Professional development in a virtual learning community

Brief Communications

Continuing professionaldevelopment in the NHSÐwhat isto be done?

VERONICA FRASER NHS Library Advisor,Department of Health, Room 302 A, SkiptonHouse, 80 London Road, London SE1 6LH, UK

The drive to modernize and improve thequality of health care services in the UnitedKingdom has led to the publication of severalstrategic policy directives during the last 18months. The earliest policies, published asGovernment White Papers, established broadoverall targets for development. To achievechange within the NHS, the NHS Executiveissues Health Service Circulars outliningindividual and organizational responsibilityfor implementing specific policies. One keyarea that has been recently addressed is theneed for ongoing professional developmentfor all NHS staff.

Continuing professional developmentin the NHS

The vision presented in `The new NHS'1

saw `Local delivery of high quality healthcare, through clinical governanceunderpinned by modernised professional selfregulation and extended lifelong learning'.Health Service Circular 1999/154 `ContinuingProfessional Development: Quality in the NewNHS'2 was published in July 1999 and setsout a long-term vision for ContinuingProfessional Development (CPD) and itsrole in supporting high standards ofprofessional practice in the new NHS.

The new CPD guidance aims to establisha new approach with the following coreprinciples. CPD should be:

. purposeful and patient centred,

. participative,

. educationally effective,

. cross boundary (professional and service),

. designed to build on previous knowledgeand skills,

. part of a wider organisational developmentplan that supports local and nationalobjectives.

A key objective in the document suggeststhat CPD should involve local and nationalpartnerships in order to develop innovativeapproaches to work-based learning, andshould seek to align existing training fundsin order to achieve greater equity among thedifferent professions.

The position of library andinformation services

Library services have been described as `thebedrock' of education and training, andNHS library services can expect greaterdemands on all their services as they supportan increased emphasis on continual, self-directed learning. The CPD guidance statesthat `library and IT strategies should providea framework for ensuring equal access for allstaff groups to the learning resources whichsupport work based learning'. This factoralone will bring challenges and opportunitiesfor librarians to take on the roles ofknowledge managers and facilitators. In ourefforts to assist NHS colleagues with theirCPD it is important that we also rememberour own CPD needs. Currently, CPD forNHS librarians is largely organized byRegional Library Units, or in regions wherethey do not exist, by regionally based, self-organized networks. The new policy,formalizing CPD for all, will requireindividual commitment as well as local,regional and national funding and activity ifit is to be effective.

A wider skills base for librarians

As user requirements become moresophisticated, and evolving information andcommunications technologies (ICT) offernew ways to communicate information,

268 # 1999 Blackwell Science Ltd


librarians face exciting and demandingopportunities. Working within the complexstructure of the NHS requires an ability andwillingness to operate alongside otherprofessions, including those responsible forimplementing Local ImplementationStrategies in response to Ìnformation forHealth',3 and on the emerging Nationalelectronic Library for Health, yet also tocontinue to satisfy existing and new users.These factors will all impact on the serviceswe provide and the skills we need in order tobe at the centre of development rather thanat the margins.

Librarian development programme

In recognition of these challenges it isimportant to develop a national frameworkfor librarian development. Earlier this year, anindependent consultant with a longinvolvement with library education andtraining issues was invited to facilitate abrainstorm group brought together to discussand draft a competency based developmentframework for NHS library staff. The groupincluded representatives from RegionalLibrary Units, Schools of Information Studiesand Librarianship, colleagues from the highereducation, research and private sectors, and amember of the Library and InformationCommission's Training Panel. The variousrepresentatives were able to bring togethercurrent experience of librarian training anddevelopment alongside knowledge ofdevelopments under way within the People'sNetwork, the higher education electroniclibraries programme and work oncompetencies for knowledge management.

The Librarian Development Programme(LDP) competencies were drawn from areasidentified by the Medical LibraryAssociation, TFPL, The Library Associationand others, and have strong links with thetraining needs identified for the People'sNetwork for public libraries. The LDPtherefore includes specialist health sectorknowledge, ICT skills, competencies inbusiness management and human resources,

learning and teaching skills, and recognitionof the need to develop personal effectiveness.The next step will be to seek formaladoption by the NHS Executive andestablish firm links between the LibrarianDevelopment Programme and relatededucation, development and organizationdevelopment programmes to ensureconsistency and co-ordination.

It is expected that formal adoption willrelease additional funding to help support theeducation and development needs of healthservice librarians. An initial project is alreadyunderway to conduct a national TrainingNeeds Analysis of NHS library staff, which isdue to be completed by the end of 1999. TheTraining Needs Analysis will identify existingqualifications and professional membershipsand link these to job title, grade and salary inorder to provide baseline data concerningcurrent skills and experience. Librarians willalso be asked to state their preferred learningmethods in an attempt to recognize the needfor, and encourage the provision of, a widerrange of learning opportunities. Informationwill be collected and analysed by region.Further projects will be undertaken tocompile a database of relevant learningopportunities and to explore accreditation oflearning outcomes. A seminar series, plannedjointly with the NHS Regional LibrariansGroup Continuing Professional Develop-ment Panel, will be run from Autumn 1999into the new year, and will examineknowledge management, CPD issues andopportunities; best value and NHS Libraries;and negotiating skills. Funding will beavailable to enable a senior librarian toparticipate in the Kings Fund SeniorManagers Programme in 2000, a crucial step iflibrarians are to be recognized as a keyresource to support the development ofclinical governance.4

Meanwhile what can be done locally? Thenew Guidance sets several very clear targetsfor immediate local action. These are:

. an audit of current arrangements andinvestment in CPD,


# 1999 Blackwell Science Ltd, Health Libraries Review 16, 268±285 269

. Personal Development Plans (PDPs) forall health service staff by April 2000,

. more opportunities for multidisciplinarylearning.

The NHS CPD guidance couldpotentially link to the Library Association'sCPD Framework and for many healthlibrarians this could prove a useful andfamiliar framework within which to developplans for ourselves and our colleagues overthe coming years.

References

1 The new NHS: modern and dependable. Cm,

3807. London: The Stationery Office, 1997.

2 Continuing Professional Development: Quality in

the New NHS. (HSC 1999/154). London:

Department of Health, 1999.

3 Information for Health: an Information Strategy

for the Modern NHS. (HSC 1998/168). London:

Department of Health, 1998.

4 Clinical Governance: in the New NHS. (HSC

1999/065). London: Department of Health, 1999.

Professional development in avirtual learning community

PHILIPPA LEVY Department of InformationStudies, University of Sheffield, Sheffield S102TN, UK

Introduction

The Internet offers an intriguing newenvironment for professional development inthe library and information field. The use of e-mail based discussion lists is already firmlyembedded into the working practices of manystaff, whether they are active participantsorÐmore likelyÐamong a larger group whoaccess and benefit from the debates andexchanges of information that take place buttend not to contribute frequently or at all.Membership of these listsÐor perhaps, `virtualcommunities'1Ðoffers excellent opportunitiesfor on-going, informal professional updating

and learning. At the same time, the Internet isbecoming increasingly attractive as a means ofoffering cost-effective, flexible access to formalprofessional development activities. As theimpact of the Internet increasingly makes itselffelt in all areas of educational work, there ismuch to explore and understand aboutdesigning and facilitating learning events basedon the use of information and communicationtechnologies (ICTs).

In this brief paper, I highlight some themesemerging from research in progress into theimplementation of a distance learning, onlineprofessional development course which washosted recently by NetLinkS,2 a training andawareness project funded by the ElectronicLibraries (eLib) programme between 1995 and1998. The course was based in part on the ideaof participation in a virtual learningcommunity, and in this paper I aim to give asense of what was meant by this in terms ofthe design and facilitation of the course, and ofhow participantsÐall of whom were new toonline learningÐexperienced involvement insuch an initiative. An overall evaluation of thecourse is available in the Final Report3 of theNetLinkS Project, and further details aboutpedagogic and technology design are alsoavailable elsewhere.4

The course

The course aimed to provide an opportunityfor learner support staff in academic librariesand resource centres to explore issues relatedto their role in `networked learner support'5

and to work on a practical, work-based projectof relevance to their own professional interestsand circumstances. Information staff areincreasingly involved in developing onlinehelp for both campus-based and distance usersof information resources; examples ofnetworked learner support from the libraryperspective include the development of Web-based information skills training materials,creation of online reference and enquiryservices, delivery of `mixed-mode' or fullyonline courses in electronic information use


270 # 1999 Blackwell Science Ltd, Health Libraries Review 16, 268±285

and, sometimes, participation in onlineconferencing to support the information-related dimensions of student project work. Atthe same time, learner support staff have a keyrole in academic liaison, aiming to promotethe use of electronic information resources inteaching and research, and, often, to linkinformation skills development activities moreclosely with the curriculum. Taking aproactive approach to developing networkedlearner support strategies and services canmake a significant contribution to culturalchange in institutions; it also entails arequirement for a new blend of professionalknowledge and skills, in areas related totechnology, pedagogy and organizationalchange as well as information resources.

Based on research into relevantprofessional development needs,6 the courseaddressed:

. the emerging educational role ofinformation services in the networkedlearning environment, and current trendsin networked approaches to informationsupport;

. current trends in networked learning andthe potential of the Internet as aneducational environment in terms ofavailable technologies and varyingpedagogic models;

. directions for networked learner supportin local contexts, and organizational issuesin developing and managing innovation inthis field.

At the same time, the aim was to enableparticipants to gain direct, practical experienceof the Internet as an environment for learningand to develop `process' knowledge and skillsthat are essential for the practice of activenetworked learning; these include skills in theareas of online group work, communicationand technology use, as well as in reflective andself-managed learning.

The course ran for a period of 17 weeksbetween September 1997 and February 1998,and comprised 36 staff from universities andcolleges of higher education all over the UK;the group included a small number of

librarians in health fields. The course structurewas based on a total of seven Units andparticipants were advised to spend between 6and 8 hours per week on course activities,including at least twice-weekly access to thecourse Website. There were no face-to-facemeetings, and most participants accessed thecourse solely from terminals at work. Allfacilities and resources were accessible via theInternet, except some suggested offlinereading. Most tutoring and technical supportwas provided by a core of four NetLinkS teammembers, with the additional involvement of anumber of other colleagues. An activity-basedlearning model was adopted, drawing onconstructivist and experiential learningprinciples, and a good deal of emphasis wasplaced on opportunities for information-exchange (for instance, about relevant,innovative initiatives in participants'institutions), small-scale collaborative activitiesin groups (learning sets), and mutual supportfor individual project-work. The maindiscussion facility was a Web-basedasynchronous conferencing system, withforums for each learning set, whole-groupseminar discussions, discussions on technologyand information issues, and a social space. Anumber of other communication optionsincluded e-mail and a MOO,7 which facilitatedsynchronous, textbased interaction in a `virtualsuite' of seminar rooms; each learning set hadits own `room' where meetings could be held.

Participants' feedback about the course wasgenerally very positive, confirming the overallrelevance of the topics to this professionalgroup. The technology design and facilitieswere judged to be easy to use and in generalthe standard of tutoring and technical supportwas perceived to be high, as was the quality ofthe course's information `resource base.'Encouragingly, the large majority enjoyed theexperience and indicated that they would behappy to consider participating in an onlinecourse again. One of the most valued aspectsof the course was its experiential element, interms of the insight offered into the learners'perspective on online learning. Manycommented that they felt far less isolated than



they had expected to be, and two-thirds of thegroup experienced a strong sense of`community feeling' despite the lack of face-to-face meetings. The course was judged to besuccessful in providing a framework withinwhich participants could pursue personalinterests and learning needs whilstcontributing to (and benefiting from) acollaborative learning community. There weremany excellent discussions in both smallgroups and the large forum, and althoughparticipants did not usually complete theirprojects within the timescale of the course, itprovided a stimulus for initiatives whichparticipants continued to develop subsequentlyand were able to implement somewhatdownstream of the course itself.

Issues in online professionaldevelopment

Alongside a good deal of enjoyment andachievement, there were also challenges andfrustrations associated with participation onthe course. Engaging with the demands ofthe online environment and of the learningapproach involved a gradual process ofacclimatization for most participants, andnearly all found some aspects of learning inthis way difficult. The pace and length of thecourse were issues here; participants oftencommented that they were just getting intotheir strideÐdeveloping awareness, skills andconfidence to work effectively in thiswayÐtowards the end of the 4-monthperiod. The following paragraphs highlightsome key issues arising from participants'feedback about their experiences.

