First Aid for the Front Line

As a newcomer to the NHS working as a medical librarian for a Community Trust, the Conference at Lancaster was a particularly useful introduction for me, to the issues involved in Primary Care, and a forum where I could meet colleagues from other libraries and share experiences.

The venue was an easy drive from Ayrshire where I am based. Arriving before lunch, I surprised myself by homing in on the registration desk immediately. Although the pre-conference information pack included a map of the campus, I had, like all good librarians, found the University site on the Internet, and downloaded the relevant information and maps.

The campus is fairly large, but situated on the outskirts of the city surrounded mostly by fields and trees, although one can glimpse the M6 through the trees. Finding my accommodation was relatively easy, although I admit to taking one or two wrong turnings. Student rooms have improved over the years, with en-suite facilities becoming the norm.

As a first-time delegate, I was invited to a welcome drink in the George Fox Complex, the main venue for the Conference. The usual exhibitors stands were already open, and I recognised a few 'old faces' from previous non-medical conferences, which made me feel more at home.

After a very welcome glass of wine, I joined a group of colleagues for a presentation by Kerr Donaldson from HEBS on Promoting Health with Information on the Internet, which I found very informative. I use the HEBS site regularly, and it was interesting to hear future development plans for it.

Linda Ward from Leicester General Hospital NHS Trust gave a review of research carried out on the subject of the Internet as an information source for community nurses. Again I found this particularly useful, as I could relate the findings to similar situations in my own library environment.

After coffee, the Chair's welcome and the AGM, Richard Smith, editor of the BMJ, gave an excellent and entertaining talk on information for doctors, the enormous amounts of information which they are bombarded with and the difficulties in sifting through this material to find relevant and 'best practice' information.

Dr John Horder followed, giving an interesting account of his experiences as a general practitioner, the history of general practice under the NHS and the important, leading role this branch of medicine was now taking in the development of Primary Care Trusts.

The day closed with the Exhibitors Reception followed by dinner, and for those with endless stamina and staying power, the bar and a quiz night.

The second day began with a presentation by Mike Farrar on Primary Care Groups where he explained some of the policies and strategies involved in the planning of Primary Care Services.

After coffee and exhibition viewing there were 3 parallel sessions. I chose the presentations dealing with Clinical governance, Nursing Informatics and Information for Nursing Practitioners in the Community. All of these topics were particularly relevant for me, as nursing staff are the largest client group in my library.

Clinical governance by Gabby Fennessy helped to clear up the mystery behind this latest buzzword. She defined the term and elaborated on the issues involved, although I have to admit, in discussions with colleagues later, there still seemed to be slight confusion lingering.

After a delicious buffet lunch, we broke up into groups for workshops and seminars. I chose Internet Resources for the Primary Health Care Team presented by Robert Kiley. After a brief introductory talk the rest of the session was hands on, where we worked through several exercises which illustrated the problems of misleading and inaccurate information on the Web. I left this session armed with several useful new Web sites and fired with enthusiasm to add them to my favourites.

The next two sessions were, firstly, Lynette Cawthra discussing Older People's Health Information Needs within primary and community care settings, and the information professionals role and secondly, Tony Hope's presentation on Ethics of Evidence and Patient Choice. The concepts of evidence-based medicine and patient centred medicine were discussed. Both presentations gave plenty food for thought, particularly the idea that patients should play a central role in decisions regarding their own health care.

The working part of the day ended with Bill Detmer from Ovid Technologies launching their new database Evidence Based Medicine Reviews. This was followed by a much appreciated reception hosted by Ovid where we enjoyed a glass of wine (or two).

During the evening, after yet another reception and dinner, Bob Usherwood, President of the Library Association gave the after dinner speech, and for those who enjoy some night life, entertainment was provided by Terry Kennaugh's Sextet , an excellent jazz and blues band.

Friday began with a keynote address by Professor Maggie Pearson on R & D in Primary Care. This was a very informative and well presented talk which again provided me with a broad view of information needs within the primary care environment, from the 'lay' carer to the professional.

The delegates then split into two parallel sessions. I attended the IT presentations Information Support for General Practice Research by Professor Alan Gillies, Internet and Community Health by Sally Hernando and The Wisdom Project by Alan O'Rourke.

The first two speakers provided me with a useful overview of information resources for general practice and the consumer on the Internet and the role the health information professional can play in helping the consumer make informed decisions regarding appropriate data bases.

