Final Report Summary - HSREPP (Health Services Research into European Policy and Practice: preparation and organisation of a European Health Services Research Conference)
Executive summary:
The project HSREP aimed to identify, evaluate and improve the contribution of Health Services Research (HSR) to the health policy process at national and European level, and thus help optimize the delivery of health care services to European citizens.
Objectives were:
a) To identify the state-of-the-art of HSR in Europe.
b) To identify at European and Member State level current and upcoming priorities in HSR for addressing policy needs.
c) To assess at Member State and European level current infrastructures for the translation of HSR into the policy and practice.
d) To offer a forum at which studies in the field of HSR can be presented, discussed and evaluated, especially aimed at filling the identified research-policy gaps for the future.
e) To contribute to agenda setting on HSR at European and Member States' level.
Given its broad nature the field was divided into five main areas, around which all activities such as literature searches and online consultations were centred:
1) Health (care delivery) systems;
2) Health care organisations and service delivery;
3) Health Technology Assessment;
4) Benchmarking and performance indicators;
5) Relationships between research and policy.
A major activity has been the creation of a platform for new research in the form of a European HSR working conference in April 2010, which took place on Thursday 8 and Friday 9 April 2010 in The Hague, the Netherlands. The meeting was attended by about 350 researchers and policy makers from a little less than 40 countries, both European and from other regions.
To validate the outcomes of the meeting its results were further refined during workshops and presentations at other conferences in 2010. A final report and special issue of the Journal of HSR&Policy provide overviews of HSR and describe the contribution that it makes to policy-making. Main outcomes were also summarized in a policy brief which was launched in April 2011. It provides an overview of future major research priorities based on policy-makers' and researchers' views at a national and European level. Examples are the need to evaluate health care reforms, the integration of care across organisations, research into the broader consequences of health technologies, stronger focus on the development and use of performance indicators and improving knowledge of how HSR is undertaken and used. In addition, the policy brief provides an overview of strategies to improve the use of research in policy, including a better balance between different types of research funding, tools to avoid the duplication of studies and learning from best examples in, among others, HTA regarding rapid assessments of research evidence (see http://www.healthservicesresearch.eu for details).
Project Context and Objectives:
Context
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. 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. 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.
These developments contribute to an ongoing debate about how to realise major cuts in health care spending, while still recognising that health care is an investment which contributes to the wealth and health of Europe. Health policy and organisational 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 7th Framework Programme 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.
Objective
The overarching aim of the project is:
"to identify, evaluate and improve the contribution of health services research to the health policy process at the level of Member States and the European Union, and thus to help optimizing the delivery of health care services to European citizens."
This general objective can be broken down to the following specific objectives:
a. To identify the state-of-the-art of HSR in Europe.
b. To identify at European and Member State level current and upcoming priorities in HSR for addressing policy needs.
c. To assess at Member State and European level current infrastructures for the translation of HSR into the policy and practice.
d. To offer a forum at which studies in the field of HSR can be presented, discussed and evaluated, especially aimed at filling the identified research-policy gaps for the future.
e. To contribute to agenda setting on HSR at European and Member States' level.
Given its broad nature the field of HSR was divided into five main areas, around which all activities were centred:
1. Health (care delivery) systems, addressing the available knowledge of HSR at the level of health care systems (national or sometimes regional);
2. Health care organisations and professional practices, located between the health care system and service provision in the interaction between patients and providers;
3. Health Technology Assessment; addressing the multidisciplinary field of policy analysis that systematically assesses the medical, social, ethical, and economic implications of the development, diffusion, and use of health technology;
4. Benchmarking and performance indicators; monitoring health services over time, pooling valuable initiatives and setting up mechanisms to exchange best practice;
5. Relationships between research and policy, focusing on how the results of research are being fed into the policy process (e.g. modes of commissioning research).
Project Results:
All scientific activities of the project, in particular mapping the state-of-the-art and determining future priorities, were broken down into the following work packages, each structured around one of the subareas in HSR:
- WP 4 - 'Health systems'
- WP 5 - 'Health care organisation and professional practices'
- WP 6 - 'Health Technology Assessment'
- WP 7 - 'Benchmarking and performance indicators'
- WP 8 - 'Research and Policy: Strengthening the research-policy cycle'
While the exact activities differ somewhat between HSR areas and work packages, there are three key elements that all work packages make use of: literature searches, country consultation forms, and an online stakeholder survey. Main S&T results of each of the work packages are summarized below.
1.3.1 Health systems research
This part of the project addressed the available knowledge of HSR at the level of health care systems, i.e. the level of nations or regions, and the issues related to the organizational structure, the model of financing, the regulation and planning of the system, the ways to create physical and human resources and to provide services, as well as it changes over time. As health care systems may contribute to the realisation of general values of universality, access to good health care, equity and solidarity, many topics that are currently high on the European research agenda are linked to the arrangements of the health system as a whole (for instance, cross-border healthcare purchasing and provision, migration of health care professionals, and patient safety).
The work package's target was to provide an assessment of the field of health systems research in Europe based on an analysis of the published literature. Health systems research analyses the contents of health reforms and policies and assess their effects - both intended and unintended - on the system itself and ultimately on the health of the population. Health systems research is thus concerned with the assessment of the performance of the system in achieving population health (and responsiveness to people's legitimate expectations as well as financial protection against ill health).
In this study, a bibliometric analysis was conducted in order to assess the status of health systems research in Europe. Besides this approach, internet searches were performed to complete the picture of health systems research. Additionally, data from a survey among researchers and policy makers in the field of health systems were taken into account. Finally, the preliminary findings were presented at the Health Services Research Working Conference in The Hague (8th and 9th of April 2010) and discussed with the participants in working sessions. This variety of approaches allowed to address the topic from different perspectives and to increase the validity of our findings.
Both the bibliometric analysis and the internet searches indicate that especially in the eastern European countries there is a need to develop health systems research capacity. There are few publications from institutions based in these countries, there are also few internet hits, and finally these countries are underrepresented in EU-funded projects. At least to some extent, each of the European countries has been targeted by research not produced in that country, although there are considerable differences among countries. For example, most of the research on Sweden has been produced there and less than 10% has been produced without Swedish involvement. In contrast, for some of these countries, none of the publications identified had been produced locally. Particularly, research on the countries from the former Soviet Union has been produced in other countries.
These and other findings from the report clearly point out the need to develop health systems research across Europe, and particularly in the countries of former Eastern Union and former Soviet Union. The health systems of that countries have been object of major reforms in the past years (cf. Health Systems in Transition series (European Observatory for Health Systems and Policies) shifting from classical Semashko health systems to different models of health system organization and financing while at the same time being under enormous financial pressures derived from the transition of socialist economic order to market oriented economic system. EU Member States have also implemented major reforms of their health systems or are in a state of continuous incremental reform. The purpose of those reforms being the achievement of financial sustainability, more equity, higher quality of care, etc. (with changing weights of each of the aims). The assessment of these reforms and policy processes require the availability of researchers and of institutional and political environments which foster research on health systems. Thus capacity building on health systems research reveals as a major priority. Capacity needs to be built on the side of researchers (i.e. education of researchers from different disciplines to conduct health systems research) as well as on the side of potential users of health systems research. The latter is of major importance, since without the convincement of key policy makers of the need to rely on sound health systems research, it will not be possible to develop sustainable research capacity.
Regarding the shaping of the research agenda on health systems in Europe, the study's findings reveal a need to address the consequences of health reforms in a sound methodological way, which allows to identify the relevant effects of health policy on health, equity and financial sustainability of European health systems. Both European and national policies need to be evaluated. Since there have been important privatization movements in many European countries and the health sector has been increasingly opened to market forces (either in an incremental way or within major privatization waves), there is a need to evaluate the effects that the growing shift from public to private sector is having on health systems and on the outcomes of health systems.
Sound assessments of health care reform require the refinement of methodological approaches. For comparative health systems research, indicators of health systems performance need to be further developed and refined. There is also a need to further develop multidisciplinary study methods to address the variety of questions related to health systems functioning and performance. In addition, there is also a need to define criteria to identify high quality research (i.e. research with high validity) in health systems in a similar way as it has been done for clinical research by the evidence based medicine movement.
The framework for health systems research and the results of the bibliometric analysis were presented at the Health Services Research Working Conference in Den Haag (8th and 9th of April 2010) and discussed with researchers and users of research in working sessions. In the working session on health systems, three specific areas for discussion were identified previously: methodological aspects of health systems research, evaluation of privatization and market competition in the health systems and issues of workforce planning and professional mobility. A set of topics to address in future research on health system emerged from the structured discussions in the working sessions.
Sources used for this section and suggested further reading:
- Velasco Garrido M, J Hansen, R Busse (2011) Mapping Research on Health Systems in Europe: a bibliometric assessment', article in Supplement Issue Journal of Health Services Research and Policy, in press.
- Velasco Garrido M, R Busse (2011) Health Systems Research in Europe. Chapter. In: HSR-Europe. Health Services Research into European Policy and Practice. Final report of the HSREPP project. Utrecht: NIVEL, 2011 (available at http://www.healthservicesresearch.eu online).
- Section 'Priorities for analysing health care systems' in Policy Brief 'Health services research: helping tackle Europe's health care challenges', HSR-Europe 2011, Utrecht: NIVEL (available at http://www.healthservicesresearch.eu online).
1.3.2 Health care organisations and service delivery
Health care organisations are a crucial component of health care, operating at the meso level between the health care system at the macro level and the interactions between patients and health professionals at the micro level. Objective of this work package was to identify the principal areas of past and current research on health care organisation and service delivery, and to relate this to future priorities at the European and country level.
As research on health care organisations can include a wide variety of issues, a framework is required to classify types of research. In this study we distinguished between four major areas of research on health care organisations, loosely based on Donabedian's (1966) framework, distinguishing between the structure of organisations, the care processes within organisations and their outcomes or performance.
The four areas are:
1. Intra-organisational control
This area focuses primarily on how organisations arrange their work internally, such as by differentiation or specialisation. Topics include workforce and skill- mix, creation of multidisciplinary teams, and reconfiguring services
2. Inter-organisational relations
As organisations relate to their environment and are part of organisational networks, they have to organise their relationships to other organizations. Topics include the continuity of care between organisations, the transfer from secondary to primary care; and the spatial distribution of services, including cross-border health care.
