tag:theconversation.com,2011:/us/topics/health-systems-research-4099/articlesHealth systems research – The Conversation2014-05-15T04:53:01Ztag:theconversation.com,2011:article/266852014-05-15T04:53:01Z2014-05-15T04:53:01ZBetter ways to spend the medical research future fund<p>One of the few real surprises in the budget was the creation of medical research future fund, to be partly funded by the introduction of a $7 GP co-payment. This injection of money provides an opportunity think strategically about role and direction of Australia’s medical research effort. </p>
<p>To be invested and managed by the Future Fund Board of Guardians, all estimated savings from health expenditure announced in Tuesday’s budget flow into the fund until it reaches $20 billion. It will also include $1 billion of uncommitted money in the existing health and hospital fund.</p>
<p>Establishment is subject to legislation passing through parliament and capital and ongoing gains will be preserved in perpetuity. Net earnings will fund medical research priorities the following year, including through the National Health and Medical Research Council (NMHRC).</p>
<p>While further details are relatively scant, the <a href="http://www.financeminister.gov.au/media/2014/mr_2014-45.html">Department of Finance indicates</a> it will fund research across a wide spectrum including:</p>
<blockquote>
<p>illness prevention and promote early intervention, reducing health costs while improving health outcomes and delivering better quality of life. </p>
</blockquote>
<p>What this does not mention is any research into health system changes. When it comes to improving the health-care system, what’s needed is research that addresses issues that are relevant to current or future policy debates.</p>
<h2>Missing research</h2>
<p>But Australia seems better at writing reports about the potential for undertaking health services-focused research than actually doing the work.</p>
<p>Health services research was a central part of the <a href="http://www.mckeonreview.org.au/">2013 Strategic Review of Health and Medical Research</a> (McKeon Review), and has been called for in the <a href="http://www.pc.gov.au/__data/assets/pdf_file/0008/128438/annual-report-2012-13.pdf">2012-13 Productivity Commission Annual Report</a>, which argues “[p]olicy-making based on good evidence is central to improving community living standards.” </p>
<p>It was also mentioned in the recent <a href="http://www.ncoa.gov.au/report/phase-one/part-b/9-1-principal-bodies.html">National Commission of Audit report</a>, which said Australia needs to “embed health and medical research in the health system” in order to “improve patient outcomes and deliver efficiencies”. </p>
<p>These aspirations are a long way from the current focus of Australian medical research, which looks more at petri dishes than patients. The most commonly used word in the <a href="http://nhmrc.gov.au/grants/research-funding-statistics-and-data/research-achievements">synposes of grants</a> given by the NHMRC from 2004 to 2012, for instance, is “cells”, which reflects its strong biomedical focus.</p>
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<img alt="" src="https://images.theconversation.com/files/48541/original/t7836vd7-1400112122.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/48541/original/t7836vd7-1400112122.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=551&fit=crop&dpr=1 600w, https://images.theconversation.com/files/48541/original/t7836vd7-1400112122.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=551&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/48541/original/t7836vd7-1400112122.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=551&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/48541/original/t7836vd7-1400112122.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=693&fit=crop&dpr=1 754w, https://images.theconversation.com/files/48541/original/t7836vd7-1400112122.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=693&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/48541/original/t7836vd7-1400112122.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=693&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The most commonly words in the synopses of grants given by the NHMRC.</span>
<span class="attribution"><span class="source">Adrian Barnett</span></span>
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<p>Most of the NHMRC-funded medical research institutes, over 40% of project grants and the majority of fellowships funding flow to basic science. Health services research constitutes less than 10% of overall funding. </p>
<h2>Evidence-free health policy debate</h2>
<p>Take the recent debate on the merits of introducing a co-payment for GP visits. It’s hard to know its potential impact on use, particularly among those on lower incomes. And to what degree it may transfer costs to other sectors, for instance, by people going to hospital emergency departments instead. Surely, it’s evidence on these factors that should frame and inform any policy debate. </p>
<p>The <a href="http://www.budget.gov.au/2014-15/content/bp2/html/bp2_expense-14.htm">introduction of a $7 co-payment in the budget</a> provides the opportunity to evaluate impact, but that would require research involving information collection from a representative sample of Australians and using administrative data to see how health-care usage changes.</p>
<p>Getting this type of research funded through the existing NHMRC grant funding system is problematic. Its investigator-initiated funding model requires researchers to apply to undertake research, rather than the NHMRC commissioning important topics to work on. </p>
<p>Pragmatic research designs that address important questions don’t often fair well in its grant evaluation processes. Even if the research does receive NHMRC funding, the earliest such a project could commence would be in early 2016, precluding any opportunity to collect data before and after the introduction of the co-payment in July 2015. </p>
