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A matter of Quality, not Quantity
- Woody Caan (6 December 2003)
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Funders and researchers do have responsibility for dissemination
- Paul M Wilson, Rachel Richardson, Alison Booth, Frances Sharp (10 December 2003)
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Increasing the impact of health service research - the definitive solution
- David Kernick (10 December 2003)
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Examples of innovative efforts to increase the impact of health services research
- Naomi J. Fulop, Stuart Anderson, Nick Goodwin, Pauline Allen, Pamela Baker, Nick Black, Aileen Clarke, Alan Burns, and Malcolm Lowe-Lauri. (11 December 2003)
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Building bridges
- Steffi Williams (12 December 2003)
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Need to acknowledge current achievements
- Gillian Parker, Professor Sir John Pattison (12 December 2003)
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A message for research funders and journal editors
- Alexander M Clark (12 December 2003)
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Improve undergraduate education and strengthen the role of nursing to increase the impact of health services research
- Fiona A Alderdice, Jackie Parkes, Senior Lecturer in Nursing (22 December 2003)
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Increasing the Impact of Health Services Research: some additional lessons learned in Scotland
- Guro O Huby, Sally Wyke, Scottish School of Primary Care, Gill Hubbard, Community Based Sciences University of Glasgow, Markus Themessl Huber, School of Nursing and Midwifery University of Dundee, Maureen McElroy, Dpt of Nursing and Midwifery University of Stirling (30 December 2003)
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Integration of research and service delivery
- Jeremy P Gray, Amy Scammell, Helen Walley, Andrew Neil. (31 December 2003)
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Woody Caan, Professor of public health APU, Chelmsford, Essex CM1 1SQ, UK
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First a confession: in relation to the question "are the results being communicated to and applied by the people who need them?" (1)I personally have, often, failed to communicate properly my findings about primary health care services. For example, the last time I submitted some health service research to Br J Gen Pract, the two reviewers responded "if this is the new research, give me the old research every time!" and "does God love General Practice?". Sometimes health services research (HSR) is junked because it is rubbish science, sometimes because it is incomprehensible, but most often because it appears useless - to the policy makers and managers who have to run a million employee National Health Service (NHS) for 57 million possible patients. Now, thanks to an inspiring discussion with the 'Children's Czar' Al Aynsley-Green (South East Public Health Observatory conference 28 November 2003), I have seen the light. In considering HSR to develop children's services, the topic came up of 1000 sudden deaths annually in young people with epilepsy (2). The NHS will never reduce deaths in this population until we learn to incorporate into 'service' research what it means to a school leaver with no qualifications, social isolation and poor prospects, to have a history of epilepsy. There is already abundant, useful clinical research on epilepsy (3): the fog of ignorance prevents our putting the delivery of effective clinical care into what the Chief Nursing Officer calls The Patient Journey or the Social Exclusion Unit calls young people's Life Chances. The BMJ has done an excellent job in communicating the concerns of the Academy of Medical Sciences (4) about the shrinking quantity of clinical research for the needs of our NHS. The fundamental weakness of British HSR is one of quality: we keep skimming the surface of problems around service delivery but we avoid the deep issues around the way organisations fail to build an alliance with so many of their patients and, indeed, what job these 'health' organisations really exist to do. This winter a storm of fog and fury is building up about one of the major primary care services: Health Visiting. Changes in legislation, regulation, education and employment threaten the unravelling of a 102 year old service for families. Before Dr. Traynor brought his skills and experience to the Health Foundation, he happened to be a health visitor. Might I suggest that a good Test Case, for the Health Foundation's aim of improving HSR, would be groundbreaking "collaborative" (1) research on the sort of home visiting service that both British families would find useful and the Department of Health could deliver? 1 Dash P, Gowan N, Traynor M. Increasing the impact of health services research. BMJ 2003; 327: 1339-1341. 2 Caan W. Epilepsy, early death and learning disabilities. http://bmj.com/eletters/326/7385/349#29786 19 February 2003. 3 Pedley TA, Hauser WA. Sudden death in epilepsy: wake-up call for management. Lancet 2002; 359: 1790-1791. 4 Bell J. Resuscitating clinical research in the United Kingdom. BMJ 2003; 327: 1041-1043. Competing interests: Practitioner-academician of the Academy of learned societies for the Social Sciences |
