Radcliffe Medical Press, Abingdon: 2002, pp. vi, 165
ISBN 1 85775 458 1
For many years, evidence-based medicine has been an important feature of health system reform in many countries, principally in the United States and United Kingdom. Yet, despite significant resources and effort having been invested in it, its impact on changing clinical practice remains far less impressive.
A side effect of the evidence-based movement in medicine has been mounting pressure to make policy and management evidence-based. This book by Rosemary Stewart, a respected international teacher and researcher in management, is therefore timely. It is not an academic text in that it does not advance theory or provide a critical analysis of evidence-based management. It is a slim, easily digestible practical guide for health professionals and it is written in a clear, almost simple, accessible style with lots of lists and boxes to break up the text as well as examples to illustrate key points.
The eight short chapters include coverage of what evidence-based management is, managing on the job, using information and knowledge, knowing whether managers are doing a good job, improving decision-making, learning to practise evidence-based management, and organisational culture.
Stewart acknowledges that it is more difficult to practise evidence-based management than evidence-based medicine and explores the similarities and differences between the two. Her aim in the book is to reduce the obstacles to practising evidence-based management.
One of the problems in any discussion of evidence-based practice is what constitutes good evidence. In evidence-based medicine the gold standard is the randomised controlled trial although this has come in for considerable criticism since evidence based on trials or systematic reviews is of little value to clinicians deciding on what course of action to adopt in respect of individual patients with their unique circumstances and needs. But in social care, for example, and areas away from clinical care, the very nature of evidence is hotly contested.
In respect of evidence-based management a measure of pragmatism is called for and the contributions of many social science disciplines and others are of relevance. Stewart singles out psychology for special mention. It is the ‘most useful discipline’ for managers because psychologists have researched how people think individually and in groups. However, it can equally be argued that other disciplines, notably political science, are just as, or perhaps even more, important. Political science deals with issues of power and who gets and does not get what. It also acknowledges the importance of organisational context. Evidence-based management is as much about context as it is about the attributes and values of individual managers.
The point becomes more important when modern health care management is of an intersectoral, cross-cutting nature. In the UK and elsewhere, governments talk of ‘joined-up’ policy and management recognising that complex problems transcend professional and organisational boundaries and demand a cross-sectoral response. Effective management practice has to be demonstrated not within particular silos, like hospital services, but around notions such as patient-centred care where services are organised around the needs of patients rather than the organisation. Hence the importance of concepts like integrated care and clinical pathways.
It is a pity, even in a guide of this nature, that Stewart resists confronting critics of evidence-based management and rather uncritically extols the virtues of scientific knowledge in providing the foundation for improved managerial decision-making.
The main problem with evidence-based management is the difficulty of isolating general phenomena and processes, which can reasonably be claimed to underlie managerial practices. This reflects the essentially (and necessarily) contingent, contextual and relatively unstable nature of managerial tasks and activities. There are severe limitations on how far the findings from studies of management practice can be generalised or transferred between situations. Moreover, in many health care systems, what managers do is determined not so much by themselves or their actions but by their employers whose actions are rarely, if ever, evidence-based. Furthermore, managerial tasks and practices are dependent upon organisational arrangements and cannot easily be isolated from their context to form the object of research. In short, managers are not the masters or mistresses of their destinies. They have only limited control over their work and over what is required, or expected, of them.
Stewart rather underplays the presence and significance of such features, which seriously limits the value of her book. However, within its narrow confines and self-imposed limitations, the guide may offer the odd piece of advice, which some managers may find useful if they have not already considered it. This is a book to flick through quickly rather than to dwell on. Therein lies both its strength and weakness. At the end of the day evidence will remain only one among many influences on management practice. The most experienced and effective managers already know this only too well.