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Department of Health Services Research and Policy

Head of Department
Department Research Degree Co-ordinator
Department Research Degree Co-ordinator
Department Manager

Tel: +44 (0) 207 927 2366 

The Department of Health Services Research and Policy carries out research to improve the quality, organisation and management of health services and systems.

This work covers all three of the essential stages required to improve services:

  • studies to establish the most effective practices and policies, including how care can be best organised and delivered
  • research assessing the quality of existing services and policies
  • establishing how improvements to services can be made. 

We aim to improve not only our understanding of how health services and systems behave but also applied research to support clinicians, managers and policymakers. Our work encompasses a wide range of methods including quantitative evaluation, policy analysis and qualitative studies. 

While most of our research focuses on high-income countries, the UK in particular, some addresses the challenges faced by health care systems in low and middle income countries.

Publications by department staff can be found in the School’s online publications repository.

Research areas

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, sociology, geography and organisational studies are all needed to study governance. Members of HSRP working in this area include Pauline Allen (law and economics),  Dorota Osipovic (sociology), Marie Sanderson (organisational studies and economics), Colin Lorne (geography), Stephen Peckham (health policy). We collaborate with colleagues in England, Wales, France, Finland, India and China.

At present, much of the research on governance is carried out under the auspices of the NIHR funded national Policy Research Unit in Health and Social Care Systems and Commissioning (PRUComm), which is a long term, large scale research collaboration between LSHTM and the universities of Manchester and Kent.

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:

In Finland, this includes comparison of public and private provision.

In China, this includes autonomous public hospitals.

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:

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. The Centre for Global Chronic Conditions, 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. The Department also hosts a hub of the European Observatory on Health Systems and Policies, a unique partnership of universities, national and regional governments, and international agencies.

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.

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, led by Andy Clark and Colin Sanderson, involves evaluating a range of different vaccine policy options in low- and middle-income countries (LMICs). It involves using decision-support models to estimate the costs, benefits, risks, risk-benefit and cost-effectiveness of different vaccines and different vaccination schedules.

The three main strands of research are:

  1. Developing decision-support models that national stakeholders can understand, populate and interact with. The aim is to strengthen: a) the technical capacity of national teams; b) the national-level ownership of results; and, c) the likelihood that the model results will influence national decisions. To date, the models have focused on vaccines that prevent severe diarrhoea, pneumonia, meningitis and cervical cancer, and been used by national teams in over 30 countries worldwide (see the Provac toolkit)
     
  2. generating estimates of the impact, cost-effectiveness and risk-benefit of different vaccines across multiple LMICs. These estimates have been used by international committees (eg, the WHO Strategic Advisory Group of Experts) and partner organisations (eg, Gavi, the Vaccine Alliance) to review their policies and activities. For example, 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, a rare bowel disorder. Using the model developed by Clark and Sanderson, it was concluded that in many countries, the additional lives saved by broadening the age restrictions far outweighed any hypothetical increase in intussusception deaths.
     
  3. Generating new evidence to improve the quality of model inputs. This includes evidence on the actual age of vaccination (Clark & Sanderson, Lancet 2009), the efficacy and duration of protection of rotavirus vaccines (Clark et al, Lancet Infectious Diseases 2019), the age distribution of rotavirus gastroenteritis (Hasso-Agopsowicz et al, Clinical Infectious Diseases 2019) and the epidemiology of intussusception (Clark et al, International Journal of Epidemiology 2019).
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.

Staff: Oliver BonningtonSimon CohnStefanie EtteltDaniel GraceJudith GreenLorelei JonesDorota OsipovicSarah Milton

 

Department staff & research students