There is a connection between evidence-based practice, local clinicians' research work and the NHS research and development strategy but they are not all the same thing, nor are they consistently implemented across the country. It is too easy to put them all under one banner (Slow-acting remedy, page 24-25, 21 May) and derive generalised assumptions from them.

Practice, by definition, means implementation - unless the 'practice' is only for the research itself. Evidence-based daily practice therefore requires evidence to be part of daily practice delivery. Local clinicians' research work does not necessarily relate to daily implementation.

Without a direct focus on whether or not care actually delivers results in an effective outcome for the patient, these concepts are nothing more than words.

What is needed is a driving intent to investigate the most effective care pathway and process methods available that result in an outcome which is clinically appropriate and effective as well as acceptable and appropriate to the patient.

In the complex, variable-ridden reality of daily human life, this produces problems for those whose research beliefs are entrenched in random controlled trials methodology and potentially results in indefinite excuses for not implementing any work which lacks this level of validation.

Inevitably what is done revolves around an elite group of academic institutions with the time and resources to maintain the machine.

R&D is not only research - in relation to practice it is the development arm that makes the whole investment of time and money worthwhile. But the development should be focused and delivered - and it should evolve from research that is designed to address the complex variables of patient- delivered reality.

This is difficult but it is the only way to make R&D applicable to the everyday needs of clinicians committed to patient-focused health gain.

Bernice Baker

Freelance nurse consultant

Horsham

West Sussex