Self-managed learning

Throughout the course our aim was tosupport participants in their development ofstrategies and skills for managing their ownlearning. We brought the learning model tothe fore early on, and built in ongoingopportunities for reflection and discussionon `learning to learn' issues. We suggestedthat participants keep reflective learning

journals and many did so (although few keptthem consistently). However, for a variety ofreasons managing personal learning in thisenvironment was not always straightforward,and those who were very familiar with theconcepts of active and independent learningin theory were not necessarily well-preparedto adopt such an approach in practice,especially within a new (online) context.Few, for instance, were familiar withconcepts associated with `reflective practice'8

in professional development. Managing timeand flexibility also posed problems; therewere a variety of arrangements withemployers regarding time spent on thecourse, so that some were able to devote 6working hours per week to it, whilst others'involvement was wholly in their own time.

Whatever the nature of arrangements,however, finding time for the course was acommon difficulty and many did not spendas much time as initially planned. This waspartly a matter of difficulties in gainingsustained periods for network access,personal study and reflection at theworkplace, combined with lack of Internetaccess from home. However, many alsoencountered difficulties in establishing apattern of participation suitable for the modeof study, with the need to take into accountthe differing temporal dimensions andrhythms of asynchronous discussion, real-time online meetings, and personal study.

Computer-mediated communication (CMC)and group-work

Although all participants were familiar with theuse of e-mail and some had experience ofnews groups and other forms of conferencing,using CMC to support formal learningactivities was a new experience for everyone.Issues related to the logistics and dynamics ofCMC loomed large for many; it was not astraightforward matter to develop effectivecommunication routines, to use text to initiateand weave discussion in large and small-groupforums, to exchange critical feedback online,to network with others across a large



community, or to establish satisfying socialrelationships. Despite the advantages affordedby different media and the opportunity tocommunicate independently of time andplace, learners often experienced bothsynchronous and asynchronous connectivity asinhibiting or disorienting, or were frustratedwhen it proved difficult to stimulate the typeof debate they wanted. Few were active`people-networkers' outside their own learningsets despite the technical opportunities and theinformation available about mutual interests inthe wider group. Many were infrequentcontributors to online discussions, whether insmall or large forums, although the value (andpleasures) of `lurking'Ðlistening withoutrespondingÐwere emphasized. There was alsoa need to develop an understanding of themerits of different technologies in relation todifferent purposes and learning activities, andof the ways in which they could be used tocomplement each other.

The fact that the course offered acombination of asynchronous andsynchronous discussion facilities provedsuccessful, and many were happy to sacrificepersonal flexibility for the chance to meetothers in real time on a regular basis;punctuating the course with real-time sessionswas found to be helpful for structuringpersonal participation and time-management.However, working in online learning sets wasoften a particular challenge. Whereas some setsdeveloped successful approaches tocollaborative and co-operative work, otherswere frustrated by difficulties encountered incementing group relationships early on andestablishing effective strategies for co-ordinating discussions and collaborative workwithin fairly tight timescales. It became clearthat more emphasis on facilitating small-groupwork early on in the course would have beenbeneficial.

Conclusions

It has not been possible in this short paper todo more than indicate the diversity and

complexity of participants' experiences ofbecoming involved in a virtual learningcommunity, or to examine the pedagogic andother issues involved. Work continues as anin-depth case study analysis of the initiative.However, this brief overview does serve tosuggest some considerations for othereducators and trainers in the LIS field whoare adopting networked methods forcontinuing professional development (CPD)and training. As a pilot for futureimplementations, the course provided a richsource of insights into the attitudes,experiences and support needs ofparticipants, and has particular implicationsfor the design and facilitation of `processsupport' for active networked learning andfor the nature of the employer's contributionto supporting staff to engage in flexible,networked CPD.

References

1 Levy, P. Virtual communities and information

services: an overview. Vine 1999, 109, 3±9.

2 NetLinkS. Web Site: http://www.netways.shef.ac.

uk

3 Levy, P., Wilson, T.D., Bowskill, N., Goodier, C.

& Ashton, S. NetLinkS: Final Report to JISC. 1998.

http://www.netways.shef.ac.uk

4 Levy, P. An example of Internet-based continuing

professional development: perspectives on course

design and participation. Education for Information

1999, 17(1), 45±58.

5 Fowell, S.P. & Levy, P. Developing a new

professional practice: a model for networked

learner support in higher education. Journal of

Documentation 1995, 51(3), 271±280. http://www.

aslib.co.uk/jdoc/1995/sep/4.html

6 Levy, P. Continuing professional development for

networked learner support: progress review of

research and curriculum design. International

Journal of Electronic Library Research 1997, 1(3), 267±

84.

7 For an explanation of MOO environments in

education see. Cook, N. & Stanley, T. MUD/

MOO environments in the delivery of user

support and training. Vine 1999, 109, 53±8.

8 Schon, D. The Reflective Practitioner. New York:

Basic Books, 1983.



Reflections on evidence-basedpractice training*

JOHN BLENKINSOPP Medical Library, NorthTees General Hospital, Stockton on Tees TS198PE, UK

Introduction

In the National Health Service it is acceptedthat medical treatment should not be basedupon muddling through elegantly as aparadigm for treatment, but on the evidencethat has been published. Evidence-basedpractice (EBP), clinical effectiveness andclinical governance have become importantissues for all clinicians. This change hashelped to stimulate increased demand formedical library resources and user education.

According to Glanville et al.,1 `There is anincreasing pressure on healthcare professionalsto ensure that their practice is based onevidence from good quality research'. Arecognition of this increasing pressure ledNorth Tees Health NHS Health Trust toformulate an Evidence-based HealthcareTraining Programme that could be madeavailable to all clinical staff in the Trust.

Background

Evidence-based medicine has been describedby Rosenberg and Donald as `The process ofsystematically finding, appraising and usingcontemporaneous research findings as a basisfor clinical decisions'.2 EBP has dominated somuch of the medical literature in recent yearsthat practitioners are in danger of beingoverwhelmed by the sheer quantity ofreferences. The information profession, andMedical Libraries in particular, have recognizedthe challenge and importance of this issue byproviding resources and expertise to help usersfind appropriate and relevant information. TheMedical Library at North Tees GeneralHospital and the Clinical Development Unit

in the Trust have worked together to developan instructional programme of informationskills required to support EBP.

This article discusses how this programmewas set up. It also looks at the results of thecourse, reports the responses from theparticipants and uses these findings to makesome predictions for future development. Thecourse included library resource orientation, aworkshop in computer searching, theidentification of relevant informationresources, the structure of information, thedevelopment of search strategies in support ofevidence-based medicine, and the identificationand evaluation of qualitative journal literature.

