister told of his early talent for whittling small models from firewood. It took his family nearly 2 years to collect enough votes for him to be elected to Essex Hall in 1850, aged 15. Here he learned to read and write and when he was transferred to Earlswood in 1855 he was put into the carpenter’s shop for training. Here he made rapid progress and was soon allowed to work on his own. Eventually he was given his own workshop and when he wasn’t engaged in carpentry for the asylum, he was allowed to work on his own productions.
Over the 60 years he lived at Earlswood he made hundreds of drawings, paintings, models and pieces of furniture. One of them is the Princess Alexandra, a six foot long 40 gun Man O’war which was on show at the asylum on every public occasion and exhibited in London and Paris where it won a bronze medal. His most famous work is probably the Great Eastern, an eleven foot long model of Brunel’s famous paddle steamer - every part made by himself. He also built a trolley to transport his large boats, which acted as a launching device and also incorporated a pulley that lifted the deck of the model, revealing the cabins below. The other remarkable model is a two foot long model called the State Barge or Fantasy Boat. Angels are in the prow and Satan subdued in the stern, carved from ivory sent to him by the Prince of Wales. The hull is solid ebony.
By the 1870s reports of the poor idiot with the remarkable mechanical genius were appearing in the national and local press and he became famous. Landseer visited him and sent him engravings of his own for him to copy. Dozens of them lined the corridors of Earlswood for years. The Prince of Wales visited him and visitors came from all over the world to see his work. With all this adulation he became very conceited and often difficult to control, if not allowed to do as he pleased. He made all sorts of booby traps to keep unwelcome visitors out of his workshop. On one occasion, having taken a violent dislike to an officer of the asylum, he set up a device to guillotine the poor fellow. Fortunately it went off a few seconds too late…
Pullen was also a very fine carver of ivory and wood and he made many small intricate items that he sold for pocket money. He used to visit Earlswood village and went regularly into Redhill, calling in at all the many pubs on the way, where he took orders and sold his brooches etc. On one of these occasions he returned to the asylum very much the worse for drink and got a severe reprimand from Dr Caldecott. He was much chastened, signed the Pledge and never drank again.
On one of these expeditions he met a young women, fell in love and insisted that he be given his discharge in order to marry her. This caused great consternation as Pullen was such a draw and money-spinner for the asylum. One of the governors called Pullen to the Board Room and told him that of course he could leave it he wanted to, but they would be sorry to lose him. If he would reconsider, they would make him an Admiral of the Fleet with a lovely naval uniform resplendent with brass buttons. This was too much for Pullen. He took the uniform and wore it on all public occasions and never mentioned the young woman again.
Many theories have been put forward to explain Pullen’s condition. He has always been quoted as the most talented Idiot Savant, but it is likely that he wasn’t really mentally retarded at all. Diana Cortazzi, a psychologist at Royal Earslwood, who started the Museum in the 60s has made a special study of Pullen. She concluded that he was suffering from aphasia with high frequency deafness; this is a difficulty in comprehending and using language due to a defect in the central nervous system.
Despite financial difficulties throughout its history the first 50 years showed steady progress and improvement, but by the start of the new century, the asylum began to lose its way. There was no longer any emphasis on training to rehabilitate to the community; patients came to stay. Attitudes were changing. The coming of the FWW caused a decline in standards, with staff shortages. Wards were overcrowded, food was poor and unimaginative treatment prevailed. Gradually things improved however.
On 5th July 1948 the hospital ceased to be a charitable institution and was absorbed into the NHS. Money was still short at first and the farm was closed. Many improvements were carried out, including the building of villas in the grounds in the 1960s, to house patients in smaller communities.
On the 31st March 1997 the Royal Earlswood closed and all the residents were moved out into the community into a variety of housing, from residential homes or staffed group homes, to self-contained flats, according to their need. They are learning to live a more normal life in the community.
So here we are 150 years on, celebrating the 50th anniversary of the NHS. Those early pioneers intended to educate, train and return their patients to the community where possible and now with community care this has truly come about. If Andrew Reed were with us today, I’m sure he would approve, and the motto "Now there is hope" still seems appropriate.
