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The Department of Health Services Research and Policy was established in 1988 and aims to carry out research that helps to improve the quality, organisation and management of health services and systems. This work extends from establishing what care should be provided and how services should be organised, through assessing the quality of existing services, to how improvements can be brought about. Our work aims to improve the understanding of how health services and systems behave, both for its own sake and as a precursor to more applied research. This includes policy analysis, sociological studies of care and studies of the organisation of care. Most of our research is in high-income countries and, in particular, the UK.
To mark the 25th anniversary of our department, we held a half-day symposium to explore how we have helped meet the challenges faced by health services and systems in the UK and abroad, and how our research has supported and guided changes and reforms.
Publications by department staff can be viewed in the School’s online repository.
- Health economics, policy and technology assessment
The Team for Health Economics, Policy and Technology Assessment (THETA) are a team of around 20 health economists and statisticians who work in the Department.
The team undertake world-leading research that combines methods development with policy-relevant applications, working closely with colleagues across the School, and collaborating extensively with leading methodologists, clinicians and policy-makers. The team has particular expertise in causal inference methods, the analysis of administrative and survey datasets, elicitation of preferences, decision modelling and health policy.
- Governance of health systems and services
Governance of health services is an important area of research, as it defines the framework in which services are delivered, affecting access to them, their efficiency and the quality of care.
Governance is concerned with the authority chains and the allocation of responsibility for actions that take place within the systems and structures of health services. It can include both the structures within which decision making that defines expectations, granting power and verifying performance occur and also the implementation of these activities.
The disciplines of economics, law, political science, psychology and organisational studies are all needed to study governance. Members of HSRP working in this area include Pauline Allen (law and economics), Christina Petsoulas (political science), Dorota Osipovic (political science), Lorraine Williams (health services research and nursing), Marie Sanderson (organisational studies and economics), Andrew Hutchings (financial management), Mary Alison Durand (psychology), Elizabeth Shepherd (health policy), Stephen Peckham (health policy). We collaborate with colleagues in England, Wales, France, Finland, India and China.
There are three levels of analysis of governance:
Macro level: Deals with the structure of the healthcare system as a whole
In the English National Health Service, this includes research on:
- the use of markets and competition in healthcare; the regulation of healthcare organisations
- the relationship between central and local agencies
In India, this includes analysis of the governance of systems to deal with outbreaks of communicable diseases.
Meso level: A key aspect is relationships between organisations within the health system
In the English National Health Service, this includes contracts between payers and healthcare delivery organisations.
In the Welsh and English National Health Services, this includes different understandings of contracts between payers and hospitals.
In China, this includes contracts between health insurers and hospitals.
Organisational level: How different care delivery organisations arrange their internal governance structures and how these relate to external governance as described in the meso and macro levels
In the English National Health Service, this includes:
In Finland, this includes comparison of public and private provision.
In China, this includes autonomous public hospitals.
- Health care performance assessment
Health services are under pressure to provide equitable access to greater numbers of patients, improve the quality of care (effectiveness, safety, experience), whilst also becoming more efficient.
Providing information on all these aspects is seen as key to helping services meet these challenges. However, there is a lack of relevant information in many areas of care. In particular, there is a need for better measures to describe the activities and performance of health care providers, both in terms of clinical indicators and patient-reported outcomes. Nearly all our research is to help inform the NHS in the UK, though we also advise health systems in other high income countries.
Evaluating and auditing the effectiveness of care
The Department of Health Services Research & Policy is a national centre of expertise in the organisation and logistics of large-scale studies into the quality of hospital care. It undertakes work in various clinical areas, and has established links with the Royal College of Surgeons of England (RCS) and the Royal College of Obstetricians and Gynaecologists (RCOG). The RCS Clinical Effectiveness Unit carries out studies on the care of cancer patients (breast cancer, prostate cancer, oesophago-gastric cancer), orthopaedic surgery, and vascular surgery. The partnership with the RCOG supports national projects on the quality of maternity care and gynaecological services, and has recently established a number of projects developing performance indicators for NHS hospitals. Staff in the Department also collaborate with the Intensive Care National Audit & Research Centre.
Patient reported outcome measures (PROMs)
Patients’ views are essential to achieving high-quality health care. Our PROMs research is helping to improve patient care by evaluating the performance of health care providers, and guiding NHS reforms.
Assessing the safety of health care
Concern about the safety of health services among the public, politicians, health service managers and clinicians has revealed the inadequacy of most existing measures of safety. Since 2008 we have been investigating the potential value of using retrospective case note review of hospital patients who have died to establish the proportion of deaths that were attributable to poor care. Our initial study (PRISM I) suggested that only 5% of deaths were avoidable, a finding that we are seeking to confirm in a larger follow-up study (PRISM II). We are also investigating the relationship between avoidable deaths and various standardised mortality ratios for hospitals, and evaluating policies to reduce cardiac arrests in hospital patients.