<h2>An evidence-based alternative</h2>
<p>You don’t have to look far for a vision of better funding system for health services and systems research in Australia. It was one of the major themes of the <a href="http://www.mckeonreview.org.au/">McKeon review</a>, which focused on better aligning research to deliver health-system impact. </p>
<p>The review suggested funding health services research by setting aside a proportion of existing funds by:</p>
<p>• quarantining a proportion of NHMRC research for “top-down strategic research”</p>
<p>• establishing an influential institute of health services research and</p>
<p>• boosting fellowships targeted at disciplines that undertake health services research.</p>
<p>If this had been implemented, an institute of health services research or the NHMRC could already be commissioning the collection of special studies to examine the impact of the GP co-payment. Unfortunately, few of the McKeon recommendations have been put into practice to date.</p>
<p>Only a small fraction of the medical research future fund would be required to kick start a systematic research effort aimed at improving key aspects of our health system. Surely, some of the funds from all Australians who will be paying the GP co-payment should be used to study its effects and thereby help directly improve our health care system.</p><img src="https://counter.theconversation.com/content/26685/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Philip Clarke receives funding from National Health and Medical Research Council and would potentially benefit from additional funding devoted to health services research.</span></em></p><p class="fine-print"><em><span>Adrian Barnett receives funding from the National Health and Medical Research Council. As a health and medical researcher he may receive future income from the proposed Research Future Fund.</span></em></p><p class="fine-print"><em><span>Danielle Herbert receives funding from NHMRC.</span></em></p><p class="fine-print"><em><span>Nicholas Graves receives funding from ARC, NHMRC, NIHR & Queensland Government</span></em></p>One of the few real surprises in the budget was the creation of medical research future fund, to be partly funded by the introduction of a $7 GP co-payment. This injection of money provides an opportunity…Philip Clarke, Professor of Public Health, The University of MelbourneAdrian Barnett, Associate Professor of Public Health, Queensland University of TechnologyDanielle Herbert, Researcher, Queensland University of TechnologyNicholas Graves, Professor of Health Economics, Queensland University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/103232012-11-06T02:52:43Z2012-11-06T02:52:43ZAustralians give an upbeat diagnosis of health system<figure><img src="https://images.theconversation.com/files/17134/original/5y3jb6kn-1351664099.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Community attitudes towards the health system have improved significantly over the last four years.</span> <span class="attribution"><span class="source">Sarah Reid</span></span></figcaption></figure><p>More than half of the Australian population believe they’re in very good to excellent health, have a high level of confidence in the health system and support the policy direction that the federal government’s aged care reforms are based on. </p>
<p>The <a href="http://www.menzieshealthpolicy.edu.au/mn_survey/index.htm">2012 Menzies-Nous Australian Health Survey</a> provides a wide-ranging snapshot of the perceptions and attitudes of Australians toward their health and the health and aged care systems. First conducted in 2008, the biennial survey focuses on the accessibility, affordability and confidence in health-care services and how these views have changed over the past four years. It’s based on a representative national sample of 1,200 people, surveyed by telephone in July 2012.</p>
<p>The survey showed that support for “fundamental” reform of the health system remains strong – at over 60%. But community attitudes towards the health system have improved significantly over the last four years, with the proportion of people indicating “the system needs to be rebuilt” at just over half the level of those who thought so in 2008. </p>
<p>These views varied according to where people lived. Those in metropolitan areas had a more positive view of the health system in terms of affordability, access to doctors and their confidence of receiving quality care if they needed it. Australians outside the big cities and those with high levels of financial stress were much less confident. </p>
<p>The report shows only 37% of Australians under high financial stress are confident they can afford the care they need. This has been a consistent finding over the past four years. This group is also half as likely to use dental and private hospitals as those reporting low financial stress – despite self-reporting poor health status. </p>
<p>It’s a matter of concern that this hasn’t improved, despite reforms aimed at improving access to basic health care, especially GP and other primary care services. It underlines findings <a href="https://www.mja.com.au/journal/2012/196/1/falling-through-cracks-hidden-economic-burden-chronic-illness-and-disability">by other researchers</a> that out-of-pocket payments remain a major problem for those facing economic hardship.</p>
<p>The picture was brighter for older Australians. People aged 65 years and over generally reported greater confidence in the health system if they fell seriously ill compared to other age groups.</p>
<p>But Australia’s aged care system will need to shape up if it is to meet the expectations of Australians who responded to the survey.</p>
<p>The baby boomer generation is now making important decisions about aged care for their family and loved ones and their views about what it takes to provide excellent aged care will ramp up over the next 20 years as they get closer to having to use it themselves. </p>