Searching for evidence-based healthcare information

In early 1998, as part of the ClinicalDevelopment Strategy in the North Tees NHSTrust, it was felt that there was a need for atraining initiative to support clinicians from allhealth care professions to meet theopportunities and challenges presented by theintroduction of clinical governance. AnEvidence-based Healthcare TrainingProgramme was devised entitled Èvidence-based Health Care Training for Medical Staff,Nurses and the Professions Allied to Medicine'.The programme was available to candidates asfive òne off' sessions each of which covered aspecific evidence-based health care topic, thesewere: Èvidence-based HealthcareÐanOverview', `Searching for Evidence-basedHealthcare Information', ÙnderstandingStatistics', `Critical Appraisal Skills' and`Developing Evidence-based Health CareGuidelines'. Staff were given the flexibility tochoose which session(s) to attend, dependingon their needs.

The second of these five 3 hour courses,and the subject of this paper, was called`Searching for Evidence-based Health CareInformation'. This course aimed to introduceelectronic information sources in the form ofInternet resources, printed library resourcesand CD-ROMs, as well as providing advice


*This paper was first submitted for the UHSL NewWriting Award.


in the planning of search strategies and thebasic principles of conducting a computer-based search. Part of the Internet teachingincluded advice in evaluating various InternetWeb pages as there was a concern thatpractitioners who were using the Web werenot always critically appraising the resourcesthat they were obtaining. The course wasaimed to last no more than 3 hours intotalÐand to make it as stimulating aspossible, it was intended that there would beless `chalk and talk' and more `hands-on'experience to allow candidates to have a`taster' session to introduce them to availableresources. The course was intended to be asimplified introduction to informationresources in EBP in order to appeal to usersat all levels and to enable candidates to beaware of sources of specialist help both inthe Trust and elsewhere.

The candidates

The candidates on the course were a mixtureof GPs, consultants and nursesÐthe coursewas made available to anyone in the Trust.Nominations were not processed on firstcome first served basis as there was an aim tohave a good multi-professional and cross-divisional balance on all parts of the trainingprogramme. No attempt was made todiscover the range of candidates' informationskills before the courseÐit was assumed thatthose expressing a need to learn would havefew IT skills.

Structure and planning

The library input was to introduce EBP byway of hard copy resources as well asproviding electronic resource demonstrations,suggesting useful Websites and providingadvice in their evaluation. The informationskills aspect of the course was over-subscribedand it was decided that to provide aworthwhile course, numbers would berestricted to a maximum of 20 participants ineach session. A waiting list was kept for

possible future courses. Based on previousexperience of teaching user education tostudents in the University sector, we felt that`hands-on' practical experience would be amore useful form of learning.

Initially, a plan for the course wasformulated by the two facilitators, and thenfurther developed using existing experienceof user education. One of the facilitators wasa clinical practitioner who was able to bringher own perspective of user needs intodesigning the programme. A pre-courseplanning meeting was organized and it wasagreed to split the course into four distinctparts, which gave both facilitators a breakbetween each. In the first part, after a shortintroduction, the services that were availablein the Medical Library were described, andhard copy and electronic EBP resourcescurrently available from the library weredemonstrated. These included a selection ofbooks, journals and, for demonstrationpurposes, a printout of the term Èvidence-based' on CINAHL and MEDLINE wasprovided to help emphasize the range andquantity of materials available on EBP.

The second session introduced the conceptof EBP and showed how it had risen as theaccepted form of researchÐseveral journalarticle references were made available asfurther reading. There was a discussion aboutthe various print and electronic resourcesavailable to practitioners. The third sessioninvolved a lengthy workshop using EBPWebsites, which were introduced anddemonstratedÐparticipants had also beenasked in advance of the course to bring theirown subjects of interest to research. Thecandidates were each given a list of usefulWebsites to take away so that they could thentry out sites that were relevant to them intheir own time. To emphasize the dangers ofaccepting Internet resources blindly,candidates were advised on how to prepare astrategy for finding and filtering informationavailable over the Internet, how to search andnavigate the Internet effectively and how toevaluate Websites for relevance and quality ofevidence. A number of apparently academic



papers available on the Internet weredemonstrated and candidates invited to drawconclusions as to their quality based on a setof quality criteria given to evaluate the papers.In the final session, core resources such as theCochrane Library and the National ResourceRegister were discussed in detail and theconcepts involved in structuring detailedsearch strategies for users who werecontemplating a systematic review or whowere simply reviewing the literature of asubject were described.

Putting planning into practiceÐperceptions and feedback

Verbal feedback from the `Searching forEvidence-based Health Care Information'course was positive. The library tourappeared to be useful to the candidatesÐespecially as it became apparent that manyhad `slipped the net' and had not had alibrary induction previously. This had theadded advantage to the medical library ofpublicizing available resources and evenregistering new members.

The completed evaluations gave thefacilitators plenty to think about, although thedemand for the course (it was over-subscribedwith a waiting list) meant that there wasenough interest to enable the planning offuture sessions. Many of the candidatesfollowed up the course by requesting one-to-one teaching sessions with library staff usingthe Internet and the databases.

Following the first two sessions, a formalmeeting was held within the Trust todiscuss the success or otherwise of thevarious areas of the course. Each of theparticipants completed an evaluation form.In general, the feedback was good, although14% of the candidates felt that the level ofinformation provided in the course was toolow. During the first running of the courseit had become immediately apparent to thefacilitators that there was a wider range ofabilities amongst the candidates than hadbeen expected and that changes would haveto be made. Some candidates were using

library and Internet resources on a regularbasis during their working life. Others wereunfamiliar with what we considered to bethe basic IT conceptsÐindeed some hadlittle or no keyboard skills.

The course was considered to have beendelivered in an ùnderstandable' format by allcandidates and most (96%) of the candidatesfelt that the content fulfilled their expectations.All of the participants felt that they could usesome aspect of the course in their clinicalpractice and that they would recommend thesession to a colleague. A selection of some ofthe comments are listed below:

`Very re-assuring presentation so I didn'tfeel too stupid if I got things wrong. Veryuseful to have hands-on sessions'

`Need to structure session for experiencedIT users and non/inexperienced users'

`The whole ``computer'' scene is new tome. I feel . . . that it has stimulated a hugeurge to go and find information to back-up clinical practice'

`Well designed sessions which gives agood overview of what is available withthe back-up that when you want to usethe facilities there are staff (medicallibrary staff ) at hand for a refreshersession as and when. Found it useful!'

