The
Pharmaceutical Journal Vol 266 No 7131 p93
Implementing change
Dietary advice
Non-prescription drugs
‘Implementing evidence-based changes in healthcare’, edited by David Evans and Andrew Haines. Pp xxi + 291. Price £27.50. Oxford: Radcliffe Medical Press; 2000. ISBN 1 85775 382 8.
This book describes the process of implementing 11 of the 15 health authority
led research and development implementation projects in the period 1996–98.
It is edited by David Evans (research and development dissemination facilitator,
NHS Executive, London) and Andrew Haines (professor of primary care, Royal Free
and University College medical school, London), who is a well-known academic
general practitioner with an established international reputation in evidence-based
practice.
It is important that evidence-based practice gets implemented into our National
Health Service, and we are all too well aware of frequent examples that show
that this is not necessarily always the case. The book brings together examples
of local projects where implementation has been tried, with external evaluation
by researchers from the King’s Fund. The book can be read consecutively (as
the editors would prefer), or can be dipped into (as Trish Greenhalgh recommends
in her foreword) to inform specific areas of clinical practice.
It is clear from the 11 projects described that there are many barriers to implementing
change that are common across all the projects, which are presented in a refreshingly
honest fashion. One might wonder if all the participants in the projects were
made aware of exactly how much in the public domain the reports would be.
Common problems encountered in the attempts to introduce evidence-based practice
are time, over-ambitious goals, reluctance on the part of practitioners to admit
to substandard practice, and a lack of baseline data against which to measure
benefit. Success, which is varied, seems to depend on realistic goal setting
and effective project management. However, the definition of success varies
from project to project - which, it must be remembered, are implementation not
research projects - and the evaluation methods used do not always follow sound
methodological principles.
The first, introductory chapter is written by the two researchers with responsibility
for external evaluation of the projects and it sets the background to the projects
and the basis of the evaluation. Each chapter concludes with “lessons learnt”
from the perspective of the project team and comments from the external evaluators.
These comments could usefully have been more constructively critical with additional
suggestions about how implementation could have been improved.
In the light of the wealth of published research on dissemination of good practice,
which is frequently referenced from within the individual reports, it is disappointing,
but perhaps not surprising, that in practice this is not always possible, perhaps
because of the lack of a product-champion at the helm. Only one project, on
guideline dissemination (chapter 11), used the theoretically best method of
educational outreach.
The clinical areas covered by the various projects reflect important topics
such as cardiovascular disease (including stroke, hypertension, heart failure
and lipids), diabetes, asthma and antibiotic and anti-ulcer drug prescribing.
It is good that such priority areas are addressed, but disappointing that outcomes
with respect to measurable changes in practice are mixed and limited. Change
may be harder to achieve in routine practice than in a research setting, in
spite of dedicated funding from the NHS.
Finally, from a pharmacy perspective the lack of pharmacist input is disappointing,
although a pharmacy audit facilitator reports well on her intervention to achieve
compliance with Helicobacter pylori eradication and community pharmacists
are mentioned briefly in two of the other projects. The book could be of value
to pharmacists working in primary care groups and trusts.
In summary, the book gives useful insight into the approaches tried, including
sample documentation that could be adapted by others. In the widest sense, benefits
are achieved in all the projects but, one must ask, at what cost? In the light
of the clinical governance agenda, the book is of value if only in highlighting
the problem in practice. It would benefit from a summary concluding chapter
from the editors.
‘Nutrition and dietary advice in the pharmacy’ (2nd edition), by Pamela Mason. Pp vi + 312. Price £24.95. Oxford: Blackwell Science; 2000. ISBN 0 632 05368 2.
The need for unbiased dietary advice and the opportunity for well-informed
pharmacists to provide it are both continuing to grow, as clients become increasingly
interested in diet as a means of maintaining and improving health. The incidence
of obesity and diabetes makes advice on dietary control especially important.
Pharmacists can also help consumers to make sense of the bewildering amount
of information published on the internet and in the popular press.
Pamela Mason is well qualified to write a book on nutrition and dietary advice
in the pharmacy. She has two higher degrees in the subject and more than 20
years’ experience in community pharmacy. This is the second edition of her book
and she includes an impressive range of new and updated material.
The book is divided into sections dealing with diet in health and disease, diet
throughout the life-cycle and diet in “particular situations”. Among these are
included short chapters on weight control, vegetarianism, cultural diversity,
low income nutrition and nutrition in sport and athletics. Two further sections
cover dietary supplements and drug-nutrient interactions, and enteral and parenteral
nutrition. Appendices provide useful information on dietary sources of vitamins
and symptoms of deficiencies.
The book is well written and the clear presentation makes the text easy to access.
It would provide a useful addition to any pharmacy book-shelf.
‘Handbook of non-prescription drugs’ (12th edition). Pp xx + 1,088. Price $120. Washington DC: American Pharmaceutical Association; 2000. ISBN 0 917330 97 8.
One cannot fail to be impressed by the amount of information and detail that
is presented in this text in just over 1,000 pages. Published by the American
Pharmaceutical Association, the book is naturally set in the context of the
US health care system. Nevertheless, provided they accept that differences exist,
British pharmacists should find this a useful option within the range of available
texts that focus on diseases and their management using over-the-counter medicines.
Arguably, the title of the book does not reflect the breadth and depth of material
included. The editors, in their preface, explicitly state that the focus is
not on non-prescription medicines per se, but on an integrated approach
to patient care. The chapters in Section I develop this by applying the concept
of pharmaceutical care to patient assessment and consultation. Adopting this
approach may explain the inclusion of some chapters on topics where few, if
any, non-prescription drugs exist for treatment or prevention of disease. Otherwise,
it is difficult for the reader to appreciate the need for including extensive
chapters on asthma, poisoning, ostomy care and supplies, infant nutrition and
diabetes in relation to non-prescription drugs alone.
This aside, the text is a useful reference source for pharmacists, preregistration
trainees and pharmacy undergraduates, as well as for other health professionals
with a role in medicines management. Most chapters provide useful tools, including
algorithms, case studies, patient assessment question and answer prompts, and
patient education boxes that include key points for self-treatment of a particular
condition. The material presented is also extensively referenced, thereby helping
to achieve subsequent evidence-based practice.
Christine Bond is professor of primary care
(pharmacy) in the department of general practice and primary care at the University
of Aberdeen.
Steven Kayne is a consultant pharmacist in
Giffnock, Glasgow.
Patricia Black is senior lecturer and postgraduate
course development manager in the department of medicines management at Keele
University.
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