Values-Based Health & Social Care

Beyond Evidence-Based Practice

Jill McCarthy, Pat Rose, Jill McCarthy, Pat Rose

• Publisher: SAGE Publications Ltd
• Year: 2010
• Print ISBN: 9781848602021, 9781848602014
• eBook ISBN: 9781446246689
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Is evidence-based practice really best practice?

This is a hotly debated question in health and social care circles and the starting point for this book. Engaging firmly in the debate, Values-Based Health & Social Care calls into question the dominance of evidence-based practice and sets out an alternative vision of care which places holism, professional judgement, intuition and client choice at its centre.

Bringing together writers from a range of health and social care backgrounds, the book describes the rise of evidence-based practice and explores major criticisms of the approach. It argues that evidence should be seen as part of a broader vision of practice which places equal value on:

- a holistic vision of the needs of patients and clients.

- professional knowledge and intuition, and

- seeing patients and clients as partners in their care.

Examples are used throughout the book to help readers link the concepts to practice. The book concludes with suggestions on how to develop a values-based approach in practice and through professional education.

Values-Based Health & Social Care sets out key debates surrounding the nature of practice which will be of interest to students and practitioners alike.

1	The Emergence of Evidence-Based Practice
	Mike Thomas, Mike Burt and Joy Parkes

Evidence-based practice (EBP) is currently the dominant model of health care intervention in the United Kingdom. As it values measurement and quantification, it has gained this status in a relatively short space of time, helped by a number of political, managerial and philosophical drivers emerging in separate arenas. EBP is not, however, new and has been the driving force within the quantitative science paradigm throughout its historical development and could be viewed as the bulwark in its battle with the developments of social conflict theory and the popularity of qualitative research methodologies within the social sciences.

The adoption by the medical profession of EBP and its subsequent support by the Cochrane Collaboration (a not-for-profit organisation supporting the practice and dissemination of systematic reviews in health care) may be seen as its entry into the modern context of health care, and its use is now widespread in all practice-based health professions. Its central tenets are that all health care interventions should be based on best evidence, which may be local, and based upon action research, and that it should be effective, particularly in comparison to other interventions. Effectiveness (achievement of desired outcome), alongside efficiency (productive with the minimum of waste or effort), meets one of two governmental requirements for public spending on care, and central support for EBP can be seen in the introduction of the National Institute for Clinical Excellence (NICE), now known as the National Institute for Health and Clinical Excellence.

The medical profession prides itself on its objective, scientific past, although this may not always be observed in clinical practice. Philosophy may be said to have as much of a claim to the truth as any science. A reflection upon one’s own values, followed by exploration, discovery and confirmation may be seen as equally important; a final knowledge of those values adding to the efficiency of the practitioner. The training of potential medical staff involves the study of physical sciences. It was not too arduous for the profession to apply the concept of effectiveness to quantitative approaches such as data collection, particularly when the Cochrane Collaboration produced systematic reviews on available published data alongside guidelines produced by NICE regarding the introduction of new interventions.

It is interesting to note that, in the UK publicly funded health system, effectiveness is allied to cost. Thomas (2008) observed that effective, widely applicable interventions reduce service user symptoms and poor health, resulting in an important behavioural change – namely, the service user requires less public-funded intervention. Thus, intervention that is cost-effective is also viewed as efficient. There is a value placed on effectiveness and efficiency that places a moral obligation on modern health care practitioners, and reflective conversation is at the heart of a commitment to improve practice. It is proposed that, in essence, the health and social care practitioner has a moral responsibility to provide effective and efficient interventions. This is supported by Holm (2004), who also notes that EBP attempts to control health and social care costs, imposing a moral obligation on practitioners to provide evidence that any intervention used is effective.

Evidence-based practice provides a rationale for politicians and policy makers to gain some control over spending. The argument that EBP also allows practitioners to abandon ineffective interventions and introduce better models allowing politicians to manage a finite financial budget may appear hollow during a so-called credit crunch when billions of pounds may be found to bail out large financial institutions. EBP, in effect, has to formalise both the preferred quantitative approach of the last 20 years alongside a wider acceptance of qualitative approaches, providing a clearer impression of what service users need, together with what they increasingly want.

EBP does allow different health and social care practitioners to explore and study interventions from their own practice standpoint. Medicine, according to Sackett et al. (2000), employs evidence-based approaches because it allows the practitioner to use diagnostic treatment and rehabilitative regimes that have themselves been rigorously examined. Medical practitioners can have the confidence in their own clinical skills to balance the risks and benefits of different interventions, reaching a judgement on which course of action to take whilst taking into account the service user’s concerns and expectations.

