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Continuing to
Were you at the conference in Edinburgh? I wonder what challenges you came away with. I felt there were four key messages: 1. Evidence based practice is a process of different actions 2.There are different levels of evidence 3.The researcher may be a different person to the consumer of evidence 4. Real evidence based practice requires collaborative networks across our profession. But what do they mean in practice?

Delegates at a European Congress were asked to consider the challenge of evidence based practice for the speech and language therapy profession. Frances Harris dissects the proceedings, and suggests where we go from here.

1. The process
Evidence based practice for me includes the following steps:
The question Finding the evidence AND / OR Generating the evidence Dissemination Apply validated ideas Should I use therapy x? How can I measure y? Literature search Critical appraisal techniques Summary of findings from the literature Design and execute a therapy trial / test an assessment tool Discussing findings Decision making informed by evidence as well as by clinical insights

A question is always the beginning for an enquiry into the literature. Typically it takes the form should I use therapy X (or Y)? or How can I measure (change in) X? Then either the literature addressing that question can be scrutinised, or some new evidence needs to be generated. The conference papers were often about therapy or assessment evaluations. Some papers instead were about the critical appraisal process. (Here we can commend Hanneke Kalf of the Netherlands for a whistle stop tutorial in summary statistics and critical appraisal techniques; I imagine only a few understood all of her notation.) Others spoke about the need to integrate the literature with clinical judgement and insights: memorably noting that what makes the speech and language therapist wise is not just expert knowledge of their domains but an understanding of the issues of the human condition. There were also poster presentations dealing with clinical decision making. Yet none of the papers I attended actually talked about case studies or examples of the application of evidenced-based ideas.

CPLOL is the Comit Permanent de Liaison des Orthophonistes-Logop` edes de lUnion Europenne, in other words the organisation for speech and language therapists across Europe. Its 5th European Congress, entitled Evidence-based Practice: a challenge for speech and language therapists, was held in conjunction with the UK professional body the Royal College of Speech & Language Therapists in Edinburgh from 5-7 September, 2003, .

case reviews and expert opinion. Sylvia TaylorGoh of the Royal College of Speech & Language Therapists gave a helpful overview of an evidence hierarchy for evaluating literature. Different levels of evidence address different types of questions. It is not simply a case of sighing over our fields lack of randomised controlled trials, and then saying that we cannot do evidence based practice as a result. One level of evidence may be a stepping stone towards developing practice even if it is not top-notch evidence. The face validity and clinical acceptability of some more recent therapy innovations has as much to do with their take up as the supporting evidence with which they were launched.

change? With this concept some people are the researchers and others are the consumers of research. What is needed is not more polymaths but more networking between teams. Then the practitioners will be enabled to have a practice based on evidence.

4. The collaboration
The issue of who does what can only really be addressed at the highest levels. We have excellent training centres, strong researchers and research centres, many teams of practitioners and even funding opportunities awaiting us. The next stage for the profession has to be integrating these sometimes remote corners of our field into collaborative networks. These ideas can be extended not just nationally but internationally: otherwise what is the point of having CPLOL and the Royal College of Speech & Language Therapists meet together? In terms of strengths, the most obvious characteristic of the conference was its diversity. There were delegates from all over Europe and some from further afield as well. Simultaneous translation into French or English was professional and

3. The people
Given the several steps within the evidence based practice process, and the many different ways of gathering or demonstrating evidence, it is clear that not every speech and language therapist can carry all these roles. Some are born to it, and some achieve it, but others object to being thrust into all of it. Why not let the Thinkers pose the questions, the Methodical gather the data, the Clinically Wise introduce a debate and process of

2. The levels
The concept came through that there are different levels of evidence which have acceptability for practice. Not just the randomised controlled trials, but treatment delay / withdrawal group trials, experimental group studies, individual case studies,

