Increasing the impact of health services researchBMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7427.1339 (Published 04 December 2003) Cite this as: BMJ 2003;327:1339
- Penelope Dash, independent consultant in health policy1,
- Natasha Gowman, health policy manager1,
- Michael Traynor, nursing and allied health professions facilitator ()1
- Correspondence to: M Traynor
- Accepted 21 November 2003
A new report from the Health Foundation and Nuffield Trust suggests managers and policy makers are not able to base decisions about reforming health services on the best available evidence
Improving quality and performance in the NHS requires a developmental approach that applies research to a planned process of change. Decision makers need many questions answering. How should clinical teams be organised and resourced to deliver higher quality, safer care? How could hospital environments be improved? How should local services be configured to ensure convenient access and optimal quality? And how can recruitment and retention of healthcare staff be enhanced? Despite clarity about the questions, decision makers feel they lack the research that would help them generate answers. So what can be done to improve the use of health service research?
State of health services research
In 2002, the Health Foundation and the Nuffield Trust jointly commissioned a review of health services research in the United Kingdom.1 The aim was to examine how independent grant funders in health could enhance the contribution of health services research to improving services and policy making and to learn from the role of charitable foundations in other countries.
Research for the review, conducted during January to August 2003, included interviews with 35 senior UK health services researchers, health service managers, policy makers, or research commissioners. It also included an analysis of case studies and a review of successful initiatives in the United States and Canada. The research showed that everyone involved with health services research is dissatisfied to some extent with the current research process, albeit from different perspectives (box 1).
Box 1: Perspectives on problem of health services research
Researchers are frustrated that their work isn't used more widely by policy makers and managers and feel that the knowledge they generate is undervalued and poorly applied
NHS managers see little of relevance in the research available to them and view health services research as poor value for money
Policy makers are concerned about the timeliness of research: to be useful to them it has to be available when political decisions are being taken
All groups feel an urgent need to reconnect the funders, users, and providers of research
Bridging the divide
Considerable research activity currently takes place in the name of health services research. Although we were surprised by how difficult it is to quantify precisely, health services research accounts for 2-3% of the £4530m spent on health research in the United Kingdom each year.2 It is unclear, however, how much of the information generated is translated and used to inform practical decisions about health and health care. Three questions in particular stand out: is research pursuing the right agenda? is it examining the right questions in the right way? and, are the results being communicated to and applied by the people who need them?
Is research pursuing the right agenda?
Health services research in the United Kingdom suffers from a disconnection between funders and beneficiaries. The prevailing sense is that the NHS is still not getting the benefits of research that focuses on its priorities (for example, how to reconfigure services to ensure optimal quality and local access for users, or how to make the best use of information technology) and processes to identify areas for research are seen as opaque and remote.
Yet considerable efforts are being made to ensure that the concerns of end users are examined and anticipated by centrally funded health services research. In England the new NHS research and development priorities and needs funding stream explicitly sets out to achieve this,3 and the National Coordinating Centre for Service Delivery and Organisation has conducted a series of listening exercises to identify the main concerns of stakeholders.4
Commissioners themselves would welcome support to increase their capacity to manage the research agenda. During interviews for the review, one said:
It has been very hard to get any dialogue going between what NHS mangers need and what the researchers can deliver. At times we have fallen into the trap of defaulting to the questions that researchers want to answer.
The right questions, in the right way?
Our research showed that both managers and researchers are frustrated about the applicability of some health services research. Decision makers feel that at times, the “how” of research overshadows the “what.” An NHS manager said:
Funding decisions are based more on the methodology rather than on the output—more about whether the research is done in a robust way rather than whether or not it answers the question.
Opportunities to generate applied research that informs service improvement and planning are not being fully exploited. Professional boundaries tend to restrict opportunities for clinicians, practitioners, and managers to cooperate in designing and carrying out research. The strengths and contributions that academics, other researchers, and practitioners could bring to the research process are widely appreciated. But, mirroring the problems with the commissioning process, opportunities to generate applied research are being lost through failures to connect across the disciplines. In one research funder's view:
There is a role for academics to help others who want to get involved with research, helping them to refine the questions and methodology.
So, why doesn't this type of collaboration happen more often? Developing these kinds of extended roles for clinical practitioners, managers, academics, and policy makers is complicated by the fact that each already has clearly defined career pathways and skills bases—and they seldom cross.