Alan O'Rourke's presentation on the WISDOM Project illustrated the idea of a 'virtual classroom' using e-mail and Web pages to develop information management and computer mediated communication skills. The WISDOM Web site can be visited allowing access to their library, archives and tutorials.

The final keynote address was given by Veronica Fraser entitled Emerging Themes and summarised the themes and issues of the conference, evidence based practice, clinical governance, primary care groups and research and the continuing need for improved access to the healthcare knowledge base.

The Conference closed after lunch and I left Lancaster with very positive impressions, having felt very welcome, and came away armed with lots of new ideas and information and even some rekindled enthusiasm.

Angela Hissett
Ailsa Hospital

A second personal view

'First aid for the front line' or getting the relevant information quickly to where it is most needed

The conference theme of information provision in primary care was timely in view of the impending health service changes, and is relevant to us all as information providers, no matter what type of library we work in. A recurring message was that 80% of health care happens outside hospitals, 80% of health libraries are within hospitals. What implications has this stark reality for the ideals of increased freedom of access to information for those in "the front line" - patients and professionals alike? The White Papers stress an enhanced profile for primary care, while the general public are seeking information themselves, for example via the Internet, and are becoming more vociferous in their demands and expectations.

I arrived at Lancaster expecting to come away with my notebook filled with new knowledge about clinical governance, how evidence-based medicine is achieving true clinical effectiveness, how we can assure that professionals and patients have quality access to all the wonderful sources of gold standard medical information. Yes, I learned something about all these, but most of all I learned that life is not that simple!

I do not intend to summarise all the sessions and workshops and hope to convey the dominant issues and dilemmas, and share with SHINE members the optimism that we can play our part in tackling these.

For those unable to attend Lancaster, my message is twofold. First, medical practitioners have no alternative but to be aware of, and adhere to, the best available evidence, in view of stricter rules on responsibility and accountability, and in response to patients' demands. Secondly, the 'evidence' is often of poor quality, and true 'evidence-based medicine' remains a dream. In other words, most of the practitioners are paying lip-service to the 'evidence' which is often poorly researched and presented.

Professor Richard Smith, the editor of the BMJ, eloquently set the tone in the opening address. His talk, "Information for doctors: drowning in the irrelevant, starved of the important", delivered a series of punchlines:

• most doctors don't keep up with research;
• they lack the knowledge to answer patients' questions;
• at least 90% of articles in even the most respected journals fail to meet scientific criteria, yet their conclusions are believed;
• doctors rely most on the least useful information, such as journal articles and colleagues.

He estimated that most of us, including himself, read less than 0.1% of what we should in order to do our jobs properly.

His message, though was positive. Recognition of this appalling situation is the first step to improving it. Soon, doctors should all have access to quality electronic resources, portable, simple to use, and linked to patients records.

Other speakers and workshops led me to recognise that the worthy aim of 'evidence-based medicine' remains some way off. Many trials are still of poor quality, many more are not published, results are subject to statistical manipulation. However, as librarians and health professionals become more skilled in evaluating results, the aim of maximum clinical effectiveness will come closer. There is a bewildering range of sources of 'the evidence' but gradually this is being systematically co-ordinated.

I am confident that recognition of the scale of this task is a major step towards true clinical effectiveness, and that the technology is becoming available to deliver top quality information in a seamless way.

What we now call the 'Internet' will become prominent - we'll all, patients and professionals, use it naturally, as we now use books and the telephone. It will barely resemble the present Internet, but within 10 years the current situation of 'hit-or-miss' medical information provision will be a ghastly nightmare.

1998 is the last Health Libraries Group Conference for some years, 1999 being the Under One Umbrella event, and 2000 seeing London host the International Congress of Medical Librarianship. Lancaster was very successful, well organised, and the stimulation of mixing with fellow professionals proving as valuable as the formal sessions. I have come home from past HLG conferences fired with enthusiasm about the exciting possibilities of ever more magical methods of delivering high-quality medical evidence. This time my mood is more subdued. I am fully aware that the explosion in health and medical information, and the increasing access to it, is not accompanied by greater quality of information, or intelligent use of it. As health librarians, we have a daunting challenge. Our role must change radically, but the prospects are positive, the future is exciting!

Janice Grant
Ayr Hospital