EVIDENCE-BASED MEDICINE

The British Library 124 pages pounds33

Will there come a time when we're all sick of evidence-based medicine? Almost certainly, but not yet. There is still plenty of scope to explore the practicalities, theories and implications of gathering evidence about healthcare interventions (or organisations, or policy) and attempting to implement the findings of scientific research. In such a rapidly moving field there is also scope, as this book makes clear, for collating a guide to the literature - which these days also includes Internet resources - and summarising the progress of the EBM debate.

The aim of Lesley Grayson's book is to provide a snapshot of EBM developments, with an emphasis on useful sources of EBM literature, both conventional and electronic. Although aimed at those who feel the need to develop a greater understanding of EBM, the odds are that even the most committed EBMphiles (yes, that includes you, Professor Sackett) will find this a useful source.

As a reference work, the book mirrors a significant problem in EBM: the sheer volume of evidence practitioners need to digest if they are to keep abreast of the latest research. Grayson notes the estimate that in general medicine a consultant needs to review around 19 articles every day of the year to remain well briefed. An impossible task.

Summarising, distilling and reviewing has therefore become an essential part of EBM. The Cochrane Collaboration and the NHS Centre for Reviews and Dissemination, together with various NHS regions and academic institutions, have been engaged in sifting through the evidence mountain (to which they also contribute through research) to try to produce more conquerable hillocks for clinicians and others who also do a full-time job.

It seems clear why clinicians should be interested in EBM - it's surely an intrinsic part of their job - but why should, say, managers and politicians pay more than a cursory glance? Grayson quotes a cynical view from David Grahame-Smith: managers are only interested in EBM as a means to contain doctors' natural anarchic urges to spend money.

Well, if EBM does lead to ineffective and inappropriate care being dropped and money saved, then fine - although Professor Trevor Sheldon in his foreword doubts this will happen. But the point about EBM is to improve healthcare - find out what works, provide it, and throw out what doesn't. Money will be 'saved', but for re-investment.

Grayson also notes arguments that EBM can act as a smokescreen for rationing and cost-containment. But for the UK at least, containing NHS spending is not really a problem; real growth in NHS expenditure since 1950 has almost exactly matched the real growth in the economy as a whole. As for rationing, can anyone really defend the continued provision of care which has been shown to be ineffective?

Following the origins of EBM, policy issues and sources of information, the book ends with a review of the patient's perspective. Information is empowering, but one wonders where to start when apparently one in 10 of the population has trouble identifying the location of the brain.

JOHN APPLEBY

Senior lecturer in health economics, school of health policy and practice, University of East Anglia.