Professor Andrew Long School of Healthcare University of Leeds June 19 th 2006 Health Systems Research: What is it? And, does it matter?

Overview of Presentation To elaborate on the range of meanings attached to health systems research To identify essential commitments of HSyR As a philosophy of practice As a commitment to problem definition To explore the HSyR features of three case studies: Evaluation of older people partnership Population health and measles prevention Fostering an outcomes culture in routine practice

Health Systems Research: playing with words? Health Healthy vs. dis-eased; well vs. ill; working vs. incapacitated And connotations within health services Managing disease Promoting health and healing Population, community or individual health Systems Complex whole; inter-connected parts Organised, structured group of things Research Systematic enquiry – acquire knowledge Enhance evidence base Inform and empower (service and research) users –> influence policy and practice

Joining the words together! Health systems Whole systems to support or improve health and well-being Whole systems of health care Systems within systems – e.g. intermediate care; TCM acupuncture within complementary and alternative medicine Health research Research applied to health and ill-health … epidemiology … Research studying health … sociology … economics … Health systems research Whole systems research (exploring complex health care interventions) Melting point for different disciplines Philosophy about a way of doing research Multiple perspectives

Some Definitions Health research Study of health – individual, community, population Health services research (HSR) study/evaluation of provision, effectiveness, efficiency and use of health services Health systems research (HSyR) study/evaluation of … health sector to enhance or contribute to health of the community Whole systems research (WSyR) study/evaluation of systems that honours the philosophy, integrity and complexity of that system, that is, its explanatory model

HSyR – Essential Commitments Field of Research: Complexity of programmes and policies in health (and other) policy sectors Beginning and end of health care, vs. social care, vs. community care Crossing the R&D Divide - Research into Practice: Involve key stakeholders (decision makers, services users, carers) in research process – design to implementation Timely, relevant research and utility for practice Evaluation and Research as Learning: Not just means to see what works, for whom, in what circumstance and from whose perspective But to identify and celebrate learning (for all stakeholders), and Enable ongoing evaluation in practice – sustainable change Mode of Working: Complexity requires working with and across disciplines Melting pot where disciplines can meet, listen, learn and share to explore the totality of the research problem

Desirable Process and Outcome The involvement of users throughout the research process helps to create a cadre of sophisticated research users who are not only able to make effective use of research, but can more clearly specify what their needs are …. (National Audit Office, 2003)

Case Study One: Evaluation of Interventions for Prevention for Older People What is the Problem Evaluating Partnerships for Older People Programme aimed at promoting independence of older people and preventing long term institutional care Policy led, research to influence longer term commitment by Treasury System Complexity Prevention = ? Success criteria = ? (whose perspective to adopt?) Outcome realisation – the more upstream the longer the time scale Understanding of what works for whom … vs. does it work? Team Composition Older people (City X Older Peoples Forum) in form of Greek chorus Change agent team... Project lead network Multiple disciplines – older people researchers, social and health systems, health economist, statistician, gerontology, sociology/social research methodology

Case Study Two: Population Health and Measles Prevention (Jackson et al) What is the Problem How to increase the take-up of MMR (vs. single disease vaccination approach) Research project to explore feasibility, acceptability and effectiveness of parent forum (plus usual care) System Complexity Conceptual model: cognitive-deficit model vs. engagement model Multiple outcomes: parents, child, vaccination, disease incidence Team Composition Parent – co-leader of Parent Forum Health Protection Agency, PCT immunisation co-ordinators Multiple disciplines – nursing/primary care/public health researchers, psychology, public health physician, decision analyst, health economist, statistician

Case Study Three: Fostering an Outcomes Culture in Routine Practice What is the Problem Sustainability – ongoing monitoring of achieved outcomes / evaluation of practice (vs. one-off external evaluation) System Complexity What outcome – different perspectives What outcome measures/measurement tools – quality and feasibility Outcomes of our intervention or others or of the whole Timescale to realise desired outcomes Commitment and time availability of practitioners Team Composition Local practitioners External facilitators – health systems research, outcome measurement, health economist External resource/service managers

HSyR: Some Benefits and Caveats Research only that which the government or other policy makers wants, timely issues, emphasis on utility and transferability of findings, that are relevant to practice Value to NHS, practice and decision making Maximising benefit to society/citizens Questions over, inter alia: Research, must be generalisable beyond the local setting (not just this particular setting) Research as enlightenment, shaping policy agenda, challenging existing assumptions and encouraging debate Public good vs. policy/political wish

Concluding Comments HSyR: At a minimum, systems approach leads to broadening of problem definition At an optimum, enabling breadth of understanding of the whole, co-working, trans-disciplinary opportunities, enhancing population health and well-being HSyR: As a means to enhance take-up of research findings into practice Engage with service users and carers Ultimate test – is practice changed?