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The dilemma of rigour and relevance

April 3, 2013
Martin Marshall Martin Marshall is Lead for Improvement Science London and Professor of Healthcare Improvement at UCL.

Only a few books have the potential to change the way we see the world but for me Donald Schon’s The Reflective Practitioner, is one of them. Schon describes two worlds, ‘the high hard ground’ where good research helps us to solve problems in a rational way and ‘the swampy lowlands’ where problems are messy and confusing and don’t seem to fit with the research evidence. Clinicians and managers working in the swampy lowlands of the NHS have to deal with the tension between these worlds, a tension which Schon refers to as ‘the dilemma of rigour and relevance’.

I was thinking about this dilemma last week at a meeting of our local Clinical Commissioning Groups. The purpose was to share learning from work being undertaken by each of the groups and it was one of the most stimulating meetings that I’ve been to in a long time. We heard about a project which has resulted in considerable savings by reducing the frequency of self-monitoring for patients with diabetes; we heard how the Quality and Outcomes Framework has dramatically improved blood pressure and cholesterol control; how the introduction of a new ECG telehealth service has improved care for patients with ischaemic heart disease and atrial fibrillation; and how a virtual ward initiative has reduced the rate of unplanned admissions at a local hospital.

For more than 2 hours not a whinge was heard about politics, poor morale or anything else. Critics who claim the NHS is in trouble and that CCGs are not up to their task would have been made to eat their words by the shear commitment and talent of the clinicians and managers who presented their work. You wouldn’t have believed that they were working for organisations that weren’t yet even legal entities. They presented ideas and interacted with each other as if they’d been around for years, and of course many of them have been in different guises and employed by different structures. The focus on content lent a healthy sense of continuity to the discussion.

Two things struck me about the meeting. With my NHS hat on I was convinced from the data presented that the work really was making a difference. I heard how services were being redesigned, could see trends heading in the right direction and was persuaded by figures clearly showing better outcomes. But with my academic hat on I wanted to ask the kinds of questions that researchers like to ask, sometimes helpfully but sometimes irritating. Like ‘are you sure that’s a trend’, or ‘is it statistically significant’, or ‘where are the controls’, or ‘do you know how these apparent changes are happening’, or ‘what’s your underpinning theory of change’, or ‘what does the published evidence say about this’. Irritating questions, as I say, but important ones if we are to move beyond successful projects to deeply embedded and sustained system-wide change.

It is neither possible nor desirable for academics to put the brakes on the kind of work that was presented at the meeting. But nor are we best serving the needs of our communities by ignoring the contribution that academics can make to service-based improvement. Schon’s dilemma is a real one that we need to solve through closer partnerships between decision makers in the health service and applied researchers.

Schon DA. The Reflective Practitioner: how professionals think in action. London, Temple Smith, 1983

One Comment leave one →
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