3. Patient relations
The performance of organisations can either be understood narrowly as the performance of the clinical process or more widely in the context of patients. An organisation's relationship with patients is considered important as they are connected to the organisation's central goals. It deals with topics such as patient involvement, patient compliance and demand management.
4. Governance and accountability
Health care organisations have their own governance structures and also function within health systems where they are subject to governance and regulation, for instance on labor conditions, patient safety and their level of autonomy and market exposure. Topics include assessment and improvement of quality and safety, the relationships between professionals and managers, and the regulation of professions or provider organisations.
To get a view of country differences, a distinction was made between countries as a keyword and countries in researchers' addresses. The first provides an overview of studies on different European countries, while the second indicates studies from each of the countries. Similar to what was found in WP 4, the numbers of publications differ considerably between countries. Overall, more research is produced on a country than from a country, reflecting in part that studies address multiple countries. It also indicates the co-authorship of many publications, in part by researchers who move from one country to the other, for example, researchers from 'low research output' countries working in 'high research output' countries.
The national versus international focus of HSR is another element that can be identified from the data. Ninety percent of studies appear to be based on one country, with only one country name in the list of keywords. About 8% include two countries, while the remainder makes a comparison between three or more countries. Studies on six or more countries are very rare.
To provide a better picture of the topics addressed, we reviewed a sample of 1,010 HSR article abstracts, 45% of which dealt with research on health care organisations. In addition, we reviewed EU-funded projects to determine topics of interest in ongoing or recently finished work. Least common are studies on inter-organisational relations possibly because it deals with phenomena that are relatively new on the policy agenda, such as continuity of care. The largest difference is in 'patient relations', being more common among published research (28%) than in EU-funded projects (13%). Differences between European regions are fairly small.
When it comes to the question what research should be done in the future, an online survey among experts in Europe focused on priorities for future research. Relating these views to past research reveals that the topic of inter-organisational relations has received much less attention than respondents suggest it should in the future.
The main exception is the topic 'assessment and improvement of quality and safety', which is already a key element both in past research and especially in EU-funded projects. Similarly, some other topics, such as 'workforce', 'e-health' or 'patient involvement' appear to be receiving increasing attention and are seen as important for the future. Additional topics such as 'chronic disease management', 'continuity of care' and 'creation of multidisciplinary teams' are also considered priorities while they are not often being studied at present. The topic of chronic disease management is already catching up at the level of European funded projects, which in turn may serve as a driver for more knowledge being developed by other (nationally funded) research initiatives.
Sources used for this section and suggested further reading:
- Hansen J, W Schafer, N Black, PP Groenewegen (2011) European priorities for research on health care organisations and service delivery', article in Supplement Issue Journal of Health Services Research and Policy, in press.
- Hansen J, Schafer W, Black N, Groenewegen PP (2011). Health care organisations and service delivery. Chapter. In: HSR-Europe. Health Services Research into European Policy and Practice. Final report of the HSREPP project. Utrecht: NIVEL, 2011 (available at http://www.healthservicesresearch.eu online).
- Section 'Priorities for studying the organisation and delivery of services' in Policy Brief 'Health services research: helping tackle Europe's health care challenges', HSR-Europe 2011, Utrecht: NIVEL (available at http://www.healthservicesresearch.eu online).
1.3.3 Health technology assessment
The development of health services in Europe is strongly influenced by new technologies with the potential to improve the health of populations through more effective care. However, not every technological innovation results in (cost-effective) health gains. There are many examples of technologies which have not produced the expected benefits or have even proved to be harmful. Also, technologies which prove to be effective create a challenge since their application may require additional finance and other resources, or require existing resources to be redistributed. Thus, it is necessary to ensure that health technologies are evaluated properly.
Health technology assessment (HTA) involves systematic, wide-ranging evaluation of the implications of technologies to inform the formulation of safe and effective health policies that are focused on the patient and achieve the best value for money. This work package provided an overview of health services research (HSR) in relation to HTA in Europe. Based on a review of published research, the trends in health services research in relation to HTA so far were identified. In addition, it provided input to a future research agenda by describing the research called for in the existing literature and discusses new directions for HTA based on the demands for future research.
Part of the aim was to present the content of the existing research and demands for the future as identified in the literature. The research was categorised into six areas:
(1) the content of analysis in HTA (such as analysis of economy, organisation and social aspects),
(2) HTA products developed to meet the needs of policy-makers (such as horizon scanning, mini-HTA, and core HTA),
(3) handling life-cycle perspectives in relation to technologies,
(4) topics that challenge existing methods and for which HTA should be developed to address the themes more comprehensively (such as public health interventions and organisational interventions),
(5) development of HTA capacity and programmes, and
(6) links between policy and HTA.
Especially research on the content of HTA and the links to policy have been conducted during the last ten years.
The research priorities emphasised in this survey correspond very well with the research needs found in the literature review. The articles included in the review addressed several research needs related to the six themes presented above. Of the 210 references included in the literature review, 99 (47 percent) addressed future research needs. In addition, the discussion rounds on HTA at the Working Conference 'Health Services Research in Europe' and the surveys among country consultants contributed to further input for the future research agenda.
Within all six areas there is a need for more knowledge. Among others, when looking at the contents of analysis in more detail, a general concern is that HTA reports often neglect the wider effects of using technologies (such as ethical, legal, organizational and social aspects) and that research in these areas is lacking. The literature review confirmed this concern, as articles reporting studies of economic evaluation in relation to HTA comprised most of the studies on the content of the analysis in HTA, leaving the wider aspects of HTA and best practices in undertaking and reporting HTA relatively under-researched.
The review and linkage to future revealed a number of newer research areas, which were not distinctly present in the review of existing research. Examples of demands for future research are: research concerning assessment of the wider effects of using technologies; research concerning coverage with evidence development and disinvestment; research concerning assessment of public health intervention, organisational interventions, and of information and communication technologies; research on the links between policy and HTA; and research on relative effectiveness.
The study also suggests that the future research needs contributions from several disciplines to satisfactorily move the HTA field forward. Both HSR and HTA are characterised by multidisciplinarity, and this overview of the research clearly illustrates the needs for a variety of methods, theories, and research backgrounds to ensure continued development of HTA as input to decision-making.
Sources used for this section and suggested further reading:
- Palmhoj Nielsen C, TM Funch, FB Kristensen (2011) Health services research in relation to health technology assessment - research trends and future priorities', article in Supplement Issue Journal of Health Services Research and Policy, in press.
- Palmhoj Nielsen C, TM Funch, FB Kristensen (2011) Health technology assessment'. Chapter. In: HSR-Europe. Health Services Research into European Policy and Practice. Final report of the HSREPP project. Utrecht: NIVEL, 2011 (available at http://www.healthservicesresearch.eu online).
- Section 'Priorities for better assessing health technologies' in Policy Brief 'Health services research: helping tackle Europe's health care challenges', HSR-Europe 2011, Utrecht: NIVEL (available at http://www.healthservicesresearch.eu online).
1.3.4 Benchmarking based on performance indicators
Measuring the quality of care through performance indicators and using this information for comparing, learning and improving (benchmarking) has become a central component of today's health care policies. Health Services Research in the countries in the European Union is related to the enrolling agenda of benchmarking and performance indicators in many different ways. The emphasis seems to be on performance measurement; trying to validate measures that tell us something about the performance of specific services or health care systems. These lines of research are closely linked to available health care statistics. Other lines of HSR focus on the actual embedding of performance measurement in policy making and health care management. These lines of research are closely linked to the wider agenda of implementation research in health care and the application of theories and methods developed in other industrial and public sectors to the health care sector.
The aim of this work package was not to give a complete overview of all ongoing Health Services Research activities in Europe related to benchmarking and performance indicators. It rather tried to identify the main themes and focuses on the opportunities to improve the HSR evidence base behind the policy developments indicators. On the bases of that information priorities identified and recommendations provided for setting the research agenda in the field performance indicators and benchmarking.
The various publications that resulted from the work package describe in more depth the identified eight fields of Health Services Research related to performance indicators and benchmarking. Both literature study and expert consultations identified a large number of existing research initiatives within the EU although the distribution of research initiatives over the EU member states seems quite uneven. The discussions during the working conference on Health Services Research confirmed that on performance indicators and benchmarking:
- Research should focus on the development of indicators (validity, reliability, relevance) as well as on the actual use (effective embedding in policy and management).
- As a consequence of the above, health services research on these topics should always involve participation of the potential users
- Both scientific approaches from bio-medicine/epidemiology and the social sciences are needed
Further progress of HSR on performance indicators and benchmarking is hampered by data-availability. Experts agreed that the following issues need addressing:
- use of Unique Patient Identifiers to facilitate linkages between separate data-bases
- further standardization of coding
- use of present-at admission codes in administrative databases
- recording of secondary diagnoses in administrative data-bases
- facilitate secondary data use from Electronic Health Records
- facilitate standardized measurement of experiences by patients and citizens
- continued collaboration between Eurostat, WHO and the OECD to facilitate the availability of international comparable performance information
HSR research on benchmarking and performance indicators on European level would benefit from strengthening the clearinghouse function on research findings, training of researchers and appropriate scientific publication media. Results of HSR research on benchmarking and performance indicators should be systematically shared with policy makers and managers of health services and systems to assure a fit with local contexts. Networking should be stimulated on European level between the research groups involved in this kind of work and the growing number of national/regional institutes involved in quality measurement and reporting.
1.3.5 Research and Policy
As an applied field of research, health services research (HSR) is undertaken primarily to inform health care policy. However, the relationship between policy and HSR is not straightforward. Many policies are developed without taking account of available evidence. Objective of this work package was to provide an overview of the infrastructure and capacity of HSR in Europe, and to explore the links between HSR and policy in European countries.
The study was based among others on a survey of health policy experts recruited specifically to act as informants in the 34 countries participating in this project. A review of the literature was also undertaken to inform the design of the survey questionnaire and the framework of analysis. Country informants were asked to complete a detailed questionnaire, which covered the following areas: funding and prioritising health services research; production and producers of health services research; health policy users of health services research; activities to promote the use of health services research; and barriers and facilitators to using health services research in policy-making.
