Best Research for Best Health

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Best Research for Best Health?

• Professor David Hunter

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An Uncertain Future
The Government is unleashing forces over which it
has, at best, imperfect control. Neither it, nor
any of us, knows where the changes will lead the
NHS. We are all engaged in a massive experiment.
The only certainty is that at no other time in
the NHSs history does its future appear so
uncertain. David Hunter, Editorial, Public Money
Management, August 2005
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Structure of Presentation

• Health policy challenges for the 21st century
• Health research strategy fit for purpose?
• Impact of NHS changes
• Getting evidence into policy and practice

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Health Policy Challenges for the 21st Century

• Chronic disease/long term conditions
• Public health
• Changing role of hospital
• Rebalancing NHS from a sickness to a health
  service

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Key Policy Statements

• 2004 Choosing health white paper
• 2005 Choosing health delivery plan
• 2005 Commissioning a patient-led NHS
• 2005 Health reform in England update and next
  steps
• 2006 Our health, our care, our say a new
  direction for community services white paper

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Wanless Review of Challenges Facing NHS 2002-2022

• Fully Engaged Scenario
• Levels of public engagement in relation to their
  health are high
• Life expectancy increases beyond current
  forecasts
• Health status improves dramatically
• People are confident in the health system and
  demand high quality care
• Health service is responsive with high rates of
  technology uptake, especially in relation to
  disease prevention
• Use of resources is more efficient

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The Challenge
We must reorientate our health and social care
services to focus together on prevention and
health promotion.
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A system like todays NHS which channels people
into high-volume, high-cost hospitals is poorly
placed to cope effectively with this.
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There has to be a profound and lasting change of
direction. (Our Health, Our Care, Our Say, 2006)
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The Redisorganisation Game is Alive and Well!

• Permanent revolution
• Constant policy and organisational churn
• disruptive governance
• constructive discomfort

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Jigsaw Policies the 5 Ps

• Private finance initiative
• Plurality of providers
• Payment by results
• Practice-based commissioning
• Patient choice
• Where is the evidence base?

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Risks

• Fragmentation of health and health care
• Loss of integration and joined up policy
• Chronic disease and public health demand whole
  systems response
• Widening inequalities in health

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Do Governments Want Evidence?
There is nothing a government hates more than to
be well-informed, for it makes the process of
arriving at decisions much more complicated and
difficult. John Maynard Keynes (1936)
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Research Strategy - Strengths

• Break with historical pattern of research funding
  and bias towards major teaching hospitals
• Emphasis on applied research
• Emphasis on translational research
• Strengthening research culture among
  professionals
• Streamlining research infrastructure and
  governance
• Bureaucracy busting emphasis

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Research Strategy - Weaknesses

• Bias towards health care rather health lack of
  balance
• Public health research appears marginalised
• Dominance of clinical research priorities
• Disease-focused rather than health-focused
• Language patients rather people
• Failure to challenge perverse incentives arising
  from RAE

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Wanless Critique of Public Health Research

• Appropriate outcome measurements to demonstrate
  effectiveness and cost-effectiveness
• Use of controls to attribute outcome to
  intervention
• Use of appropriate timeframes for evaluation of
  outcomes
• Consideration of the degree of change to outcomes
  that would constitute success

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The Wider Determinants of Health
Based on the Whitehead and Dahlgren (1991)
diagram as amended by Barton and Grant (2006) and
the UKPHA Strategic Interest Group (2006)
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Evidence-based Policy Rhetoric or Reality?
Opinion-based Policy
Evidence-based Policy
Increasing Pressure
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Policy-Making Models

• Knowledge-driven model
• Problem-solving model
• Interactive model
• Political model
• Enlightenment model
• Tactical model

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The Knowledge-Driven Model

• The rational linear model of knowledge generation
  and direct application to policy

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The Problem-Solving Model

• The instrumental view whereby research provides
  evidence to solve policy problems

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The Interactive Model

• Search for knowledge moves beyond research to
  include a variety of sources, including politics
  it seeks to reflect the complexity of policy

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The Political Model

• Research is not welcome unless it serves
  political gain evidence is sought to justify the
  problem and the solution

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The Enlightenment Model

• Cumulative research shapes concepts and
  perspectives that permeate the policy process
  over time, influencing how people think about
  issues

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The Tactical Model

• Evidence is used to support and justify
  government inaction, or rejection of and delay in
  commitment to a policy issue

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Scientific findings do not fall on blank minds
that get made up as a result. Science engages
with busy minds that have strong views about how
things are and ought to be.
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Peoples willingness to take action influenced
their view of the evidence, rather than the
evidence influencing their willingness to take
action. Michael Marmot (2004)
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Barriers to Evidence-based Policy and Practice

• Complexity and contestability of evidence
• Intricacies of policy process
• Influence of political priorities
• Multiple, and often contradictory, goals of
  policy-makers and managers
• Tacit knowledge valued over and above research
  evidence
• Absence of research culture she who does,
  knows
• Lack of consensus about the evidence whose
  opinions count?
• The play of power
• Curse of the temporal challenge

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Some Discomforts of Researching the Policy
Process

• Grant starvation
• Denial of access
• Restrictions on publication
• Give us only the good news, not the bad
• Inconvenient research findings ignored, buried,
  rubbished
• Researchers attacked for their motives

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Conclusions

• Preserve and build on health strategys strengths
• Rebalance strategy more towards public health
  research
• Allow researchers to speak truth to power
• Support researchers get evidence into policy and
  practice
• Get the balance right between RD R into D into
  P P
• Forge new relationship between researchers and
  policymakers and practitioners
• Give attention to communication and dissemination

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High above the hushed crowd, Rex tried to remain
focused. Still, he couldnt shake one nagging
thought He was an old dog and this was a new
trick