Conclusion

The `hands-on' approach to teaching EBPwas successful. However, we were rather toooptimistic in thinking that IT searchingabilities would be fairly standard amongst thecandidates when we were in the planningstage. As a result, before running the courseagain, it was decided that candidates shouldbe split into two groups for the last session.Those who were more competent wouldspend the time learning how to developdetailed search strategies while the otherswould be able to spend more timeundertaking basic CD-ROM and Internetsearches. All users were given an opportunityto play and practice with the machines and to



make and learn from their mistakes, thushelping them build up confidence insearching techniques. It had become clear inconversation that this was something thatthey had been unable to do during theirnormal working week. The opportunity torequest help where it was needed during thecourse and to have the ability to requestfurther help at a future time when theywished to further develop their interests wasappreciated. To reiterate, many of thecandidates are reinforcing the knowledgedeveloped during the courses by bookingadditional library training in searchingtechniques. It is worth emphasizing that thelast half-hour of the course was designed toallow candidates to `do their own thing' withthe facilitators on hand to provide help andadvice where needed. When the course wasrun the second time, candidates were soenthusiastic the course lasted an extra hour!

References

1 Glanville, J., Haines, M. & Auston, I. Sources of

information on clinical effectiveness and methods

of dissemination. In: A Haines & A Donald (eds).

Getting Research Findings into Practice. London: BMJ

Books, 1998.

2 Rosenberg, W. & Donald, A. Evidence-based

medicine: an approach to clinical-problem solving.

British Medical Journal 1995, 310, 112±26.

Meeting Report

Consumer Health InformationÐNew Directions Consumer HealthInformation Study Day. St Thomas'Hospital, London, 13 April 1999

HILARY HAMES, Information Services, EssexLibraries, PO Box 882, Market Road,Chelmsford, Essex, UK

In the late 1990s there has been an explosionof interest in consumer health information;

this workshop explored recent changestemming from the government'sÌnformation for Health' strategy which willput IT at the heart of the NHS. By 2005there will be electronic transfer of patientrecords all over the country and smartcardswill record every detail of our healthcarejourney from the cradle to the grave. Theinformation strategy also proposes a NationalElectronic Library for Health (NeLH) whichwill provide easy access to best currentknowledge on various `knowledge floors' forboth clinicians and patients.

The workshop concentrated on the qualityof health information for consumers and itsdelivery. David Gilbert of the Office of PublicManagement set the scene by describing workdone by the Kings Fund with patient focusgroups to investigate availability and quality ofpatient information using 10 common healthproblems as a sample. Information was oftenfound to be patronizing, out-of-date and notevidence based. Frequently the problemsassociated with treatments were glossed overand the success rates of interventions notconsidered. The Centre for HealthInformation Quality (CHiQ), which is basedat the Help for Health Trust, provided thenext speaker. Working closely with NHSbodies and patient support groups, CHiQ aimsto improve patient information by developingappraisal tools and offering training materialsfor the writing/assessing of health information.Recently the role of the Centre has beenstrengthened to enable it to provide the`patient floor' of NeLH which will be agateway, using high-quality filters, to patientinformation on the Internet. NHS Online, asit will be called, will be a distinct Website fromautumn 1999. Technical information such asclinical guidelines will be included, rewrittento be comprehensible to patients and carers.

Sweden has a highly developed consumerhealth information service. Torbjorn Perssonof Spri, the national resource library for health,gave an impressive account of their Internetdatabases. Ninety per cent of requests fordocuments are supplied within the same day.Health and social care is an integrated function

Meeting Report


of the county councils in Sweden and 41consumer helplines cover the country. JackieChapman described the setting up inNottingham of one of the first NHS Directpilot projects. This government funded nurse-led telephone advice service, has beenenthusiastically received by the public and willbe rolled out over the entire country by theend of the year. During the year 2000 the lesserknown NHS Health Information Service(0800 665544) will be fully integrated withNHS Direct and extensively publicised. It maynot be a freephone service, but we will all have24 h telephone access to advice on dealingwith illness and emergencies plus informationon conditions and treatment and details ofpatient support groups.

In the future, some enquirers might wellgo direct to NHS Direct but libraries canstill expect to be used for in-depthinformation. The NeLH strategy documentpaints a picture of many public librarieshaving a less than reasonable collection ofmedical texts. As NHS On-line develops andas more health information providers,particularly the major patient support groups,adopt CHiQ guidelines for writing theirpublications, the service we all provide inhealth information can only be enhanced.

The last speaker was Roger Stewart from theTelephone Helplines Association (THA). He isthe Quality Development Manager for theAssociation. The THA exists to promote thehighest possible standards for helplines. It has amembers' support unit, a quality unit and atraining unit. The Association produces aleaflet on setting up a new helpline forproviders and a leaflet for the public onconfidentiality. There is also a complaintsprocedure for callers who feel that theyreceived an unsatisfactory service from amember helpline. The phone number of theTelephone Helplines Association is0171 2483388.

ChiQ http://www.centreforhiq.demon.co.uk

NeLH http://www.nelh.nhs.ukTHA http://www.helplines.org.uk

Research

Evidence-based health servicemanagement

JANE FARMER* and DOROTHY WILLIAMSy,*Department of General Practice and PrimaryCare, Aberdeen University, Foresterhill HealthCentre, Aberdeen and ySchool of Information andMedia, Robert Gordon University, Aberdeen

The tidal wave of the evidence-basedmovement has brought an understanding ofthe factors affecting the uptake of researchfindings by clinicians. Less is known aboutthe use of evidence by managers in thehealth service. Clinicians' obligations to useevidence are acknowledged, but what are theobligations of managers and how canevidence be actioned within managementprocesses? Research findings are beginningto appear that shed light on the mysteriousprocesses by which managers make decisionsand the information they use

In 1995 Stocking set out to explain `Whyresearch findings are not used bycommissions and what can be done aboutit'.1 This column will look at three researchpapers exploring different aspects of thisissue. While the findings discussed belong tothe years of the internal market, they stillprovide relevant insights.

Introducing the evidence

Dixon, Booth & Perrett2 exploredcommissioning managers' priority settingprocesses. They aimed to examine howresearch findings were actually used in makingdecisions, and whether introducing evidenceinto the process affected the outcome. In theDistrict Health Authority (DHA) that theyinvestigated, priority setting had five stages: aninitial invitation to providers to submitproposals; an evaluation of the proposalsreceived against criteria of health gain, equity,

Research


contribution to priorities and `quality'; aweighting and ranking of the scores for eachproposal; a multi-professional meeting to rankthe priorities among the scored proposals; andfinal adjustments made later.

