Published: 15/01/2004, Volume II4, No. 5888 Page 16 17
Too much health research is isolated from NHS management.And managers make decisions that do not have a sound evidence base - behaviour that would be frowned on in the commercial sector
Too much health research is isolated from NHS management.And managers make decisions that do not have a sound evidence base - behaviour that would be frowned on in the commercial sector Much of what is produced in the name of health services research is irrelevant to NHS managers.
That was the uncompromising message gathered for a joint report by the Health Foundation and the Nuffield Trust. NHS managers saw the research funds levied from their organisations disappearing into a black hole, producing little return on investment.
At several points in my NHS management career, I felt badly served because the evidence needed to support important decisions was not available.
When managing hospitals, I expected staff to check the track record of suppliers and provide a clear business case with the rationale behind the choices they were making. If we were appraising our catering or domestic services, that was possible. But if the changes were a shift in the balance of care away from acute to intermediate services, for example, it was a different matter. All too often, the information was hard to come by.
On occasions, however, it was possible to commission timely and focused research to underpin difficult decisions. I recall, in the midst of the 'Child B' case (on healthcare rationing), that while my health authority took the decision not to fund£75,000 of unproven leukaemia treatment her father demanded, they did approve a£400,000 expenditure for a single child with haemophilia to receive recombinant factor VIII.
These decisions were based on sound, if controversial, evidence for the time.
In the 1990s, health authorities and trusts had to marshal the evidence to make these decisions themselves. Today, NHS managers often have the benefit of advice from the National Institute for Clinical Excellence when making decisions about clinical efficacy.
Yet not all the difficult decisions faced by NHS managers are purely clinical.Most concern more complex, multi-faceted issues such as service redesign, patient-centred delivery and workforce planning.However good the evidence is, the answers to every question will not be immediately apparent from available research. Even so, in my view, NHS managers are too willing to settle for a situation that would not be tolerated in other sectors. They take strategically important decisions without recourse to a sound evidence base in a manner that would be regarded as cavalier in much of industry.
Much could be done to improve matters, especially in the way academic research is presented. However, our report also suggests that many managers lack the appreciation of research that would ensure it occupies an appropriate place in decision making.
Understanding evidence is only half the battle.Appraising evidence and using it to inform sound judgement, balancing it against political imperatives, and arriving at a realistic assessment of risk requires a further set of skills.
The case studies featured in our report suggest the commercial sector has found ways to achieve a much more direct relationship between research and strategic planning. The research available to business decision-makers seems to be both relevant to their questions and more readily applicable. The client focus of the business environment seems to follow through into the research process, together with an expectation that research will deliver value for the organisation.
NHS organisations and central government departments have given money to universities, or entered into 'partnerships'with academic institutions, in the hope that some of the understanding of science would rub off on them.
But this approach has fallen short of expectations.At best, some commissioners of health services research feel they have become overly reliant on academic advice.At worst, the view is that some academics purely follow their own agendas.
'It has been very hard to get any dialogue going between what NHS managers 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, ' one research commissioner told us.
Many of the managers we spoke to were dissatisfied with the return they were getting on their research spend. But others grudgingly admitted that the blame cannot be laid entirely at the researchers' doors.
What should NHS managers expect from health services research, and how might they go about getting it? Developing a stronger customer focus is always hard when no-one knows exactly who pays the bill. The current structures place further obstacles in the way of researchers who want to deliver the kind of topical, applied research that can change healthcare, rather than generating new theories and descriptions.
Locating health services research in traditional academic environments leaves researchers on the outside of the health service, looking in. They may generate high-quality information, but there are too many barriers in the way of its dissemination and application, leaving academics and managers bound into their own separate reward structures.
For some time, the NHS research and development programme in England has funded applied health services research via the service delivery and organisation programme.
Other countries, meanwhile, have found their own ways to narrow the gap between researchers and decision makers (see box).
Independent institutions, such as Academy Health in the US and the Canadian Health Services Research Foundation, offer much greater opportunities for information exchange. They broker continuous dialogue about the issues of the day and long-term challenges that fuels the production of highly relevant research and virtually guarantees its application.
The Health Foundation is ready to make a significant investment in this area over the coming years.We want to challenge users of health services research to tell us how they think our money could best be spent.
We have launched a consultation process to stimulate debate.
Are there enough incentives for managers to make use of the research that is commissioned?
What do managers want from research teams when they communicate their work? How big is the skills gap among managers who need to commission, appraise and apply research? We plan to work with the research and management communities to improve the quality of commissioning and dissemination.
What sort of opportunities would be attractive to managers who want to gain direct experience of research? And how could the NHS host researchers who want to get a better understanding of the daily decisions that their findings should be informing?
Could there be value in creating a new kind of independent research institution, not embedded in the NHS, government or academia? It could take the best from each.
Crucially, everyone involved would have a stake in the research process. During 2004, we will be working with other organisations to see what scope there might be for creating such an institution in the UK. l Stephen Thornton is chief executive of the Health Foundation, an independent charitable foundation and grant maker in health.
Increasing the impact of health services research on service improvement and delivery, a report for the Health Foundation and the Nuffield Trust, is by Penny Dash.
Comments are sought by 5 February.View the consultation document and provide your comments by visiting www. health. org. uk, e-mail hsr@health. org. uk or phone 020-7257 8000.
www. nuffieldtrust. org. uk/ policy_themes/docs/hsrreport. pdf
How other countries have bridged the gap
Academy Health, in the US, 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 for more than 3,600 individuals and 120 affiliated organisations.
An independent, not-for-profit foundation, the Canadian Health Services Research Foundation promotes and funds management and policy research and works with health system decision makers to support and enhance their use of research evidence.