Challenging the rhetoric and reality: only an individual and systemic approach will work for evidence-based occupational therapy.

351 During the last decade the evidence-based movement has spread around the world. This is a remarkable achievement. The potential positive impact of evidencebased practice and policy making is unquestionable, particularly on the quality of health care. This is for two prime reasons. First, evidence-based practice supports the ethical imperative to “do no harm.” There is now an increased probability that individuals will receive health care that benefits them with greater protection from harmful interventions (Smith, Ebrahim, & Frankel, 2001). The second reason is related to the need to know what works, whether at the level of specific interventions, care packages, or whole services. This means that there is an equal imperative to generate robust research of clinical and cost effectiveness. Yet, there has been much deliberation within this forum, and elsewhere, about the rhetoric and reality of evidence-based practice. The debate has focused upon methodological and pragmatic factors (Ballinger & Wiles, 2001; Christiansen & Lou, 2001). For example, one debate has been about whether systematic reviews and meta-analyses of randomised controlled trials, which give the numbers needed to treat or harm or both, can enhance the clinical reasoning process when working with people with complex, enduring health problems and occupational needs. There is also the task of persuading health care professionals to change their treatment approaches and use research to confirm or refute their routine practice. In this paper I hope to extend the debate by introducing a dualistic approach to evidence-based practice. This dualism involves placing the traditional, individual practitioner-focused strategies within an organizational framework of service improvement. I will argue that a twin focus upon individuals and the whole system is necessary if evidence-based occupational therapy is to become a reality. The National Health Service (NHS) in England provides a model of how evidencebased practice has evolved. During the last few years there has been a significant shift from individual approaches towards a whole system of service improvement across primary, secondary, and community care. I will describe the key features of each approach—individual and systemic—and provide examples from the current quality framework (as shown in Figure 1) to illustrate the system of setting, supporting, and monitoring national standards of care. I am sure that other countries may learn lessons from our experience in England.