Intended for healthcare professionals


Health services research

BMJ 2003; 327 doi: (Published 04 December 2003) Cite this as: BMJ 2003;327:1301
  1. Lomas Jonathan, executive director (jonathan.lomas{at}
  1. Canadian Health Services Research Foundation, 1565 Carling Avenue, Suite 700, Ottawa, ON, Canada K1Z 8R1

    More lessons from Kaiser Permanente and Veterans'Affairs healthcare system

    Imagine a health system that improved diabetes control from 51% to 94%, screening for cervical cancer from 62% to 93%, and use of blockers for myocardial infarction at discharge from hospital from 70% to 95%. Imagine another system that costs the same as the NHS but has consistently higher quality of care as measured by process and outcome measures. Actually you don't have to imagine them because these two systems already exist—in the United States. Between 1995 and 2000 the Veterans' Affairs healthcare system achieved these remarkable improvements in quality for its more than 3.5 million users while reducing costs per patient by 25%.1 2 In the second case, the starkly better results for the 9 million members of the Kaiser Permanente health system compared with the NHS were documented in a 2002 study published in this journal.3

    That both these systems invest heavily in health services research is probably no coincidence. The Veterans' Affairs system puts in $50m (£29m; €;42m) a year, including support for the quality enhancement research initiative, which “purposely links research activities… to clinical care in as close to real time as possible, thereby leading to rapid adoption of best clinical practices and improvement in patient outcomes.”1 Kaiser Permanente invests more than $80m of its $17bn annual budget in research, including $12.3m for its care management institute, to “synthesize knowledge about the best clinical approaches and create, implement, and evaluate effective and efficient health care programs.”4

    The striking characteristic of these organisations' investments is that they are not granting councils giving out funds to meritorious applicants. They are frontline delivery organisations using health services research to respond to the direct needs of their managers and clinicians for better information on which to base their decisions.

    For these organisations the research function is not a separate activity hived off to experts in universities and other stand alone units (although many of the researchers have university appointments). The research agenda is set by the organisations' needs; the research is done collaboratively between the managers, the clinicians, and the researchers; and the results find their way directly into practice through integrated management structures and processes such as practice guidelines, computer reminders, test ordering systems, disease management teams, and so on. As Mark Smith of the California Healthcare Foundation said: “Health services research is too important to leave to just health services researchers.”5

    The importance of “linkage and exchange” between health services researchers and those who can use their results is not a new discovery. Studies and systematic reviews show it is the best predictor of when and how research gets used.68 We adopted this approach at the Canadian Health Services Research Foundation in 1998, acting as a broker between researchers and the system to improve evidence based decision making capacity,9 with positive results.10 For too long implementation of health services research has been viewed as a technical exercise in better dissemination; now is the time to highlight the importance of inter-personal links and the need to embed exchange between applied research and practice within health service delivery organisations.

    The limited adoption of this linkage and exchange approach in the United Kingdom may well go part way to explaining the disappointing results from over a decade of investments in the NHS research and development strategy. This strategic omission is highlighted in both the Health Foundation-Nuffield Trust report on health services research—summarised in this issue11—and the report to parliament in April of the Comptroller and Auditor General on governments' use of research in policy making.12 The latter concluded that “the early involvement of potential users of the research will increase the likelihood that research results will be utilised.”

    The Health Foundation-Nuffield Trust report provides some good ideas for how to embed such linkage and exchange into the health services research domain. The report proposes a UK Academy for Health Services Research; the development of “knowledge translators”; and fellowships that build strategic alliances between the NHS, academia, and policy makers. These will all increase the ongoing dialogue between researchers, funders, and users at each of the crucial stages of setting the priorities, doing the research, disseminating it, and ensuring its application and use.

    Most important, however, and most neglected to date, is the demand side of the equation—the need to build users' appreciation of health services research, their skills to commission or find it, and their ability to apply it in everyday care for management of patients. It is not the researcher's job to implement findings;13 the investments needed to ensure the application of health services research are the responsibility of clinicians, managers, and the organisations in which they work. If the Veterans' Affairs healthcare system and Kaiser Permanente can do it in the United States, why not the NHS in the United Kingdom?

    Education and debate p 1339


    • Competing interests JL and Mark Smith (quoted in the text) were on the international expert steering group that assisted Penny Dash and colleagues on the design of the Health Foundation-Nuffield Trust study of health services research summarised in this issue.


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