Nick Fahy

Research impact in the community-based health sciences: an analysis of 162 case studies from the 2014 UK Research Excellence Framework

BackgroundThe 2014 UK Research Excellence Framework (REF2014) generated a unique database of impact case studies, each describing a body of research and impact beyond academia. We sought to explore the nature and mechanism of impact in a sample of these.MethodsThe study design was manual content analysis of a large sample of impact case studies (producing mainly quantitative data), plus in-depth interpretive analysis of a smaller sub-sample (for qualitative detail), thereby generating both breadth and depth. For all 162 impact case studies submitted to sub-panel A2 in REF2014, we extracted data on study design(s), stated impacts and audiences, mechanisms of impact, and efforts to achieve impact. We analysed four case studies (selected as exemplars of the range of approaches to impact) in depth, including contacting the authors for their narratives of impact efforts.ResultsMost impact case studies described quantitative research (most commonly, trials) and depicted a direct, linear link between research and impact. Research was said to have influenced a guideline in 122 case studies, changed policy in 88, changed practice in 84, improved morbidity in 44 and reduced mortality in 25. Qualitative and participatory research designs were rare, and only one case study described a co-production model of impact. Eighty-two case studies described strong and ongoing linkages with policymakers, but only 38 described targeted knowledge translation activities. In 40 case studies, no active efforts to achieve impact were described. Models of good implementation practice were characterised by an ethical commitment by researchers, strong institutional support and a proactive, interdisciplinary approach to impact activities.ConclusionREF2014 both inspired and documented significant efforts by UK researchers to achieve impact. But in contrast with the published evidence on research impact (which depicts much as occurring indirectly through non-linear mechanisms), this sub-panel seems to have captured mainly direct and relatively short-term impacts one step removed from patient outcomes. Limited impacts on morbidity and mortality, and researchers’ relatively low emphasis on the processes and interactions through which indirect impacts may occur, are concerns. These findings have implications for multi-stakeholder research collaborations such as UK National Institute for Health Research Collaborations for Leadership in Applied Health Research and Care, which are built on non-linear models of impact.

Beyond Adoption: A New Framework for Theorizing and Evaluating Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies

Background Many promising technological innovations in health and social care are characterized by nonadoption or abandonment by individuals or by failed attempts to scale up locally, spread distantly, or sustain the innovation long term at the organization or system level. Objective Our objective was to produce an evidence-based, theory-informed, and pragmatic framework to help predict and evaluate the success of a technology-supported health or social care program. Methods The study had 2 parallel components: (1) secondary research (hermeneutic systematic review) to identify key domains, and (2) empirical case studies of technology implementation to explore, test, and refine these domains. We studied 6 technology-supported programs—video outpatient consultations, global positioning system tracking for cognitive impairment, pendant alarm services, remote biomarker monitoring for heart failure, care organizing software, and integrated case management via data sharing—using longitudinal ethnography and action research for up to 3 years across more than 20 organizations. Data were collected at micro level (individual technology users), meso level (organizational processes and systems), and macro level (national policy and wider context). Analysis and synthesis was aided by sociotechnically informed theories of individual, organizational, and system change. The draft framework was shared with colleagues who were introducing or evaluating other technology-supported health or care programs and refined in response to feedback. Results The literature review identified 28 previous technology implementation frameworks, of which 14 had taken a dynamic systems approach (including 2 integrative reviews of previous work). Our empirical dataset consisted of over 400 hours of ethnographic observation, 165 semistructured interviews, and 200 documents. The final nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework included questions in 7 domains: the condition or illness, the technology, the value proposition, the adopter system (comprising professional staff, patient, and lay caregivers), the organization(s), the wider (institutional and societal) context, and the interaction and mutual adaptation between all these domains over time. Our empirical case studies raised a variety of challenges across all 7 domains, each classified as simple (straightforward, predictable, few components), complicated (multiple interacting components or issues), or complex (dynamic, unpredictable, not easily disaggregated into constituent components). Programs characterized by complicatedness proved difficult but not impossible to implement. Those characterized by complexity in multiple NASSS domains rarely, if ever, became mainstreamed. The framework showed promise when applied (both prospectively and retrospectively) to other programs. Conclusions Subject to further empirical testing, NASSS could be applied across a range of technological innovations in health and social care. It has several potential uses: (1) to inform the design of a new technology; (2) to identify technological solutions that (perhaps despite policy or industry enthusiasm) have a limited chance of achieving large-scale, sustained adoption; (3) to plan the implementation, scale-up, or rollout of a technology program; and (4) to explain and learn from program failures.

Who is shaping the future of European health systems

The bailout deals for Ireland, Portugal, and Greece include startlingly detailed changes for their national health systems. Nick Fahy asks whether the tighter European rules proposed to save the euro will mean the EU steering national health systems across all of Europe?

How will Brexit affect health and health services in the UK? Evaluating three possible scenarios

The process of leaving the European Union (EU) will have profound consequences for health and the National Health Service (NHS) in the UK. In this paper, we use the WHO health system building blocks framework to assess the likely effects of three scenarios we term soft Brexit, hard Brexit, and failed Brexit. We conclude that each scenario poses substantial threats. The workforce of the NHS is heavily reliant on EU staff. Financing of health care for UK citizens in the EU and vice versa is threatened, as is access to some capital funds, while Brexit threatens overall economic performance. Access to pharmaceuticals, technology, blood, and organs for transplant is jeopardised. Information used for international comparisons is threatened, as is service delivery, especially in Northern Ireland. Governance concerns relate to public health, competition and trade law, and research. However, we identified a few potential opportunities for improvement in areas such as competition law and flexibility of training, should the UK Government take them. Overall, a soft version of Brexit would minimise health threats whereas failed Brexit would be the riskiest outcome. Effective parliamentary scrutiny of policy and legal changes will be essential, but the scale of the task risks overwhelming parliament and the civil service.

