Health services and research – difficult decisions, rich debate

There were no ivory towers at last month’s Health Services Research Network symposium in Nottingham.  Researchers were getting down and dirty, grappling with pressing problems from urgent care to patient experience in surgery to safer discharge planning.  I was struck by the interjections from senior leaders – with seasoned chief executives like Peter Homa giving his thoughts on measuring quality (following Nick Black’s barnstorming critique of HSMRs) to Simon Pleydell noting that struggling organisations often just don’t know what good looks like.  There was a note of buoyancy from Gary Ford on the role of AHSNs in pushing forward evidence-based innovation – and his own experience as a stroke physician of how research can inform service change for the good.

But elsewhere optimism was thin on the ground.  In a plenary session on integrated care, Martin Roland reflected wryly that he could well be dubbed the professor of what doesn’t work.  He took no pleasure in enumerating the many reasons why promising innovations to integrate care often failed to live up to the promise in rigorous evaluations – from regression to the mean to difficulties in attribution and causality.  I was thinking of this in the recent controlled evaluation of Birmingham OwnHealth by Adam Steventon and colleagues (http://www.bmj.com/content/347/bmj.f4585) – despite much championing in the service, this plausible initiative to promote self-care by motivational coaching showed no impact on health and service use (indeed, a slight rise in admissions).   This was all very topical, given the Better Care Fund initiative and difficult local decisions on how best to join up services and support people with complex needs.

There was an interesting debate on why research so rarely gives managers the `good news’ stories they crave.  And why the NHS is so bad at valuing failure or remembering what went before – in the words of Rudolf Klein (cited by one speaker), innovation is just a function of forgetting.  Could researchers work more closely with service leaders at an early stage to clarify the aims and programme logic of new system changes?

And yet, and yet.  In the packed parallel sessions, buzzing coffee breaks and stimulating plenaries I sensed not defeat but invigoration.   To take just one example, in the session which I chaired on workforce, three HS&DR funded projects provided brilliant examples of just how research can provide findings which really matter to managers, clinicians and patients.   This ranged from hard evidence on the effectiveness of multidisciplinary teams (too many cooks can spoil the broth or dilute the effectiveness of care planning); to practical recommendations on how best to recruit, support and develop peer workers in the half of mental trusts now using them; to physician assistants as cost-effective and acceptable addition to ease general practice workloads.

So health services research has much to offer.  And it seems that the NHS (from the new chief executive down, whose recent address to the NHS Confederation was seen by many as signalling a renewed commitment to evidence and research) is really ready to listen…