by Dr Ollie Minton, Macmillan consultant and honorary senior lecturer in palliative medicine
2004 was a long time ago (not quite in a galaxy far, far away), but sufficient time has passed for the highly lauded NICE supportive and palliative care guidance to have been enacted. ( https://www.nice.org.uk/guidance/csg4 )
The clearly stated aim was 7 day services – forgive me if you’ve heard that one before- yet the recent Royal College end of life care audit showed this was achieved in only one third of hospitals. So by my reckoning it’s been 12 years to achieve what was mandated with limited success.
I use this as an example of the lack of perceived progress to move the health infrastructure forward. We provide care in a variety of settings and hospitals are only one aspect of that. Again the same themes emerged from the James Lind Alliance priority settings . No one was focused on complex symptom management or which interventional pain methodology was best. On the contrary everything in the top 10 (and significantly beyond) was focused on health service delivery, continuity and communication across care settings.
One of the frustrations of these efforts is how this is “translated” to provide impact on the ground. We are very able now to identify unmet need, where palliative care is likely to be beneficial and evidence to support our involvement both with economic and, yes, even possible survival benefit . I have quoted these studies and evaluations at every local CCG or network meeting.
I wonder if it is our own introspection that defeats us or over complicating the methods of assessments without an explicit link to finances. If there is no incentive to translate this knowledge into practice this is perhaps one reason that exemplars of best practice are not more widely adopted or replicated. Equally we should not adopt a new initiative without the supported evidence base and an implicit tension arises. Are we as a speciality less likely to adopt new practice, do we aspire to a higher standard on the evidence hierarchy or is the knowledge not being disseminated? It is likely as in all areas of medicine to be a mixture and accepting the time required to alter practice.
I was really enthused by the discussion at the recent Hospice UK attempts to revitalise research in hospices. Naturally there was reference to the origins of an evidence based approach by Dame Cicely with recognition that this was broader than doing more RCTs.
In the current parlance: asking the right questions & taking into account the local networks. The aim being to achieve maximum impact and relating evidence and data obtained to promote innovative & best practice. However there was an appreciation that supporting clinical research – including for example which is the best sub lingual fentanyl formulation and dose titration – is needed.
This is born out in the lack of consistent guidelines which on the face of it nationally reach broad consensus. However one recent example locally has been the treatment of hypercalcaemia – which drug, what dose, how often – and not a Cochrane review in sight. There are other examples we all will have but as a hospital specialist attempting to influence a clinical pharmacist without a meta-analysis- you can imagine your argument is neither strong nor compelling. Within the speciality you only need to attend a conference to see the fixed beliefs and biases we all have to appreciate how liberally guidelines are interpreted.
I make one plea to use the short cuts on the website and digested studies from the APM science committee – we’ve done the hard work so you don’t have to.
No one wants a minimum standard to be marked against but as the NHS constitution states it aspires to highest standards of excellence and professionalism through the “conduct and use of research to improve the current and future health and care of the population”. If we cannot achieve this at the end of life wherever the setting is, we are not having the impact we are capable of doing at one of the most important times to do so.