Educational meetings and printed educational materials are the two most common types of continuing education for health professionals. An important aim of continuing education is to improve professional practice so that patients can receive improved health care.

A Cochrane Study was set up to assess the effects of educational meetings on professional practice and health care outcomes. They searched the Cochrane Effective Practice and Organisation of Care Group specialised register, MEDLINE (from 1966), the Research and Development Resource Base in Continuing Medical Education in January 1999 and reference lists of articles.

Randomised trials or well designed quasi-experimental studies examining the effect of continuing education meetings (including lectures, workshops, and courses) on the clinical practice of health professionals or health care outcomes were included.

Two reviewers independently applied inclusion criteria, assessed the quality of each study, and extracted study data. They attempted to collect missing data from investigators and conducted both qualitative and quantitative analyses.

Thirty-two studies were included with a total of 36 comparisons. The studies involved from 13 to 411 health professionals (total N= 2995) and were judged to be of moderate or high quality, although methods were generally poorly reported.

There was substantial variation in the complexity of the targeted behaviours, baseline compliance, the characteristics of the interventions and the results. The heterogeneity of the results was best explained by differences in the interventions.

For ten comparisons of interactive workshops, there were moderate or moderately large effects in six (all of which were statistically significant) and small effects in four (one of which was statistically significant). For interventions that combined workshops and didactic presentations, there were moderate or moderately large effects in 12 comparisons (eleven of which were statistically significant) and small effects in seven comparisons (one of which was statistically significant). In seven comparisons of didactic presentations, there were no statistically significant effects, with the exception of one out of four outcome measures in one study.

Thus despite the comments of Alexi Sayle that anyone involved in a workshop, who is not a light engineer, is a ****er interactive workshops can result in moderately large changes in professional practice. Didactic sessions alone are unlikely to change professional practice.

Three NHS Direct pilot sites were launched in March 1998 and the service now covers all of England. While not the first telephone health service in the world, it promised something more than triage of emergency calls. Initially set up to provide clinical advice, health information, and referral to other NHS services via the telephone, it is now set to become the hub of out of hours care. In January the National Audit Office, an independent body that scrutinises public spending on behalf of parliament, published its report on NHS Direct in England.

NHS Direct is presented in a positive light, but not all is rosy. In addition to difficulty with meeting call handling targets there has been no visible effect on demand for NHS services overall. The hoped for reduction in demand for other services might be achieved by the proposed integration of NHS Direct with existing out of hours general practice co-operatives and ambulance services. Where such integration has taken place demand for general practice consultation has fallen, especially for telephone consultation.

Despite shortcomings, customer satisfaction with NHS Direct is high – that is, among those who use it. Sadly, the evidence indicates that they are the same people who use existing health services. It is underused by older people, ethnic minorities, and other disadvantaged groups. Rather than reach people who are currently failed by the health system NHS Direct may have discovered previously unexpressed demand among the worried and well middle classes.

What of NHS Direct online? The Internet version of the telephone service makes only a brief appearance in the report, but its use is clearly limited to those with access to the Internet and money to pay for it.

When callers reach a nurse the advice they get may vary – usually on the side of caution. This is predictable, but has inevitable consequences. The predictive value of a diagnostic test depends on the prevalence of the condition being tested for. The rarity of serious disease among callers to NHS Direct must mean that its computer based decision support system, however good, has a low predictive value for serious illness. For every caller with a serious condition detected by NHS Direct, many more with self limiting conditions will be directed into the health system. Consistently to err on the side of safety might seem logical, but the effect of doing so is to fill a health system with people who do not need to be there.

Finally is it worth the money? The report suggests that half of the £90m annual cost of NHS Direct has been offset by encouraging more appropriate use of NHS services. Cost savings are calculated according to other health service contacts avoided. These are determined on the basis of callers’ stated future actions rather than on actual data. The savings are therefore speculative and in any case a maximum estimate.

Is £45m, the theoretical additional cost of NHS Direct, worth it for a system that eventually might work as a co-ordinator of access to health care? It seems unlikely that NHS Direct will do anything to address health inequality, and it may even serve to widen existing differences. Ask yourself. If you had £45m a year to spend on improving health, empowering the socially disadvantaged, and reducing health inequality what would you spend it on?

Ref: web

A new review from NICE summarises literature about clinical audit, its effectiveness, methods of undertaking audit, and how audit projects and programmes are most appropriately coordinated and run.

The evidence was used to underpin a book, Principles for Best Practice in Clinical Audit. The review is intended for staff in the NHS with particular interest in, or responsibility for, clinical audit and clinical governance. It builds on previous reviews and provides guidance on aspects of audit and reference to relevant publications. It does not give guidance on how to undertake or manage audit. The review is best found at the national electronic library for health at: