Professionals and patients need clean clear knowledge for decision making just as they need clean clear water for hand washing Water may look clear but be polluted and poisonous

At present people simply hold out a basin to collect knowledge, or dip a bucket in the sea of PubMed, one of the wonders of modern healthcare but peer review is no guarantee of freedom from pollutants - bias and errors due to chance- or poison due to the deficiencies of the peer review and editorial process

3 types of generalisable knowledge Knowledge from research - Evidence Knowledge from measurement of healthcare performance-Statistics Knowledge from experience-Of patients and clinicians 2 types of particular knowledge Knowledge about this patient Knowledge about this service

Better decisions Finding out what knowledge people need Obtaining the knowledge Organising the knowledge Mobilising the knowledge Utilising the knowledge

NLH 2011

NLH CONTENT 2011

Protocols for systematic reviews or additional research Reports of research Systematic reviews of research Guidelines informed by systematic reviews Summaries of knowledge eg BNF Information about uncertainties eg DUETs Patient Experience Reports Tools for diagnosis, treatment & monitoring Prompts & reminders BETTER DECISIONS& ACTIONS

‘Conclusions in trials funded by for profit organisations may be more positive due to biased interpretation of trial results’ The experimental drug was recommended as treatment of choice in 16% of trials funded by nonpofit organisations 51% of trials funded by for-profit organisations (p<0.001) Trials funded by for-profit organisations were significantly more likely to recommend the experimental drug as the treatment of choice – odds ratio 5.3 (CI ) Association of funding and conclusions in randomised drug trials Als-Nielsen B et al (2003) JAMA 290;

“evidence from recent trials, no matter how impressive, should be interpreted with caution” claims for efficacy made in 45 highly cited citations were subsequently contradicted or weakened for 14 of the interventions Ionnidis JPA (2005) Contradicted and initially stronger effects in highly cited clinical research JAMA 294;

NLH SERVICES 2011

All serious health problems are managed by more than one bureaucracy and always will be. They are managed by clinical networks which cross many bureaucracies.

Shared Vision Hypertext organisation Bureaucratic Organisation (Nonaka & Takeuchi OUP 1995 ; The Knowledge Creating Company

The National IBD Service

A National IBD Service would have A National set of objectives, criteria and standards A nationally agreed templates of a care pathways expressed using the Map of Medicine A National Dataset A single specification for all information system providers A National knowledge base updated annually A National community of practice, including patients A single web site X local services, where X is >1 and <150

NLH READERS 2011

Patient centred care The Clinician was the driving force in the 20th Century, the patient will be the driving force in the 21st century

Most patients in 2011 Feel responsible for their own record Know their NHS number Read and think about the quality assured knowledge sent to them before the consultation Enter their own data before the consultation Use a decision aid before taking the decision to have an operation Know where they are on a care pathway Accept that medical knowledge is of variable quality

Muir Gray has familial hypercholesterolaemia Every six months he receives an reminder from the lab to have a blood test He receives 2 SMS reminders if no blood sample is received within 2 weeks If no specimen is received his GP receives a copy If there is a result is sent to the GP and to his Healthspace where it is stored in sequence Appropriate advice and support is automatically generated

Mrs A is worried about familial breast cancer and phones for a GP appointment The healthcare assistant asks if Mrs A would like to tell her the nature of her problem On learning it, she 1.Ascertains her access to NHS Direct 2. identifies the relevant page on NHS Direct 3.Sends it to Mrs A Mrs A consults the site which 1. Ascertains her preferred reading level 2. Ascertains her knowledge of genetics eg the meaning of the term mutation 3. Offers information about genetics and familial breast cancer including the experience of other women in DIPEX 4.Allows her to complete a family risk assessment 5. Stores all this information on her Healthspace

20th century Knowledge Clinician Patient

21st century Knowledge ClinicianPatient

Knowledge ClinicianPatient www Seeks advice Offers reflection

HEALTHY CHOICES WILL BE EVERYWHERE

NLH KNOWLEDGE DELIVERY 2011 Phased in National Knowledge Weeks Focussed through My Library Active

Guidance in long esoteric documents can be embedded in lab request and report forms

“The false positive rate [for Hepatitis C] is especially important in low prevalence settings where the number of false positives may exceed the number of true positives” Booth JCL et al (2001) Gut 49 (Suppl 1) i4 column 1 Section 3.1 lines 23-27

What it really looks like

Royal Cornwall Lab Service Muir Gray 21/06/1944 NHS number ELISA25.5 Hepatitis C is of low prevalence in Cornwall. National guidance is that diagnosis should be confirmed by PCR test in low prevalence populations For PCR test click here For access to full text of guidance click here To test your knowledge in one minute click here

NLH LIBRARIANS 2011

1,275 librarians Image from Sinasis Technologies via free clip art service

“It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is the most adaptable to change.”

Ignorance is like cholera; it cannot be controlled by the individual alone it requires the organised efforts of society