<p>The aged care questions in the survey shed some light on what Australians think is important to make aged care services better.</p>
<p>For those who knew someone using residential aged care recently, it may come as no surprise that satisfaction rates sit at 54%, the second lowest for all health services rated in the survey. This compares badly to community care where the satisfaction rates were higher at 72%; GPs at 78% and; pharmacists at 89%. </p>
<p>Putting more resources into a new National Home Support program is an important part of the government’s aged care reforms. In a big tick for the plans to shift the focus of aged care away from nursing homes and into home care, the survey showed resounding support for more care services in people’s homes. Half those surveyed saw the most important improvements needed in aged care as more home support, followed by better pay and conditions for aged care workers. </p>
<p>There were mixed sentiments about consumer-directed care, increasing the say of consumers and their carers on who delivers care. There was strong support (95%) for the proposal that consumers should decide what care they receive. But when posed in a slightly different way (to avoid bias), more than two thirds (69%) agreed aged care professionals should decide. </p>
<p>The message on the location of care remained strong. Only 53% thought aged care professionals should decide where people receiving aged care should live, reinforcing the general view that people should have the final say in their location of care.</p>
<p>One of the survey’s most compelling findings was on the funding of reforms. Almost two-thirds agreed they would pay more taxes if it meant older people could stay at home and receive the required levels of care. </p>
<p>Overall, Australians overwhelmingly agree that the community should contribute towards paying for aged care, with 92% indicating the public should pay some of the costs towards aged care based on financial means (but not at the expense of selling their house) and the government should pay the rest.</p>
<p>Health reform is about transforming the way we organise health services to meet the growing burden of chronic illness. In contrast, public opinion as measured by this survey, is content with the existing system. But the findings on aged care funding suggest that public opinion, given an open enough policy debate, can make the politicians look timorous. </p>
<p><em>Gillian McFee from the Nous Group helped write this article.</em></p><img src="https://counter.theconversation.com/content/10323/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>James Gillespie receives funding from the National Health and Medical Research Council. </span></em></p>More than half of the Australian population believe they’re in very good to excellent health, have a high level of confidence in the health system and support the policy direction that the federal government’s…Jim Gillespie, Deputy Director, Menzies Centre for Health Policy & Associate Professor in Health Policy, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/101452012-10-17T00:34:42Z2012-10-17T00:34:42ZMcKeon review should consider the well-being of health system<figure><img src="https://images.theconversation.com/files/16609/original/d5xv989c-1350432254.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">We need to research the health of the health system for the sake of sustainability.</span> <span class="attribution"><span class="source">Greg Boege</span></span></figcaption></figure><p>The <a href="http://www.mckeonreview.org.au/10857/Consultation_Paper/">consultation paper</a> by the panel of the <a href="http://www.mckeonreview.org.au/">McKeon Review</a> is available and open for public comment now, so it’s worth examining whether this review (the latest of many into health and medical research) is different from those that have come before. </p>
<p>We can also now assess whether the current recommendations will meet what McKeon has called “the overarching message” of the review - that Australia needs a “stronger connection between health and medical research, and the delivery of health-care services”.</p>
<p>Although this is a summary document (the detailed paper is expected to be released in the next week or so), in general, the recommendations are familiar. Since at least the 1960s, reviews of Australian health and medical research have called for greater investment in health services and systems research to meet the challenge of maintaining a sustainable health-care system. </p>
<p>It’s gratifying to see recognition of the need for health systems research and health economics. Although its not new, the emphasis in this review is stronger than other recent reports. But it fails to grasp the breadth of research required in this area.</p>
<p>As well as informing delivery of services, research also needs to inform “big picture” health policy. While some aspects of health care provision, such as efficacy, quality and safety will benefit from research evidence produced at the level of service delivery, we also need evidence about how efficient, accessible and equitable the health system is.</p>
<h2>A better way</h2>
<p>Unlike many other Australian government policy areas, the <a href="http://www.health.gov.au/">Department of Health and Ageing</a> doesn’t have its own internal research capacity or funding; it relies on the National Health and Medical Research Council (<a href="http://www.nhmrc.gov.au/">NHMRC</a>) to fulfil this role. This may be appropriate for biomedical and clinical research, but it doesn’t work for health services, health policy and health economics research. </p>