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Paul M Wilson, Research Fellow Centre for Reviews and Dissemination, University of York, York, UK, YO10 5DD, Rachel Richardson, Alison Booth, Frances Sharp
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The lack of responsibility for dissemination amongst funders and researchers(1) may reflect a lack of understanding about what dissemination actually entails. For many, dissemination is often used to describe implementation activities, rather than viewed as an important awareness raising activity in its own right. At CRD, we have always tried to ensure that our approach to dissemination takes account of the ways by which different audiences become aware of, receive, access, read and use research findings. If researchers are to repackage their outputs in ways that suit the needs of the end user (and we think they should), these issues have to be addressed. Given this, funders need to recognise that if the communication of research findings is to be improved, dissemination activities need to be adequately resourced. (1) Dash P, Gowan N, Traynor M. Increasing the impact of health services research. BMJ 2003; 327: 1339-1341. Competing interests: we all have responsibility for promoting the findings of research |
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David Kernick, General Practitioner St Thomas Health Centre, Exeter EX4 1HJ
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The recent report from the Health Foundation and the Nuffield Trust featured in last week's BMJ (1) confirmed what practitioners have known for years - the history of health service research has been characterised by an overwhelming volume of literature that has an impercievable impact on those who actually get on and do the work. The focus has been on an examination of why evidence is not accommodated into practice and how the barriers to implementation can be reduced. The fact that the evidence- based product may not be relevant to those at who it is directed had not until recently been considered a possibility. A useful analytical framework to address the problem is provided by the concept of "communities of practice." This refers to a description of relating that occurs through particular activities or practices undertaken by a group of people that facilitates their sharing of knowledge and negotiating of meaning amongst them (2). Communities of practice consist of three structural elements: practice - the set of ideas, tools and documents that they share; community - the environment in which people interact, learn and build relationship; domain - know-how or highly specialised professional expertise. Although knowledge is transmitted effectively within communities of practice, it does not pass well across their boundaries. Therefore, the current emphasis is on managing the interface, examining why evidence is not accommodated into practice and how the barriers to implementation can be reduced (3). But more useful solutions may be obtained by closer scrutiny of the academic community. Despite the rhetoric and some methodological development, university institutions hold themselves as the highest legitimising body for valid knowledge. They remain committed to a particular epistemology that fosters selective inattention to the problems of the real world. Research is viewed as “a retail store in which researchers are busy filling shelves with a comprehensive set of all possible relevant studies that a decision maker might someday drop by to purchase"(4). The academic community of practice is consolidated within a hierarchical structure that inhibits flexibility and innovation. Where funding spirals, assessment exercises, and internal politics divorce activity from the real world. The only way to increase the impact of research in the NHS is to close down the university departments of health service research and send their staff into the trenches. REFERENCES: 1. Dash P, Gowman N, Traynor M. Increasing the impact of health service research. BMJ 2003;327:1339-41. 2. Wenger E. Communities of practice. Cambridge University Press: Cambridge, 1998. 3. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of changing patients care. Lancet 2003 ;362:1225- 30. 4. Lomas J. Connecting research and policy. Can J Policy Res 2000;1:140- 144. Competing interests: None declared |
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Naomi J. Fulop, Director, National Co-ordinating Centre for NHS Service Delivery and Organisation R&D London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, Stuart Anderson, Nick Goodwin, Pauline Allen, Pamela Baker, Nick Black, Aileen Clarke, Alan Burns, and Malcolm Lowe-Lauri.
