I Think You'll Find It's a Bit More Complicated Than That (26 page)

Randomisation, in a trial, adds one simple extra chink to this existing variation: we need a group of schools, teachers, pupils or parents who are able to honestly say: ‘We don’t know which of these two strategies is best, so we don’t mind which we use. We want to find out which is best, and we know it won’t harm us.’

This is a good example of how gathering good evidence requires a culture shift, extending beyond a few individual randomised trials. It requires everyone involved in education to recognise when it’s time to honestly say ‘We don’t know what’s best here.’ This isn’t a counsel of despair: in medicine, and in teaching, we know that most of what we do does some good (if we’re not better than nothing, then we’re all in big trouble!). The real challenge is in identifying what works the best, because when people are deprived of the best, they are harmed too. But this is also a reminder of how inappropriate certainty can be a barrier to progress, especially when there are charismatic people who claim they know what’s best, even without good evidence.

Medicine suffered hugely with this problem, and as late as the 1970s there were notorious confrontations between people who thought it was important to run fair tests, and ‘experts’, who were angry at the thought of their expertise being challenged and their favourite practices being tested. Archie Cochrane was one of the pioneers of evidence-based medicine, and in his autobiography he describes many battles he had with senior doctors, in glorious detail. In 1971, Cochrane was concerned that coronary care units in hospitals might be no better than home care, which was the standard care for a heart attack at the time (we should remember that this was the early days of managing heart attacks, and the results from this study wouldn’t be applicable today). In fact, he was worried that hospital care might involve a lot of risky procedures that could even, conceivably, make outcomes worse for patients overall.

Because of this, Cochrane tried to set up a randomised trial comparing home care against hospital care, despite great resistance from the cardiologists. In fact, the doctors running the new specialist units were so vicious about the very notion of running a trial that when one was finally set up, and the first results were collected, Cochrane decided to play a practical joke. These initial results showed that patients in coronary care units did worse than patients sent home; but Cochrane switched the numbers around, to make it look as if patients on CCUs did better. He showed the cardiologists these results, which reinforced their belief that it was wrong of Cochrane even to dare to try running a randomised trial of whether their specialist units were helpful. The room erupted: ‘They were vociferous in their abuse: “Archie,” they said “we always thought you were unethical. You must stop this trial at once.” … I let them have their say for some time, then apologised and gave them the true results, challenging them to say as vehemently, that coronary care units should be stopped immediately. There was dead silence and I felt rather sick because they were, after all, my medical colleagues.’

Similar confrontations are reported in many fields, when people try subjecting ideas and practices to fair tests, in randomised trials. But being open and clear about the need for research – when there is no good evidence to help us choose between interventions – is also important, because it helps make sure that research is done on relevant questions, meeting the needs of teachers, pupils and parents. When everyone involved in teaching knows a little about how research is done – and what previous research has found – then we can all have a better idea of what questions need to be asked next.

But before we get on to how this can happen, we should first finish the myths about trials. From now on, these are all cases where people overstate the benefits of trials.

For example, sometimes people think that trials can answer everything, or that they are the only form of evidence. This isn’t true, and different methods are useful for answering different questions. Randomised trials are very good at showing that something works; they’re not always so helpful for understanding
why
it worked (although there are often clues when we can see that an intervention worked well in children with certain characteristics, but not so well in others). ‘Qualitative’ research – such as asking people open questions about their experiences – can help give a better understanding of how and why things worked, or failed, on the ground. This kind of research can also be useful for generating new questions about what works best, to be answered with trials. But qualitative research is very bad for finding out whether an intervention has worked. Sometimes researchers who lack the skills needed to conduct or even understand trials can feel threatened, and campaign hard against them, much like the experts in Archie Cochrane’s story. I think this is a mistake. The trick is to ensure that the right method is used to answer the right questions.

A related issue involves choosing the right outcome to measure. Sometimes people say that trials are impossible, because we can’t capture the intangible benefits that come from education, like making someone a well-rounded member of society. It’s true that this outcome can be hard to measure, although that is an argument against any kind of measurement of attainment, and against any kind of quantitative research, not just trials. It’s also, I think, a little far-fetched: there are lots of things we try to improve that are easy to measure, like attendance rates, teenage pregnancy, amount of exercise, performance on specific academic or performance tests, and so on.

However, we should return to the exaggerated claims sometimes made in favour of trials, and the need to be a critical consumer of evidence. A further common mistake is to assume that, once an intervention has been shown to be effective in a single trial, then it definitely works, and we should use it everywhere. Again, this isn’t necessarily true. Firstly, all trials need to be run properly: if there are flaws in a trial’s design, then it stops being a fair test of the treatments. But more importantly, we need to think carefully about whether the people in a trial of an intervention are the same as the people we are thinking of using the intervention on.

The Family Nurse Partnership is a programme that is well funded and popular around the world. It was first shown to be effective in a randomised trial in 1977. The trial participants were white mothers in a semi-rural setting in upstate New York, and people worried at the time that the positive results might have been exceptional, and occurred simply because the specific programme of social support that was offered had suited this population unusually well. In 1988, to check that the findings really were applicable to other settings, the same programme was assessed using a randomised trial in African-American mothers in inner-city Memphis, and was again found to be effective. In 1994, a third trial was conducted in a large population of Hispanic, African-American and Caucasian mothers from Denver. After this trial also showed a benefit, people in the US were fairly certain that the programme worked, with fewer childhood injuries, increased maternal employment, improved ‘school readiness’, and more.

