Doctors and other healthcare professionals are a driving force in the vision of the NHS’s National Knowledge Service, of which the National Library for Health is an integral part. Dr Stephen Singleton talked to Elspeth Hyams about the service they want from information professionals.
Physicians and healthcare professionals are drowning in data. There is too much evidence, too much research (of varying quality), too many journal articles, and not enough synthesis, analysis and support (in spite of the Cochrane Database). Doctors do not have time to sort the wheat from the chaff, nor, necessarily, do they have the means or expertise to do so. Which is why the medical professions want experts –information professionals – to help them. In some sectors strategic managers are insufficiently aware of how the information professional can add value. That is not so in health, where, arguably, not all the information professionals who could are rising to new challenges and opportunity.
Dr Stephen Singleton is Chair of the Board of the National Library for Health (NLH). He is Regional Director of Public Health at the Government Office for the North East and Medical Director of NHS North East Strategic Health Authority. By training, he is a GP, who ‘trained in public health partly because I felt (like many people) that there has got to be a better way than just treating people when they’ve got problems and, even then, not necessarily getting on top of the problem’.
He became interested in the implications for public health of evidence-based practice when it came into focus in the early 1990s. As Director of Public Health in Northumberland, one of his priorities was to develop access for GPs and primary care practitioners to ‘a library and information service they had never had’.
This, he said, came ‘on the back of my ambition to practise and develop’. His vision was to identify the best treatment at the time the diagnosis was made but, before that, to make people aware of the standard work on the condition in question. ‘Before the National Service Frameworks came about we were beginning to say “There’s actually a good way of preventing heart disease, a good way of dealing with mental health in the community, and so on”.’
By 2001, he was responsible, in his executive role, for information for health and the implementation of better IT systems. As he sees it, ‘I was an executive in charge of quality and safety of practice, but also the infrastructure to improve e-communications and patient records’. This all became mainstream with Connecting for Health (the national programme for IT) and work on the patient record service.
Less apparent to outsiders was a parallel movement to change the regulation of doctors and introduce a standards-driven approach to healthcare generally. ‘There was much more interest in doing the right thing, and doing it all the time.’ In 2002, Stephen became medical director of one of the new SHAs (at that time, Northumberland, Tyne and Wear). And, suddenly, things fell into place. From then on he realised it was ‘all about a strategy for managing knowledge for better clinical practice’.
It was at this point that he was invited by J. A. Muir Gray to get involved with the National Library for Health. For him, it was ‘a logical extension of my interest for the last 15 years’.
Medical practitioners’ vision of the National Knowledge Service
The visionary’s view of information as a key resource in clinical practice was set out in a recent consultation document, Best Current Evidence Strategy. In it Muir (as he is known in health information circles) makes a challenging proposition: ‘The application of what we know will have a bigger impact on health and disease than any single drug or technology likely to be introduced in the next decade.’
According to Muir, ‘by putting knowledge into practice, we can prevent or minimise the seven universal problems of healthcare’. In his model there are three strands to working with knowledge: the Best Current Evidence Service (explored in detail in the report); the NLH, which he sees as being charged with ‘organising and mobilising the evidence’; and the National Knowledge Infrastructure, which contains technical standards, tools and services.
The health service is operating at a time of resource constraints, and the preamble to this document contains a trenchant warning. It is, says Muir, ‘hard to justify more money until the publicly funded knowledge services have co-ordinated their production and procurement’.
As we have reported previously, the physicians who are driving the strategy for development of the National Knowledge Service believe that medical practitioners are swamped. They need knowledge support that is simple and effective, offered ‘just in time, where and when they need it’.
Behind that simplicity should lie a synthesis of up-to-date best evidence. That evidence is produced by research, and needs to be linked to the knowledge produced from data analysis (statistics), together with knowledge derived from the experience of clinicians and patients.
There are four sources of evidence, which McMaster University, a pioneer of evidence-based medicine, has encapsulated in the concept of four ‘S’s’ – Study reports, Systematic reviews and guidelines, Synopses, and Systems.
