Health systems, services and strife
 Health Services & Policy Research Conference
13-16 November 2005, Canberra
Ellen McIntyre, Elizabeth Kalucy (presenter), PHC RIS
Delegates at the fourth Health Services and Policy Research conference heard some excellent speakers discuss features of the health systems and services of several countries to illustrate the challenges of translation of research, reform, and change. Several speakers suggested 'don't do it our way'. They recommended monitoring outcomes as well as processes, being aware of context in policy and research, and not underestimating values and culture when trying to implement change in complex systems.
Professor Alan Maynard (University of York, UK) outlined how spending more money on health does not necessarily improve health or health care, and suggested we treat UK health reform with extreme caution. Structures and policies without clear goals, and aligned incentives to deliver those goals have wasted considerable resources in the UK. Associate Professor Jeanne Lambrew (George Washington University, USA) on the other hand, analysed the failure of health reform in the US during the Clinton administrations using it to highlight the pertinent features required to ensure more success, such as the commitment of leaders as well and good planning. Associate Professor Kassem Kassak (American University of Beirut, Lebanon) posed the challenges faced in the eastern Mediterranean region. These countries although they share much in terms of culture and ethnicity, have distinct variability in the provision and delivery of health services attributed largely to the level of development, economy and governance in these countries.
Research conducted by the Commonwealth Fund (presented by the President, Karen Davis) identified ten core values that define high performance health systems - long, health and productive lives; the right care; coordinated care over time; safe care; service excellence; efficient, high value care; universal participation; affordable care; equitable care; and knowledge and capacity to improve performance.
Professor Charles Normand (University of Dublin) in his presentation Towards high impact health systems research identified the importance for researchers and policy makers of understanding how to make things happen. He stated that "the challenge of moving towards evidence informed policy is heightened by the combination of relatively insecure and complex evidence, and a complex process for applying the evidence. We need to build new working relationships between systems researchers and policy makers, and to carry out complex research on complex issues, and to avoid the temptation always to simplify to the point of meaninglessness."
Plenary sessions are available at http://www.hsraanz.org/plenaries.html
Evidence informed health care, action research and patient/public empowerment
5 December 2005, Melbourne
Ann Alfred, as a PHC RIS consultant
Seminar presented by Dr Sandy Oliver through La Trobe University's Institute for Advanced Study and School of Public Health. Dr Oliver is Reader in Public Policy and Deputy Director, Social Science Research Unit, Institute of Education, University of London, UK
The three social movements, evidence-informed health care, practitioner led action research and patient/public participation in research, policy and personal decision-making share a common purpose of improving public health. However, they represent different paradigms of approach to research and policy development.
Evidence-informed health care is mainly based on systematic search and synthesis of randomised controlled trials (RCTs). Practitioner led action research can challenge the academic from a social science, context base. Patient/public participation in research, policy and personal decision-making actively involves lay people in the what, how and how used of the research process.
These movements both challenge and complement each other. Used in a mutually supportive way, they can maximise the rigour and relevance of research and lead to policies that are both evidence informed and sensitive to people's diverse circumstances.
Key issues/highlights:
Dr Oliver discussed the historical failure of research to use a holistic approach as a result of conflicting views of researchers about the values of different paradigms. She identified the following common criticisms, challenges and concerns of:
- evidence based research - unethical, irrelevant, excludes public, in pocket of pharmaceutical industry, determined by clinicians
- action research - unscientific, context specific, guided by participants not others, provides answers for participants not others
- public/patient based research - policy on a shoestring, poorly reported.
Dr Oliver discussed the shortcomings of each approach when used in isolation. She proposed that it is possible to improve research outcomes by using elements of each approach, leading to participative, evidence informed policy with outcomes in policy development and implementation. She described six research programmes, including studies in aspects of youth health, infant screening and smoking in pregnancy, to demonstrate the effectiveness of this holistic approach.
These studies measured success at different stages in the research cycle from commissioning research through to policy development against the criteria of:
- relevance to the public
- rigour of research
- impact as in reach of change.
The outcomes of these studies were positive, demonstrating that because they were influenced by lay people when the questions were set and incorporating the three paradigms, the research:
- was much more relevant to the public
- was rigorous and inclusive
- had wide reach, informing policy at a national level.
Dr Oliver reported on further gains which have been made as a result of the success of the combined approaches in the winning of newly commissioned publicly funded research projects with outcomes which address the public's concerns and interests. Furthermore she predicts that these projects will not lose money as would studies of interventions not seen as priorities by consumers.
The approach has demonstrated that action research brings practical know-how and improved evidence to research. Used in combination with an evidence based approach and public engagement it can facilitate real change in research direction and public policy development. The greatest influence of the combined approach is upstream, in commissioning new and relevant research.
Recommendations for research bodies:
- include lay people in deciding research and research questions
- synthesise findings of individual studies as well as RCTs to accumulate collective knowledge
- include both qualitative and quantitative research results in literature reviews to reflect meaning for participants and therefore more relevant social policy.
Relevance/implications for policy:
- needs-led research using an approach incorporating evidence from RCTs and action research with patient/public involvement will lead to real outcomes and relevant evidence bases for public health policy.
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