With the advent of primary care groups, the theme of this conference was appropriately chosen as primary care. During the conference three key issues were highlighted
Evidence based resources (little specifically on primary care)
Library provision (little specifically available for primary care)
Information skills training (sporadic would be the best description)
It is worth mentioning two specific papers presented at the parallel sessions, which were especially pertinent and stimulating.
The first paper was based on research by Sue Capel of the University of Northumbria, entitled Information for Nursing Practitioners in the Community - form, function and future. She concluded with 15 issues, which need to be addressed to enable an effective service to be given to primary care practitioners. One example is the need for health visitors to have access to databases which have a sociological content to support their practice; another is to encourage practice nurses to develop professional networks. I liked this idea of encouragement because librarians can have an important role in developing people’s confidence to do research.
The second paper of particular relevance was an evidence based information service. Kate Misso has the interesting post of Information Officer at South Humber HA running a Primary Care Information Service. A mark of its success is that it had funding for an initial year and this has now been extended. She outlined various strategies which have contributed to the success of the project. One that struck me was the importance of timing, for example getting information on resources on new buzz words as they come into common usage - clinical governance for example.
Plenary sessions were given by Professor Maggie Pearson, R&D North West Director, and Mike Farrar,(Head of the General Medical Service branch at the NHS Executive in Leeds. Their talks gave NHS perspectives on developments, and most importantly, conference delegates gave some ideas to the speakers on how to include librarians on their agendas.
There were two other plenary sessions, one by Dr Jack Horner who proclaimed his success in raising the status of GPs over 40 years. Finally Richard Smith, editor of the BMJ, gave us a rather tongue in cheek account of the information explosion, at the same time making relevant comments on the importance of appropriate information. He considered that the ideal for many doctors was a nice pocketbook of evidence-based material which could be updated regularly - a constantly updated bible of information. The first has now been published under the title Clinical Effectiveness and the plan is to publish it every six months. Oh for a nice pocketbook for all subjects...but here again is a possible role for some librarians.
Lancaster University is an academic village with excellent facilities, friendly personnel and a new library - though the Ruskin library is more of a showpiece at the entrance to the campus than a "real" working library. I think most people enjoyed a well-organised conference as well as the fact that it took place during the week.
If anyone would like further details on any of the sessions mentioned above, do contact me.
Denise Brady, Library, St Christopher’s Hospice, HSL
PACE (Promoting Action on Clinical Effectiveness) was funded by the NHS E, and set up at the Kings Fund in the autumn of 1995. As the programme nears the end of its three years, the PACE team has organised a series of seminars around the country to present the results of the sixteen projects. The team is anxious to ensure that further projects of this kind do not only happen with large injections of outside money, but that lessons learned can be generalised and taken into mainstream practice. They are also keen to encourage a culture where health staff are empowered to help change practice for the better.
In Reading we heard about the Dorset menorrhagia project, the Gloucester Royal NHS Trust management of stroke patients project, the Oxfordshire post operative pain control project and the Royal Berkshire and Battle Hospitals NHS Trust leg ulcer project.
Despite the projects being based on very different health problems there were a number of findings they had in common:
The time it took to set up the project, making sure all relevant stakeholders were on board, and begin to make some progress towards the goal, was emphasised by all;
The importance of informing all relevant stakeholders and in particular Chief Executives, so that administrative wheels could be oiled;
How much better it went when the project team was truly multi-professional;
How project management skills helped the smooth running of the project;
Where the project was based on guidelines, "good enough" was better than "perfect". Revision and updating of guidelines must be built into the project.
All the projects were "successful" in that improvements were made when compared with the local situation before the project started:
In Dorset there was a reduction in the number of D&Cs performed and a change in prescribing habits from norethisterone to tranexamic acid;
In Gloucester an integrated care pathway for the treatment of stroke patients was introduced, and length of patient stay was dramatically reduced;
In Oxford post-operative pain control was improved;
In Berkshire leg ulcer treatment has been standardised and improved.