This work package is the first attempt to describe the nature, and extent of the links between health services research and policy in European countries. The most prominent finding is how little information is available about health services research, and the health services research and policy relationship. This is particularly true with regard to the amount of funding available for health services research, which is largely due to problems distinguishing funding for health services research from funding for other health-related research. Still, it is evident that the level of funding varies widely among countries. A comparison of spending would only be meaningful if related to a country's national income or total spending on health care. In most countries, a large proportion of funding for health services research is provided through public resources, mostly provided by national governments. To a lesser extent, private and external sources of funding play a role in some countries, although these sources of funding may be more relevant in countries with small public budgets for research in general and health services research in particular.
Overall, the picture that emerges is one of diversity with health services research being more comprehensively developed in England, Scotland, Germany and the Netherlands than in others, as judged by the extent of opportunities for funding, training, networking and publishing. The range of research users at the policy level largely reflects the institutional governance structure of health systems, with central governments usually being the main users. In countries, in which health system governance has largely been devolved to corporatist bodies, professional and provider associations, are the principal users of health services research, such as the Federal Joint Committee in Germany. Likewise, in countries in which political decision-making is largely devolved to regions and/or municipalities, local or regional governments are important users of research, such as municipal councils in Finland. Decentralised policy-making increases the number of potential research users, thus creating a larger and more complex interface between research and policy. A larger number of users may create more opportunities for research uptake. However, these organisations are presumably smaller and may individually have less capacity to utilise research and liaise with researchers.
Developing capacity in health services research
- Given that countries vary substantially in the maturity of this field of research, any changes should be geared to the stage of development and level of recognition of health services research in each country. There will be no 'one size fits all' approach possible for developing national capacity, although there may be a role for external research funding and support, such as through the European Commission or WHO.
- Given that priority-setting in health services research is absent in most countries, there should be efforts to establish approaches to align research with the needs of policy-makers through priority-setting and strategic planning. Arguably, priority-setting is particularly relevant in countries, in which financial resources for research are very constrained.
- Opportunities for strengthening international exchange and mutual learning should be explored, including the creation of a European platform for health services research through a European Association for Health Services Research and/or an annual European Health Services Research Conference.
Improving the capacity of users of health services research
- Opportunities for improving the willingness and ability of policy-makers to use health services research should be considered. Efforts to improve research use skills could include, for example, tailored training in research methods and the use of bibliographic databases.
- There may also be opportunities for improving the integration of the use of research into policy processes and for creating a more research-friendly culture in policy organisations which should be further explored. An example could be the checklist for research use developed in Canada (Lomas and Brown, 2009) or experiences of research and policy co-location, as in the Netherlands.
Enhancing activities that support the use of health services research in policy
- Efforts should be made to strengthen the relationship between health services researchers and policy-makers both at national level and internationally, for example, by strengthening/ establishing national and European forums for exchange.
- Further developments could include establishing new organisations at the interface of health services research and policy, such as government research organisations or knowledge centres for health services research.
Sources used for this section and suggested further reading:
- Ettelt S, N Mays (2011) Health services research in Europe and its use for informing policy: use of HSR in Europe', article in Supplement Issue Journal of Health Services Research and Policy, in press.
- Ettelt S, N Mays (2011) 'Health Services Research in Europe and its use to inform policy. Chapter. in: HSR-Europe. Health Services Research into European Policy and Practice. Final report of the HSREPP project. Utrecht: NIVEL, 2011 (available at http://www.healthservicesresearch.eu online).
- Section 'The use of health services research in policy' in Policy Brief 'Health services research: helping tackle Europe's health care challenges', HSR-Europe 2011, Utrecht: NIVEL (available at http://www.healthservicesresearch.eu online).
- Section 'Strengthening health services research and its linkage to policy' in Policy Brief 'Health services research: helping tackle Europe's health care challenges', HSR-Europe 2011, Utrecht: NIVEL (available at http://www.healthservicesresearch.eu online).
1.4 Potential impact and the main dissemination activities and exploitation of results
A core element within the project has been the creation of a platform for new research in the form of a European working conference on health services research. In preparation to the conference, assessment reports were written for each of the five HSR areas. Each report included a review of the literature in that area to identify the state-of-the-art of research. In addition, reports made use of expert opinions, among others through a consultation form for country consultants and an online survey among almost 300 health care experts, this to determine priorities for future research. In the second reporting period, each report was finalised and circulated prior to the working conference to all participants to enable them to review the material.
The working conference took place on Thursday 8 and Friday 9 April 2010 in the World Forum Convention Centre in The Hague, the Netherlands. In terms of content, the conference had two main aims. One was to receive inputs for priority setting of research in these five areas of HSR. The second was to analyse the relationships between research and policy in Europe and the third aim was to contribute to capacity and community building for HSR in Europe. As it was organised as a working conference, the emphasis was not on presentations but on discussion of topics of shared interest, with a mix of plenary sessions and decentralized debate sessions. Core of day one was a cluster of thematic workshops with overviews of the state-of-the-art, followed by carousel rounds of interactive discussions on research priorities in main areas of HSR. The day ended with poster sessions and a selection of special workshops, that were added to the programme based on the abstract submissions by participants. This included among others an extra session on the use of systematic reviews, the possibility of country comparisons based on Health in Transition reports by the European Observatory on Health Systems and Policies and a session with lessons on HSR from outside Europe, based on a substantial number of abstract submissions by non-European institutes, mostly from Canada, Australia and New-Zealand. Day 2 of the conference addressed the future of health services research and how to improve its contribution to the health policy process. After sketching and debating the future research-to-policy landscape a closing session delivered main outcomes and concrete action points to a panel of representatives of the policy and research community both at European and national level.
To validate the outcomes of the meeting and to create awareness of the project's main outcomes a number of additional steps were taken. First, the results of the meeting were further refined based on single presentations and/or organising conference sessions at relevant occasions. During the project period these included:
- A workshop organised by the project team during the 2nd European Public Health Conference, organised by EUPHA and ASPHER in November 2009.
- A workshop organised by the project team during the EHMA Annual Conference in June 2010, together with a circulation of the project's online survey to all of its participants, which provided an extra validation of the online survey results among those involved in health management issues.
- A poster presentation during the 3rd biannual EFPC Conference on the Future of Primary Care in Europe, in August 2010.
- A workshop organised by the project team during the 3rd European Public Health Conference, organised by EUPHA and ASPHER, in November 2010.
- A presentation during the Second Croatian Congress on Preventive Medicine and Health Promotion, October 2010.
- A presentation during a DG Research led workshop at the WHO World Health Organization (WHO) First Global Symposium on Health Systems Research, in November 2010.
A second means of validation has been by summarizing main outcomes of the conference and the inputs used in preparation to it in a draft policy brief, which was then circulated for consultation through various channels, including members of the FP7 Programme Committee, conference participants and newsletter subscribers of the project. This has led to additional refinement of a research agenda, highlighting priorities for future research in various areas of health services research. The final policy brief has been launched in April 2011 and was circulated to the same channels, including representatives of all EU Member States and relevant international organisations. The policy brief is also available at http://www.healthservicesresearch.eu online.
The various products that came out of the project provide an overview of health services research and describe the contribution that it makes to policy-making. These include a final report with more elaborate outcomes of the project including overviews of the literature on HSR so far. The final report 'Health Services Research into European Policy and Practice' was published April 2011 at the project website. A draft version was used as input for the working conference, which contained an overview of the state-of-the art in all five fields of HSR. A second main product has been a collection of six articles, published together as Supplement Issue of the Journal of Health Services Research and Policy (scheduled for release in July 2011).
A number of activities have been undertaken after the working conference, to ensure effective distribution of final publications. Distribution activities included:
- Digital copies of the draft policy brief to conference participants, country consultants, SAC members, newsletter subscribers and FP7 programme committee.
- Digital and print copies of the final policy brief to the same groups (for newsletter subscribers only digital copies), plus print copies to about 500 other experts who were invited earlier to join the conference and to representatives of all Ministries of Health, the European Commission, members of the EUSANH network of national health councils and other international organisations, including World Bank, OECD and WHO.
- Digital copies of the final report to conference participants and newsletter subscribers, print versions also to country consultants, SAC members and the European Commission.
- In July 2011 a Supplement issue of the Journal of Health Services Research and Policy will be published. Print copies will be made available to conference participants, country consultants, SAC members, Ministry of Health representatives, the European Commission and other experts who were invited to the working conference.
Other publications not foreseen beforehand which have been or are to be published in relevant European journals include:
- Schafer W, PP Groenewegen, J Hansen, N Black (2011) Priorities for health services research in primary care. Quality in Primary Care 2011;19:77-83.
- Hansen J (2011) Tackling Europe's healthcare challenges. To appear in the June 2011 issue of International Innovation.
- Groenewegen PP, R Busse, S Ettelt, J Hansen, N Klazinga, N Mays, W Schafer (2011) Health services research in Europe: what about an open marriage? European Journal of Public Health (2011) 21 (2): 139-141. Note. This article was part of a collection of three viewpoint articles in the same issue, written in response to the working conference, organised by the HSREPP project. One was titled 'Health services research and public health research in Europe: stay married or file for divorce? (by Diana Delnoij) and the other 'Should EUPHA publish a new journal for European health systems research?' (by Mark McCarthy).
In terms of activities, the working conference itself contributed to establishing an effective and sustainable European network for health services research and clearly showed there is a clear need for activities that bring together experts in the field of health services research. To build on this potential it is vital that follow-up activities will remain available, offering the opportunity for health services research to meet and share information, thus contributing to capacity and community building. In order to strengthen resources, many of these follow-up activities are being organised close to existing associations, in particular EUPHA and its Section on HSR and EHMA, as both are key partners for revitalising and bringing together health services researchers within Europe.
Follow-up workshops are therefore scheduled for conferences in 2011 and 2012, in particular:
- A workshop organised by the HSREPP project team in collaboration with the EUPHA Section on HSR on effective knowledge transfer of health services research evidence at the EHMA annual conference in June 2011. Confirmed speakers will share highlights from the HSREPP project itself, as well as from other EU-funded projects, in particular BRIDGE and STEPS.
- A debate session organised by HSREPP during the Annual Research Meeting of AcademyHealth in the United States, June 2011. This activity addresses the element of improving international comparability of health services research, and brings together panellists from the US itself, Europe and Canada.
