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Review of:

Knowledge to action? Evidence-based health care in context edited by Sue Dopson, Louise Fitzgerald
Oxford University Press, 2005
Pages: 223+xv. £45

Reviewed By: Steve Harrison
Reviewed in: Public Administration
Date accepted online: 02/11/2007
Published in print: Volume 85, Issue 1, Pages 227-253
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Reviews

Although its transatlantic progenitors have perhaps held more nuanced views, the UK's 'evidence-based medicine' (or evidence-based health care) movement, as it developed from the early 1990s, is substantially founded on simplistic, linear perspectives about the diffusion of research evidence into clinical practice. In brief: evidence on a given topic should be aggregated from multiple valid findings; valid evidence is defined with reference to research designs (especially randomized controlled trials) that seek to minimize bias; most clinicians lack the time and possibly the skills to interpret primary research studies or meta-analyses of them; algorithmic guidelines are therefore an appropriate vehicle for getting 'evidence into practice' or, as this book's title has it, 'knowledge into action'. The evidence-based health care movement has discovered from numerous studies that such guidelines are not self-implementing, yet continues to research this problem with little apparent recognition of the social and context-bound character of the enterprise. Social scientists have been commenting on this delusion for more than a decade, but it is only with the recent appearance of this book and that by Greenhalgh et al. (2005) that sustained analysis has been undertaken.

Knowledge into Action arises from the efforts of two groups of researchers (five in total), from a broadly management studies discipline, to pool (or 'upscale' as they put it) the findings from seven primary qualitative studies (comprising a total of 49 case studies) that they had previously conducted into the implementation of evidence-based health care in the British National Health Service. Accordingly, the evidence assembled is extensive; some 1400 interview transcripts together with more than 2000 questionnaire responses and some documentary analysis. However, only about 25 per cent of the book's page count is occupied by extracts from the authors' primary evidence, with much of the remainder being devoted to a wide-ranging series of conceptual and theoretical discussions relevant to aspects of the analysis. These include the literatures related to theories of organisation, theories of the professions, the diffusion of innovations, and the nature of 'knowledge', in addition to explanations of the authors' (essentially interpretivist) epistemological positions and primary research and 'upscaling' methods. The substantive conceptual discussions will provide a valuable starting point for readers wishing to become acquainted with the particular literatures, though I suspect that practitioner readers of the book will find them heavy going, in part because of the way in which they are distributed throughout the text and in part because the internal 'signposting' between sections is sometimes rather cursory.

This volume is the product of a welcome enterprise and its overall findings are important, if perhaps unsurprising to social scientists. First, a social perspective is required in order to understand the translation (or otherwise) of evidence into clinical practice. Such an approach 'scripts in to a much greater extent [than mainstream approaches] the perspectives and concerns of the field' (p. 183). Second, knowledge of context is crucial to the understanding of such outcomes. Moreover, 'context' is not an analytically unproblematic given; rather, it includes both internal and external, both structural and processual factors, and is interpreted, even enacted, by subsets of organizational actors. Third, actors working to implement evidence-based health care need in particular to understand the part of such contexts that is constituted by professional cultures and boundaries. Fourth, 'skilled action' is possible; opinion leaders 'were able to influence and stimulate innovation pathways actively' (p. 185). Again, however, the notion of 'opinion leader' is not unproblematic; the authors rightly remind us that such status derives from its assignment by clinicians rather than by managers. Finally, in case studies where 'best' implementation occurred, formal research evidence and clinical experience were to some extent symbiotic.