Each project presenter was asked about the plans to continue with the current project, and any plans for taking the experiences learned and using them in other projects to improve services in other problem areas. One of the four, the team in Gloucester, had already taken the lessons forward and now had over a hundred integrated care pathways either fully implemented or well on the way. The Berkshire team was concerned about the ongoing funding required after the project ended, particularly for the training element currently carried out by two people in posts funded by the project.
A talk by the PACE team representative and the panel discussions reiterated many of the points made by the project presenters. Some of their ideas were:
Writing a strategy for pursuing the clinical effectiveness agenda, but generating enthusiasm for it, not putting it on a shelf;
Carefully selecting subjects to look at. They must be genuine local priorities. Having a sexy topic helps;
Involving patients, and using them to help change the ideas of health service staff;
Learning the lessons of communication, keep in touch with EVERYBODY, keep in touch and most importantly, keep in touch;
Accepting that any change in practice will take time, that individuals will have a steep learning curve and building in time within the project to reflect;
An economic evaluation helps to get Chief Executives on board. The Chief Executive on the panel refuted this, she said it was the quality agenda that had grabbed her;
Remembering to build in the time and opportunities for the education that will be required, particularly with the non-medical professionals where there is little or no culture of time for education;
Not forgetting the importance of project managing skills.
Altogether a very thought-provoking day.
Caroline Sawers, Associate Director, South Thames Library and Information Service, RLIU
CLINICAL GOVERNANCE - THE NEXT CHALLENGE. Royal Westminster Hotel, London, 21st October 1998
This meeting was organised by the IHSM and was attended by a wide mix of managers, although I have to admit to being the only librarian. The morning was chaired by Gabriel Scally, Regional Director of Public Health, South & West Regional Office, who also gave the first talk. His topic was "Clinical Governance and the Drive for Quality Improvement". He discussed the problems in defining quality and how various scandals (e.g. Bristol), intolerance of failure and the shift to external standards for measuring quality, had driven the move for clinical governance. The take-up for clinical audit had been patchy to date but it would now be compulsory. The National Institute will set quality standards for clinical excellence and by National Service Frameworks. These standards will be delivered by clinical governance, lifelong learning and professional self-regulation. Standards will be monitored using clinical indicators, the National Framework for Assessing Performance, the Commission for Health Improvement (which will have a 3/4 year monitoring cycle) and the National Survey of Patient and User Experience. Professional staffing is an area of concern, recruitment and retention is always difficult but qualifications and references must be thoroughly investigated and staff track records taken into account. This is taken far more seriously in the USA and in this country there are too many cases of inaccurate CVs being accepted. Finally he recommended that the accreditation visits from various colleges plus the visits from the deaneries should be rationalised into one visit.
The second topic was "Avoiding a Visit to Court". This was a two-part presentation, the first from Tessa Shellens, Bevan Ashford, and the second from Trevor Sheldon, Director, NHS Centre for Reviews and Dissemination, University of York. Tessa Shellens posed a series of questions "Can failure to comply with guidelines be interpreted as negligence?" and how would the courts interpret any divergence of practice from guidelines. Quality will be a statutory duty in regard to services provided, but a duty to whom? The Government or the patient? If you establish a duty what happens if you fail to provide that service? The disciplinary process at present doesn’t provide the ability to change practice. The Commission for Health Improvement will be sent in to deal with serious problems. Trevor Sheldon raised the question of evidence-based healthcare and whether significant variation in practice implies that some patients are receiving sub-optimal care. He emphasised the importance of research evidence and how opinion will be replaced by evidence as far as the courts are concerned. Evidence-based healthcare has changed the view of negligence. Risk management will be more concerned with negligence than accidents. Guidelines should assist decision making for appropriate care. There is a statutory duty for quality of care but what is quality? And what is sufficient quality? And how do you measure it? If you adhere to the guidelines how were they produced and are they anchored in the evidence? Risk managers need to map current practice against the known research evidence. Anywhere with major gaps between practice and evidence needs to be treated as a high-risk area. It is vital to ensure the implementation of national guidelines and that the organisation has the mechanisms to discuss and incorporate them into organisational practice. The organisation needs a "knowledge officer". Implementation and outcomes must be monitored. There are two paradoxes in this scenario. 1) Increasing attention to quality may increase the number of legal actions taken and won by patients; this is because negligence will be defined more broadly, empirical definition makes it easier to identify negligence and patient’s expectations will be higher. 2) Efforts to raise quality could lower quality; performance frameworks may provide incentives to comply with only what can be measured, external will replace internal and informal quality control, and national guidelines may not be anchored by research evidence. Guidelines may reflect professional and vested interests, they may ignore cost effectiveness; a lot will depend on the composition and constitution of NICE. Effective Health Bulletins will now be incorporated into NICE.