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climb
impressive, taking into its stride all sorts of jargon. The diversity of people and languages was seen also in the range of poster presentations and speakers. The posters were generally of a high standard; not only well displayed, but also showing clear thinking. The conference benefited from a strong foundation of good organisation and clear communication. The room allocations worked well, with advance selection of seminars by the delegates proving very helpful. When not in the conference centre, Edinburgh provided well for social possibilities, even when a major rugby match with Ireland seemed to take over many restaurants capacities. Informal discussions and meeting old colleagues were a real bonus of the weekend for me. As well as the three keynote speakers, there were numerous presentations to smaller groups, with parallel sessions running concurrently. Here the range of topics was wide, but so also was the quality. The unfortunate Frenchman with only a one per cent return rate on his questionnaire struggled to maintain credibility as he went into detailed analysis of his results. Audiences were provided with a CD file of the presentations. In practice this meant (without my laptop) that I could not read abstracts or texts in advance, and audiences could only think of discussion questions at the time of the presentation. Over the refreshments and meal times, international huddles were rare; my impression was that delegates tended to stay in their cultural groups. I also felt that there was insufficient time or opportunity to draw together the ideas from the conference. The concluding round table discussion (in fact an oblong dias for the keynote speakers) for me should have been at the beginning of the weekend: it worked well to open up debate and could have been used to draw out key messages to a much greater extent. I came away with these challenges: Who takes the lead at different points in the evidence based practice process? How can we promote collaboration between therapists and research teams? How can we be more transparent about applying evidenced-based ideas to practice? How can we achieve cross-national discussion of ideas, evidence and practice? The sound bite of the weekend, however, goes to Kath Williamson: Evidence based practice should be a climbing frame and not a cage. I want to continue to climb. Frances Harris is a speech and language therapist with the Sure Start speech and language development project at City University, London. Further thoughts on the conference from editor Avril Nicoll at www.speechmag.com.

e mails to the editor

21 October 2003 Dear Avril, One of the many ways of communicating with people is through the written word. Professional posters at conferences are one form of communication for which guidelines may be drawn up. These give advice on how to catch the eyes and interest of the passing audience. At another level of communication, instructions may need to be given in writing to someone with a learning difficulty or with dementia. Mencap has already produced very helpful guidelines for accessible writing, available as a pdf file through its website (www.mencap.org.uk). This is clearly directed at a specific audience, although interestingly contains some good advice for poster presenters! At the Dementia Services Development Centre, University of Stirling, we are considering a similar production but geared to people with dementia. Lest duplicating work already done, does anyone know of an existing text that provides guidance for those needing to communicate in writing with people with dementia? Or should we develop guidelines on writing in a way that is clearly understood by this group of people? Responses would be welcome by staff at the Centre and to Marion Munro in the first instance. Marion Munro Publications Coordinator Dementia Services Development Centre University of Stirling Stirling FK9 4LA Tel: 01786 467740 Fax: 01786 466846 Email: m.g.munro@stir.ac.uk

15 October, 2003 Dear Avril, I was interested to find your website, and wondered if you are aware of the ground breaking research conducted by Professor Sue Buckley at The Down Syndrome Educational Trust (www.downsed.org) in Portsmouth? They have established, through peer reviewed research, the enormous benefit of early reading (preschool reading, as young as 2 or 3 years) in helping develop speech and language in children with Down syndrome. (Some preschool children are demonstrating a capable level of reading and comprehension before they can even speak.) DownsEd are recognised worldwide as a Centre of Excellence and regularly have people travel from overseas to attend their workshops and training days for parents and professionals. (They also conduct workshops specifically for speech and language therapists). They publish a wide range of information booklets in their Issues and Information Series, and they produce speech and language resource materials which, in the early years, we have found invaluable in developing our daughters speech and language. With their help, through training workshops and also by having our daughter attend their Early Development Classes, our daughter was reading before she started school aged 41/2 years, and now aged 7 she is still reading at a level one year ahead of the level expected for typically developing children of her age. (I know of several other children with Down syndrome who have also excelled in reading.) Along with the sound card resources, early reading has had an enormous benefit on the development of speech and language for our daughter. I am a grateful parent and, looking through your website, I hoped that our experiences may be of interest to speech and language therapists generally. Kind Regards, Greg Sneath

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003