‘Study reports’ are usually published in journals, traditionally one of the most used sources of evidence, but there is deep distrust of the peer review system, which Muir believes is ‘so unreliable’ that journals are not suitable for busy clinicians and patients, ‘unless they conform to very strict protocols’.
Systematic reviews ‘are not easy to use in their current form’. Better for the practitioner are synopses – ‘readable documents produced from systematic reviews and guidelines’.
Finally, ‘systems’ should be an outcome of the introduction of the Care patient record service, a way to compile ‘knowledge’ as an outcome of best practice processes, and routine recording of patient information. A National Library of Pathways is being developed, along with another library of tools and rules. The idea is that ‘quality assured pathways, tools and rules’ provided to all information system providers will function as a National Clinical Decision Support Service. It is a highly complex and ambitious vision.
At its heart is a national system of standardised processes and data collection. There are a number of key components. The National Institute for Clinical Excellence will develop criteria and systems to appraise decision-support systems. National agencies will collaborate to make their knowledge available ‘through a search engine in a consistent form’. A search engine for the whole of the NHS will allow ‘all of these sources to be searched through a one-stop shop’. Further, there will be an integrated Clinical Synopsis Service; a National Library for Medicines, free of advertising; ‘filters in addition to peer review’ applied to the sources of ‘study reports’ to reduce the number of journal articles that clinicians have to read; templates of care – best practice for particular conditions – that can be adapted to local ‘constraints and opportunities’. And so on.
Most important for information professionals, the Best Current Evidence Service will be developed in partnership with the NLH to create a National Knowledge Service, ‘based on a common technical infrastructure, and using to the full the skills of librarians and their local services’.
Chief Knowledge Officers – a role for librarians?
The National Knowledge Service will not be a traditional library service, but that is what perhaps too many librarians in the NHS are still employed to deliver. So, how does Stephen see the role of the librarian evolving? There has been talk of Chief Knowledge Officers for all of the country’s 10 SHAs. Where might librarians fit in this model?
Part of the problem, Stephen thinks, is the need for executive responsibility as well as leadership. CKOs will need to be ‘key leaders in all NHS organisations’. They could be librarians – people such as Margaret Haines, former President of CILIP, for example – but it is more likely that they will be medical directors, or nursing directors, because ‘it’s at that kind of executive level that someone needs to be identified as CKO. That is because the CKO needs to be someone who is strategically driving through the quality programme that depends upon good information and knowledge management’.
However, the whole concept of the National Knowledge Service revolves around the way the relevant information is organised and then presented to the people who need it, when they need it. And the doctors and other users definitely need help. ‘We need judgment about things like research journals, reviewing the evidence base.’ But the role of the librarian as a specialist – for heart disease, say, or mental health – also involves the idea that they should be navigators and tutors for staff. And, in this, their role has developed dramatically.
‘I’ll give you an analogy. Years ago, the pharmacist was someone who was locked away in a basement somewhere, counting tablets. Now you’ll find them doing the ward round with the professor of medicine, giving critiques of the prescribing habits of the doctors in certain situations.’ This change of role has come about partly because of ‘the quality of the prescribing being done by doctors’ and mainly to mobilise the expertise of pharmacists.
Active participants
In a similar way, he says, the role of the librarian might develop, ‘from someone who is seen as a place-based person, i.e. in the library, to a much more active participant in a clinical team, thinking about how clinical staff get and use information and evidence. They should be out there as coaches and trainers, helping clinicians improve the quality of their information skills, but also acting as navigators and experts, helping with the difficult problems.’
If that is the case, the CKO’s role is likely to be more a matter of ‘organisational leadership, to create a culture of vision in their organisation, where the timely use of better information is highly valued’. By implication, the librarian’s role is critical in actual delivery.
But there is another analogy, like that of yesteryear’s pharmacist. ‘The NHS has long parked the LIS service with education and research, supporting people in their research, or on a course. In other words, it has been seen very much as part of the education and training debate, rather than the mainstream service delivery debate. They’re often funded through post-graduate deaneries or through workforce development, not necessarily as a key overhead of the kind of quality programme we are talking about.’ This will have to change.