There was a discussion after this presentation and many medical staff were concerned about "clinical freedom" and the development of innovation. The reply was that innovation should be undertaken only within a framework of research; that many patients’ claims are due to their doctor "trying something new". To be a learning organisation is expensive, resources are needed, but it is essential that all staff, including consultants, find time to keep up-to- date with guidelines.
The third presentation was "Information - the Black Hole" from David Robson, Consultant Cardiologist and Director of IM&T, Greenwich Healthcare NHS Trust. He decided to look at clinical governance in the light of the new information strategy. He decided that one of the major problems was a lack of IT professionals both in the country as a whole and in the NHS in particular. From a library point of view the most interesting things he had to say were about provision of a knowledge base which he thought should support professionals in the care of the individual patient. This should include access to care protocols, on-line textbooks and on-line journals and should be available throughout a hospital/practice. If doctors had these accessible at night they could avoid making mistakes. Patients often come to see clinicians with information they’ve found on the Internet - some may be incorrect but some may be more up-to-date than the doctor’s own information so it needs to be carefully assessed. Dependable local services require:
1) professional self regulation, 2) lifelong learning using networked books, care protocols, prescribing protocols, research databases, intelligent systems and other people, 3) local clinical governance. There should be standardisation of systems to avoid costly duplication. There are issues about value for money, but the Government is convinced that a very aggressive IT policy is necessary.
"Going Back to School" was a presentation from Gladys Tinker, Medical Director, Llandough Hospital and Community NHS Trust. She said that clinical decisions were a process of weighing up risks and benefits, but everyone is bombarded by protocols, guidelines etc. and must learn to use information effectively. The undergraduate education curriculum now includes critical appraisal but people already in post must learn it. However there is not much enthusiasm and it doesn’t get much support if offered in the PGME programme. SpRs should be putting audit/critical appraisal into practice - in interviews for new consultants they should be asked about this.
Clinical effectiveness: doing the right thing
Clinical audit: doing the thing right
Internal Continuing Medical Education is just ticking boxes in a diary; there’s no proof you’ve carried out reflective practice. After ward rounds, there should be discussions, preferably in a side room of the ward, with the whole multidisciplinary team and with access to on-line textbooks and databases available at the time. There should be more interactive, multidisciplinary teaching and it should be fun too. Role play and videoing techniques should be used. There should be inducements and rewards for clinical governance not sanctions. She was concerned that clinical governance might highlight the fact that quality standards can not be met due to lack of resources. There should be more rigorous control in the recruitment and management of medical staff to match control already in place for other staff groups. The culture of meetings for monitoring patient care should be changed to be more multidisciplinary and less threatening.