While proposers submitted evidence insupport of their proposals, the researchersalso searched for evidence to feed into theevaluation process. The five `best' pieces ofliterature retrieved (determined by thequality of research design) were used to givea `strength of recommendation' score.

Quality research evidence identified by theresearchers was compared with the èvidence'used by the proposers in support of theirbids. Only 7% of the items used byproposers were also chosen as `best availableevidence' by researchers.

Looking at the priority setting process, theresults suggested that evidence probably had aninfluence when assessing health gain, but norelationship was found between researchevidence input and the eventual priority orderof proposals in the DHA purchasing plan. Theresearchers concluded that formal decisionswere made without due consideration of theevidence and that, in any case, many decisionsprobably `bypassed' formal priority setting.They suggested that a more interactiveapproach between researchers/evidence inputsand commissioners might prove more success-ful, but effective means of implementing sucha system would need to be identified.

A question of structure

Dixon, Booth & Perrett concentrated on thestage at which research evidence is formallyintroduced into the decision process. Theyqueried whether stages later in the processmight somehow erode the influence ofevidence. McCarthy looked at the influencesat work in the contracting round,3 and hisarticle provided details of several of thefactors that may intervene to reduce theinfluence of research evidence inmanagement decisions.

McCarthy's overall impression was thatfinancial considerations, in particular the

formal policy structures related to budgetingand contracting, had a strong influence oncommissioning decisions. Public Healthadvice emerged as only one factor in theprocess, introduced early in strategicplanning, and tending to be dissipated bybudget consider-ations and the format offinal decision-making.

While the strategic and priority settingstages of the process were made on a diseaseor health-issue basis, the final stage wasconducted by the provider not byprogramme. Therefore, the way funds wereallocated fitted better with specific providercontracts than it did with provision forspecific health problems. This suggests notso much that research evidence is a weaklink in a `chain' of decision-making, but thatthe `chain' does not exist, i.e. managementdecision-making is not a single, linear,process. Early stages of the commissioningprocess may invite and consider researchevidence, but eventual decisions are made ona different basis, which tends to discountresearch evidence in favour of factors arisingfrom operational matters.

McCarthy's study observed an event thathighlights this issue. The Health Authoritymembers in his study played a simulationgame in which they prioritized health careon the basis of disease prevalence, treatmenteffectiveness and equity. The prioritiesarrived at in the game were compared withthe actual budget allocations for each area,and were found to be very different. So it isnot simply a matter of making the evidenceavailable to decision-makers in a robust andappropriate way: both of the studies we havelooked at so far raise the question of theinteractions and relationships betweenevidence and managers as the decision-making process unfolds.

A matter of trust

The interface between managers and theresearch they commission was the subject ofan exploration by Harries, Elliott & Higgins.4

Examining nine case studies of the

Research


commissioning process, they found thathealth service managers and researchers oftenhave different models of the role of researchevidence, and a variety of local relationshipsemerged as a consequence. They found thatresearch appeared to influence the process ofdecision-making in a nonlinear, iterative way,with the researcher or team influencing themanagers in a developing relationship oftrust, rather than the decision being made onthe basis of an item of evidence introducedat a particular stage.

They concluded that developing theserelationships between research andmanagement may be more important thanformal structures in actioning evidencewithin decision-making. They suggest that itmay be a mistake to concentrate only ondisseminating items of evidence and that theinfluence of research is an ongoing,interactive, interpersonal issue involvingfactors such as trust and having informationavailable at the crucial time. If, as theysuggest, change is the only real certainty forthe NHS in the near future, then how andwhen research findings are introduced intothe process may be as important to theoutcomes of decisions as the quality andcontent of evidence.

In all three of these studies, differentbarriers hindering the influence of evidencewithin management decision processes wereexamined. Research evidence may not beavailable, it may not be considered, or itsimpact may be dissipated by the over-ridinginfluence of other factors.

So returning to Stocking's 1995 title,evidence is beginning to accumulate aboutwhy research findings are not used bycommissioners (and managers generally). Weknow there are barriers to its uptake, but whatcan be done about it? This is a question thatneeds to be tackled if evidence-based healthcare is to include the effective use of evidenceby all staff groups. Much has been written,research conducted and projects developed toimprove the use of evidence by doctors. It isnow time to look at the role of health servicemanagers in evidence-based health care.

References

1 Stocking, B. Why research findings are not used

by commissions and what can be done about it.

Journal of Public Health Medicine 1995, 17(4), 380±2.

2 Dixon, S., Booth, A. & Perrett, K. The application

of evidence-based priority setting in a District

Health Authority. Journal of Public Health Medicine

1997, 19(3), 307±12.

3 McCarthy, M. The contracting round: achieving

health gain or financial balance? Journal of Public

Health Medicine 1998, 20(4), 409±13.

4 Harries, U., Elliott, H. & Higgins, A. Evidence-based

policy-making in the NHS. Exploring the interface

between research and the commissioning process.

Journal of Public Health Medicine 1999, 21(1), 29±36.

Book Reviews

Evidence-Based Health Care Workbookincluding the Evidence-Based HealthCare CD-ROM. Oxford: UpdateSoftware Ltd, 1999. ISBN 1±901868±01-X.76 pp. (plus cd-rom). £35.

As we enter the new millennium all of uswill become de facto librarians of the 21stCentury. However, will we have acquiredthe essential skills of critical appraisalrequired for effective management ofresearch literature, and of small groupteaching, necessitated by increasing demandsfor user education? If your answer fallsanywhere short of a resounding `Yes' thenthis exciting product is for you.

The EBHC Workbook and cd-rom, asbefits their Oxford pedigree, capture the stateof the art of current practice in both findingand appraising the evidence. Taking the userthrough Àsking the Question', `Finding theEvidence', Àppraising a RandomisedControlled Trial' and Àppraising a Review'the course provides an individual with aseamless alternative to an activity otherwisebest practised in groups. Furthermore,helpful supporting tools such as a glossary

Book Reviews


and a `statistics made simple' section are onhand to ease the progression up theotherwise steep learning curve.