- A plenary session on cross-border health services research at the fourth HSRN / SDO Network annual conference in Liverpool, United Kingdom, June 2011.
- A special preconference training day for young health services researchers at the EUPHA/ASPHER annual conference in November 2011, organised by the HSREPP project team in collaboration with the EUPHA Section on HSR and the EUPHAnxt initiative, bringing together young public health researchers. The training day will address ways how to improve the contribution of health services research to decision-making and how to make the research by participants more practice and policy-oriented while maintaining scientific and methodological requirements.
- For 2012 a second European working conference is scheduled, titled 'Strengthening the European Dimension in Health Services Research'. The working conference will be organised as pre-conference day before the start of EUPHA 2012 in Malta, thus enabling participants to join both events without additional travel costs. Central theme will be the added value of European comparative HSR. Objectives will be to raise the quality of internationally comparative HSR, helping national decision makers in identifying and using international research evidence, and strengthening capacity building both at the research and policy side. All aspects will be reflected in a conference programme, among others in terms of sessions on identifying good practice, transferability of research findings, and on proposal preparation and partner selection in international projects.
Organising future events will ensure that the network established through the project can continue in enhancing the contribution of HSR to policy in the future. Events will be organised in collaboration with existing associations, in particular EUPHA and its Section on HSR and EHMA, as both are key partners for revitalising and bringing together health services researchers within Europe. Instead of being a one-time event, the initiative will thus continue sharing expertise and reinforcing the European health services policy arena.
Another means of improving the use and impact of the HSREPP-project is by revitalising and renewing its project website http://www.healthservicesresearch.eu In the period prior to and after the working conference the website served as conference website, providing interested parties the opportunity to register, submit their abstract or learn more about the conference's outcomes. To continue contributing to the visibility and use of HSR in Europe, the project website has been transformed into a community-based website. It provides among others an overview of conferences, training activities and other events related to European health services research.
Potential Impact:
A core element within the project has been the creation of a platform for new research in the form of a European working conference on health services research. In preparation to the conference, assessment reports were written for each of the five HSR areas. Each report included a review of the literature in that area to identify the state-of-the-art of research. In addition, reports made use of expert opinions, among others through a consultation form for country consultants and an online survey among almost 300 health care experts, this to determine priorities for future research. In the second reporting period, each report was finalised and circulated prior to the working conference to all participants to enable them to review the material.
In terms of content, the conference had two main aims. One was to receive inputs for priority setting of research in these five areas of HSR. The second was to analyse the relationships between research and policy in Europe and the third aim was to contribute to capacity and community building for HSR in Europe. As it was organised as a working conference, the emphasis was not on presentations but on discussion of topics of shared interest, with a mix of plenary sessions and decentralized debate sessions. Core of day one was a cluster of thematic workshops with overviews of the state-of-the-art, followed by carousel rounds of interactive discussions on research priorities in main areas of HSR. The day ended with poster sessions and a selection of special workshops, that were added to the programme based on the abstract submissions by participants. This included among others an extra session on the use of systematic reviews, the possibility of country comparisons based on Health in Transition reports by the European Observatory on Health Systems and Policies and a session with lessons on HSR from outside Europe, based on a substantial number of abstract submissions by non-European institutes, mostly from Canada, Australia and New-Zealand. Day 2 of the conference addressed the future of health services research and how to improve its contribution to the health policy process. After sketching and debating the future research-to-policy landscape a closing session delivered main outcomes and concrete action points to a panel of representatives of the policy and research community both at European and national level.
To validate the outcomes of the meeting and to create awareness of the project's main outcomes a number of additional steps were taken. First, the results of the meeting were further refined based on single presentations and/or organising conference sessions at relevant occasions.
During the project period these included:
- A workshop organised by the project team during the 2nd European Public Health Conference, organised by EUPHA and ASPHER in November 2009.
- A workshop organised by the project team during the EHMA Annual Conference in June 2010, together with a circulation of the project's online survey to all of its participants, which provided an extra validation of the online survey results among those involved in health management issues.
- A poster presentation during the 3rd biannual EFPC Conference on the Future of Primary Care in Europe, in August 2010.
- A workshop organised by the project team during the 3rd European Public Health Conference, organised by EUPHA and ASPHER, in November 2010.
- A presentation during the Second Croatian Congress on Preventive Medicine and Health Promotion, October 2010.
- A presentation during a DG Research led workshop at the WHO World Health Organization (WHO) First Global Symposium on Health Systems Research, in November 2010.
A second means of validation has been by summarizing main outcomes of the conference and the inputs used in preparation to it in a draft policy brief, which was then circulated for consultation through various channels, including members of the FP7 Programme Committee, conference participants and newsletter subscribers of the project. This has led to additional refinement of a research agenda, highlighting priorities for future research in various areas of health services research. The final policy brief has been launched in April 2011 and was circulated to the same channels, including representatives of all EU Member States and relevant international organisations. The policy brief is also available at http://www.healthservicesresearch.eu
A number of activities have been undertaken after the working conference, to ensure effective distribution of final publications. Distribution activities included:
- Digital copies of the draft policy brief to conference participants, country consultants, SAC members, newsletter subscribers and FP7 programme committee.
- Digital and print copies of the final policy brief to the same groups (for newsletter subscribers only digital copies), plus print copies to about 500 other experts who were invited earlier to join the conference and to representatives of all Ministries of Health, the European Commission, members of the EUSANH network of national health councils and other international organisations, including World Bank, OECD and WHO.
- Digital copies of the final report to conference participants and newsletter subscribers, print versions also to country consultants, SAC members and the European Commission.
- In July 2011 a Supplement issue of the Journal of Health Services Research and Policy will be published. Print copies will be made available to conference participants, country consultants, SAC members, Ministry of Health representatives, the European Commission and other experts who were invited to the working conference
Other publications not foreseen beforehand which have been or are to be published in relevant European journals include:
- Schafer W, PP Groenewegen, J Hansen, N Black (2011) Priorities for health services research in primary care. Quality in Primary Care 2011;19:77-83.
- Hansen J (2011) Tackling Europe's healthcare challenges. To appear in the June 2011 issue of International Innovation.
- Groenewegen PP, R Busse, S Ettelt, J Hansen, N Klazinga, N Mays, W Schafer (2011) Health services research in Europe: what about an open marriage? European Journal of Public Health (2011) 21 (2): 139-141. Note. This article was part of a collection of three viewpoint articles in the same issue, written in response to the working conference, organised by the HSREPP project. One was titled 'Health services research and public health research in Europe: stay married or file for divorce? (by Diana Delnoij) and the other 'Should EUPHA publish a new journal for European health systems research?' (by Mark McCarthy).
In terms of activities, the working conference itself contributed to establishing an effective and sustainable European network for health services research and clearly showed there is a clear need for activities that bring together experts in the field of health services research. To build on this potential it is vital that follow-up activities will remain available, offering the opportunity for health services research to meet and share information, thus contributing to capacity and community building. In order to strengthen resources, many of these follow-up activities are being organised close to existing associations, in particular EUPHA and its Section on HSR and EHMA, as both are key partners for revitalising and bringing together health services researchers within Europe. Follow-up workshops are therefore scheduled for conferences in 2011 and 2012, in particular:
- A workshop organised by the HSREPP project team in collaboration with the EUPHA Section on HSR on effective knowledge transfer of health services research evidence at the EHMA annual conference in June 2011. Confirmed speakers will share highlights from the HSREPP project itself, as well as from other EU-funded projects, in particular BRIDGE and STEPS.
- A debate session organised by HSREPP during the Annual Research Meeting of AcademyHealth in the United States, June 2011. This activity addresses the element of improving international comparability of health services research, and brings together panellists from the US itself, Europe and Canada.
- A plenary session on cross-border health services research at the fourth HSRN / SDO Network annual conference in Liverpool, United Kingdom, June 2011.
- A special preconference training day for young health services researchers at the EUPHA/ASPHER annual conference in November 2011, organised by the HSREPP project team in collaboration with the EUPHA Section on HSR and the EUPHAnxt initiative, bringing together young public health researchers. The training day will address ways how to improve the contribution of health services research to decision-making and how to make the research by participants more practice and policy-oriented while maintaining scientific and methodological requirements.
- For 2012 a second European working conference is scheduled, titled 'Strengthening the European Dimension in Health Services Research'. The working conference will be organised as pre-conference day before the start of EUPHA 2012 in Malta, thus enabling participants to join both events without additional travel costs. Central theme will be the added value of European comparative HSR. Objectives will be to raise the quality of internationally comparative HSR, helping national decision makers in identifying and using international research evidence, and strengthening capacity building both at the research and policy side. All aspects will be reflected in a conference programme, among others in terms of sessions on identifying good practice, transferability of research findings, and on proposal preparation and partner selection in international projects.
Organising future events will ensure that the network established through the project can continue in enhancing the contribution of HSR to policy in the future. Events will be organised in collaboration with existing associations, in particular EUPHA and its Section on HSR and EHMA, as both are key partners for revitalising and bringing together health services researchers within Europe. Instead of being a one-time event, the initiative will thus continue sharing expertise and reinforcing the European health services policy arena.
Another means of improving the use and impact of the HSREPP-project is by revitalising and renewing its project website http://www.healthservicesresearch.eu In the period prior to and after the working conference the website served as conference website, providing interested parties the opportunity to register, submit their abstract or learn more about the conference's outcomes. To continue contributing to the visibility and use of HSR in Europe, the project website has been transformed into a community-based website. It provides among others an overview of conferences, training activities and other events related to European health services research. The website also contains an overview of materials collected in the HSREPP project, including an overview of relevant EU funded projects. As the searchable database offers the opportunity for everyone to add and display their own research activities, the website will continue to build an online repository of relevant HSR in Europe, this to display relevant research across Europe, which can facilitate knowledge exchange and improve a fine-tuning of research agendas across Europe.
Together these activities and products should address and appeal to a wide range of target groups and thus contribute in promoting effective interfaces between research and policy for the benefit of scientific underpinning of health care policies.
Project website: http://www.healthservicesresearch.eu
Contact:
Scientific representative of the project's coordinator:
Johan Hansen, PhD
NIVEL, Netherlands institute for health services research
PO Box 1568
3500 BN Utrecht
The Netherlands
Tel: +31-302-729743
Fax: +31 302-729729
E-mail: j.hansen@nivel.nl
The project HSREP aimed to identify, evaluate and improve the contribution of Health Services Research (HSR) to the health policy process at national and European level, and thus help optimize the delivery of health care services to European citizens.