"How Can We Influence Clinical Behaviour" was presented by Kieran Walshe, Senior Research Fellow, Health Services Management Centre. He undertook some research to look at the impact on clinical behaviour of three issues of Effective Health Care Bulletins. He looked at whether the recommendations had been put into practice and what had happened to the Bulletins themselves. He found that only 40% of Trusts had anyone monitoring their use; some clinicians disagreed with the findings and so refused to put them into practice; most Health Authorities couldn’t tell whether practice had changed or not (especially if it was a nursing issue). He found that there was poor knowledge about how information was used. Some issues were acknowledged but not tackled; the impact depended on the topic - this showed that sending out a Bulletin only works if people are already convinced of the findings and it’s a priority topic. In the past, quality assurance in the NHS was always a matter of persuasion e.g. audit, confidential enquiries, Kings Fund organisational audit etc. But in the future there will be regulations: National Institute of Clinical Effectiveness, national service frameworks, Commission for Health Improvement. The change from persuasion to regulation will be difficult, but it ensures change, it fits the wider culture and it meets the need for stronger interventions. Quality in the new NHS will have a more formal and explicit mechanism, there will be mandatory participation, real incentives and sanctions and there will be shared ownership across all professions; but it will be expensive. The study showed that just sending out Effective Health Care Bulletins didn’t work, although this may change when they are taken over by NICE. This will mean that the government will expect to see their implementation. The discussion brought up the point of reading time being "desperately short" and complaints about "never enough evidence". He felt that it was time to stop change being blocked by individual clinicians. But change must be based on proper evidence.
These presentations were followed, after lunch, by a discussion forum chaired by Alan Maynard, Professor of Economics, Health Policy Group, University of York. He first stated his views on clinical governance and then introduced four other speakers who put forward their points of view from different parts of the health service.
Alan Maynard was concerned that no guidelines or Royal College recommendations mention cost-effectiveness. What happens if a treatment is twice as effective but five times as expensive as another treatment? A lot of effort and resources will be wasted unless "quality" is defined. NICE should be doing this. Clinical governance will be enormously expensive. How can we prioritise?
David Colin-Thome, GP and Fellow in Health Services Management, Manchester University, was concerned with clinical governance in primary care. GPs must look at clinical governance in their own practices but also in the organisations to which they are referring their patients. PGME should provide a structure for knowledge control/organisation and should also look at providing educational programmes and incentives to attend them. Carol Lawrence-Parr, General Manager, Swanage Medical Practice, thought that clinical governance depended on teamwork and shouldn’t be doctor led. She said that primary care had no structure for clinical governance as GPs all have independent contractor status. Where was the money coming from to train the whole team, organise data collection and monitor the whole thing? Patients must be involved in the whole process. Evidence-based practice is important but how can we disseminate the information and monitor the findings? Susan La Brooy, Divisional Director of Medicine, Hillingdon Hospital NHS Trust, said that "we have got to achieve what we are required to deliver". There may be little money to support clinical governance and it may be down to "terror not charm" to implement it. Clinical information in Trusts is very important but is generally very poor. Medical students are being educated about quality but it is down to consultants to improve their own education. Accredited education for consultants is contentious - there is no time for surgeons to go back to school but no new technique (especially invasive surgery) should be introduced into a Trust until people are trained and accredited to undertake that procedure.
James Smith, Chief Executive, Kent and Canterbury Hospitals NHS Trust, wondered whether the cytology scandal would have happened if clinical governance had been in place. He thought little would have changed. Would evidence based practice have picked it up? Not necessarily but Trusts have now been softened up for clinical governance. It has refocused clinical audit but only where people have an interest, not necessarily in high risk areas. Not everyone can adapt to new skills. There is lack of evidence or even baseline data in certain areas.
There was then a discussion that brought up the following points:
Clinical governance means choosing guidelines, justifying them, following up and monitoring and only altering them if there is good evidence for it.
Patients’ views should be collected via user groups.
If clinicians refuse to change, how can they be persuaded? Show them the evidence but listen to why they don’t want to follow it - if their results are good you shouldn’t force them to change. Peer pressure is the best persuader. There must be trust all round. The process of clinical governance should be supportive to clinicians.
At the meeting the following documents were also provided:
Clinical Governance Toolkit, IHSM 1998. This was a draft copy. A revised copy is out in February and then the pack will be updated every 2 months.
