Health services research in Europe: Evaluating and improving its contribution to health care policy

Health care challenges

Europe's health systems face several challenges. One of the most prominent, high on political agendas, is the unstoppable ageing of the population as the current and future citizens of Europe live longer and in better health than before. This trend will increase the demand for health care substantially, with non-communicable diseases and, in particular, chronic illnesses becoming the main burden of disease.^1-2 The same demographic developments will affect the available workforce. From 2020 onward, fewer people will be in the working age population, able to ensure our future prosperity. ³ At the same time, the need for European countries to evaluate their health care systems is being fed by the increasing pressure on government budgets, with spending on health care for many, if not all, European countries rising faster than economic growth. ⁴

These developments contribute to an ongoing debate about how to realize major cuts in health care spending, while still recognizing that effective health care spending is an investment which contributes to the wealth and health of Europe.^5-6 Health policy and organizational innovations that can help make health care more effective and efficient will be very valuable in the context of an ageing population and increasing cost pressures. The need to find solutions for common health care problems is acknowledged by the European Commission. Its Seventh Framework Programme identified for the first time identified health care systems and services as a distinct area of research under the pillar ‘Optimising the delivery of health care to citizens’. Such activities aim to provide the necessary evidence for informed policy decisions on health care systems.

Health Services Research into European Policy and Practice

This supplement addresses how health services research can help decision-makers address the challenges they face and provide scientific evidence to inform policies and practices. It is based on the project Health Services Research into European Policy and Practice (HSREPP), funded under the European Union's (EU's) Seventh Framework Programme. Our aims were to describe the main areas of research within the field of health services and to identify priorities for which more research is required. Setting such priorities is crucial since health services research (HSR) is applied research that is largely funded publicly and should, therefore, ask the right questions at the right time in order to meet the needs of policy-makers. ⁷

In the past, a number of attempts have been made to solicit the opinions of experts on HSR on future priorities. These are often focused on national research priorities, such as the Canadian ‘Listening for Direction’ initiative ⁸ , and similar initiatives in the UK and the USA.^9-10 At an international level, the World Health Organization (WHO) has put strong emphasis on identifying priorities for international, or global, research, both in the areas of biomedical research and health services or systems research.^11-12

There is a need to establish priorities at an international level for two reasons. Firstly, many countries, especially those with low and middle incomes, lack the resources and capacity to set priorities at a national level. ¹³ Secondly, HSR has a clear and strong international component. In Europe, the incremental way in which health systems have developed has resulted in a collection of unique ‘patchworks’, in which knowledge from HSR is highly dependent on understanding the national context. As a result, simply copying service arrangements from different health care systems is rarely justified.^14-15 The importance of context calls for greater understanding and comparison of health care provision across countries in order to achieve effective policy-making. This is especially true as health systems and health care policies across Europe become more interconnected because many of the challenges that are faced do not stop at national borders. As the EC notes: ‘this increased interconnection raises many health policy issues, including quality and access in cross-border care; information requirements for patients, health professionals and policy-makers; the scope for co-operation on health matters; and how to reconcile national policies with the obligations of the EU's internal market?' ¹⁶ It is therefore crucial to address the manner in which health services can be studied from a European perspective, while remaining aware of the diversity among European health care systems.

The process of priority-setting in HSR

Setting research priorities at the European level calls for more clarification as to how the process is conducted and how it relates to criteria identified by others for priority-setting. Lomas et al. identified two broad strategies: technical and interpretive. ¹⁷ The first is often dominated by quantitative approaches such as epidemiology and cost data, while the second is dominated by the consensus views of informed participants. Lomas et al. propose a combined approach in which both technical data and the views of those involved in health care have a role. Ideally, five steps should be undertaken for a so-called interpretive ‘listening model’ for priority-setting (see also Viergever et al. for a similar checklist). ¹⁸ These are: identify the stakeholders whom you wish to see participate in the consultation; identify and assemble any data needed for the consultation; design and complete the consultation with the stakeholders to assess the issues likely to be a priority over the next three to five years; validate the identified priority issues against similar exercises; and finally translate priority issues into priority research themes.