Objectives were:
a) To identify the state-of-the-art of HSR in Europe.
b) To identify at European and Member State level current and upcoming priorities in HSR for addressing policy needs.
c) To assess at Member State and European level current infrastructures for the translation of HSR into the policy and practice.
d) To offer a forum at which studies in the field of HSR can be presented, discussed and evaluated, especially aimed at filling the identified research-policy gaps for the future.
e) To contribute to agenda setting on HSR at European and Member States' level.
Given its broad nature the field was divided into five main areas, around which all activities such as literature searches and online consultations were centred:
1) Health (care delivery) systems;
2) Health care organisations and service delivery;
3) Health Technology Assessment;
4) Benchmarking and performance indicators;
5) Relationships between research and policy.
A major activity has been the creation of a platform for new research in the form of a European HSR working conference in April 2010, which took place on Thursday 8 and Friday 9 April 2010 in The Hague, the Netherlands. The meeting was attended by about 350 researchers and policy makers from a little less than 40 countries, both European and from other regions.
To validate the outcomes of the meeting its results were further refined during workshops and presentations at other conferences in 2010. A final report and special issue of the Journal of HSR&Policy provide overviews of HSR and describe the contribution that it makes to policy-making. Main outcomes were also summarized in a policy brief which was launched in April 2011. It provides an overview of future major research priorities based on policy-makers' and researchers' views at a national and European level. Examples are the need to evaluate health care reforms, the integration of care across organisations, research into the broader consequences of health technologies, stronger focus on the development and use of performance indicators and improving knowledge of how HSR is undertaken and used. In addition, the policy brief provides an overview of strategies to improve the use of research in policy, including a better balance between different types of research funding, tools to avoid the duplication of studies and learning from best examples in, among others, HTA regarding rapid assessments of research evidence (see http://www.healthservicesresearch.eu for details).
Project Context and Objectives:
Context
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. 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. 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.
These developments contribute to an ongoing debate about how to realise major cuts in health care spending, while still recognising that health care is an investment which contributes to the wealth and health of Europe. Health policy and organisational 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 7th Framework Programme 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.
Objective
The overarching aim of the project is:
"to identify, evaluate and improve the contribution of health services research to the health policy process at the level of Member States and the European Union, and thus to help optimizing the delivery of health care services to European citizens."
This general objective can be broken down to the following specific objectives:
a. To identify the state-of-the-art of HSR in Europe.
b. To identify at European and Member State level current and upcoming priorities in HSR for addressing policy needs.
c. To assess at Member State and European level current infrastructures for the translation of HSR into the policy and practice.
d. To offer a forum at which studies in the field of HSR can be presented, discussed and evaluated, especially aimed at filling the identified research-policy gaps for the future.
e. To contribute to agenda setting on HSR at European and Member States' level.
Given its broad nature the field of HSR was divided into five main areas, around which all activities were centred:
1. Health (care delivery) systems, addressing the available knowledge of HSR at the level of health care systems (national or sometimes regional);
2. Health care organisations and professional practices, located between the health care system and service provision in the interaction between patients and providers;
3. Health Technology Assessment; addressing the multidisciplinary field of policy analysis that systematically assesses the medical, social, ethical, and economic implications of the development, diffusion, and use of health technology;
4. Benchmarking and performance indicators; monitoring health services over time, pooling valuable initiatives and setting up mechanisms to exchange best practice;
5. Relationships between research and policy, focusing on how the results of research are being fed into the policy process (e.g. modes of commissioning research).
Project Results:
All scientific activities of the project, in particular mapping the state-of-the-art and determining future priorities, were broken down into the following work packages, each structured around one of the subareas in HSR:
- WP 4 - 'Health systems'
- WP 5 - 'Health care organisation and professional practices'
- WP 6 - 'Health Technology Assessment'
- WP 7 - 'Benchmarking and performance indicators'
- WP 8 - 'Research and Policy: Strengthening the research-policy cycle'
While the exact activities differ somewhat between HSR areas and work packages, there are three key elements that all work packages make use of: literature searches, country consultation forms, and an online stakeholder survey. Main S&T results of each of the work packages are summarized below.
1.3.1 Health systems research
This part of the project addressed the available knowledge of HSR at the level of health care systems, i.e. the level of nations or regions, and the issues related to the organizational structure, the model of financing, the regulation and planning of the system, the ways to create physical and human resources and to provide services, as well as it changes over time. As health care systems may contribute to the realisation of general values of universality, access to good health care, equity and solidarity, many topics that are currently high on the European research agenda are linked to the arrangements of the health system as a whole (for instance, cross-border healthcare purchasing and provision, migration of health care professionals, and patient safety).
The work package's target was to provide an assessment of the field of health systems research in Europe based on an analysis of the published literature. Health systems research analyses the contents of health reforms and policies and assess their effects - both intended and unintended - on the system itself and ultimately on the health of the population. Health systems research is thus concerned with the assessment of the performance of the system in achieving population health (and responsiveness to people's legitimate expectations as well as financial protection against ill health).
In this study, a bibliometric analysis was conducted in order to assess the status of health systems research in Europe. Besides this approach, internet searches were performed to complete the picture of health systems research. Additionally, data from a survey among researchers and policy makers in the field of health systems were taken into account. Finally, the preliminary findings were presented at the Health Services Research Working Conference in The Hague (8th and 9th of April 2010) and discussed with the participants in working sessions. This variety of approaches allowed to address the topic from different perspectives and to increase the validity of our findings.
Both the bibliometric analysis and the internet searches indicate that especially in the eastern European countries there is a need to develop health systems research capacity. There are few publications from institutions based in these countries, there are also few internet hits, and finally these countries are underrepresented in EU-funded projects. At least to some extent, each of the European countries has been targeted by research not produced in that country, although there are considerable differences among countries. For example, most of the research on Sweden has been produced there and less than 10% has been produced without Swedish involvement. In contrast, for some of these countries, none of the publications identified had been produced locally. Particularly, research on the countries from the former Soviet Union has been produced in other countries.
These and other findings from the report clearly point out the need to develop health systems research across Europe, and particularly in the countries of former Eastern Union and former Soviet Union. The health systems of that countries have been object of major reforms in the past years (cf. Health Systems in Transition series (European Observatory for Health Systems and Policies) shifting from classical Semashko health systems to different models of health system organization and financing while at the same time being under enormous financial pressures derived from the transition of socialist economic order to market oriented economic system. EU Member States have also implemented major reforms of their health systems or are in a state of continuous incremental reform. The purpose of those reforms being the achievement of financial sustainability, more equity, higher quality of care, etc. (with changing weights of each of the aims). The assessment of these reforms and policy processes require the availability of researchers and of institutional and political environments which foster research on health systems. Thus capacity building on health systems research reveals as a major priority. Capacity needs to be built on the side of researchers (i.e. education of researchers from different disciplines to conduct health systems research) as well as on the side of potential users of health systems research. The latter is of major importance, since without the convincement of key policy makers of the need to rely on sound health systems research, it will not be possible to develop sustainable research capacity.
Regarding the shaping of the research agenda on health systems in Europe, the study's findings reveal a need to address the consequences of health reforms in a sound methodological way, which allows to identify the relevant effects of health policy on health, equity and financial sustainability of European health systems. Both European and national policies need to be evaluated. Since there have been important privatization movements in many European countries and the health sector has been increasingly opened to market forces (either in an incremental way or within major privatization waves), there is a need to evaluate the effects that the growing shift from public to private sector is having on health systems and on the outcomes of health systems.
Sound assessments of health care reform require the refinement of methodological approaches. For comparative health systems research, indicators of health systems performance need to be further developed and refined. There is also a need to further develop multidisciplinary study methods to address the variety of questions related to health systems functioning and performance. In addition, there is also a need to define criteria to identify high quality research (i.e. research with high validity) in health systems in a similar way as it has been done for clinical research by the evidence based medicine movement.
The framework for health systems research and the results of the bibliometric analysis were presented at the Health Services Research Working Conference in Den Haag (8th and 9th of April 2010) and discussed with researchers and users of research in working sessions. In the working session on health systems, three specific areas for discussion were identified previously: methodological aspects of health systems research, evaluation of privatization and market competition in the health systems and issues of workforce planning and professional mobility. A set of topics to address in future research on health system emerged from the structured discussions in the working sessions.
Sources used for this section and suggested further reading:
- Velasco Garrido M, J Hansen, R Busse (2011) Mapping Research on Health Systems in Europe: a bibliometric assessment', article in Supplement Issue Journal of Health Services Research and Policy, in press.
- Velasco Garrido M, R Busse (2011) Health Systems Research in Europe. Chapter. In: HSR-Europe. Health Services Research into European Policy and Practice. Final report of the HSREPP project. Utrecht: NIVEL, 2011 (available at http://www.healthservicesresearch.eu online).
- Section 'Priorities for analysing health care systems' in Policy Brief 'Health services research: helping tackle Europe's health care challenges', HSR-Europe 2011, Utrecht: NIVEL (available at http://www.healthservicesresearch.eu online).
1.3.2 Health care organisations and service delivery
Health care organisations are a crucial component of health care, operating at the meso level between the health care system at the macro level and the interactions between patients and health professionals at the micro level. Objective of this work package was to identify the principal areas of past and current research on health care organisation and service delivery, and to relate this to future priorities at the European and country level.
As research on health care organisations can include a wide variety of issues, a framework is required to classify types of research. In this study we distinguished between four major areas of research on health care organisations, loosely based on Donabedian's (1966) framework, distinguishing between the structure of organisations, the care processes within organisations and their outcomes or performance.
The four areas are:
1. Intra-organisational control
This area focuses primarily on how organisations arrange their work internally, such as by differentiation or specialisation. Topics include workforce and skill- mix, creation of multidisciplinary teams, and reconfiguring services
2. Inter-organisational relations
As organisations relate to their environment and are part of organisational networks, they have to organise their relationships to other organizations. Topics include the continuity of care between organisations, the transfer from secondary to primary care; and the spatial distribution of services, including cross-border health care.
