DOI: 10.1097/01.yco.0000133824.09887.23

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Issn Print: 0951-7367

Publication Date: 2004/07/01


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Evidence into practice: the culture and context of modern professionalism in psychiatry

Richard Williams

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Excerpt

In recent editorials in this Journal, I have drawn attention to a revolution that is taking place in healthcare in substantial portions of the developed world [1-3]. In 2000, I explored the role of research evidence in translating policy into effective child and adolescent mental health services. Last year, Bill Fulford and I published an editorial review that introduced the concept of values-based practice in child and adolescent mental healthcare, and I have proposed its equivalent in policy development [4,5]. I explore, in a forthcoming chapter, some of the properties of evidence-based and values-based policy and draw parallels with evidence-based practice and values-based practice [5].
In 2002, I highlighted the opinion that similar processes relating to managing complexity, coping with uncertainty and the morale of the medical profession are affecting healthcare delivery and professional practice in many different parts of the developed world [3]. Now, there are many more sources of evidence of major shifts in the context and conduct of healthcare practice; they include the three UK reports that bear the shorthand title ‘Wanless Report’ [6-8].
The first of those reports, more accurately titled ‘Securing Our Future Health: Taking a Long-term View’ [6], was inspired by the Chancellor of the Exchequer in the UK. It attempts to quantify ‘the financial and other resources required to ensure that the NHS can provide a publicly funded, comprehensive, high quality service available on the basis of clinical need and not ability to pay’. In his covering letter to the Chancellor, Wanless identifies the main influences on the resources required as follows: commitments already made to improve the quality of the health service and its consistency; changing patient and public expectations; advances in medical technologies; changing health needs of the population; prices for health services resources, including skilled staff, that have risen faster than the general level of inflation; and the level of productivity improvement that can be achieved.
This first ‘Wanless Report’ provides estimates of resources (including those of workforce and capacity) required by each of three future scenarios. Overall, it highlights the need for a very substantial increase in resources for health and social care, and identifies the conditions that would have to be met to moderate these costs.
The second ‘Wanless Review’ is ‘The Review of Health and Social Care in Wales’ [7]. The team that was established from the NHS, the National Audit Office, and the Welsh Assembly Government, advised by Wanless, identified a number of future imperatives. They are that demand for health and social care services could overwhelm the system of provision and the workforce; increases in funding provided by the Government since 2002 should provide greater certainty about future resources; health and social care organizations should improve performance and modernize services to justify increases in resources; citizens and communities must be involved in decision-making about health and social care services and must contribute by taking greater responsibility for their own health; services need to be better aligned to focus on prevention and early intervention; and health and social care services must be brought closer together in order to achieve necessary changes in terms of where and how care is provided. It is clear that these changes must be: evidence-based; backed by robust financial strategies; and supported by more sophisticated workforce planning (in which roles are clarified and accountability strengthened with increased incentives), improved technology and information, investment in estates, and better performance management. Importantly, implementation should be underpinned by a realistic programme of change and development.
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