Health services research: the gradual encroachment of ideas

1. Health services research: the gradual encroachment of ideas Nick Black Professor of Health Services Research London School of Hygiene & Tropical Medicine University of Kent 4 July 2014

2. Health services change steadily over time… Aware of some changes: • buildings • treatments But less so of others: • organisations • roles • attitudes • relationships Easy to forget how much these aspects have changed over past few decades…

3. So how does change come about?How much influence has health services research had? Who drove change in 2013? Consensus view of 12 member panel How many were health services researchers?

4. Top 50 influencers of NHS policy and practice during 2013 • ‘Civil servants’ (23) • Politicians (7) • Regulators (7) • NHS managers (4) • Trades unionists (4) • Clinicians (3) • Independent policy advisers (2) • Academics/researchers (0)

5. Reflects…. • Background of the judges • managers, management consultants, policy wonks and journalists • Focus on ‘implementers’, the most proximal or direct influencers • So, not an appropriate method to assess underlying influencers, in particular, researchers

6. Just to make clear... • HSR is ‘research on health services’ • effectiveness; efficiency; humanity; equity; organisation; governance; professional roles; history etc etc. • Multidisciplinary • inc. epidemiology, sociology, statistics, history, economics, psychology, policy analysis • Before adoption of the term in 1980s • most researchers studying health services identified with their home discipline

7. So, how might we assess the impact of HSR? • Economists advocate positivist ‘payback’ approach • Retrospective: what research influenced a particular clinical practice or policy? • Prospective: what impact has a particular research study had on policy or practice? • Largely based on a linear model of policy-making • Research  Policy or practice • May be appropriate for biomedical paradigm (if prepared to make heroic assumptions about attribution) • Only occasionally appropriate for judging applied social science such as HSR – though striking examples exist • Apparent lack of impact of HSR is self-fulfilling as health care policy doesn’t generally get made like that

8. But health services researchers need not despair… • HSR has had a profound and sustained impact • Principally, the internalisation of theory by policy-makers • altered ways of thinking and conceptualising issues • Research is on a long-burning fuse • Consequence: difficult to predict how and when it will make an impact

9. Let’s consider health services since 1950 • Key change has been emergence and growth of public accountability • dominance of professional autonomy increasingly challenged by corporate rationalisers and consumerism • Can be seen by exploring the six key assumptions about medicine and health care that predominated in days of Lancelot Spratt

10. Assumption 1: Interventions are effective

11. Starting in the 1970s… • reappraisal of role of medicine in decline of infectious diseases • history & epidemiology (Tom McKeown) • need for rigorous evidence of effectiveness • clinical trials (Archie Cochrane): • By the 1990s… • systematic reviews, meta-analyses • Cochrane Collaboration (Iain Chalmers) • emergence of clinical epidemiology • Yale (Alvan Feinstein) & McMaster University (David Sackett, Gordon Guyatt et al) • Manifest today as… • evidence-based medicine • NICE • clinical guidelines, technology appraisals, quality standards, organisational guidelines

12. Assumption 2: Doctors know best

13. Pre 1950 • study in USA in 1920s: ‘always 40-50% of children need surgery’ • tonsillectomy in UK in 1930s (Alison Glover) • unexplained geographical variation in rates • 1950s • Still commonplace to defer to doctors • Patients seeking explanation was tantamount to non-compliance and criticism • But from the 1970s… • Start of challenge to ‘doctors know best’ • Stimulated by epidemiology, sociology and economics

14. Epidemiology demonstrated… • inexplicable geographical variations in use were widespread (John Wennberg & Dartmouth College) • 90% of treatments show greater variation than hysterectomy • inappropriate use of common treatments (Bob Brook & RAND) • lack of consensus about appropriate criteria for interventions • such findings not confined to market-driven health systems; present in England • inherent feature of health care