In truth the creative input has been focusedon the cd-rom with the book being primarily arepository for offprints and checklists for theappraisal process. Nevertheless I am sure thatthe two-page handout on Building Questionswhich we have already incorporated intovirtually all our teaching sessions is destined tofigure in similar instruction across the country.It is quite simply the most clear and concisepresentation on this topic I have as yetencountered.

Installation of the cd-rom is verystraightforward as one might expect from acompany that has cut its teeth on theCochrane Library software, and this mighthelp to make this a product as much for theward-based workstation as for a cd-rom stackin the hospital library.

If one was to wish to gild this otherwiseperfectly acceptable lily then it would stemfrom the feeling that this package captures,rather than extends, existing practice. This is,however, the rather world-weary view ofsomeone who has been practising criticalappraisal for the last 5 years and probably bearslittle relation to the acknowledged needs of anovitiate spent at the cutting edge. In fact thispackage fills a significant niche in a market thatnecessitates a conservative rather than a radicalapproach and the entrepreneurial spirit that wehave come to associate with its two partnerproducers is seen in its chosen deliverymedium rather than its content. Top of my listof selling points for the cd-rom comes its boldand imaginative use of icons and the intuitivefeel of the interface. Materials have beenselected to appeal to the widest possiblemultidisciplinary audience. In short this willprove a useful addition to any health careenvironment and can serve as either an end-product in its own right or as an invaluablesupport tool for local critical appraisal teaching.In a domain increasingly populated by teachingpackages such as the West Midlands ProjectApple initiative (http://library.hsrc.org.uk/projectapple/) and, dare I mention, the

ScHARR South and West librariesRES&WRCE (http://www.shef.ac.uk/~scharr/reswce/reswce.htm), this seems destined to setthe gold standard to which the rest of us mustaspire.

ANDREW BOOTH

SCHOOL OF HEALTH AND

RELATED RESEARCH

UNIVERSITY OF SHEFFIELD

Copyright: interpreting the law forlibraries, archives and informationservices. 3rd edn. GRAHAM P.CORNISH. London: Library AssociationPublishing, 1999. ISBN 1±85604±344±4.iv, 188 pp. £19.95.

Copyright in health libraries. 3rd edn.SANDY NORMAN. London: LibraryAssociation Publishing, 1999, ISBN 1±85604±323±1. viii, 84 pp. £9.95.

The increasing speed of change in thecopyright field, especially with respect toelectronic copyright and other developmentsarising from EU directives, is reflected bythe publication pattern of these two books.Both were first published in 1990, with asecond edition in 1996 (Norman) and 1997(Cornish), followed rapidly by the presentthird editions.

Graham Cornish's book is set out in theform of about 600 questions and answers. Itis intended to serve as a practical work ofreference for library staff at all levels and inall types of library, providing simple answersto the most common types of copyrightquery. Most of the answers are stated baldly,without specific reference to the legislationor code of practice on which they are based.The strength of this book undoubtedly liesin the definite nature of the answers given,in a field where much advice tendsnecessarily to be qualified and ambiguous.

The book is divided into chapters dealingwith the different types of copyright material(literary, dramatic and musical works, artistic

Book Reviews


works, sound recordings, films and videos,etc.). It is generally easy to establish quicklywhether or not the book contains an answerto any particular query either by scanning therelevant chapter or by consulting the index,which is helpful but perhaps rather short.Since the second edition, the chapter on`Databases and electronic materials' has beensubstantially rewritten to incorporate thenew concept of `Database Right' which wasintroduced into UK law in 1997. Otherchanges seem to be fairly minor.

Sandy Norman's Copyright in HealthLibraries is an introductory guide to UKcopyright law for librarians, aimed specificallyat those working in nonprofit health libraries.Librarians working in profit-based sectorssuch as pharmaceutical companies are referredto Copyright in Industrial and CommercialLibraries, another volume in the series ofLibrary Association copyright guides of whichthis book forms part.

The law and the various codes of practicethat lie behind the bald questions andanswers in Cornish's book are clearlydescribed in Norman's guide, so the twobooks complement each other very well.Also included are a summary of legislativechanges since the 1988 Act and a selection ofcase law, the most recent dating fromNovember 1998, most of which I have notseen collected together in one place before.There is thus a good balance between basicinformation about photocopying limits onthe one hand, and discussion of currentdevelopments on the other. Future editionswould need to appear even more frequentlyin order to maintain this degree of currency.

Most of the material in this book wouldbe relevant to any nonprofit library. Apartfrom brief discussions of journal clubs andof the relationship (or lack of one) betweenthe Copyright Licensing Agency and theNHS, I could find little in it specific to thehealth sector. None of the other volumes inthe Library Association series of copyrightguides are subject-specific, and it might bequestioned whether the health sector reallyrequires its own guide.

Those needing a lot of detail might findRay Wall's optimistically titled CopyrightMade Easier (2nd edn, Aslib, 1998), or theloose-leaf Aslib Guide to Copyright, moreuseful, but taken together these two LibraryAssociation books form an excellent sourceof advice and information about copyright.The preface to Norman's book says that it isintended not just to describe the law, but `topromote respect and understanding ofcopyright'. Certainly neither of thesepublications shy away from giving definiteadvice and recommendations, which I amsure is what many librarians will be seeking.

STEPHEN DALE

CAMBRIDGE UNIVERSITY LIBRARY

SCIENTIFIC PERIODICALS LIBRARY

Exploring the contexts of informationbehaviour. Proceedings of the 2ndInternational Conference on Research inInformation Needs, Seeking and Use inDifferent Contexts, 13/15 August 1998,Sheffield, UK. Edited by T. D. Wilsonand D. K. Allen. London: Taylor Graham,1999. ISBN 0947568 75 1. 625pp. £65.00[paperback].

This volume contains papers from theSecond Conference on Information SeekingIn Context (ISIC2). The conference attractedparticipants from 17 countries, drawnpredominantly from schools of library andinformation science. As with ISIC1,1 theproceedings place an emphasis on researchpresentations that demonstrate rigorousmethodology and conceptual modelling. The42 papers included five keynote addressesand 37 contributed reports grouped togetherinto broad categories. One of these, `TheHealth Services Context', contains sixpapersÐfour from the USA and one eachfrom Spain and the UK. They describestudies into the information-seeking needsand practices, or `human informationbehaviour', of physicians, community nurses

Book Reviews


and medical students, discussing howappropriate methodologies can be developedand applied to suit specific areas ofinvestigation, and reporting the results ofsurveys that employed those methods.