A doctor may find a fair proportion of any accessed data to be quantitative and the same model espoused by Sackett et al. (2000) could be used by a health professional or by a social care professional accessing data that is more qualitative by design and content. This is understandable given the biological determinism found in the curriculum of medical and health sciences education, compared with the social construct focus dominant in the curriculums of other professions such as social work. Yet the central core of EBP is its emphasis on good, solid research which demonstrates the effectiveness and efficiency of interventions and, importantly, attempts to retain the service user and carer views of intervention itself, the so-called acceptability principle. This individual perspective can, in turn, provide some defence against a generalised approach to evidence-based studies.

The use of EBP has spread since the early 1990s and is now firmly established, an achievement worthy of mention. It is not often that a movement gains such widespread acceptance in such a short time frame across so many health and social care professions, policy makers, sections of academia and the government as budget holder. The welfare state as a publicly funded structure has existed for more than 60 years, but proponents of EBP, whilst claiming a response to the culture of hearsay practice, have made no claims that, prior to its adoption, the nation’s health care was based on invalid or unreliable data as illustrated in Vignette 1.1. They have however come close with the insistence that EBP does lead to a cessation of inappropriate invalid practices.

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Vignette 1.1

My doctor always used to tell me to go to bed and lie flat when I had lumbago. Now, he calls it back pain and he has sent me on a course where they tell me to take pain killers and keep as mobile as possible. How come it can suddenly change like this? I used to enjoy my week in bed with my wife fussing over me – it brought us closer.

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The Political Context of EBP

To understand its adoption, EBP must be contextualised within a historical perspective involving political, philosophical and managerial developments. In medicine, the resurgence of biological determinism coincided with the political and managerial focus of controlling public funding alongside the rise of entrepreneurship as the new business theory. For other health and social care professions, the rise of consumer power, of advocacy and internet groups and of the independent sector has impacted on service users’ claims for more autonomy and control over their own care.

With the change of focus, the NHS altered beyond recognition from its roots in social welfare. Long-term care moved to the fee-charging private companies now termed independent care providers from the District General Hospitals. The Ambulance Service and the primary care providers converted to semi-independent NHS Trusts, the 1990 NHS and Community Care Act requiring Trusts to behave like businesses and be active in the marketplace. This social engineering became clear a year later when, in 1991, the NHS was again restructured to encourage the invention of a new internal market. Regional Health Authorities were re-designated Commissioners and instructed to purchase health care from the provider Trusts now selling their services. Both parties formalised these arrangements through contracts, although such contracts have no real basis in contract law, thus demonstrating the centrally controlled power held by government. The Department of Health, however, ensured commitments made in these contracts must be honoured.

Effectiveness and efficiency, originally measured through the provision of local services to meet local targets, now faced a fundamentally different measurement. Provision of service had still to be focused on local needs, but annual budgets were abandoned. Trusts were instructed to both generate their own income and to compete against other local services, particularly through the strategy of undercutting each other, an added benefit being the reduction of centrally allocated funds. This was at a time when EBP was beginning to gain a voice, and the political imperative for the new market was increasing efficiency and user choice.

Talbot-Smith and Pollock (2006) highlight the fact that the previously held local pride in building a hospital was now dead. Between 1990 and 1994, 254 hospitals were closed in England and Wales. During these years, the government introduced a new tier of resource-intensive service into the health sector. Trusts desperate to avoid closure spent more and more funding on contract management, competing for the tender of risk management and financial services. To add to their problems, the government used the 1990 Act to allow private profit-based companies to hold contracts to deliver estates, capital management and technological provision. These were to be paid not from what had previously been a Department of Health service (regional offices being closed), but from the Trust budgets. As Talbot-Smith and Pollock (2006) observe, the Trusts were now trading in the newly invented health market, selling their services to service brokers (Commissioners) and, in turn, buying consultancy services to keep their organisation competitive against other market players including other parts of the NHS.

This competition forced some out of the market and the merging of others. This removed the financial burden on central government. Local services, particularly capital estates, expanded to take on the extra services now being offered from a smaller number of NHS Trusts. Private, independent, profit-orientated companies were allowed to form a partnership with Trusts to erect new buildings, expand existing estates and operate the services such as maintenance and cleaning in these buildings and, in some cases, share rental leases for retail outlets. Much like a mortgage or long-term loan, the profit-based partner would be paid for their contribution, the Trust paying them over a long period of time, guaranteeing income in excess of 25 years in most cases. As we have seen, over 250 hospitals closed in the three years of the new market and by 2005 only 50 hospitals had increased their building or estate; 42 of these were held in Private Finance Initiative contracts (Talbot-Smith and Pollock, 2006).

Since the turn of the century, the primary care sector has been assimilated into the current Primary Care Trusts (PCTs) and the effectiveness and efficiency focused on preventative and community care. Government targets are aimed at reducing cancers, strokes, cardiopulmonary problems, simultaneously transferring much of the care for chronic and long-term conditions into the community. Consequently, Primary Care Trusts have recently been split into two services, one a commissioning arm buying services from providers and the other the provider arm. The old District General Hospitals which evolved into NHS secondary and tertiary Care Trusts have undergone yet another change; several of them are now designated Foundation Trusts with even more independence from central control. Via a tendering process, they can compete for the delivery of services against local PCT providers, independent organisations and the voluntary sector and can purchase other sites in order to expand services.

The system is now embedded in contract law, and there are a number of regulatory bodies which oversee quality and provide guidance on provision, tendering, Foundation status and local requirements. The PCT commissioners in turn base their decisions regarding tendering on efficiency (cost), effectiveness (achievement of outcomes) and acceptability by the local population.

Compared to the closure of the great industrial bases in the UK, such a radical dismantling of a centrally funded National Health Service occurred with little social unrest, with managerial enthusiasm in a majority of cases, and all in the last 20 years. When presented against the privatisation of the health system and the need to operate within highly controlled budgets, the impact of evidence-based practice is, politically, not too surprising. A political lead was taken on adopting such a system as EBP, its attractiveness to the political leaders self-evident. It removes ineffective interventions, introduces new, more effective care allied to efficiency and it has a strong element, linked to action research, of the user’s perspective in its philosophy. The science of health care delivery via EBP was promulgated at just the right time to meet government expectations. It also lent credibility to the decision-making of managers, providing a rationale for discussions with contract holders who, in turn, had been through a socio-cultural change.

EBP in Social Work

The tension between evidence and values-based approaches has featured in the development of the social care and social work knowledge base since the mid-Victorian period. The Charity Organisation Society was formed in 1869 to provide an alternative to indiscriminate charitable giving, attaching importance to what they regarded as a scientific approach to distributing charity. Their casework approach thoroughly examined the individual circumstances of applicants, and determined how specific provision might be successfully used by the recipient (Woodroofe, 1961).

The development of knowledge from surveys of the poor, the impact of economic cycles and the social sciences reduced the significance attached to individual culpability, informing the development of a much wider range of provision. Harris (1999: 48), from the beginning the 20th century, argues that ‘one of the most striking features of “social reform” literature over the next 30 years was to be the continuing interaction between sociological theory, social philosophy, empirical investigation, casework, and the analysis of practical social policy’. She highlights in the development of this social-scientific culture, the role of the Fabian Society, local Charity Organisation Societies, and, subsequently, the British Institute of Social Service, the Guild of Help movement, and the councils of social welfare and civic trusts of the Edwardian period. Harris (1999) argues that the development of social welfare provision was influenced by the social philosophy of the Idealists, and notes, in particular, the role of Edward Urwick. He was the first head of the Charity Organisation Society’s School of Sociology in 1903 and, subsequently, the first head of the department of social science and administration at the London School of Economics in 1912. Harris suggests that, after the Victorian and Edwardian periods, social scientists became increasingly aware of the limitations of biological and natural-scientific models. Idealist academics and philosophers were involved in establishing early departments of social science where the first academically trained social workers and social scientists were taught. She further suggests that Idealism didn’t discourage the empirical research of specific social problems, but claimed that the facts were meaningless without a broader vision and framework for the reconstruction of the whole of society within which the moral character of individuals could be reformed. This framework promoted the creation of a state based on the contribution of individuals, including the poor, as responsible citizens to society.

The application of social science knowledge to individual cases within the social casework of the period was formulated by Richmond’s (1917) influential Social Diagnosis, written explicitly in the USA to assert that social work could be regarded as a profession. She wrote about the systematic collection of social evidence, drawing inferences, developing hypotheses and making interpretations. Clement Brown (1939) identifies this tradition in social casework in the UK, also drawing attention to the different role of a social worker who emphasises the importance of a continuing relationship with a service user through which change is effected, itself a role developed in the USA and influenced by psychoanalytic theory.

Following post-war legislation, social work roles developed within state provision. The journals of the different occupational groups contained articles which were based on empirical research and used to promote a particular development for policy and practice. However, the range of material was sufficiently limited to the extent that very little academic research had been carried out in the UK. The National Institute for Social Work Training, established in 1961, included a centre for research. The Seebohm Report (1968) advocated that social service departments should be established, recommending that more research should be carried out within these. The influence of the study of sociology in the 196...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• About the Authors
• Introduction
• 1 The emergence of evidence-based practice
• 2 Evidence-based practice within values-based care
• 3 Caring: Values and evidence
• 4 Values of reductionism and values of holism
• 5 Valuing professional judgement
• 6 The value and values of service users
• 7 A values-based era in professional caring
• Index