From Lucy Selman, the Revd Peter Speck, and Vicky Simms
Sir, — We thank Robert Stovold for his response (Letters, 8 April) to our letter of 18 March regarding the National Secular Society’s (NSS’s) report on chaplaincy. We welcome interest in the important area of spiritual care research, and would like to reflect on his main points.
Mr Stovold states that our view that the NSS report takes absence of evidence of effect as evidence of absence of effect is not supported. We apologise to the NSS if we misunderstood their position, and are gratified that they recognise that their study does not show chaplaincy services to be ineffective.
The NSS report’s conclusion, however, that “there is no evidence that an increased proportion of income spent on chaplaincy results in improvements in quality” is wrong, because it has looked for evidence of improvements in quality in a place where evidence could not possibly be found. The issue here is not whether chaplaincy is effective or not, but rather that the methods used do not allow us to know the answer to that question. The outcome measures used are not appropriate.
Mr Stovold argues that these outcome measures, despite their limitations, are the best available tools by which to compare chaplaincy services between all Trusts. That does not mean that they are worth using for the purpose. Rather, it shows that a comparative approach using routine data is not a viable study design to determine the effectiveness of chaplaincy.
In an era of patient-centred care, outcomes that take into account patients’ experiences of illness are crucial. Our quoting of the Standards for Better Health commitment to holistic outcomes was meant to highlight this point, and not refer to the ability of the Standards to assess them, which the Standards are not designed to do. As Mr Stovold recognises, the Standards are quality benchmarks, not an outcome-assessment tool.
Effectiveness should be studied by assessing the primary clinical outcomes that one would expect to be affected by chaplaincy, such as satisfaction with care and the prevalence and burden of psychological and spiritual distress (e.g. feeling at peace, having a sense of meaning). Validated assessment tools with specific psychometric properties have been developed to measure these outcomes.
In our research area, palliative care, several studies have used these kinds of outcome measures to evaluate spiritual-care interventions [e.g. 1-3]. This was not done in the NSS study.
We wholeheartedly agree that good-quality research is lacking in the area of spiritual care, and as social scientists we are keen to correct this neglect. Spiritual care is a complex intervention, however, and cannot be studied in the same way as a pharmacological drug; a double-blind RCT is, of course, impossible, just as it is for other complex interventions, such as psychotherapy. But the Medical Research Council (MRC) provides clear guidelines for the evaluation of complex interventions . Key to the approach is unpicking and understanding the different ingredients of an intervention in order to determine which aspects to evaluate and which outcomes to use.
One of the first steps in the MRC framework is conducting a comprehensive systematic review of the evidence in the field. One of us (Speck) is involved in a Cochrane review of spiritual care interventions in end of life care. This review will highlight what is known in this area, gaps in the evidence and directions for further research. Preliminary findings suggest that pastoral care discussions, a key component of chaplaincy, are an effective aspect of spiritual-care interventions [5, 6].
If the NSS are interested in the effectiveness of chaplaincy, a better option than their adopted methodology would have been to conduct a similar systematic review of studies of spiritual and religious care interventions in healthcare, or to design and execute a study evaluating a chaplaincy-based intervention following the MRC framework. Both of these approaches we would applaud and support.
The current study, however, is not a useful contribution to the field, owing to its methodological limitations. We would expect that the reviewers of any peer-review scientific journal would have similar concerns to ours, as our criticisms are based on scientific considerations, not personal belief.
Department of Palliative Care,
Policy and Rehabilitation
King’s College, London
Cicely Saunders Institute
King’s College, London
London SE5 9PJ
 Chochinov, H. M., et al. (2005), “Dignity therapy: a novel psychotherapeutic intervention for patients near the end of life”, Journal of Clinical Oncology, 23(24), 5520-5525.
 Hall, S., et al. (2009), “Assessing the feasibility, acceptability and potential effectiveness of Dignity Therapy for people with advanced cancer referred to a hospital-based palliative care team: Study protocol”, BMC Palliat Care, 8: 5.
 Breitbart, W., et al. (2010), “Meaning-centered group psychotherapy for patients with advanced cancer: a pilot randomized controlled trial”, Psychooncology, January 2010; 19(1):21-8.
 Medical Research Council (2008), Developing and Evaluating Complex Interventions: New guidance.
 Candy, B., et al., “Spiritual and religious interventions for adults in the terminal phase of disease”, Marie Curie Annual Research Conference, Royal Society of Medicine, London, UK, 26 March 2010.
 Nolan, S. (2011), “Hope beyond (redundant) hope: how chaplains work with dying patients”, Palliative Medicine 25(1), 21-25.