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Dash and colleagues (1) and Lomas (2) rightly point out that there is much to gain by increasing the relevancy and use of health services research. Dash et al draw attention to the initiatives carried out by the NHS Service Delivery and Organisation (SDO) R&D Programme in England and the Canadian Health Services Research Foundation in Canada to set a relevant research agenda by ‘listening’ to a wide range of key stakeholders (3). It is important to recognise that this involvement of stakeholders should not end at the ‘listening’ phase so that the continuing relevance of the research is ensured and it is communicated in effective ways. The SDO Programme has attempted to involve stakeholders throughout the whole process of defining topics, selecting proposals, creating evidence, and translating research into knowledge to inform decision- making. Managers, health care professionals, user representatives, as well as academic researchers, are members of the SDO Programme Board advising on strategic direction, and serve as members of commissioning groups that select proposals and advise on communicating the findings. Research findings are communicated in a range of ways identified by users as highly effective, such as briefings written by ‘expert communicators’ in consultation with researchers. Other initiatives include the establishment of a forum for NHS chief executives to learn about research findings and listen to their needs for research. The SDO Programme has commissioned a wide range of research around the themes arising from the listening exercise to address the needs of the NHS, which include access to services, organisational change, and the health care workforce. Just a few examples of the highly relevant research being funded by the SDO Programme include a review of the literature on reducing attendances and waits in accident and emergency, and empirical studies including an evaluation of Diagnostic and Treatment Centres (DTCs) and an evaluation of new models of configuring acute services locally which are attempts at balancing access and quality (more information is available at www.sdo.lshtm.ac.uk). Despite this, more needs to be done. The current increase in funds for the NHS has not been matched by an increase in NHS R&D funds, when arguably the need for research is even greater. While we share the belief that partnerships between research funders, researchers and decision-makers will increase the impact of health services research (4), this needs to be demonstrated through rigorous evaluation. In addition, we need to understand which strategies are successful in increasing the impact of health services research and in which contexts (5). Naomi Fulop, Director Stuart Anderson, Senior Lecturer in Organisational Behaviour Nick Goodwin, Senior Lecturer in Health Service Delivery and Organisational Research Pauline Allen, Lecturer in Organisational Research Pamela Baker, Programme Manager National Co-ordinating Centre for NHS Service Delivery and Organisation R&D, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT Nick Black, Professor of Health Services Research London School of Hygiene and Tropical Medicine Aileen Clarke, Reader in Health Services Research Queen Mary, University of London Alan Burns, Chief Executive, Trent Strategic Health Authority Malcolm Lowe-Lauri, Chief Executive, Kings College Hospital NHS Trust 1 Dash P, Gowan N, Traynor M. Increasing the impact of health services research. BMJ 2003; 327: 1339-1341. 2 Lomas J. Health services research. BMJ 2003; 327(7427): 1301 - 1302. 3 Lomas J, Fulop N, Gagnon D, Allen P. On being a good listener: setting priorities for applied health services research. Milbank Quarterly 2003; 81(3): 363-88. 4 Journal of Health Services Research and Policy 2003; 8 (supplement 2). 5 Lavis J, Ross S, McLeod C, Gildiner A. Measuring the impact of health research. Journal of Health Services Research and Policy 2003; 8(3): 165- 170. Competing interests: Fulop, Anderson, Goodwin, Allen and Baker work for the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSDO), Black is grant-holder for NCCSDO, Clarke undertakes work for NCCSDO, Burns is Chair and Lowe-Lauri is member of the SDO Programme Board. |
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Steffi Williams, Senior Lecturer, UWCM & Director Research & Professional Development, Centre for Health Leadership W PGMDE School, University of Wales College of Medicine, Heath Park, Cardiff CF14 4XN
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EDITOR:-Increasing the impact of health services research BMJ vol 327 6 December 2003 Recent research carried out across the public service delivery and academic sectors in Wales identifies similar barriers to translating research evidence into improved practice as those identified by Dash et al (Increasing the impact of health services research 6 Dec03). Our research canvassed the views of over 70 senior stakeholders across Wales to find out how managers viewed the research available to them, and to what extent they felt able to access evidence to inform their decision-making on service delivery improvements. Respondents reported that organisational capacity is severely limited in terms of both skills and status: “We don’t value research in management unless it is presented by an individual with a global reputation and even then we listen but don’t apply it to practice” as one neatly summed up the situation. Stakeholders also reported that management-related research is viewed as a “poor relation” to clinical research both in terms of quality, funding and accessibility. Operational pressures and resource constraints combined to leave research looking like a luxury rather than an essential activity. Differential funding streams favouring single discipline activity over the applied multidisciplinary work needed to inform service delivery improvements all contributed to a perceived growing chasm