Contact information: Professor Jonathan Karnon (President of the HSRAANZ), School of Public Health, University of Adelaide, Level 7, 178 North Terrace, Adelaide, SA 5005
Tel: 08 83133562
The Health Services Research Association of Australia & New Zealand (HSRAANZ) supports and promotes the conduct and dissemination of applied research to improve the delivery and organisation of health services in Australia and New Zealand. We have 250 individual members and 20 corporate members. Covering universities, research centres, government departments, independent government agencies, and consumer groups. The Association bridges the gap between research and policy, as well as reflecting consumer issues. We also have two special interest groups, focussing on Emerging Researchers and Indigenous Health Services Research.
The goals of health services research (HSR) are to identify effective and efficient ways to organise, manage, finance, and deliver safe and high quality care.
It is important to continue to develop and commercialise new healthcare technologies and HSR has a crucial role to play in determining their safety, effectiveness and cost-effectiveness. HSR can further support the appropriate uptake of new technologies and services through structured engagement and co-design of implementation strategies with relevant stakeholders including clinicians and consumers.
There is increasing recognition that Australian’s should be making better use of existing healthcare resources. The McKeon Review stated that up to one third of all healthcare spending is used for services that produce no health benefit or even cause harm to patients. The Bureau of Health Information in NSW has also reported significant variations in patient outcomes across hospitals, and national hospital costing data shows huge variations in the costs of treating similar conditions at different hospitals. The ongoing Medicare Benefits Scheme (MBS) review aims to reduce the observed inappropriate use of MBS-subsidised services, tests and procedures but there is scope across all sectors of the healthcare system to make significant improvements to the organisation and delivery of healthcare.
HSR has a central role to play in reducing waste and improving the efficiency of the Australian healthcare system.
It is useful to distinguish between smaller scale, local HSR that identifies and addresses issues that relate to a jurisdiction such as a State Department of Health, a Primary Health Network (PHN), a Local Health Network (LHN), or a hospital department, and large scale HSR that investigates broad health service issues such as financing approaches, incentive schemes and generalisable models of care.
Strategies are required to develop:
- Capacity and Motivation for local HSR
- Priorities and Funding for large scale HSR
Capacity and Motivation for local HSR
At a local level, HSR can inform the effective and efficient organisation and delivery of local healthcare services.
Local HSR focuses primarily on the evaluation of technologies and services in a local context and the improvement of specific health care services, in the hospital, in a primary health care setting and in the community. Robust evaluation and improvement does not occur spontaneously. It requires a commitment to invest in building capacity and processes and funding to support high value HSR. A culture of high value care needs to be owned and developed by consumers and clinicians, with health care professionals empowered and rewarded to identify, pilot and sustain advances in health care delivery. Health care professionals understand the problems, can recognise low value care and often have good ideas to improve services. Yet they are unlikely to have the research skills or capacity to quantify the issue, disseminate data on improvements or advocate for innovation. Sensible investments in partnerships will build capacity for HSR and a culture of innovation will develop.
The NHMRC funds few local HSR projects and the Australian Commission on Safety and Quality in Health Care (ASQCHC) provides guidance on clinical standards and safety and quality indicators, but does not have the resources to provide more direct support for local HSR. Increased public reporting by the ASQCHC and the National Health Performance Authority and more activity based funding of public hospitals provide some motivation to improve services. However, capacity for local HSR is largely dependent on State governments and commitment is variable.
A more systematic and sustainable approach to local HSR is required. A first step is a review of international approaches and an audit of current practice in Australia.
In England, the Sustainable Improvement Team connects "local resources and expertise in service improvement". In health technology assessment (HTA – a subset of HSR) there is increasing interest in local or hospital-based HTA for which alternative models have been proposed: the ambassador model, mini-HTA, the internal committee, and the HTA unit. Analogous approaches to local HSR more generally could be considered.
In Australia, a potential model for building capacity for HSR is the Australian Centre for Health Services Innovation (AusHSI), which has invested resources and training in clinician led HSR in Queensland. They focus on improving value for money and are now prioritizing implementation to translate existing evidence into routine practice. But across Australia, what local HSR is being undertaken? Who is doing it? What data are being used? What is its quality? Who is funding it? How is it funded? What is its impact?
The findings should inform a national strategy to build capacity and motivation for local HSR. The centrepiece of such a strategy might be a National Centre for Health Services Research that provides support and guidance on how to develop and organise local HSR capacity, including research training in HSR, prioritisation processes, data access and management, stakeholder engagement and implementation. Such a Centre might also manage a local HSR fund to which applications are made for funds to undertake local quality improvement or implementation projects.
Priorities and Funding for large scale HSR
A National Centre for Health Services Research could also co-ordinate funding of large scale HSR to inform policy at a Commonwealth level or that is applicable across jurisdictions (e.g. evaluating new models of care). Currently some large scale HSR is funded through the NHMRC or through ad hoc contract research funded by the Department of Health and Ageing, such as the evaluation of the Diabetes Care Project.
NHMRC funding is primarily investigator led and not necessarily aligned with health system priorities. Government contract research focuses on the evaluation of major policy initiatives and not HSR to inform the design and implementation of health policy.
In England, the National Institute for Health Research (NIHR) funds tender-based HSR through nine research programs, which include separate programs for ‘health services and delivery research’ and ‘HTA’. A separate Policy Research Programme commissions high quality research to meet the needs of Ministers and national policymakers. A feature of the NIHR tendering process is the submission of proposals from any interested party that are further developed and then reviewed by priority setting panels who select the topics for which research is tendered.
In the US, the Agency for Healthcare Research and Quality (AHRQ) supports "health services research that will improve the quality of health care and promote evidence-based decision-making". A key activity of the AHRQ is the Effective Health Care Program (EHCP) that funds research to be used by clinicians, consumers, and policymakers. The EHCP also tenders research that is informed by open submissions.
In 2015, the NHMRC reported that it allocated 6.4% ($57.6m) of it’s total research budget to HSR. The McKeon report called for increased focus on HSR and a more recent audit by the Office of the Queensland Chief Scientist reported that HSR is "seriously underdone". The low level of funding for HSR may be partly explained by inadequate infrastructure to create the capacity and motivation to undertake high quality HSR, and to bring researchers, health professionals and managers and policymakers and consumers together to identify, prioritise, undertake and translate high value HSR.
The lack of infrastructure results in fragmented and reduced impact HSR, which perpetuates the lack of investment in HSR, but more importantly does not fulfil the potential of HSR to create a high quality, equitable, efficient and therefore sustainable health care system for the Australian population.
HSR is not like basic or clinical science or even public health research, where research can be conducted in isolation and then reported with an expectation that positive research findings will be implemented. Health care is delivered in an increasingly complex system and research to improve health services must involve ongoing engagement between all stakeholders in a continuous process of improvement.
This submission has defined two broad forms of HSR – local HSR and large scale HSR – and provided a rationale and some broad suggestions to improve the conduct and impact of both forms of HSR in Australia. Further work is required to develop and appraise specific actions, but an overarching component of this submission is the call for a National Centre for Health Services Research. The Centre will oversee both forms of HSR and provide the basis for developing the necessary infrastructure to ensure HSR reaches its potential to improve the health and wellbeing of all Australians.