In the HSREPP priority-setting exercise we started with a more general step, namely defining what we considered to be HSR and narrowing down which elements to include in a priority-setting process. We adopted the definition used by AcademyHealth: HSR is ‘the multidisciplinary field of scientific investigation that studies how social factors, financial systems, organizational structures and processes, health technologies and personal behaviours affect access to health care, the quality and cost of health care and, ultimately, the health and well-being ofcitizens’. ¹⁹ This definition illustrates key elements of HSR, both in the wide range of disciplines that it encompasses and the broad array of factors that it addresses in its attempt to understand and to evaluate health care. Within this general approach, we distinguished three interconnected perspectives: •

Macro or system level (health care policy and systems analysis);

In order to understand or evaluate many aspects of health services in practice, studies at more than one level are required as one level influences the other. Two additional, cross-cutting, themes were identified. One is the growing field of selecting and defining performance indicators to establish ‘good practice’ and compare health care organizations or systems. ²⁰ The other focuses on the relationship between HSR and health policy at various levels – regional, national and European – of the health care system, increasingly described as a model of ongoing linkage and exchange between researchers and policy-makers throughout the research process.

As for the identification of relevant stakeholders, it is crucial, as stressed by Lomas et al., to involve both policymakers and researchers. The first group consists of the potential users of the results of HSR: ‘Having them help identify the priorities thus increases their sense of ownership and the likelihood that they will adopt and apply the research findings’. At the same time, it is important to ensure the involvement of researchers, which can help to counterbalance the possibility of policy problems being dominated by short-term and political motives. In the HSREPP project, the involvement of both groups was considered central. The full project report provides detailed information on the steps taken to involve people from both groups. ²¹

With regards to the data needed, each of the five studies in this supplement made use of a literature search to identify the state-of-the-art of research in the area. In addition, an online consultation form was developed, building on the experiences of similar processes of priority-setting. ²¹ The form, open to all interested parties, was completed by about 300 people. It included closed as well as open questions to obtain as many responses as possible on potential HSR priorities. By linking these views to the literature reviews, we achieved an inventory of HSR areas that are currently under-researched from a policy perspective. Next, a special working conference was organized in April 2010 in the Hague, the Netherlands. It attracted about 350 participants from inside and outside Europe, and contributed to identifying more specific research priorities within broader topic fields. Equally important, it was aimed at identifying the ways in which the potential of HSR to support policy for the improvement of health in Europe could be better realized. The fruits of these discussions and analyses are provided in a special policy brief. ²²

Key directions for future research

In this supplement, four articles identify the major areas of HSR that need further development. Velasco Garrido et al. ²³ show how much can be learnt from considering health services at the macro level of national health care systems. Their analysis of both published research and EU-funded projects shows an increasing amount of health systems research, although some countries are far more dependent on research from other countries than others. It illustrates the need to strengthen research capacity, especially in eastern European countries, and to involve these countries in cross-national comparisons. They also show that certain topics, in particular, the effects of health care reforms, have only been studied to a limited extent. This is in contrast to the fact that in many countries major reforms are taking place, the consequences of which for health care, quality and cost, are often uncertain. Examples are the growing emphasis on privately owned health care provision, or the introduction of co-payments designed to reshape the health care system in, it is hoped, a positive way. ²⁴

Hansen et al. ²⁵ address HSR at the level of health care organizations, with particular focus on primary and hospital care. They follow a similar literature search approach and show that more evidence is needed on two particular issues: the best way to configure hospital and primary care services, and on how to better integrate care. This is especially the case in light of the shifting emphasis from the need for acute hospital care to preventive care and long term care at home and in community settings. ²⁶ A related topic of importance is that of patient involvement and patient-centredness in health care, as European citizens expect to be more closely involved in decisions affecting their health and treatment. The topic of workforce and skill-mix is a third priority, as many European countries are facing the challenge of supplying enough staff with the right qualifications and competences to care for an ageing population with complex health problems. ²⁷

In the study by Palmhøj Nielsen et al., ²⁸ the focus is on ensuring that new technologies are thoroughly assessed in order to determine and improve their contribution to the delivery of care. Rather than trying to predict which types of technologies most need assessment in Europe, the authors’ focus is on improving the contribution of HTA to decision-making. Their review of the literature indicates that while HTA often addresses the economic effects of using health technologies, the wider ethical, legal, organizational and social effects are relatively neglected. Since HTA faces similar methodological challenges to other HSR areas, it too can benefit from a multidisciplinary approach, for example, when incorporating organizational perspectives. In return, one of the valuable elements of HTA for the rest of HSR lies in its strong linkage to policy. It can provide valuable lessons to other HSR areas, particularly in terms of the types of assessments developed to respond to the sometimes rapid needs of decision-makers. ²²