Methodological research on large databases
All our studies using large databases include methodological research. For example, we have developed and evaluated coding algorithms to identify patients in Hospital Episode Statistics with specific conditions or who underwent specific procedures. We have demonstrated that linking hospital episode statistics to clinical databases strengthens our ability to map patients’ care trajectories. Comparing outcomes across NHS providers requires adjustment for differences in “case mix” so that we can compare “like with like” and avoid penalising hospitals, teams or individual clinicians who treat more serious cases. Regression models that can predict the risk of a poor outcome are often used to produce “risk adjusted outcomes”. An alternative approach to take case mix into account is based on matching patients on their “propensity” to receive a certain treatment National clinical audit databases present further methodological challenges. Minimum datasets need to be developed that are detailed enough to capture all essential clinical information to assess the quality of care in a meaningful way but at the same time minimise the burden on health service staff involved in data collection. We develop indicators of the performance of health care providers and evaluate the validity, statistical power, and fairness of such indicators. For example, we demonstrated that for many surgical specialties the number of procedures an individual surgeon carries out each year is so low that it is unlikely that a surgeon with increased mortality rates could be detected, leading to false complacency.
- Health systems in Europe and beyond
Major social change provides both threats and opportunities for health and a detailed understanding of the role of change on health is essential. ECOHOST – The Centre for Health and Social Change based in the Department, provides high quality evidence on the impacts of social change on health in the UK, Europe and globally through research, policy engagement and teaching. Staff have developed an extensive network of collaborators while strongly engaging with policy makers. The Centre brings together researchers on health systems, policy analysis, epidemiology, health economics, complex systems, and knowledge translation to protect and improve health during times of social change.
- Policy evaluation and analysis
Policy evaluation is a core activity within the School and the Department of Health Services Research and Policy undertakes a considerable amount of evaluation research, particularly on policies and programmes in the UK.
Researchers are involved in a range of evaluations, covering impact, process and economic evaluations, using a wide range of approaches and specific methods,reflecting the multi-disciplinary nature of the Department. Current projects include evaluations of policies relating to health care systems and services (mostly, but not exclusively, in the English NHS), social care and public health services, often conducted in collaboration with colleagues in other departments at the LSHTM and other universities, benefiting from the strength of our combined expertise.
We are also interested in the development of evaluation methods (e.g. work on how to reduce selection bias in the selection of pilot sites and ‘controls’ in quasi-experimental evaluations and several projects reflect on current practices of evaluation, its relevance for policy, and the role of evidence in policy-making more broadly).
The Department hosts two policy research units funded by the Department of Health in England: PIRU, the Policy Innovation Research Unit and PRUComm, the Policy Research Unit in Commissioning and the Healthcare System.
Led by Nicholas Mays, PIRU is a collaboration led from the School which includes the Personal Social Services Research Unit at the London School of Economics, RAND Europe, the Nuffield Trust and the Imperial College Business School. The Unit is funded until December 2017 primarily to advise on and undertake evaluations of national level policy innovations (usually in the form of pilots, trailblazers and demonstrations) across health services, social care and public health. The aim of the Unit is to try to ensure that considerations of evaluation are introduced into the policy process from an early point, preferably at the ideas stage. Read more on current projects and reports.
Led by Stephen Peckham, PRUComm studies how system wide policy changes are shaping the health care commissioning system in the English NHS. The Unit’s work focuses on: commissioning and system management; clinically-led commissioning, the measurement of health gain from commissioning; and commissioning for health and well-being. The Unit has published reports on clinical engagement in local commissioning, the early working of Clinical Commissioning Groups (CCGs) and their use of different contractual mechanisms. It continues to track the evolution of the commissioning system. Read more on current projects.
Getting research into policy (GRIP-Health)
Through GRIP-Health, researchers contribute to a programme of work that aims to better understand the politics of, and political constraints on, evidence use in different countries. The programme is analysing the institutional frameworks that enable, hinder and shape how evidence is used to inform policy decisions by comparing a number of low, middle and high-income countries.
Evaluation of the London polysystems programme
In 2007, the strategy ‘Healthcare for London’ planned polyclinics in each part of the capital to help improve the primary care infrastructure. Polyclinics are intended to serve as a hub for a group of GP practices which combined form a ‘polysystem’. The evaluation aimed to investigate the processes of care and the impact of the services provided in ‘polysystems’ on indicators such as unplanned (emergency) admissions.
Comparing the performance of the four health systems of the UK
Staff in the Department have a long standing interest in the performance of the NHS in the four UK countries before and after devolution in 1999 when system policies began to diverge appreciably. The most recent report was published in April 2014. It shows a complex picture comparatively with some signs of convergence between the four systems and persistent differences (e.g. in rates of amenable mortality). Overall, the analysis does not indicate that one system consistently out-performs the others despite increasing differences in policy settings.