Bloor K & Maynard A: Clinical Governance: clinician health thyself. ISHM 1998
Helen Alper, St George’s Library, St George’s Hospital Medical School, GEO
‘New Libraries for Old’ was the intriguing title of a one-day conference held in November. The purpose was to look at how library and information services (LIS) and information and communication technologies (ICT) can best co-operate in the delivery of the key objectives laid out in the government documents, The New NHS and Our Healthier Nation. Delegates were drawn primarily from NHS library staff - three representatives from each region and from other groups involved in facilitating access to the evidence base of health. The distance travelled by some librarians (from as far afield as Canada and Scotland), and the high calibre of the speakers, signalled the importance and relevance of the occasion:
The aims of the day were:
1. To celebrate information and library access initiatives as part of NHS 50.
2. To share examples of integrating information and communication technologies with LIS.
3. To develop ideas and working practices arising from Information for Health.
4. To encourage cross-sector working, partnerships and information sharing, between NHS information professions.
5. To link information and library services with improving patient care and patient involvement in services.
The conference was chaired with verve and authority by Linda Wishart, DoH Head of Information Management, Veronica Fraser, NHS Library Advisor and Dr Muir Gray, Director R&D, Anglia & Oxford. A succession of distinguished speakers gave a series of fifteen minute presentations addressing the impact on librarians of the changes of emphasis implicit in the recent government papers. The delegates had a veritable Aladdin’s cave of ideas opened to them, and were left with the message that to survive in the electronic age, the librarian has to change his image, re-skill (Continuous Professional Development), market himself vigorously and build professional partnerships (joined-up librarianship).
The opening speaker, Dr Andrew Holt, Head of Information Services Division, DoH, outlined the government philosophy on health information, the stress it places on co-operation (joined-up government) and its strong public information strategy. He foresees ‘First Direct’ government within 15 years, maintains that 25% of government transactions will be electronic by the year 2002 and that, by then, the National Electronic Library for Health will be in place. Faced with possibly unfriendly rivals in the information scrum of the future, he warns that the professional librarian must be responsive to change and manage it effectively.
A selection of ‘sound bites’ from the day will point up the messages we should heed:
Veronica Fraser brought this stimulating conference to a close by reminding the delegates that in the story of Aladdin it is the ‘old’ rather than the ‘new’ which is valuable and that while focusing on the future we should remember the value of what we have at present. The traditional skills of the librarian are the bedrock of the future.
Marion Morrison, Sally Howell Library, Epson, ES
The New Libraries for Old conference proved to be a fascinating forum. It was especially rewarding for a South Thames’ librarian, as many of the issues raised were ones which had been debated at our own conference not a month before. I hope to outline what, for me, were the salient features of the day, without giving a speaker by speaker account of the conference.
There is no doubt that healthcare librarians are facing yet another period of change, as the Government seeks to use information technology to implement change across the public services. It was inevitable that this desire would have an impact on the National Health Service since it is often seen as one of Labour’s greatest achievements and is therefore one of the Blair Administration’s primary concerns. Herein, however, lies the great opportunity. As this wave of reform is information led, the possibility arises to find ourselves almost centre stage. We must note, that though the Government hopes to use information technology to reform the health service, the strategy is actually called Information for Health not Information Technology for Health.
The Government is seeking to benefit its citizens by using information technology to make government both more transparent and more responsive. The aim is for "joined-up government" - whereby the citizen needs only to deal with one agency and not a number of different ones, and business with the state can be conducted in one go, either via the telephone or an on-line link, just as it can be with a bank now. One projection was that by 2002, 25% of government transactions will be electronic. This aim of making public services as accessible as commercial services via technological linkage was one that was reiterated throughout the day.
This idea of the importance of the public, of patients and their representatives, was one of the key themes of the day and something of a culture shock for a librarian like me who had only amended the library rules last year to allow access for non-NHS staff. The National Electronic Library for Health (NeLH) will have a "virtual floor" of patient information, and NHS Direct is an information service for the public. One of the new engines driving the NHS in the direction of a quality service will be the demands of a public, who are increasingly well informed about health matters. I know some of my colleagues around the Region are wary about moving in this direction, without the funding which will allow the acquisition of appropriate skills and stock, but it seems clear that the policy both in broad strategy and particulars is placing emphasis on informing the public.