Readers of Health Libraries Review mayinstinctively gravitate first towards thissection, but the proceedings as a whole meritfurther study for the lessons that can belearnt about the research process. Whilesome papers are undoubtedly moretheoretical than others, there is much herethat is potentially valuable for those involvedin, or contemplating, operational library andinformation research, and who wish toensure that their operational investigationsare founded on good methodologyÐà signof maturity in the field', as the editors put it.

References

1 Vakkari, P., Savolainen, R. & Dervin, B.Information seeking in context. Proceedings of anInternational Conference on Research inInformation Needs, Seeking and Use in DifferentContexts, 14±16 August 1996, Tampere, Finland.London: Taylor Graham, 1997.

PETER MORGAN

CAMBRIDGE UNIVERSITY MEDICAL LIBRARY

ADDENBROOKE'S HOSPITAL CAMBRIDGE

The new review of information andlibrary research. Edited by P. BROPHY,Vol. 4. London: Taylor Graham, 1998.ISSN 1361±455X. £65.00 [paperback].

The fourth volume of this annualpublication, which until 1994 was known asthe International Journal of Information andLibrary Research, marks a change of editor,Peter Brophy taking over from StephenRoberts, and a change of direction. Itcontains a selection of papers from theDecember 1998 conference Ìntegrate, Co-operate, Innovate' held in London by theUK's Electronic Libraries Programme (eLib).The conference marked the start of eLibPhase 3, which is devoted to research intohybrid libraries, clumps (large scale resource

discovery systems), digital preservation, andthe development of Phase 1 and 2 projectsinto services. This volume concentrates onthe hybrid library concept, with anintroductory paper and 13 presentations ofresearch projects.

All the projects are based within the UKhigher education sector, reflecting eLib'sprimary remit. Their significance though, aswith earlier eLib projects like OMNI(http://omni.ac.uk/), is far wider. They havebegun to explore issues central to the hybridlibraryÐissues such as resource description;user authentication and authorization;standards and interoperability; scalability andsustainability; and accessibility. All are issuesthat also confront those working outside thehigher education sector on the developmentof information services, whether national inscope like the National electronic Libraryfor Health (NeLH) (http://www.nelh.nhs.uk/) or more localized, that seek tointegrate conventional library resources withnetworked information resources; and in anycase, sectoral boundaries becomeincreasingly irrelevant in the world ofhybrid libraries. Similarly, while the reportsin this volume are not specifically concernedwith health-care information, the underlyingprinciples for the technical models theydescribe, the collaborative structures theyemploy and the user needs they analyse areall relevant to health-care informationstrategies.

PETER MORGAN



Health and British magazines in thenineteenth century. E. M. PALMEGIANO.Lanham, Md. & London: Scarecrow Press,1998. ISBN 081083486 3. 296pp. $59.50

This book is an annotated bibliography ofarticles on health published in the popularBritish periodical press during the nineteenthcentury. The author, Eugenia Palmegiano, is

Book Reviews


Professor of History at Saint Peter's Collegein New Jersey, and President of theAmerican Journalism Historians Association.Professor Palmegiano defines her scope as`wellness as science and society understood itat the time'. She has selected 48 magazinesfrom those included in The Wellesley Index toVictorian Periodicals or Poole's Index to PeriodicalLiterature, all of them notable for theregularity of their writings on the subject ofhealth. While acknowledging that thesemagazines would have a bias towards readersand writers of the middle and upper classes,she argues that their personal and socialperspectives were sufficiently varied andchanging to ensure a broad-based presentationof health issues.

After an introductory essay, thebibliography is arranged alphabetically bymagazine, and under each magazine articlesare listed chronologically with a briefdescriptive annotation. Each list is prefacedby a succinct description of the magazine'sessential character: thus The London QuarterlyReview, `backed by Methodists but not boundto religious texts. . .inspected especiallyepidemics and the evolution of women's rolein community vigor'. Many of the topicscoveredÐdrug abuse, vivisection, exercise,for exampleÐhave a late twentieth centuryring to them; others less so, like the TempleBar article of 1866±7 on `Hippophagy andOnophagy' which advertised thenutritiousness of horse and ass meat.Running throughout these lists is a strongfeeling of political activity, of a popular presscommitted to campaigning for improvementsin living and working conditions as theessential precursor to improved publichealth. (It comes as no surprise to learn thatboth Dickens and Trollope edited magazinesincluded here.) As a source of material forsocial and medical historians, and forstudents of nineteenth century literature, thisbibliography offers rich rewards.

PETER MORGAN



Catalogue of the pre-twentieth centuryholdings in the library of the ReadingPathological Society in the RoyalBerkshire Hospital. Compiled byD. T. O'ROURKE. Reading: ReadingPathological Society, 1999. ISBN 095360900 6. x, 93 pp. £6.00 [paperback].

In the days before postgraduate medicalcentres and libraries became a standardfeature of educational and professional life,their role as meeting places and providers ofstudy resources was largely filled by medicalsocieties. The great national societies andtheir libraries are still a familiar and highlyvalued part of the scene. Less well-knownare the many local societies that flourishedaround the country and that in many casesare still active.

One such is the Reading PathologicalSociety, founded in 1841, later amalgamatedwith the Reading Medico-Chirurgical Society,and closely associated throughout its existencewith the Royal Berkshire Hospital. For manyyears the Society's collection served as thehospital library until a new postgraduatecentre, incorporating a modern library, wasbuilt in 1974. Following refurbishment of theÒld Library' in 1992, the historical collectionhas been recatalogued by DiarmuidO'RourkeÐformerly of Reading UniversityLibrary, where he worked with the ColeLibrary of Early Medicine and AnatomyÐandthis volume is one result.

It records 735 books and manuscripts and34 journals published (with a few exceptions)before 1901. The entries generally followAnglo-American cataloguing rules and arearranged alphabetically by author, with aseparate title list for journals. There areindexes of authors and contributors,provenance and subjects, and some well-chosen illustrations. The devoted historicalbibliographer may regret the absence ofpagination and other physical descriptors, butwill welcome the annotations on provenance.

Although there is a scattering of earlierworks, the greater part of the collectionconsists of nineteenth century publications.

Book Reviews


It has continued to grow through a numberof significant twentieth century donations,but most volumes were presented to theSociety by its members in its early years. Thecatalogue thus provides the social historian ofmedicine with a valuable picture of the

learning resources used by nineteenthcentury medical practice.

PETER MORGAN



Book Reviews


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