But, given that CKOs in most cases are not yet in place, who will lead this change in strategic direction? According to Stephen it is, by definition, a leadership role and, if librarians want to take it, they will have to stop seeing themselves as people ‘with a detailed knotty problem to chew at’. Instead, they should start seeing themselves as ‘an important cog, improving the quality of all patient care, in a rather large hospital’. He is very tactful about this, but firm. ‘It tends not to be how they see themselves. Hence the need for somebody different, at an executive level, who says “As CKO it’s my role to make this happen”. ’
Strategic role
Make no mistake – he thinks ‘absolutely’ that LIS people have a strategic role in the organisation. But there also needs to be ‘executive leadership of the pursuit of a vision of quality’. Delivering timely and appropriate information is integral to that. So is prompting medical practitioners on safety issues, and helping them with the management of patients. But there is a fundamental difference from the past. The new knowledge programme is not about the academic research agenda, but about modern healthcare practice. He is quite specific. ‘It’s about standard work, to make sure we are accurately doing, and doing properly, the things we’ve not always been doing for years yet known for years needed to be done.’
How will the massive transformation that this implies take place, given almost constant reorganisations, bad news about IT project delivery, and the alleged negativity of some doctors about the Connecting for Health IT programme, of which the National Knowledge Service is part?
Clearly, things need to settle down after the current reorganisation. But, he says, the NHS is used to changes and can quickly bounce back. In the meantime, although records are generally electronic in general practice, most in hospitals are still paper-based because of the complexity and nature of the records themselves. ‘There are enormous numbers of very dedicated people who, despite all the reorganisations, manage to make it all work very well.’ There is not a problem with the vision. Nor with KM in the interim. ‘I think everybody is willing the Care record service to work, and everyone is conscious of the need to maintain organisational memory through all this change.’
If doctors have sometimes been negative about the changes, he says, it is because they have developed ‘individual, sometimes idiosyncratic, solutions of their own, using databases, bits of personalised software, special routines on bits of paper… . Then, along comes someone and says “One day, all of this functionality will be in the new system, but in the meantime, you’ve got to stop using your personal system.” A lot of doctors are worried about giving up what they’ve developed locally, for a national solution.’ He is confident that the health service will achieve its goals eventually. But at the moment it is in a phase ‘where the sceptics can say “I told you so”.’
It is not unlike the NLH itself. ‘People expect it to have the level of functionality it might have one day. It’s a bit like the problem of the evolution of the eye, isn’t it? How can an eye evolve if anything other than an eye isn’t what you want? How does the pre-eye stage work, if it doesn’t evolve into an eye? I think it’s a philosophical riddle. People say “It’s capable of becoming an eye, one day it will be one”. It’s a natural reaction to say “We want it now”. But it’s not possible to get from where we are today to where we want to be in one step – especially if we are doing it in a consultative way, for example involving stakeholders in the design of the web portal. We’re going to go through a dip before we’re out the other side.’
In the meantime, it is interesting that, from the strategic heights of his position as medical director, Stephen sees managing operational information (records management) joining up seamlessly with the information services provided by librarians. Certainly, it is patient records that will supply the detailed evidence on which the National Knowledge Service will draw, and librarians’ expertise is crucial in integrating these with knowledge sources.
And the role of librarians in keeping the information service together, and their contribution to keeping the project on track? There’s an important role for the strategic leaders of the former Library and Knowledge Development Network. ‘They are a major stakeholder group, influencing and supporting the development of the NLH.’ The real challenge for them, he says, is to get the hardworking frontline member of library staff to get a feel for the project objectives, while they carry on delivering the service.
‘If everyone sat around in groups, talking about the vision, nothing would happen. People have got to be out there doing. We’ve just got to keep our nerve, and keep talking about the critical role of all these staff to an integrated quality programme in a healthcare organisation. We cannot do without them!’
* J. A. Muir Gray. Best Current Evidence Strategy. March 2006 (www.library.nhs.uk/nlhdocs/Bestcurrentevidence.doc).
Dr Stephen Singleton is Medical Director for the North East Strategic Health Authority and Regional Director of Public Health in the Government Office for the North East.
Updated: 08 November 2006