A further development for our profession to be aware of, is an increasing emphasis on refining the information we provide. The NeLH aims to "hallmark" its information so that its users are made aware of the quality and rigour of the research behind it. The information may also be "distilled", to make those elements that have a direct impact on practice stand out. As Dr Muir Gray remarked it is pointless having information in the NeLH which can be reached in a matter of seconds, if the entry then takes fifteen minutes to assess. In South Thames we have already taken steps to prepare for this world with the first ‘Becoming Adept’ training course and now the CAS/FIND programme.
This ties in with yet another theme of the day, a theme which some of the STELLA working groups also looked at, which is the need for re-skilling to meet the challenges of the information led NHS. Some in the audience felt that there was actually less need for librarians to re-skill, or even re-brand themselves as knowledge managers, than some of the speakers thought, and more need to inform people about what our skills already are. It is certain, however, that our electronic data gathering skills need to be constantly up-to-date with the latest technological developments. If this were not enough other speakers suggested there was also an ever increasing requirement to be even more knowledgeable about teaching methods, research practice and even medicine in general, so that we have a more complete understanding of our users’ requirements.
The need for healthcare librarians to be multi-skilled was nowhere better illustrated than in the discussion of services for primary care, especially GPs. The suggestion was that this group of users would go elsewhere for their information if it could not be provided in ways that they needed. Again the importance both of remote access to, and refining information, was emphasised with "speed, speed and speed" given as the key factors in serving a client group, which only has minutes to evaluate each patient, and often less time to spare than it takes to find a hospital parking place. Despite the sometimes daunting nature of the challenge, with Primary Care Groups going to control significant budgets, we must try to provide a service which impresses, in a world where so much other business can be transacted with a single telephone call.
If I had to sum up the day in a single word it would be exciting. It was exciting in a number of different ways. Firstly because it gave a glimpse of what the future will hold for us all, a future which will be full of different challenges. Exciting too, because I realised that we have already gone some way down the road the conference mapped with the STELLA groups and the CAS/FIND days; and I think that it is exciting to find yourself part of such a broad wave of change.
Jonathan Baker, Librarian, Thanet Health Care NHS Trust, Margate, KMA
This meeting was organised by IHSM North Thames, in association with the British Computer Society. The local branch of ASSIST was also well represented.
Ann’s message was very clear and in three parts:
The timetable for implementing is tight and the agenda to be covered huge, but Ann was careful to stress that she did not want to see boxes to be ticked as the end of a process, but as milestones built into the strategy. While the Year 2000 problem is real and urgent, solving it must not act as a planning blight. The items further down the timetable have been put further down because the planning will take longer, not as an excuse to put off starting them. There is money in the modernisation fund. It is there for new and innovative ideas, not for propping up old ones. The key to getting projects considered for funding is to emphasise the connecting together of stakeholders. It is appreciated that there are no neat boundaries and some of the linkages will be problematic. Concern was expressed by several questioners that this emphasis on partnerships might have the effect of holding back trusts that were more advanced, especially acute trusts. Whilst conceding that this might be true, Ann was at pains to point out that what was needed was levelling up of the laggards, not any diminution of effort from those ahead. She suggested that they should take the opportunity to lead the process. She confirmed that access to the modernisation fund would be through Health Authorities. Direct application from single organisations would negate the joined-up working that will be required.
Ann suggested that these partnerships are one way of capitalising on the scarce skills within the NHS. She pointed out that jobs in health informatics had been deliberately excluded from the management costs exercise in order to avoid any possibility of NHS organisations being unable to afford to implement the strategy.
The culture change required by all in the NHS, not just IM&T people, to embrace the strategy, was all pervading in Ann’s presentation. Also all pervading, and particularly welcome to the librarians in the audience, was her insistence on the importance of the information to be carried and the linkage with other, non electronic sources of information.