between practitioners in the field and academics working in lofty isolation. But, unlike Kernick, far from closing down university departments of health services research, we are trying to build better bridges to incorporate them more effectively. Despite the formidable obstacles noted above, respondents across all sectors reported conviction that things had to change, recognising knowledge management as a core organisational competence for the future. Almost because the pace of change is so rapid, managers and academics alike reported commitment to the need to put service improvement at the top of the research agenda. Recognising that a real change in culture will be needed to effect such a shift in priorities, both the Welsh Assembly Government’s Ministers for Health and Social Care, and Education, endorsed the study findings. Supported by the Assembly’s Director of Health and Social Care, we are now working to test the infrastructure needed to support establishing a service development research network, to build capacity to engage in research across the service delivery sectors, and - most importantly - to develop a distinctive research agenda appropriate to Wales’ specific and strategic aims. The path towards implementing this is rocky, but the potential prize includes better services to patients and a more informed workforce operating in a more stimulating and productive environment. Steffi Williams Director Research and Professional Development Centre for Health Leadership Wales and Senior Lecturer, PGMDE School, University of Wales College of Medicine Competing interests: None declared |
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Gillian Parker, Head of Policy Research Department of Health, Skipton House, 80 London Road, London SE1 6LH, Professor Sir John Pattison
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From the Office of the Director of Research and Development Professor Sir John Pattison Richmond House 79 Whitehall London SW1A 2NS Tel: 020 7210 5556 Fax:020 7210 5868 john.pattison@doh.gsi.gov.uk 12 December 2003 Dear Sir The article by Penny Dash and colleagues, and the accompanying editorial by Jonathan Lomas (6th December 2003) raise some interesting points about the application of health services research in the UK context. However, elements of their analysis do not seem to square with the reality. First, Dash et al claim that funders, researchers and users believe that responsibility for disseminating the findings of research and supporting its application does not rest with them. The English Department of Health (DH) currently spends around £83m pa directly on research to inform policy and practice, through its commissioned research programmes. Structures are in place to ensure that the knowledge generated by this investment is, indeed, applied to both policy-making and practice. For example, the DH Policy Research Programme commissions research directly informed by policy-makers’ needs, which is then used by them to inform, implement and improve national policy-making. This often has a direct impact on practice at a service level. The NHS Health Technology Assessment R&D programme has made a major contribution to the international pool of evidence about ‘what works’ in clinical care. Its programme is influenced by questions clinicians and policy makers raise, and its outputs feed directly into guidelines developed by the National Institute of Clinical Excellence. By coupling this evidence base with clinical governance structures in every NHS provider and new contracts in primary care that have quality improvement at their heart, the NHS has, to use Paul Shekelle’s words in the BMJ earlier this year, “vault[ed] over anything being attempted in the United States, the previous leader in quality improvement initiatives.” (1) And the newer NHS R&D programme on Service Delivery and Organisation is directly driven by questions raised from NHS managers, professionals and service users. These groups play a direct role in commissioning research and the programme has a vigorous approach to dissemination. This active programme of dissemination includes a developing relationship with the Modernisation Agency to ensure that its change management activity is underpinned by high quality research evidence. Lomas refers to the NAO report that argued the importance of ‘linkage and exchange’ and implies that the ‘limited adoption’ of such linkage goes some way to explaining ‘the disappointing results from over a decade of investments in the NHS R&D strategy’. In fact, the NAO report did not review DH-funded research but, if it had, it would have shown that DH already meets all of the key recommendations of the report. Secondly, Dash et al claim that health services decision makers are anxious that, at times, the ‘how’ of research overshadows the ‘what’. But the issue is not, surely, that the ‘what’ is more important than the ‘how’. Poor quality research remains poor quality research, no matter how important the topic. The trick is to get both right – something to which the DH R&D programmes, as described above, are absolutely committed. We welcome any additional resources dedicated to the perennially difficult issue of implementing research knowledge in systems that are continually developing, and where influences other than pure rationality (evidence) have a perfectly legitimate role. We particularly welcome any input that helps to increase health service deliverers’ appreciation of how to use health services research. But it is important that this input starts from an informed position in relation to existing structures and activity in the system it is aiming to influence. Yours sincerely PROFESSOR SIR JOHN PATTISON Director of Research and Development PROFESSOR GILLIAN PARKER Head of Policy Research Programme (1) Shekelle P, New contract for general practitioners. BMJ 2003,326: 457-8. Competing interests: None declared |