How to meet the challenge of ageing populations

EU countries need to work together with health professionals and other stakeholders

SCALS: a fourth-generation study of assisted living technologies in their organisational, social, political and policy context

Introduction Research to date into assisted living technologies broadly consists of 3 generations: technical design, experimental trials and qualitative studies of the patient experience. We describe a fourth-generation paradigm: studies of assisted living technologies in their organisational, social, political and policy context. Fourth-generation studies are necessarily organic and emergent; they view technology as part of a dynamic, networked and potentially unstable system. They use co-design methods to generate and stabilise local solutions, taking account of context. Methods and analysis SCALS (Studies in Co-creating Assisted Living Solutions) consists (currently) of 5 organisational case studies, each an English health or social care organisation striving to introduce technology-supported services to support independent living in people with health and/or social care needs. Treating these cases as complex systems, we seek to explore interdependencies, emergence and conflict. We employ a co-design approach informed by the principles of action research to help participating organisations establish, refine and evaluate their service. To that end, we are conducting in-depth ethnographic studies of peoples experience of assisted living technologies (micro level), embedded in evolving organisational case studies that use interviews, ethnography and document analysis (meso level), and exploring the wider national and international context for assisted living technologies and policy (macro level). Data will be analysed using a sociotechnical framework developed from structuration theory. Ethics and dissemination Research ethics approval for the first 4 case studies has been granted. An important outcome will be lessons learned from individual co-design case studies. We will document the studies’ credibility and rigour, and assess the transferability of findings to other settings while also recognising unique aspects of the contexts in which they were generated. Academic outputs will include a cross-case analysis and progress in theory and method of fourth-generation assisted living technology research. We will produce practical guidance for organisations, policymakers, designers and service users.

Maximising value from a United Kingdom Biomedical Research Centre: study protocol.

BackgroundBiomedical Research Centres (BRCs) are partnerships between healthcare organisations and universities in England. Their mission is to generate novel treatments, technologies, diagnostics and other interventions that increase the country’s international competitiveness, to rapidly translate these innovations into benefits for patients, and to improve efficiency and reduce waste in healthcare. As NIHR Oxford BRC (Oxford BRC) enters its third 5-year funding period, we seek to (1) apply the evidence base on how best to support the various partnerships in this large, multi-stakeholder research system and (2) research how these partnerships play out in a new, ambitious programme of translational research.MethodsOrganisational case study, informed by the principles of action research. A cross-cutting theme, ‘Partnerships for Health, Wealth and Innovation’ has been established with multiple sub-themes (drug development, device development, business support and commercialisation, research methodology and statistics, health economics, bioethics, patient and public involvement and engagement, knowledge translation, and education and training) to support individual BRC research themes and generate cross-theme learning.The ‘Partnerships’ theme will support the BRC’s goals by facilitating six types of partnership (with patients and citizens, clinical services, industry, across the NIHR infrastructure, across academic disciplines, and with policymakers and payers) through a range of engagement platforms and activities. We will develop a longitudinal progress narrative centred around exemplar case studies, and apply theoretical models from innovation studies (Triple Helix), sociology of science (Mode 2 knowledge production) and business studies (Value Co-creation). Data sources will be the empirical research studies within individual BRC research themes (who will apply separately for NHS ethics approval), plus documentary analysis and interviews and ethnography with research stakeholders. This study has received ethics clearance through the University of Oxford Central University Research Ethics Committee.DiscussionWe anticipate that this work will add significant value to Oxford BRC. We predict accelerated knowledge translation; closer alignment of the innovation process with patient priorities and the principles of responsible, ethical research; reduction in research waste; new knowledge about the governance and activities of multi-stakeholder research partnerships and the contexts in which they operate; and capacity-building that reflects the future needs of a rapidly-evolving health research system.

Briefing on current and future developments in European Union policy and practice in healthcare.

The coming year is a key period of challenge for health systems across Europe. The current Eurozone financial crisis is already bringing changes to some health systems directly, with revisions to the European role in national finances that seem likely to have an impact more widely. The European Union’s (EU) own finances for the coming years will be up for negotiation, including potentially substantial funding opportunities for health systems research and infrastructure. And the implementation of the EU directive on cross-border health care will have an impact not only on patients wishing to go to other countries, but on health systems more widely.

Patient Mobility in Times of Austerity: A Legal and Policy Analysis of the Petru Case.

The case-law of the Court of Justice (ECJ) on patient mobility was recently challenged by a ruling that a patient could go to Germany for treatment when facilities in Romanian hospitals were inadequate. Given the reported impact of austerity measures in the field of health care this raises the question; what is the impact of the ECJs ruling on how Member States can manage expenditure and limit outflows of patients and how should such measures be legally evaluated? The objective of this article is to analyse potential impact on health systems in the context of increasing pressure on public financing for health. While the ECJ mainly referred to the requirement of treatment in due time, we also analyse possible austerity reductions of the basket of care against the background of EU law (i.e., EGJ case-law, patient mobility directive, Charter of Fundamental rights and social security regulation).

Future EU strategy on health services.

Health systems are primarily the responsibility of the member states, and those responsibilities are explicitly recognised in the treaty establishing the European community. Nevertheless, European action on health services is increasingly called for in order to support the member states. The European Commission is therefore consulting on possible community action on health services, focusing in particular on uncertainties around the application of Community law to health services.