Now the Family Nurse Partnership programme is being brought to Britain, but the people who originally designed the intervention have insisted that a randomised trial should be run here, to see if it really is effective in the very different setting of the UK. They have specifically stated that they expect to see less dramatic benefits here, because the basic level of support for young families in the UK is much better than that in the US: this means that the difference between people getting the FNP programme and people getting the normal level of help from society will be much smaller.

This is just one example of why we need to be thoughtful about whether the results of a trial in one population really are applicable to our own patients or pupils. It’s also an illustration of why we need to make trials part of the everyday routine, so that we can replicate them in different settings, instead of blindly assuming we can use results from other countries (or even other schools, if they have radically different populations). It doesn’t mean, however, that we can never trust the results of a trial. This is just another example of why it’s useful to know more about how trials work, and to be a thoughtful consumer of evidence.

Lastly, people sometimes worry that trials are expensive and complicated. This isn’t necessarily true, and it’s important to be clear what the costs of a trial are being compared against. For example, if the choice is between running a trial, and simply charging ahead, implementing an idea that hasn’t been shown to work – one that might be ineffective, wasteful, or even harmful – then it’s clearly worth investing some time and effort in assessing its true impact. If the alternative is doing an ‘observational’ study, which has all the shortcomings described above, then the analysis can be so expensive and complex – not to mention unreliable – that it would have been easier to randomise participants to one intervention or the other in the first place.

But the mechanics and administrative processes for running a trial can also be kept to a minimum with thoughtful design, for example by measuring outcomes using routine classroom data that was being collected anyway, rather than running a special set of tests. More than anything, though, for trials to be run efficiently, they need to be part of the culture of teaching.

Making evidence part of everyday life

I’m struck by how much enthusiasm there is for trials and evidence-based practice in some parts of teaching; but I’m also struck that much of this enthusiasm dies out before it gets to do good, because the basic structures needed to support evidence-based practice are lacking. As a result, a small number of trials are done, but these exist as isolated islands, without enough bridges joining the people and strands of work together. This is nobody’s fault: creating an ‘information architecture’ out of thin air is a big job, and it might take decades. The benefits, though, are potentially huge. Some individual randomised trials from the UK have produced informative results, for example, but these results are then poorly communicated, so they don’t inform and change practice as well as they might.

Because of this, I’ve sketched out the basics of what education would need, as a sector, to embrace evidence-based practice in a serious way. The aim – which I hope everyone would share – is to get more research done, involving as many teachers as possible; and to get the results of good-quality research disseminated and put into practice. It’s worth being clear, though, that this is a first sketch, and a call to arms. I hope that others will pull it apart and add to it. But I also hope that people will be able to act on it, because structures like these in medicine help capture the best value from the good work – and hard work – that is done all around the country.

Firstly – and most simply – it’s clear that we need better systems for disseminating the findings of research to teachers on the ground. While individual studies are written up in very technical documents, in obscure academic journals, these are rarely read by teachers. And rightly so: most doctors rarely bother to read technical academic journals either. The
British Medical Journal
has brief summaries of important new research from around the world; and there is a thriving market of people offering accessible summary information on new ‘what works’ research to doctors, nurses and other healthcare professionals. The US government has spent vast sums of money on two similar websites for teachers: ‘Doing What Works’, and the ‘What Works Clearing House’. These are large, with good-quality resources, and they are written to be relevant to teachers’ needs, rather than dry academic games. While there are some similar resources in the UK, these are often short-lived, and on a smaller scale.

For these kinds of resources to be useful at all, they then need to land with teachers who know the basics of ‘how we know’ what works. While much teacher training has reflected the results of research, this evidence has often been presented as a completed canon of answers. It’s much rarer to find all young teachers being taught the basics of how different types of research are done, and the strengths and weaknesses of each approach on different types of question (although some individual teachers have taught themselves on this topic, to a very high level). Learning the basics of how research works is important, not because every teacher should be a researcher, but because it allows teachers to be critical consumers of the new research findings that will come out during the many decades of their career. It also means that some of the barriers to research that arise from myths and misunderstandings can be overcome. In an ideal world, teachers would be taught this in basic teacher training, and it would be reinforced in Continuing Professional Development, alongside summaries of research.

In some parts of the world, it is impossible to rise up the career ladder of teaching without understanding how research can improve practice, and publishing articles in teaching journals. Teachers in Shanghai and Singapore participate in regular ‘Journal Clubs’, where they discuss a new piece of research, and its strengths and weaknesses, before considering whether they would apply its findings in their own practice. If the answer is no, they share the shortcomings in the study design that they’ve identified, and then describe any better research that they think should be done on the same question.

This is an important quirk: understanding how research is done also enables teachers to generate new research questions. This, in turn, ensures that the research which gets done addresses the needs of everyday teachers. In medicine, any doctor can feed up a research suggestion to NIHR (the National Institute for Health Research), and there are organisations that maintain lists of what we don’t yet know, fed by clinicians who’ve had to make decisions, without good-quality evidence to guide them. But there are also less tangible ways that this feedback can take place.

Familiarity with the basics of how research works also helps teachers to get involved in research, and to see through the dangerous myths about trials being actively undesirable, or even ‘impossible’, in education. Here, there is a striking difference with medicine. Many teachers pour their heart and soul into research projects which are supposed to find out whether something worked; but in reality the projects often turn out to be too small, being run by one person in isolation, in only one classroom, and lack the expert support necessary to ensure a robust design. Very few doctors would try to run a quantitative research project alone in their own single practice, without expert support from a statistician, and without help from someone experienced in research design.