3. Patient relations
The performance of organisations can either be understood narrowly as the performance of the clinical process or more widely in the context of patients. An organisation's relationship with patients is considered important as they are connected to the organisation's central goals. It deals with topics such as patient involvement, patient compliance and demand management.
4. Governance and accountability
Health care organisations have their own governance structures and also function within health systems where they are subject to governance and regulation, for instance on labor conditions, patient safety and their level of autonomy and market exposure. Topics include assessment and improvement of quality and safety, the relationships between professionals and managers, and the regulation of professions or provider organisations.
To get a view of country differences, a distinction was made between countries as a keyword and countries in researchers' addresses. The first provides an overview of studies on different European countries, while the second indicates studies from each of the countries. Similar to what was found in WP 4, the numbers of publications differ considerably between countries. Overall, more research is produced on a country than from a country, reflecting in part that studies address multiple countries. It also indicates the co-authorship of many publications, in part by researchers who move from one country to the other, for example, researchers from 'low research output' countries working in 'high research output' countries.
The national versus international focus of HSR is another element that can be identified from the data. Ninety percent of studies appear to be based on one country, with only one country name in the list of keywords. About 8% include two countries, while the remainder makes a comparison between three or more countries. Studies on six or more countries are very rare.
To provide a better picture of the topics addressed, we reviewed a sample of 1,010 HSR article abstracts, 45% of which dealt with research on health care organisations. In addition, we reviewed EU-funded projects to determine topics of interest in ongoing or recently finished work. Least common are studies on inter-organisational relations possibly because it deals with phenomena that are relatively new on the policy agenda, such as continuity of care. The largest difference is in 'patient relations', being more common among published research (28%) than in EU-funded projects (13%). Differences between European regions are fairly small.
When it comes to the question what research should be done in the future, an online survey among experts in Europe focused on priorities for future research. Relating these views to past research reveals that the topic of inter-organisational relations has received much less attention than respondents suggest it should in the future.
The main exception is the topic 'assessment and improvement of quality and safety', which is already a key element both in past research and especially in EU-funded projects. Similarly, some other topics, such as 'workforce', 'e-health' or 'patient involvement' appear to be receiving increasing attention and are seen as important for the future. Additional topics such as 'chronic disease management', 'continuity of care' and 'creation of multidisciplinary teams' are also considered priorities while they are not often being studied at present. The topic of chronic disease management is already catching up at the level of European funded projects, which in turn may serve as a driver for more knowledge being developed by other (nationally funded) research initiatives.
Sources used for this section and suggested further reading:
- Hansen J, W Schafer, N Black, PP Groenewegen (2011) European priorities for research on health care organisations and service delivery', article in Supplement Issue Journal of Health Services Research and Policy, in press.
- Hansen J, Schafer W, Black N, Groenewegen PP (2011). Health care organisations and service delivery. Chapter. In: HSR-Europe. Health Services Research into European Policy and Practice. Final report of the HSREPP project. Utrecht: NIVEL, 2011 (available at http://www.healthservicesresearch.eu online).
- Section 'Priorities for studying the organisation and delivery of services' in Policy Brief 'Health services research: helping tackle Europe's health care challenges', HSR-Europe 2011, Utrecht: NIVEL (available at http://www.healthservicesresearch.eu online).
1.3.3 Health technology assessment
The development of health services in Europe is strongly influenced by new technologies with the potential to improve the health of populations through more effective care. However, not every technological innovation results in (cost-effective) health gains. There are many examples of technologies which have not produced the expected benefits or have even proved to be harmful. Also, technologies which prove to be effective create a challenge since their application may require additional finance and other resources, or require existing resources to be redistributed. Thus, it is necessary to ensure that health technologies are evaluated properly.
Health technology assessment (HTA) involves systematic, wide-ranging evaluation of the implications of technologies to inform the formulation of safe and effective health policies that are focused on the patient and achieve the best value for money. This work package provided an overview of health services research (HSR) in relation to HTA in Europe. Based on a review of published research, the trends in health services research in relation to HTA so far were identified. In addition, it provided input to a future research agenda by describing the research called for in the existing literature and discusses new directions for HTA based on the demands for future research.
Part of the aim was to present the content of the existing research and demands for the future as identified in the literature. The research was categorised into six areas:
(1) the content of analysis in HTA (such as analysis of economy, organisation and social aspects),
(2) HTA products developed to meet the needs of policy-makers (such as horizon scanning, mini-HTA, and core HTA),
(3) handling life-cycle perspectives in relation to technologies,
(4) topics that challenge existing methods and for which HTA should be developed to address the themes more comprehensively (such as public health interventions and organisational interventions),
(5) development of HTA capacity and programmes, and
(6) links between policy and HTA.
Especially research on the content of HTA and the links to policy have been conducted during the last ten years.
The research priorities emphasised in this survey correspond very well with the research needs found in the literature review. The articles included in the review addressed several research needs related to the six themes presented above. Of the 210 references included in the literature review, 99 (47 percent) addressed future research needs. In addition, the discussion rounds on HTA at the Working Conference 'Health Services Research in Europe' and the surveys among country consultants contributed to further input for the future research agenda.
Within all six areas there is a need for more knowledge. Among others, when looking at the contents of analysis in more detail, a general concern is that HTA reports often neglect the wider effects of using technologies (such as ethical, legal, organizational and social aspects) and that research in these areas is lacking. The literature review confirmed this concern, as articles reporting studies of economic evaluation in relation to HTA comprised most of the studies on the content of the analysis in HTA, leaving the wider aspects of HTA and best practices in undertaking and reporting HTA relatively under-researched.
The review and linkage to future revealed a number of newer research areas, which were not distinctly present in the review of existing research. Examples of demands for future research are: research concerning assessment of the wider effects of using technologies; research concerning coverage with evidence development and disinvestment; research concerning assessment of public health intervention, organisational interventions, and of information and communication technologies; research on the links between policy and HTA; and research on relative effectiveness.
The study also suggests that the future research needs contributions from several disciplines to satisfactorily move the HTA field forward. Both HSR and HTA are characterised by multidisciplinarity, and this overview of the research clearly illustrates the needs for a variety of methods, theories, and research backgrounds to ensure continued development of HTA as input to decision-making.
Sources used for this section and suggested further reading:
- Palmhoj Nielsen C, TM Funch, FB Kristensen (2011) Health services research in relation to health technology assessment - research trends and future priorities', article in Supplement Issue Journal of Health Services Research and Policy, in press.
- Palmhoj Nielsen C, TM Funch, FB Kristensen (2011) Health technology assessment'. Chapter. In: HSR-Europe. Health Services Research into European Policy and Practice. Final report of the HSREPP project. Utrecht: NIVEL, 2011 (available at http://www.healthservicesresearch.eu online).
- Section 'Priorities for better assessing health technologies' in Policy Brief 'Health services research: helping tackle Europe's health care challenges', HSR-Europe 2011, Utrecht: NIVEL (available at http://www.healthservicesresearch.eu online).
1.3.4 Benchmarking based on performance indicators
Measuring the quality of care through performance indicators and using this information for comparing, learning and improving (benchmarking) has become a central component of today's health care policies. Health Services Research in the countries in the European Union is related to the enrolling agenda of benchmarking and performance indicators in many different ways. The emphasis seems to be on performance measurement; trying to validate measures that tell us something about the performance of specific services or health care systems. These lines of research are closely linked to available health care statistics. Other lines of HSR focus on the actual embedding of performance measurement in policy making and health care management. These lines of research are closely linked to the wider agenda of implementation research in health care and the application of theories and methods developed in other industrial and public sectors to the health care sector.
The aim of this work package was not to give a complete overview of all ongoing Health Services Research activities in Europe related to benchmarking and performance indicators. It rather tried to identify the main themes and focuses on the opportunities to improve the HSR evidence base behind the policy developments indicators. On the bases of that information priorities identified and recommendations provided for setting the research agenda in the field performance indicators and benchmarking.
The various publications that resulted from the work package describe in more depth the identified eight fields of Health Services Research related to performance indicators and benchmarking. Both literature study and expert consultations identified a large number of existing research initiatives within the EU although the distribution of research initiatives over the EU member states seems quite uneven. The discussions during the working conference on Health Services Research confirmed that on performance indicators and benchmarking:
- Research should focus on the development of indicators (validity, reliability, relevance) as well as on the actual use (effective embedding in policy and management).
- As a consequence of the above, health services research on these topics should always involve participation of the potential users
- Both scientific approaches from bio-medicine/epidemiology and the social sciences are needed
Further progress of HSR on performance indicators and benchmarking is hampered by data-availability. Experts agreed that the following issues need addressing:
- use of Unique Patient Identifiers to facilitate linkages between separate data-bases
- further standardization of coding
- use of present-at admission codes in administrative databases
- recording of secondary diagnoses in administrative data-bases
- facilitate secondary data use from Electronic Health Records
- facilitate standardized measurement of experiences by patients and citizens
- continued collaboration between Eurostat, WHO and the OECD to facilitate the availability of international comparable performance information
HSR research on benchmarking and performance indicators on European level would benefit from strengthening the clearinghouse function on research findings, training of researchers and appropriate scientific publication media. Results of HSR research on benchmarking and performance indicators should be systematically shared with policy makers and managers of health services and systems to assure a fit with local contexts. Networking should be stimulated on European level between the research groups involved in this kind of work and the growing number of national/regional institutes involved in quality measurement and reporting.
1.3.5 Research and Policy
As an applied field of research, health services research (HSR) is undertaken primarily to inform health care policy. However, the relationship between policy and HSR is not straightforward. Many policies are developed without taking account of available evidence. Objective of this work package was to provide an overview of the infrastructure and capacity of HSR in Europe, and to explore the links between HSR and policy in European countries.
The study was based among others on a survey of health policy experts recruited specifically to act as informants in the 34 countries participating in this project. A review of the literature was also undertaken to inform the design of the survey questionnaire and the framework of analysis. Country informants were asked to complete a detailed questionnaire, which covered the following areas: funding and prioritising health services research; production and producers of health services research; health policy users of health services research; activities to promote the use of health services research; and barriers and facilitators to using health services research in policy-making.