If you want any further information try HSC 1998/225
Caroline Sawers, Associate Director, South Thames Library and Information Service, RLIU
INFORMATION FOR HEALTH, South East Region, Millbank, December 2nd 1998
The purpose of this meeting on the strategy document ‘Information for Health’ was to ensure that key stakeholders from the NHS were aware of the document, understood the key objectives, and their responsibilities in implementing them. The delegates list records 130 names, evenly split between Chief Executives and IT Directors. There were five GPs, one Public Health Consultant and one Librarian.
The keynote address was given by Frank Burns, Chief Executive of Wirral NHS Trust, and author of the strategy. He stated that the purpose of the strategy was to put in place over the next seven years the people, resources, culture and processes to ensure that NHS clinicians and managers have the information they need to support the core purpose of the NHS. He defined the core purpose as the care of individual patients and the health of the population. Secondly the strategy’s purpose was to give both public and patients a range of quality information, which was easily accessible, about health and health services. Then followed the content of the document. He emphasised that the Government meant to see the strategy implemented and were working on the principle that they would be in office for two terms. He also told the audience that implementation had to be led by Chief Executives and not delegated to IT Managers. He ended by saying that the strategy was as basic to the running of the NHS as plumbing was to the health of the people.
Other presentations came from Dr Jonathan Kray, a chemical pathologist from Oxford, on Clinical Intranets. This was hard going. One of my notes says "Use middle ware to find information contextually". He described the IT systems which are now routinely used across four hospitals in Oxford. Hand books, guidelines and directories had been put up as well as BNF, Cochrane and Bandolier. He described Intranets as filling in the ‘white spaces’ in the Information for Health strategy.
Another presentation by Dr Peter Berkin, a GP from Milton Keynes gave us a picture of the paperless office. He had spent 20 years getting to this stage and had achieved electronic appointments, internal e-mail, full problem- orientated EHRs, all outgoing and incoming letters electronically stored and linked and all registrations and IOS claims were electronic.
Every encounter was auditable using Read Codes. EBNF, the Oxford Clinical Mentor, protocols, advice sheets and waiting lists were all on-line. He whizzed through his morning surgery of 26 patients, describing each one. Most consultations involved him printing out leaflets on flu, or sore throats or looking up information on a disorder during the consultation. I was worried about how self-satisfied he seemed just using the Oxford Clinical Mentor and his patient leaflets to answer the majority of his questions. The main problem was the lack of a standard for transferring his patient data electronically, if a patient needed hospital treatment. He felt that primary care computing was way ahead of secondary care.
At the end of the afternoon Dr Muir Gray gave a short presentation on the National Electronic Library for Health. He felt that the NELH would provide both knowledge and know-how, equally available to clinicians and patients. He did not give any details about what would be selected to go into this Library, nor who would do the selecting, but painted a picture where information would be decentralised, with ‘branch libraries’ for patients and clinicians. Unaware that amongst the Chief Executives and IT Mangers there was a lurking librarian, he got easy laughs by asking ‘When you need a librarian - in the evening or weekend, they aren’t there’. ‘The only people that go to libraries are people with personal problems’. For a supposed champion of libraries, this wasn’t exactly the take home message I wanted to hear or I wanted Chief Executives to hear either, even if it was tongue-in-cheek.
Judy Lehmann, Librarian, Sussex PGMC , SBR
COFFEE CLUB ON GREY LITERATURE, Pembury, December 8th 1998
Lots of good ideas about how to find sources of grey literature, what we should collect, and how we should catalogue and organise what we collect, were generated by the meeting.
SOURCES OF OBTAINING GREY LITERATURE
HOW TO GET THE LIBRARY TO BECOME A PLACE OF DEPOSIT FOR GREY LITERATURE
CATALOGUING THE WRETCHED STUFF
Janet Holman, Associate Director, South Thames Library and Information Service, RLIU & Judy Lehmann, Library, Sussex Postgraduate Centre, SBR