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Alexander M Clark, Assistant Professor Faculty of Nursing, University of Alberta, Edmonton, Canada. T6G 2G3
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The paper by Dash et al raises relevant issues regarding the frequent schisms between heath service researchers, decision makers, research funders and the academic establishment. Working in the field of interventions to improve heart health, I recognize a clear preference from funders and journal editors for studies and findings that can be generalized across populations, ideally, based on large randomized control trials. While being esteemed methodologically and therefore more likely to be published in prominent journals (1), the findings of such studies are often inconsistent (2-4) and do little to improve service quality(5) or the chronic problem of low service uptake(6). Health service researchers by nature tend to focus on contextual, social, cultural and organizational factors that influence service implementation and effectiveness. Yet, recognition that these factors can influence the effectiveness of heart health interventions is often absent. This ignores a wealth of evidence to the contrary (7-9). Though rightly valued, in isolation, a randomized control trial does not explain why an intervention is successful in one setting but fails to replicate these benefits in others (8). Nor does this method identify why some groups are better served by an intervention than other groups (8). If the effectiveness of health services is to be improved for all patient groups, a greater emphasis is needed on examining these kinds of ‘why’ questions. Research funders and the editors of our esteemed journals need to recognize this and respond accordingly. References 1. Dolby RGA. Uncertain Knowledge. London: Cambridge University Press, 1996. 2. Ebrahim S, Davey Smith G. Systematic review of randomised controlled trials of multiple risk factor interventions for preventing coronary heart disease. British Medical Journal 1997;314:1666. 3. Jones DA, West RR. Psychological rehabilitation after myocardial infarction : Multicentre control trial. British Medical Journal 1996;313:1517-1521. 4. McAlister F, Lawson F, Teo K, Armstrong P. Randomised trials of secondary prevention programmes in coronary heart disease: systematic review. British Medical Journal 2001;323:957-962. 5. Lewin RJP, Ingleton R, Newens AJ, Thompson DR. Adherence to cardiac rehabilitation guidelines : A survey of rehabilitation programmes in the United Kingdom. British Medical Journal 1998;316:1354-1355. 6. Cooper AF, Jackson G, Weinman J, Horne R. Factors associated with cardiac rehabilitation attendance: a systematic review of the literature. Clinical Rehabilitation 2002;16:541-552. 7. Wilkinson R, Marmot M, editors. Social determinants of health: The solid facts. Geneva: World Health Association, 1998. 8. Pawson R, Tilley N. Realistic Evaluation. Sage: London, 1997. 9. Stewart M, Reutter L, WIlliamson D, Raine K, Wilson D, Fast J, et al. Low-income consumers' perspectives on determinants of health services use. Ontario: Canadian Health Services Research Foundation, 2001. Competing interests: None declared |
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Fiona A Alderdice, Lecturer in Health Sciences School of Nursing & Midwifery, Queen's University Belfast, Jackie Parkes, Senior Lecturer in Nursing
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Editor Dash et al1 rightly debate the need to increase the impact of health services research (HSR) in the NHS. While we agree with many of their conclusions, we are very struck by the lack of recognition afforded to undergraduate and postgraduate education of health care professionals. We suggest that a considerable strengthening of the HSR contribution could be made if health care professionals were taught HSR at undergraduate level and if they were taught together through inter-professional education initiatives. Here we make particular reference to the part to be played by nursing to strengthening the impact of HSR in the NHS. Historically nurses in the United Kingdom have been taught research methods primarily from a theoretical perspective and usually ‘borrowed’ from the social sciences. Furthermore they are often taught by non- research staff which means the focus remains theoretical when it should be applied and practical. Essentially nurses should be taught HSR, ideally in the company of other health care professionals and by active nurse researchers with links to disciplines like Epidemiology as well as Sociology and Psychology. A greater focus should be paid to developing pertinent research questions likely to influence the care given to patients and to patient outcomes rather than the tendency to focus on research methodology per se often in isolation from clinical application. As nurses represent the largest section of the workforce in the NHS, the introduction of an HSR approach to research teaching in nursing and midwifery education would provide an important bridge between research and practice. We fully agree with a recent report by Professor Gerry McKenna who concluded that patient care would be greatly improved if nurses and other healthcare professionals were given more training in clinical research2. In particular, conducting empirical research as part of a taught Master’s programme should be an essential part of postgraduate education for nursing. However the implementation of the research governance framework for health and social care may create significant barriers for students undertaking dissertations involving patients. The potential of the nursing contribution to HSR has repeatedly been reiterated3,4,5 but such recognition has not been matched by equal access to funding or adequate management strategies to break the cycle of disadvantage nurses have experienced in contributing to the R&D agenda6. Rafferty argues that nurses account for 70% of the NHS wage bill and 40% of the NHS budget, therefore 40% of the