This work package is the first attempt to describe the nature, and extent of the links between health services research and policy in European countries. The most prominent finding is how little information is available about health services research, and the health services research and policy relationship. This is particularly true with regard to the amount of funding available for health services research, which is largely due to problems distinguishing funding for health services research from funding for other health-related research. Still, it is evident that the level of funding varies widely among countries. A comparison of spending would only be meaningful if related to a country's national income or total spending on health care. In most countries, a large proportion of funding for health services research is provided through public resources, mostly provided by national governments. To a lesser extent, private and external sources of funding play a role in some countries, although these sources of funding may be more relevant in countries with small public budgets for research in general and health services research in particular.
Overall, the picture that emerges is one of diversity with health services research being more comprehensively developed in England, Scotland, Germany and the Netherlands than in others, as judged by the extent of opportunities for funding, training, networking and publishing. The range of research users at the policy level largely reflects the institutional governance structure of health systems, with central governments usually being the main users. In countries, in which health system governance has largely been devolved to corporatist bodies, professional and provider associations, are the principal users of health services research, such as the Federal Joint Committee in Germany. Likewise, in countries in which political decision-making is largely devolved to regions and/or municipalities, local or regional governments are important users of research, such as municipal councils in Finland. Decentralised policy-making increases the number of potential research users, thus creating a larger and more complex interface between research and policy. A larger number of users may create more opportunities for research uptake. However, these organisations are presumably smaller and may individually have less capacity to utilise research and liaise with researchers.
Developing capacity in health services research
- Given that countries vary substantially in the maturity of this field of research, any changes should be geared to the stage of development and level of recognition of health services research in each country. There will be no 'one size fits all' approach possible for developing national capacity, although there may be a role for external research funding and support, such as through the European Commission or WHO.
- Given that priority-setting in health services research is absent in most countries, there should be efforts to establish approaches to align research with the needs of policy-makers through priority-setting and strategic planning. Arguably, priority-setting is particularly relevant in countries, in which financial resources for research are very constrained.
- Opportunities for strengthening international exchange and mutual learning should be explored, including the creation of a European platform for health services research through a European Association for Health Services Research and/or an annual European Health Services Research Conference.
Improving the capacity of users of health services research
- Opportunities for improving the willingness and ability of policy-makers to use health services research should be considered. Efforts to improve research use skills could include, for example, tailored training in research methods and the use of bibliographic databases.
- There may also be opportunities for improving the integration of the use of research into policy processes and for creating a more research-friendly culture in policy organisations which should be further explored. An example could be the checklist for research use developed in Canada (Lomas and Brown, 2009) or experiences of research and policy co-location, as in the Netherlands.
Enhancing activities that support the use of health services research in policy
- Efforts should be made to strengthen the relationship between health services researchers and policy-makers both at national level and internationally, for example, by strengthening/ establishing national and European forums for exchange.
- Further developments could include establishing new organisations at the interface of health services research and policy, such as government research organisations or knowledge centres for health services research.
Sources used for this section and suggested further reading:
- Ettelt S, N Mays (2011) Health services research in Europe and its use for informing policy: use of HSR in Europe', article in Supplement Issue Journal of Health Services Research and Policy, in press.
- Ettelt S, N Mays (2011) 'Health Services Research in Europe and its use to inform policy. Chapter. in: HSR-Europe. Health Services Research into European Policy and Practice. Final report of the HSREPP project. Utrecht: NIVEL, 2011 (available at http://www.healthservicesresearch.eu online).
- Section 'The use of health services research in policy' in Policy Brief 'Health services research: helping tackle Europe's health care challenges', HSR-Europe 2011, Utrecht: NIVEL (available at http://www.healthservicesresearch.eu online).
- Section 'Strengthening health services research and its linkage to policy' in Policy Brief 'Health services research: helping tackle Europe's health care challenges', HSR-Europe 2011, Utrecht: NIVEL (available at http://www.healthservicesresearch.eu online).
1.4 Potential impact and the main dissemination activities and exploitation of results
A core element within the project has been the creation of a platform for new research in the form of a European working conference on health services research. In preparation to the conference, assessment reports were written for each of the five HSR areas. Each report included a review of the literature in that area to identify the state-of-the-art of research. In addition, reports made use of expert opinions, among others through a consultation form for country consultants and an online survey among almost 300 health care experts, this to determine priorities for future research. In the second reporting period, each report was finalised and circulated prior to the working conference to all participants to enable them to review the material.
The working conference took place on Thursday 8 and Friday 9 April 2010 in the World Forum Convention Centre in The Hague, the Netherlands. In terms of content, the conference had two main aims. One was to receive inputs for priority setting of research in these five areas of HSR. The second was to analyse the relationships between research and policy in Europe and the third aim was to contribute to capacity and community building for HSR in Europe. As it was organised as a working conference, the emphasis was not on presentations but on discussion of topics of shared interest, with a mix of plenary sessions and decentralized debate sessions. Core of day one was a cluster of thematic workshops with overviews of the state-of-the-art, followed by carousel rounds of interactive discussions on research priorities in main areas of HSR. The day ended with poster sessions and a selection of special workshops, that were added to the programme based on the abstract submissions by participants. This included among others an extra session on the use of systematic reviews, the possibility of country comparisons based on Health in Transition reports by the European Observatory on Health Systems and Policies and a session with lessons on HSR from outside Europe, based on a substantial number of abstract submissions by non-European institutes, mostly from Canada, Australia and New-Zealand. Day 2 of the conference addressed the future of health services research and how to improve its contribution to the health policy process. After sketching and debating the future research-to-policy landscape a closing session delivered main outcomes and concrete action points to a panel of representatives of the policy and research community both at European and national level.
To validate the outcomes of the meeting and to create awareness of the project's main outcomes a number of additional steps were taken. First, the results of the meeting were further refined based on single presentations and/or organising conference sessions at relevant occasions. During the project period these included:
- A workshop organised by the project team during the 2nd European Public Health Conference, organised by EUPHA and ASPHER in November 2009.
- A workshop organised by the project team during the EHMA Annual Conference in June 2010, together with a circulation of the project's online survey to all of its participants, which provided an extra validation of the online survey results among those involved in health management issues.
- A poster presentation during the 3rd biannual EFPC Conference on the Future of Primary Care in Europe, in August 2010.
- A workshop organised by the project team during the 3rd European Public Health Conference, organised by EUPHA and ASPHER, in November 2010.
- A presentation during the Second Croatian Congress on Preventive Medicine and Health Promotion, October 2010.
- A presentation during a DG Research led workshop at the WHO World Health Organization (WHO) First Global Symposium on Health Systems Research, in November 2010.
A second means of validation has been by summarizing main outcomes of the conference and the inputs used in preparation to it in a draft policy brief, which was then circulated for consultation through various channels, including members of the FP7 Programme Committee, conference participants and newsletter subscribers of the project. This has led to additional refinement of a research agenda, highlighting priorities for future research in various areas of health services research. The final policy brief has been launched in April 2011 and was circulated to the same channels, including representatives of all EU Member States and relevant international organisations. The policy brief is also available at http://www.healthservicesresearch.eu online.
The various products that came out of the project provide an overview of health services research and describe the contribution that it makes to policy-making. These include a final report with more elaborate outcomes of the project including overviews of the literature on HSR so far. The final report 'Health Services Research into European Policy and Practice' was published April 2011 at the project website. A draft version was used as input for the working conference, which contained an overview of the state-of-the art in all five fields of HSR. A second main product has been a collection of six articles, published together as Supplement Issue of the Journal of Health Services Research and Policy (scheduled for release in July 2011).
A number of activities have been undertaken after the working conference, to ensure effective distribution of final publications. Distribution activities included:
- Digital copies of the draft policy brief to conference participants, country consultants, SAC members, newsletter subscribers and FP7 programme committee.
- Digital and print copies of the final policy brief to the same groups (for newsletter subscribers only digital copies), plus print copies to about 500 other experts who were invited earlier to join the conference and to representatives of all Ministries of Health, the European Commission, members of the EUSANH network of national health councils and other international organisations, including World Bank, OECD and WHO.
- Digital copies of the final report to conference participants and newsletter subscribers, print versions also to country consultants, SAC members and the European Commission.
- In July 2011 a Supplement issue of the Journal of Health Services Research and Policy will be published. Print copies will be made available to conference participants, country consultants, SAC members, Ministry of Health representatives, the European Commission and other experts who were invited to the working conference.
Other publications not foreseen beforehand which have been or are to be published in relevant European journals include:
- Schafer W, PP Groenewegen, J Hansen, N Black (2011) Priorities for health services research in primary care. Quality in Primary Care 2011;19:77-83.
- Hansen J (2011) Tackling Europe's healthcare challenges. To appear in the June 2011 issue of International Innovation.
- Groenewegen PP, R Busse, S Ettelt, J Hansen, N Klazinga, N Mays, W Schafer (2011) Health services research in Europe: what about an open marriage? European Journal of Public Health (2011) 21 (2): 139-141. Note. This article was part of a collection of three viewpoint articles in the same issue, written in response to the working conference, organised by the HSREPP project. One was titled 'Health services research and public health research in Europe: stay married or file for divorce? (by Diana Delnoij) and the other 'Should EUPHA publish a new journal for European health systems research?' (by Mark McCarthy).
In terms of activities, the working conference itself contributed to establishing an effective and sustainable European network for health services research and clearly showed there is a clear need for activities that bring together experts in the field of health services research. To build on this potential it is vital that follow-up activities will remain available, offering the opportunity for health services research to meet and share information, thus contributing to capacity and community building. In order to strengthen resources, many of these follow-up activities are being organised close to existing associations, in particular EUPHA and its Section on HSR and EHMA, as both are key partners for revitalising and bringing together health services researchers within Europe.
Follow-up workshops are therefore scheduled for conferences in 2011 and 2012, in particular:
- A workshop organised by the HSREPP project team in collaboration with the EUPHA Section on HSR on effective knowledge transfer of health services research evidence at the EHMA annual conference in June 2011. Confirmed speakers will share highlights from the HSREPP project itself, as well as from other EU-funded projects, in particular BRIDGE and STEPS.
- A debate session organised by HSREPP during the Annual Research Meeting of AcademyHealth in the United States, June 2011. This activity addresses the element of improving international comparability of health services research, and brings together panellists from the US itself, Europe and Canada.
- A plenary session on cross-border health services research at the fourth HSRN / SDO Network annual conference in Liverpool, United Kingdom, June 2011.