Opinions were divided about the most appropriate responses to this. Establishing multidisciplinary action research or change management teams was widely supported. Clinicians and managers leading change in the health service need the facility to acquire, appraise, adapt, and apply research evidence to their decision making,5 and there was recognition that additional support and training needs to be accompanied by practical experience.
Communicating research to the people who need it?
Definitions of health services research abound, but there is one defining characteristic: the information produced should inform service improvement and planning. To be of any use at all, it has to be capable of being applied.
Funders, researchers, and users seem united in one belief: responsibility for disseminating the findings of research and supporting its application does not rest with them. This lack of ownership may have its roots in the opaque funding streams that pay for much health services research. Few direct incentives exist to ensure the delivery of relevant, applicable outputs.
The situation is further complicated by the fact that clinicians, academics, and managers have discrete occupational cultures that limit opportunities to exchange information. The three groups tend not to find themselves at the same meetings. They attend different conferences, and they read different journals. But it is clear that the people who need it often don't have the skills or the time to access original research. A researcher in the commercial sector said:
Research needs to be made understandable and relevant to clients. There are analogies with accounting practice, where accountants translate financial laws into real applications for companies. Academics don't want to and often can't provide that service.
The United States and Canada
The review considered whether the United Kingdom could learn from the ways other countries had responded to similar challenges. It looked in particular at two North American organisations involved in health services research, AcademyHealth in the United States and the Canadian Health Services Research Foundation (box 2). The contribution of these two organisations was widely referred to in positive terms in the course of our research. As one academic told us:
You could argue that the most important role the Canadian Health Services Research Foundation has taken on is that of brokerage between managers, policy makers, and researchers.
Room for improvement
The information and views elicited through this project suggest several ways that health services research could be strengthened. These include:
Establishing a more client centred approach to commissioning research—including a clear understanding of who is paying for work and what benefits will be achieved, and improving the coordination of research programmes at the commissioning stage
Enabling users, funders, and researchers to assess the value of different approaches to generating the high quality, relevant, and timely research needed by health service decision makers
Increasing opportunities for cross-sectoral collaboration at every stage of the research process
Box 2: International examples
AcademyHealth (USA) promotes interaction across the health policy arena by bringing together health services researchers, policy analysts, and practitioners. Established in 2000, it is now seen as the professional society of more than 3600 individuals and 120 affiliated organisations.
Canadian Health Services Research Foundation—An independent, not for profit foundation established in 1997 with an endowment of $C66.5m ($US51m, £39m, €;56m) from the government. The foundation promotes and funds management and policy research and works with health system decision makers to support and enhance their use of research evidence.
Looking outside the health and public sectors for research and information that may be useful
Increasing the focus on the development of skills to analyse, access, and use research
Adopting a greater emphasis on the user friendly presentation of research and analysis
Developing new roles to support the implementation of the conclusions of research, as part of a service improvement programme, at a local level.
The Health Foundation intends to develop a new programme of activity in 2004 to support the development of health services research. Everyone involved in health services research recognises the existence of long standing problems. The best chance of progress lies in bringing together funders, users, and researchers to develop solutions.
Health services research is still not making its full contribution to health service improvement
Despite many attempts to streamline and organise NHS research funding, funders, researchers, and the users of research are uncertain about how best to work together
Responsibility for communication of the results of research to users is unclear
International experience suggests independent organisations can help bridge the divides between users, funders, and researchers
Editorial by Lomas
The Heath Foundation has launched a consultation exercise on a programme of support for health services research in the United Kingdom. Comments on a range of possible activities the foundation could support are sought by 5 February 2004. A copy of the consultation document and the research referred to in this article can be obtained from www.health.org.uk or by telephoning +44 (0)20 7257 8000. We thank Anne Smith and Helen Donohoe for help in producing the report.
Funding The production of the report which informed this article was jointly funded by the Health Foundation and the Nuffield Trust.
Contributors and sources PD is an independent health services consultant who has worked in the health services as a clinician and in policy roles. NG has a particular interest in evidence based policy formation. In 2000 she coauthored, with Anna Coote, Evidence and public health: towards a common framework, published by the King's Fund. MT is seconded to the Health Foundation from the London School of Hygiene and Tropical Medicine. He has written extensively about evidence based healthcare and nursing research policy.
Competing interests PD works as a paid advisor for several organisations and companies associated with health care, including the NHS, private healthcare providers, consulting companies, and pharmaceutical companies.