NHS Research and Development budget should be invested in research that impacts upon their work7. Furthermore funding agencies need to be more creative in their approach to developing the research capacity of the workforce. They must recognise that most nurses in a position to undertake research training opportunities (studentships, fellowships or career scientists awards) are working in tenured positions in Universities and not in the health service. Placing restrictions on eligibility criteria (e.g. being employed in the NHS or having a fixed term contract) only further limits the extent to which nurses can make a contribution. In this sense nursing is a special case. If a more client centred approach to commissioning research is adopted as recommended by Dash et al1, the nature of the nurse-client relationship makes nurses key players in such developments6. By strengthening research teaching of HSR in nursing and with more inclusive approaches to financial investment in nursing research - commensurate to the workforce’s contribution to public health and patient well-being8, the impact of HSR in the NHS would be significantly enhanced. 1 Dash, P., Gowman, N., Traynor, M. (2003) Increasing the impact of health services research. British Medical Journal, 327; 1339-1341. 2 Gould, N. Training is the key to better care. [Findings of a report by Professor Gerry McKenna, University of Ulster] Belfast Telegraph, 23rd September 2003. 3 Department of Health Research and Development Task Force (1994) Supporting Research and Development in the National Health Service (Culyer Report) London: HMSO. 4 Department of Health (1999). Making a Difference: Strengthening the nursing, midwifery and health visiting contribution to health and healthcare, London, DoH. 5 Department of Health (2000). Towards a strategy for nursing research and development. Proposals for action, London, DoH. 6 McKenna H & Mason C (1998) Nursing and the wider R&D agenda:Influence and contribution. Nursing Times Research, 3 2:10115. 7 Rafferty A M (2000) Influencing the research and development agenda, paper presented to a Department of Health Research and Development Workshop, York, March 2000 cited in Department of Health (2000). Towards a strategy for nursing research and development. Proposals for action, London, DoH. 8 Aiken, L.H., Clarke, S. P., Cheung, R. B., Sloane, D. M. and Silber, J. H. (2003) Educational levels of hospital nurses and surgical patient mortality. Journal of the American Medical Association, Vol. 290, No. 12: 1617-1623. Competing interests: None declared |
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Guro O Huby, Senior Research Fellow Community Health Sciences, University of Edinburgh, 20, West Richmond Street, EDINBURGH EH8 9DX, Sally Wyke, Scottish School of Primary Care, Gill Hubbard, Community Based Sciences University of Glasgow, Markus Themessl Huber, School of Nursing and Midwifery University of Dundee, Maureen McElroy, Dpt of Nursing and Midwifery University of Stirling
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The paper by Dash et. al reporting findings from a Health Foundation and Nuffield Trust study about the lack of impact of health services research (1) has sparked off a much needed and fruitful debate. In Scotland, a primary care based R&D programme is now in its 3 year (2). This initiative has taught us many, and at times hard earned, lessons about the relationship between research, practice and policy in the British NHS. We would fully endorse the paper’s recommendations in relation to action needed to make research more effective as a lever for change. We would also add some considerations based on our own experience. The ‘Research-based Development of Scottish Primary Care’ is jointly and directly funded by the Scottish Primary Care Trusts (PCTs) and facilitated by the Scottish School of Primary Care. It is carried out by a team of 4 research fellows, with research assistant and administrative support. The research fellows work in 4 different Scottish academic departments with strong primary care research connections. This structure allows the initiative to bring the academic and service communities closer together, and contributes to improved understanding between them and ensures that rigour is not compromised in the development of practice oriented research. The initiative revolves around 4 different projects, identified as important for development by the PCTs themselves. The projects concern the integration of health and social care for older people and for people with mental health problems, diabetic retinopathy screening and prevention of unscheduled acute admissions for the oldest old (see (2) for detailed description). Each PCT and relevant partner organisation (e.g. Social Care or Acute Trust) has signed up to one project. The research fellows in charge of each project work closely with nominated contacts within each participating PCT to develop a project focus which is directly relevant to practice and development of services within those organisations. Mutual learning and a strategic focus for R&D are two cornerstones for the initiative. Because several PCTs participate in each project, there is room for mutual comparison and learning. This makes it possible to develop strategic R&D which links national priorities and policy to local variation in their implementation. We also work systematically to increase capacity among our collaborators for rigorous and applied research with immediate practical relevance. This initiative thus facilitates ‘linkage and exchange’ (3) and directly addresses many of the points raised in the paper: • it avoids the disconnection between funders and beneficiaries of the research; • it facilitates the development of research approaches which are directly relevant to practice, without compromising on rigour; • the collaboration between researchers and end users of the research at all stages of a project makes it easier to communicate research