1.1 The story of this book
Let me start with a warning: this book is not going to give you a cookbook answer to the question of how to implement evidenceâbased healthcare (EBHC). My (more modest) aim is threefold:
- To introduce you to different ways of thinking about the evidence, people, organisations, technologies and so on (read the chapter headings) that are relevant to the challenge of implementing EBHC.
- To persuade you that implementing EBHC is not an exact science and can never be undertaken in a formulaic, algorithmic way. Rather â and notwithstanding all the things that are known to help or hinder the process â it will always require contextual judgement, rules of thumb, instinct and perhaps a lucky alignment of circumstances.
- To promote interest in the social sciences (e.g. sociology, social psychology, anthropology) and humanities (e.g. philosophy, literature/storytelling, design) as the intellectual basis for many of the approaches described in this book.
This book was a long time in gestation. The idea first came to Anna Donald and me in the late 1990s. At the time, we were both working in roles that involved helping people and organisations implement evidence â and it was proving a lot harder than the textbooks of the time implied. That was the decade in which evidenceâbased medicine (EBM), which later expanded beyond the exclusive realm of doctors to EBHC (to include the activities of other health professionals, managers and lay people), was depicted as a straightforward sequence of asking a clinical question, searching the literature for relevant research articles, critically appraising those articles and implementing the findings. The last task in the sequence was depicted as something that could be ticked off from a checklist.
Anna and I penned an outline for the book (it looked very different then â because most of the research into knowledge translation and implementation cited here had not yet been done). But, tragically, Anna became ill before we got much further and died a few years later, with our magnum opus barely started. Whilst the detail of what is described here is my own work, there is still a sense in which it is Annaâs work too. Even in those early days, before terms like âimplementation scienceâ, âresearch utilisationâ, âknowledge translationâ and âevidenceâintoâactionâ became part of our vocabulary, Anna recognised that we would never be able to produce a set of evidence implementation checklists in the same way as she and I once drew up a set of critical appraisal checklists for our students.
It has taken me nearly 20 years to produce this book, partly because when Anna died, I lost a dear friend as well as a formidable intellectual sparring partner â but also because the question âHow do you implement EBHC?â is a good deal too broad for a single book. And yet, one book to scope the field and run a narrative through its many dimensions was exactly what was needed. I have long been convinced that whilst there are definite advantages to asking dozens of different authors, each with different views on the subject, to cover different aspects of this complex and contested field (Sharon Straus and her team did just that, and the book they edited is worth reading [1]), the EBHC community (nay, network of communities) also needs a singleâauthor textbook whose goal is to achieve some degree of coherence across the disparate topics.
EBM and EBHC have come a long way since the 1990s. The âcampaign for real EBMâ, which I helped establish in 2014, has called for a broadening of EBMâs parameters to include the use of social science methodologies to study the nuances of clinical practice, policymaking and the patient experience â as well as considering the political dimension of conflicts of interest in research funding and industry sponsorship of trials [2]. It is, perhaps, a reflection of the broadening of the EBM/EBHC agenda that implementation science has been established as a separate interdisciplinary field of inquiry (with much internal contestation), with its own suite of journals, research funding panels and conference circuit [3].
One important development in EBHC in recent years is the growing emphasis on value for money in the research process and an emerging evidence base on how little impact research so often has on practice and policy. This overlaps with the expectation on universities (in the United Kingdom at least, via the Research Excellence Framework) to demonstrate that the research they undertake has impact beyond publishing papers in journals read only by other academics. I have reviewed the literature on research impact elsewhere [4].
In 2014, Sir Iain Chalmers led a series in the Lancet that highlighted different aspects of research waste, including waste in the allocation of research funds (too often, we study questions people donât want answered and fail to study the ones they do) [5]; waste in the conduct of research (studies are underpowered, use the wrong primary endpoints and/or the wrong measurements and so on) [6]; and waste when the findings of research prove âunusableâ in practice (because the findings are not presented in ways that could be applied by practitioners or policymakers) [7]. Most recently, John Ioannidis has written a masterly review on âWhy Most Clinical Research Is Not Usefulâ [8]. I look at this last paper in detail in Section 9.1. The bottom line is clear: there is a huge gap between evidence and its implementation â and itâs not easily explained.
The final impetus for me finishing this book was taking up a new job at the University of Oxford in 2015. My new job description included leading (along with Kamal Mahtani) the module âKnowledge Into Actionâ. This was part of the popular and wellâregarded MSc in EvidenceâBased Health Care run by Carl Heneghan and his team from the Centre for EvidenceâBased Medicine. The students on the Knowledge Into Action course were asking for a textbook. Some (the less experienced ones) were looking for checklists and formulae â but many who had worked at the interface between evidence and practice for years knew that the field was not predictable enough to be solved by such things. These more enlightened students wanted a way to get their heads round why implementing EBHC is not an exact science.
In sum, this book looks two ways. Looking retrospectively, it is dedicated to the memory of Anna Donald, who helped inspire it. And looking prospectively, it is dedicated to those who study the implementation of EBHC with a view to improving outcomes for patients. It also seeks to make a contribution to increasing value and reducing waste in research by increasing the proportion of good research that has a worthwhile impact on patients (the sick) and on citizens (including those of us who pay taxes and who may become sick).