<p>We’re disappointed that the report has recommended that the management and leadership of health services research be left with the NHMRC, given the organisation’s poor track record in supporting this type of research. We believe that to truly achieve evidence–based policies, the review should recommend a similar approach to the United Kingdom, where the <a href="http://www.dh.gov.uk/en/index.htm">department of health</a> has its own policy research program and the <a href="http://www.nhs.uk/Pages/HomePage.aspx">National Health Service</a> (NHS) has the <a href="http://www.nihr.ac.uk/Pages/default.aspx">National Institute of Health Research</a>, in addition to the separate <a href="http://www.mrc.ac.uk/index.htm">Medical Research Council</a>. </p>
<p>A new Australian institute of health systems research would be the recipient of quarantined funding for health systems and health services research. This would fall in line with the review’s recommendation that at least 3% of Australian and state and territory government health expenditure (an additional A$2bn to A$3bn per year by mid-2023) be set aside to drive research activity within the health system as an embedded component of the Australian government’s health reforms. </p>
<p>The second important task for such an institute would be to set priorities for health systems research. While the review supports priority setting for research with earmarked funds, many researchers have been less than satisfied with previous priority setting processes in this type of research. </p>
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<span class="attribution"><span class="source">marsmet521/Flickr</span></span>
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<p>Over the past 15 years, we have seen a diverse range of attempts at health system and services research, including ones based on national health priorities, national research priorities, a priority-based collaboration between the states and the commonwealth, partnership projects and now partnership centres. </p>
<p>While consultations were undertaken prior to each new scheme, no independent evaluation has assessed the success or otherwise of these schemes. And most have come and gone so fast that, in practice, the individual research projects they supported resembled poorly-funded commissioned projects.</p>
<h2>Building research capacity</h2>
<p>Implementing a new national institute would require research capacity. When a similar need to build research and research capacity was identified in primary care, the response was the <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/pcd-programs-phcred">Primary Health Care Research Evaluation and Development Strategy</a> and the funding of an institute to provide leadership, and support centres of research excellence alongside, not instead of, access to NHMRC funding. </p>
<p>While the review recognises the importance of building research capacity, it fails to understand that this requires more than providing training, funding and time for health-care professionals to undertake research. Health services researchers come from many non-clinical disciplines and need to be sustained along a career path. </p>
<p>Access to high-quality data is also an essential part of the infrastructure required for health services research. Clinical trials are only one, and an increasingly expensive, way to deliver evidence on what works. We also need to know what works when new treatments are made available to all patients. We need to know what works for so-called rare diseases, where the patient population is not large enough to enable powerful trials, but where the prevalence is increasing, and many people are living with ongoing severe conditions. There’s an urgent need for support for better collections of observational data (such as registries and longitudinal data). </p>
<p>And we need to have the means to link data from various sources. In particular, we need to be able to link data on inputs (health professionals, hospitals and GP practices, for instance) to outputs and outcomes (volume of services provided, performance indicators, and health outcomes). </p>
<p>So far, the data linkage process has focused on linking patients’ data (linking individuals’ in-patient and emergency data with data from cancer registries, for instance). While this is important, there’s very little linkage of patients’ data to data on the health-care providers who treated them. Hospital data don’t indicate who referred patients, for instance, so there’s no link to primary care services. This is a major omission in data linkage given the importance of primary care in reducing hospital expenditures. </p>
<p>There are currently significant barriers to accessing linked data because the extraction process is costly and time consuming. And one-off data extractions that a researcher must keep confidential runs contrary to others reproducing and testing results of a study.</p>
<p>The <a href="http://www.who.int/en/">World Health Organization</a> calls health systems research the “brains of the health system”, and <a href="http://www.who.int/rpc/publications/scaling_up_research.pdf">argues for increased investment</a> in this field of research. If the Australian health-care system is not to be left without brains, the final report of the McKeon review will need make health systems research a part of the future of the our system.</p><img src="https://counter.theconversation.com/content/10145/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jane Hall receives funding from the ARC, NHMRC and APHCRI. Professor Hall is a health systems researcher. </span></em></p><p class="fine-print"><em><span>Marion Haas does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The consultation paper by the panel of the McKeon Review is available and open for public comment now, so it’s worth examining whether this review (the latest of many into health and medical research…Marion Haas, Professor of Health Economics, Deputy Director of CHERE, University of Technology SydneyJane Hall, Professor of Health Economics and Director, Centre for Health Economics Research and Evaluation, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.