Completed programmes - Health Reform Evaluation Programme (HREP)
HREP is a recently completed programme of research to evaluate the English NHS reforms set out in the Department of Health publication Health Reform in England: update and next steps. The programme was funded by the Department of Health between 2006 and 2013. The Scientific Coordinator was Professor Nicholas Mays in the Department of Health Services Research and Policy.
- Public health research
Researchers in the department are working to strengthen evidence and understanding for better decision-making on the social and environmental factors that determine public health
SPHR@L: School for public health research
Part of the NIHR School for Public Health Research, the multidisciplinary SPHR@L team is led by Mark Petticrew and Karen Lock, and has extensive expertise in working with local government, and research expertise in the fields of: complex decision-making, medical science, housing, food and alcohol, the environment, transport, inequalities, smoking, education, criminology, community development and citizenship.
Transport and Health Group
The Transport and Health Group is a multidisciplinary group of researchers looking at the links between transport and health in the context of a broad definition of the public health, which includes physical, mental and social well-being. Research includes evaluations of the impact of large scale transport interventions on public health; health outcomes of different transport modes; and the wider public health implications of transport systems.
- Quantitative modelling for decision support
This area of research springs from our interest in strengthening decision-making in health care policy and management. We start from the position that decision-making in health care is difficult because there are many stakeholders, objectives are often unclear or conflicting, and the impact of care activity and population health is often uncertain. Further, we believe that in the right circumstances, methods of problem structuring, of estimating the likely outcomes of different options under different scenarios, and of synthesising data on outcomes, risks and preferences can improve decision-making. To this end we have been developing simple, transparent models that decision makers can understand and interact with.
Models for decisions about choice of vaccines and vaccine schedules
In recent years much of our work has been in the field of policy-making around new vaccines in middle and low income countries. This has been commissioned by PAHO and WHO Geneva, and funded by the Bill and Melinda Gates Foundation. Prior to that we had developed two large micro-simulation models, one for vaccine cost-effectiveness (Andy Clark, Colin Sanderson) (DfID), and one for coronary heart disease prevention policy (Hannah Babad, Colin Sanderson) (DoH).
- TRIVAC is a spreadsheet model that estimates the impact and cost-effectiveness of childhood vaccines against Haemophilus influenza type b (Hib), pneumococcus, and rotavirus (RV). The aim is to allow national policymakers to estimate the benefits of these new vaccines under a variety of scenarios informed by national estimates of disease burden, vaccine coverage and timeliness, and by regional estimates of vaccine efficacy. We have also developed a large web-based repository of vaccine information. This is aligned with the data requirement of the TRIVAC model and is available online, see OLIVES. The CERVIVAC model evaluates the impact and cost-effectiveness of the human papilloma virus (HPV) vaccine. It has a similar interface to TRIVAC, but draws on output from an HPV micro-simulation model developed at Harvard.
- Until recently the advice from WHO was to not to provide rotavirus vaccine to children outside a limited age ‘window’ because of concerns about an elevated risk of intussusception. The rotavirus risk/benefit model assesses the benefits and risks of adhering to this advice as against broadening the age restriction. It was concluded that in developing countries, the additional lives saved by broadening the age restrictions far outweighed any hypothetical increase in intussusception deaths. More information is available, see WHO position paper on rotavirus vaccines - January 2013.
- The vaccination schedules model is designed to help evaluate the public health impact of alternative schedules for Hib, pneumococcal and rotavirus. Factors that can be varied include target age at each dose, timeliness of the programme, number of doses, and +/- booster. This model was commissioned by WHO's Vaccine Schedules Initiative.
- These models are being used by national managers and key decision makers to aid decisions on national vaccination schedules, and by international committees and partner organisations (e.g. the Global Alliance for Vaccines and Immunisation and the Bill and Melinda Gates Foundation) to review their policies and activities.
These models are being used by national managers and key decision makers to aid decisions on national vaccination schedules, and by international committees and partner organisations (e.g. the Global Alliance for Vaccines and Immunisation and the Bill and Melinda Gates Foundation) to review their policies and activities.
In parallel with this but in a very different context, we have been working on prognostic models to support decisions on admission to intensive care in England, for patients with chronic obstructive pulmonary disease (Martin Wildman, Colin Sanderson) (MRC), and more recently for patients with acute sepsis (Steve Harris, Colin Sanderson) (Wellcome).
- Sociology and anthropology
As a group of sociologists and anthropologists, we draw on a range of social theory as well as different qualitative techniques to investigate the broader social and cultural context of a wide variety of health related issues.
Primarily focusing on UK and other high-income locations, we are committed to preserving both the complexity and the specificity of particular topics and locations. Our work complements not only research conducted by other colleagues within the department, but across the Faculty and School as a whole. Acknowledging the overall aims of LSHTM, an on-going challenge is to find ways to reformulate and sometimes resist the distinction made between theoretical and applied research, and instead demonstrate how both are intrinsic dimensions of the other.