- A special preconference training day for young health services researchers at the EUPHA/ASPHER annual conference in November 2011, organised by the HSREPP project team in collaboration with the EUPHA Section on HSR and the EUPHAnxt initiative, bringing together young public health researchers. The training day will address ways how to improve the contribution of health services research to decision-making and how to make the research by participants more practice and policy-oriented while maintaining scientific and methodological requirements.
- For 2012 a second European working conference is scheduled, titled 'Strengthening the European Dimension in Health Services Research'. The working conference will be organised as pre-conference day before the start of EUPHA 2012 in Malta, thus enabling participants to join both events without additional travel costs. Central theme will be the added value of European comparative HSR. Objectives will be to raise the quality of internationally comparative HSR, helping national decision makers in identifying and using international research evidence, and strengthening capacity building both at the research and policy side. All aspects will be reflected in a conference programme, among others in terms of sessions on identifying good practice, transferability of research findings, and on proposal preparation and partner selection in international projects.
Organising future events will ensure that the network established through the project can continue in enhancing the contribution of HSR to policy in the future. Events will be organised in collaboration with existing associations, in particular EUPHA and its Section on HSR and EHMA, as both are key partners for revitalising and bringing together health services researchers within Europe. Instead of being a one-time event, the initiative will thus continue sharing expertise and reinforcing the European health services policy arena.
Another means of improving the use and impact of the HSREPP-project is by revitalising and renewing its project website http://www.healthservicesresearch.eu In the period prior to and after the working conference the website served as conference website, providing interested parties the opportunity to register, submit their abstract or learn more about the conference's outcomes. To continue contributing to the visibility and use of HSR in Europe, the project website has been transformed into a community-based website. It provides among others an overview of conferences, training activities and other events related to European health services research.
Potential Impact:
A core element within the project has been the creation of a platform for new research in the form of a European working conference on health services research. In preparation to the conference, assessment reports were written for each of the five HSR areas. Each report included a review of the literature in that area to identify the state-of-the-art of research. In addition, reports made use of expert opinions, among others through a consultation form for country consultants and an online survey among almost 300 health care experts, this to determine priorities for future research. In the second reporting period, each report was finalised and circulated prior to the working conference to all participants to enable them to review the material.
In terms of content, the conference had two main aims. One was to receive inputs for priority setting of research in these five areas of HSR. The second was to analyse the relationships between research and policy in Europe and the third aim was to contribute to capacity and community building for HSR in Europe. As it was organised as a working conference, the emphasis was not on presentations but on discussion of topics of shared interest, with a mix of plenary sessions and decentralized debate sessions. Core of day one was a cluster of thematic workshops with overviews of the state-of-the-art, followed by carousel rounds of interactive discussions on research priorities in main areas of HSR. The day ended with poster sessions and a selection of special workshops, that were added to the programme based on the abstract submissions by participants. This included among others an extra session on the use of systematic reviews, the possibility of country comparisons based on Health in Transition reports by the European Observatory on Health Systems and Policies and a session with lessons on HSR from outside Europe, based on a substantial number of abstract submissions by non-European institutes, mostly from Canada, Australia and New-Zealand. Day 2 of the conference addressed the future of health services research and how to improve its contribution to the health policy process. After sketching and debating the future research-to-policy landscape a closing session delivered main outcomes and concrete action points to a panel of representatives of the policy and research community both at European and national level.
To validate the outcomes of the meeting and to create awareness of the project's main outcomes a number of additional steps were taken. First, the results of the meeting were further refined based on single presentations and/or organising conference sessions at relevant occasions.
During the project period these included:
- A workshop organised by the project team during the 2nd European Public Health Conference, organised by EUPHA and ASPHER in November 2009.
- A workshop organised by the project team during the EHMA Annual Conference in June 2010, together with a circulation of the project's online survey to all of its participants, which provided an extra validation of the online survey results among those involved in health management issues.
- A poster presentation during the 3rd biannual EFPC Conference on the Future of Primary Care in Europe, in August 2010.
- A workshop organised by the project team during the 3rd European Public Health Conference, organised by EUPHA and ASPHER, in November 2010.
- A presentation during the Second Croatian Congress on Preventive Medicine and Health Promotion, October 2010.
- A presentation during a DG Research led workshop at the WHO World Health Organization (WHO) First Global Symposium on Health Systems Research, in November 2010.
A second means of validation has been by summarizing main outcomes of the conference and the inputs used in preparation to it in a draft policy brief, which was then circulated for consultation through various channels, including members of the FP7 Programme Committee, conference participants and newsletter subscribers of the project. This has led to additional refinement of a research agenda, highlighting priorities for future research in various areas of health services research. The final policy brief has been launched in April 2011 and was circulated to the same channels, including representatives of all EU Member States and relevant international organisations. The policy brief is also available at http://www.healthservicesresearch.eu
A number of activities have been undertaken after the working conference, to ensure effective distribution of final publications. Distribution activities included:
- Digital copies of the draft policy brief to conference participants, country consultants, SAC members, newsletter subscribers and FP7 programme committee.
- Digital and print copies of the final policy brief to the same groups (for newsletter subscribers only digital copies), plus print copies to about 500 other experts who were invited earlier to join the conference and to representatives of all Ministries of Health, the European Commission, members of the EUSANH network of national health councils and other international organisations, including World Bank, OECD and WHO.
- Digital copies of the final report to conference participants and newsletter subscribers, print versions also to country consultants, SAC members and the European Commission.
- In July 2011 a Supplement issue of the Journal of Health Services Research and Policy will be published. Print copies will be made available to conference participants, country consultants, SAC members, Ministry of Health representatives, the European Commission and other experts who were invited to the working conference
Other publications not foreseen beforehand which have been or are to be published in relevant European journals include:
- Schafer W, PP Groenewegen, J Hansen, N Black (2011) Priorities for health services research in primary care. Quality in Primary Care 2011;19:77-83.
- Hansen J (2011) Tackling Europe's healthcare challenges. To appear in the June 2011 issue of International Innovation.
- Groenewegen PP, R Busse, S Ettelt, J Hansen, N Klazinga, N Mays, W Schafer (2011) Health services research in Europe: what about an open marriage? European Journal of Public Health (2011) 21 (2): 139-141. Note. This article was part of a collection of three viewpoint articles in the same issue, written in response to the working conference, organised by the HSREPP project. One was titled 'Health services research and public health research in Europe: stay married or file for divorce? (by Diana Delnoij) and the other 'Should EUPHA publish a new journal for European health systems research?' (by Mark McCarthy).
In terms of activities, the working conference itself contributed to establishing an effective and sustainable European network for health services research and clearly showed there is a clear need for activities that bring together experts in the field of health services research. To build on this potential it is vital that follow-up activities will remain available, offering the opportunity for health services research to meet and share information, thus contributing to capacity and community building. In order to strengthen resources, many of these follow-up activities are being organised close to existing associations, in particular EUPHA and its Section on HSR and EHMA, as both are key partners for revitalising and bringing together health services researchers within Europe. Follow-up workshops are therefore scheduled for conferences in 2011 and 2012, in particular:
- A workshop organised by the HSREPP project team in collaboration with the EUPHA Section on HSR on effective knowledge transfer of health services research evidence at the EHMA annual conference in June 2011. Confirmed speakers will share highlights from the HSREPP project itself, as well as from other EU-funded projects, in particular BRIDGE and STEPS.
- A debate session organised by HSREPP during the Annual Research Meeting of AcademyHealth in the United States, June 2011. This activity addresses the element of improving international comparability of health services research, and brings together panellists from the US itself, Europe and Canada.
- A plenary session on cross-border health services research at the fourth HSRN / SDO Network annual conference in Liverpool, United Kingdom, June 2011.
- A special preconference training day for young health services researchers at the EUPHA/ASPHER annual conference in November 2011, organised by the HSREPP project team in collaboration with the EUPHA Section on HSR and the EUPHAnxt initiative, bringing together young public health researchers. The training day will address ways how to improve the contribution of health services research to decision-making and how to make the research by participants more practice and policy-oriented while maintaining scientific and methodological requirements.
- For 2012 a second European working conference is scheduled, titled 'Strengthening the European Dimension in Health Services Research'. The working conference will be organised as pre-conference day before the start of EUPHA 2012 in Malta, thus enabling participants to join both events without additional travel costs. Central theme will be the added value of European comparative HSR. Objectives will be to raise the quality of internationally comparative HSR, helping national decision makers in identifying and using international research evidence, and strengthening capacity building both at the research and policy side. All aspects will be reflected in a conference programme, among others in terms of sessions on identifying good practice, transferability of research findings, and on proposal preparation and partner selection in international projects.
Organising future events will ensure that the network established through the project can continue in enhancing the contribution of HSR to policy in the future. Events will be organised in collaboration with existing associations, in particular EUPHA and its Section on HSR and EHMA, as both are key partners for revitalising and bringing together health services researchers within Europe. Instead of being a one-time event, the initiative will thus continue sharing expertise and reinforcing the European health services policy arena.
Another means of improving the use and impact of the HSREPP-project is by revitalising and renewing its project website http://www.healthservicesresearch.eu In the period prior to and after the working conference the website served as conference website, providing interested parties the opportunity to register, submit their abstract or learn more about the conference's outcomes. To continue contributing to the visibility and use of HSR in Europe, the project website has been transformed into a community-based website. It provides among others an overview of conferences, training activities and other events related to European health services research. The website also contains an overview of materials collected in the HSREPP project, including an overview of relevant EU funded projects. As the searchable database offers the opportunity for everyone to add and display their own research activities, the website will continue to build an online repository of relevant HSR in Europe, this to display relevant research across Europe, which can facilitate knowledge exchange and improve a fine-tuning of research agendas across Europe.
Together these activities and products should address and appeal to a wide range of target groups and thus contribute in promoting effective interfaces between research and policy for the benefit of scientific underpinning of health care policies.
Project website: http://www.healthservicesresearch.eu
Contact:
Scientific representative of the project's coordinator:
Johan Hansen, PhD
NIVEL, Netherlands institute for health services research
PO Box 1568
3500 BN Utrecht
The Netherlands
Tel: +31-302-729743
Fax: +31 302-729729
E-mail: j.hansen@nivel.nl