Klazinga et al. ²⁹ aim to identify the main activities in Europe related to comparing performance (benchmarking) and the opportunities for improving the evidence behind the use of performance indicators. Their review of the literature and report on the working conference debates led to the identification of three particular themes for further research: a stronger emphasis on testing the validity and reliability of performance indicators; linking these to national and international strategies and policies such as accreditation and certification; and taking further steps to improve the availability of data, such as facilitating secondary data use from electronic health records and facilitating the standardized measurement of patient-reported outcomes of care. The importance of this research field is reinforced by the growing recognition that wide variations exist both within and between countries in the productivity and quality of health care that cannot always be explained or justified. To measure and understand these variations in order to improve health care, both at a systems and organizational level, is becoming a central component of current health care analysis and policy-making. ³⁰

Each of the four articles highlighted so far contributed to identifying priorities in major areas of HSR. There are clear similarities between the various studies and previous priority-setting approaches in other regions of the world that help validate their outcomes. For example, the theme of measuring patient experiences was identified in the articles on health care organizations, health technology assessment and benchmarking. It has also emerged in several other priority-setting studies.^10,31 The same applies to studying health care reforms.^11,31 For example the Listening for Direction initiative considered sustainable funding and resource allocation as one of the key topic areas, including the effects and effectiveness of public-private partnerships. A third example is the area of human resources for health. Priority-setting studies which identified this theme included those of the WHO, addressing low and middle income countries^32–33 and scoping exercises in Europe and North America^10,27,31 The specific problems differ by region, with low income countries suffering especially from an exodus of expert staff, while in Europe and North America other challenges such as establishing task delegation and skill-mix may be higher on the agenda. However, an overarching element is the problem of a limited capacity to meet the demands of countries’ populations.

These similarities call for a comparative perspective between Europe and other regions, not only in terms of the topics to be addressed, but also when it comes to finding agreement on how best to collect and use the growing amounts of data, in order to ensure sound international comparisons. As Klazinga et al. ²⁹ note, continued collaboration between international organizations, including Eurostat, WHO and the OECD, can play a vital role in achieving this.

Linkage and exchange

The closing article of this supplement, by Ettelt and Mays ³⁴ , is different in that it maps the institutional infrastructure of HSR in Europe, and examines the links between HSR and European policy-making. It does so by means of a survey of health policy experts, acting as informants in 34 European countries. Their study clearly shows how few empirical studies are available about the relationship of HSR with policy, in spite of the well-recognized importance of ‘linkage and exchange’ between the two arenas. They call for a stronger body of knowledge on how HSR is undertaken and used. This could be achieved, in part, by an in-depth study of the politics of health care policy-making processes in different countries and by identifying ‘best practice’ in transferring knowledge from research to policy. Their study is itself a good example of how comparisons between countries can offer insights into improving how the infrastructures for dissemination and uptake of HSR may result in affecting policy. It clarifies, too, the wide variation between countries in the levels of HSR funding and in the level of transparency in determining how these mostly public funds are allocated, as HSR has to compete with funding for other health-related research.

In line with the other studies in this supplement, Ettelt and Mays show how the capacity for HSR and its ability to influence policy differ considerably between countries. This can be seen in the opportunities for funding, training, publishing and networking in HSR. Their analysis calls for more investment in strengthening HSR capacity. This should be both in the maintenance of a research community organized at a national and European level, and in co-ordinating research efforts between countries. The barriers to the use of HSR in policy reported in their study include issues about timeliness, the mismatch of research and policy questions, and the absence of incentives for researchers to engage with policy making. Since the barriers are very similar to those found in earlier studies, they illustrate the need for action rather than solely better awareness in improving the contribution of policy-based HSR to evidence-influenced policy.

Conclusion

This supplement draws attention to two interconnected issues in HSR. One is the refinement of a European agenda for HSR, tuned to the information needs of policy-makers. The other is the identification of more effective platforms for the interaction between the research community and policy-makers in order to improve the scientific underpinning of health care policies. Together, these will enable scientific evidence already available to be applied better and for new scientific evidence to be produced more efficiently, resulting in policy measures and health care systems that are more effective, more efficient and more responsive to the needs of European citizens.