findings to all relevant parties. This approach is producing practice-oriented R&D. However, the initiative would be more successful, and provide far better returns on the PCTs investment, if there were better continuity and stability in relationships between researchers and service collaborators. In our experience, both NHS service and the academic community (including the relevant Scottish Executive Departments) need to give long-term consideration to how their interface can be improved. For the NHS service community this means (see also (4): • seriously looking at the effects of constant service reorganisation and change; • formulating short term political imperatives in ways which do not take away from the long-term development work with less immediate results; • considering the effects of several short term ‘pilot’ projects, each funded from different sources and often working to the same target populations, but poorly joined up; • improving the career prospects and working conditions for middle managers so that the good managers stay and see projects through, with appropriate research input. For the (medical) academic community it means: • recognising that applied health services research founded on rigorous case-comparisons of direct relevance to NHS organisation is important and worth investment; • valuing and providing career structures for researchers who work across traditional service/academic boundaries; • valuing development of combined methodologies which are flexible and practice oriented. Without an organisational infrastructure for R&D at the interface between the NHS and academic communities we fear that the recommendations of the Health Foundation/Nuffield Trust report may have less than maximum effect. We look forward to the forthcoming consultation exercise and hope that some of these long-term issues will be addressed. 1. Dash P, Gowman N, Traynor M ‘Increasing the impact of health services research’ BMJ:327:1339-41 (6th December) 2. http://www.rdspc.org.uk/ 3. Lomas J ‘Health Services Research’ BMJ 2003;327:1301-2 (6th December) 4. Pettigrew M, Ferlie E, McKee L Shaping Strategic Change SAGE 1994 Competing interests: None declared |
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Jeremy P Gray, GP Wandsworth PCT SW11 5TU, Amy Scammell, Helen Walley, Andrew Neil.
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The topic of increasing the impact of health services research is certainly one vital to all those involved in R&D in primary care. At Battersea Research Group (BRG), a primary care research network funded by the Department of Health R&D levy, we believe that the situation on the front line can change and would like to highlight some examples of change taking place in one south London Primary Care Trust. We believe there are some core areas and goals that can be attained through a process of more integrated working. Firstly, a major issue is the need to break down barriers between service and research organizations. The BRG was originally set up as a research charity operating in primary care, however, over the past 15 months we have been working closely with Wandsworth PCT to develop more integrated and effective research and development activities. From January 2004 BRG will merge into the PCT becoming part of the Nursing and Clinical Governance Directorate developing our link into the PCT R&D Committee. We hope that staff integration and the co-ordination of a shared research management and governance agenda will increase contact between researchers and health professionals and managers facilitating greater understandings of research and ability to disseminate and implement findings. Secondly, there is a need to increase the opportunities for research relating to service development. We also hope that the development of a PCT wide R&D strategy via the R&D Committee will enable more PCT employees to liaise with the research group and develop collaborative work directly relevant to their clinical practice and service delivery. Of course, funding of research and resource pressure is a major issue. However, one method may be to encourage individuals to work together as a unit using personal or team development time to develop and undertake research directly relevant to their particular service. Additionally, Wandsworth PCT is the local Teaching PCT and through the steering committee and associated funds it may be possible to utilize the research group to help groups undertake particular pieces of project work focusing on core areas of skill mix, recruitment and retention or links between primary and secondary care. As yet no commission from the PCT has been received by the research group to answer a specific service orientated question as Dash et al state is the case in the USA and Canada. Indeed the research group would not expect to receive such a commission without external competition. PCTs may not be used to commissioning such work and research groups may not always have the capacity to respond sufficiently fast. However integration allows for infrastructure and relationships to develop and this means that the stage is set for discussions about how questions that are raised within the organisation might be answered to mutual satisfaction providing both useful answers and meeting academic targets (such as publications). Already the skills of the research group are being called upon to think about generic issues such as the collection and analysis of data held in primary care or referrals processes for smoking cessation service. It is only a matter of time before these questions yield both useful answers and publications. Dr Jeremy Gray – Director, BRG – Wandsworth’s Primary Care Research Centre Amy Scammell – Research Manager, BRG. Helen Walley Chief Executive Wandsworth Primary Care Trust Dr Andrew Neil Joint Medical Director and Chair Wandsworth PCT R&D Committee Competing interests: None declared |
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