15. Sociology & social psychology shed light on... • ways in which doctors and patients interacted • complexity of relationship (David Silverman, Phil Strong) • profound impact on patient behaviour and use of services • relative ineffectiveness of doctor’s communication skills • role of other health care workers in helping patients to understand eg cleaners • patients unrecognised and unmet needs (Jean Macfarlane)

16. Economics demonstrated... • impact of financial incentives • on doctors’ decision-making (such as supplier-induced demand) (Bob Evans) • moral hazard • when doctors and patients do not share same level of information • impact of patients’ involvement in decision-making on efficiency of care • better compliance with drug therapy

17. Manifest today as… • people other than clinicians can and should be involved in policy making • promotion of patient choice (consumerism) as a driver of quality and efficiency • encouragement of patient participation • shared decision-making • expert patient • long-term disease management (co-production) • development of evidence- based commissioning • use of financial incentives (pay for performance)

18. Assumption 3: Services are well organised

19. 1960/70s • initially focus on long-stay institutions • adverse impact of institutionalising long-stay patients (Erving Goffman) • insidious effects of closed institutions could lead to inhumanity (John Martin) • 1970/80s • studies in general practice (Ann Cartwright) • lack of appointment system in general practice • studies of hospitals and professionals (Meg Stacey) • early morning waking of inpatients • block-booking outpatients • limited visiting times...

20. Professionals’ needs prioritised over patients’ needs

21. Manifest today as: • appointments systems • day surgery • care in the community • outreach services • clinical pathways

22. Assumption 4: Services are efficient

23. 1960s onwards • Technical (productive) efficiency (Alan Williams) • reliant on development of valuation of life (Victor Fuchs) • development of health status measurement by psychometricians • Cost-utility analysis • Quality Adjusted Life Year (QALY) • facilitated consideration of allocative efficiency; led to transparent, informed rationing • Financial incentives and disincentives • to encourage greater efficiency • Manifest today as: -explicit rationing (NICE); prospective payment (DRGs/HRGs); re-engineering production

24. Assumption 5: Services are equitable

25. 1960s • continuing disparities despite NHS • ‘inverse care law’ (Julian Tudor Hart) • improve geographical equity through resource allocation • based on population indicators of need • 1980s • epidemiological research • documenting socioeconomic inequalities • inequity by age, sex, ethnicity • sociological research • complex relationship between demand and supply: illness behaviour, lay referral Manifest today as: - funding mechanisms; resource allocation formulae; enhancing access

26. Assumption 6: Care is of good quality

27. 1970s • need to distinguish between • inputs; processes; outcomes (Avedis Donabedian) • routine assessment (audit) of quality of care • limited to comparison of inputs and processes • development of measures • outcomes and satisfaction (health psychologists, epidemiologists and economists) • revealed considerable variation between providers • 1980s/90s • comparison of providers • risk adjustment models developed (statisticians) • patient experience questionnaires (psychometricians) • research on how to improve quality • public disclosure, incentives, education, re-engineering services

28. Manifest today as: • performance management • regulation (Care Quality Commission) • public information (NHS Choices; Quality Accounts) • revalidation

29. Changes not entirely due to HSR! • Changes in • health technologies (laboratory & clinical research), public health, expectations, demography, family structure… • HSR has made a key contribution • changing clinicians’, managers’, politicians’ and the public’s ways of thinking about health care • Difficult (impossible) to quantify such influence • But just because its impossible to measure doesn’t mean research has had no impact

30. With apologies to John Maynard Keynes and economists …the ideas of health services researchers, both when they are right and when they are wrong, are more powerful than is commonly understood. Practical men, who believe themselves to be quite exempt from any intellectual influences, are usually the slaves of some defunct health services researcher. Madmen in authority, who hear voices in the air, are distilling their frenzy from some academic scribbler of a few years back. The General Theory of Employment, Interest and Money, 1936.

31. When researchers are frustrated by their apparent lack of influence… I am sure that the power of vested interests is vastly exaggerated compared with the gradual encroachment of ideas. (Keynes) Many contemporary ideas about health care and health services have come from researchers