PubL tthh, Lond. (1979) 93, 50-53
Academics, Practitioners and Health Policy Carlos J. M. Martini* -M.D., M,P.H.~ M.Sc,, M.F.C.M.
Department of Community Hea/th. Queen's Medica/ School Nottingham University The aim of this paper is to discuss the need for collaboration in Health Services Planning, between academics in community medicine and community physicians, working at different levels of the National Health Service. Some of the reasons for the .actual deficiency in participation of academics in health policy issues are analysed with emphasis on the different life styles and motivations of these professionals. The type of activities in planning, where academic participation can be more valuable, are menlioned, and specific areas, like health services evaluation, information systems and the analysis of the interactions between hospital and community services are proposed as providing some of 'the most feasible opportunities for collaboration. Introduction Although few would disagree that collaboration between academics in community medicine and practitioners could be very useful in health policy issues at area and district levels, this is still not as frequent in the U.K. as ought to be expected (the very important contributions of some academics at National or Regional levels is specifically excluded from this discussion). Practitioners include not just community physicians but all other medical and non-medical personnel involved in administration and planning. Examples of possible areas for collaborative study which will be discussed more fully later, include the whole field of medical care evaluation, allocation of resources between hospital and community care, and the development o f information systems for planning purposes. This lack of collaboration is partially due to the inherent difficulties of these areas, but also to at least three other possible causes. 1. Lack o f il~terest 01 some o f lhe subject :'~reas Many academics in community medicine ace not interested in information systems and planning and there is a lad¢ o f emphasis on these subjects by research teams, both iJ;sidc and outside Universities. Epidemiotogy is a discipline,which prot~abty has, in the U.K. at least, one specialist in every academic department o f community medicine and is the basis, with statistics, o f what these departments teach undergraduates. The epidemiologist :knows how di'sease and population interact and how .disease pa'tterns have been evolving over time. Most epidemiologists however, are interested in the past, not the future, while health services planners are interested in the future and not the past. Perhaps one o f the most exciting advances in epidemiological method at present is the potential ability, to predict future events. For instance, the whole philosophy of high risk strategies is based on this possibility. But in spite of several .meetings of the International Epidemiological Association and many publications in which the relevance of epidemiology to planning has been proposed, ~ not many epidemiologists are interested in health policy issues.
*At the .present Professor and Director, Division of Community Health School of Medicine, University Of Colorado, U.S.A. 0038-3506/79/010050+04 $01.00[0
~ 1979 The Society of Community Medicine
Academics, practRioners and health polio3'
51
Acknowledging the importance of the understanding o f the natural history o f disease, the main challenge these days in still the identification and quantification o f prognostic factors. In this the health service system should be treated as one of a set of environmental factors affecting health status and health behaviour in the exposed population. For this type of approach epidemiologists would require to increase their interest in consumers o f the service and decrease their dedication to diagnosed cazes. Furthermore, if we look carefully at ~he publications in the last 4 or 5 years, in the main ep.idemiologicai journals, both here and in America, we will see that most place emphasis o n independent rather than dependent variables, that most are descriptive o f the system and its use, and that there is not too much interest yet in the interactions o f the system and testing o f alternative policies. In the area of health services research carried out by academics the situation is similar,. Looking at research projects financed by D.H.S.S. of which lhere were a total 449 different projects at 1 April 1972, e only 35 or 8 ~ can be included truly within this categc~ry o f health services research (where the planning, organization, staffing, financing, management, operation, .maintenance, use and evalution of health services were part of the main objectives). Another 29 or 6 ~ were related to nursing activities, and by contrast, 80 projects or I8 ~ h a d incidence, prevention and treatment of specific illness as their main objective. In 1976, 3 and in 1977,4 the situation had not changed. It is extremely difficult to determine precisely how many individual projects o r activities were in the area o f Health Services Research, but out of 680 different projects in progress in 1976, a only 10 ~'~seem to be directly related to -this area (although many others are of course relevant in some way to the provision of health services). Funding by other sources is even more infrequent, Under the locally organized research schemeS~in England and Wales o f the 290 new research proposals accepted in 1976, only 48 or t 4 ~o were on health services research/epidemiology. It has been mentioned that some regional committees did not support research in this area. 6 Under :this scheme, p~anning and monitoring activities should be funded, but it appeared in some cases "even when the titles of proposals suggested methodological innovations that migh~ have become generally applicable, some regional committees rejected them as inappropriate", r
2. Contrasting life styles The second possible obstacle to collaboration is a mutual misunderstanding of the potential contribution o f practitioners and academics. The main questions .here .are no longer "what is known" and "how to collaborate", but how to bring the executive life style into any kind of productive contact with the research and innovation life style. This can best be expressed by the two differing perspectives: voiced by the academic on the one hand, who comments, "'the important issue is to understand, to know what to ask, and how to evaluate innovations"; while the practitioner on the other hand comments "there is too much data which is not needed and we don't want to be confused by all these facts, our decisions have to be made at once and on the basis o f experience and social policy". This latter poi-,at~.is well taken for, indeed, the N.H.S. has been ~haped, at least until recently, by a series'of historical determinants and the use, in most places, of the combination o f two differeht decision making approaches to our planning activities. The first decision making approach uses information based on a network of experts (persons who know). The second approach is based on routinely published data. In both o f these models, the data available and the problems are not always associated. Most of the data is usually cross-sectional relating to special groups in the population and, in many cases, corresponds to different geographical areas and time periods.
52
C. J. M. Marthfi
These two models are usually the basis of "strategic" plans. However we now know much more of .the cultural, demographic and environmental determinants of disease and of the existence of vulnerable groups in the population. This knowledge is not yet fully used to make our systems of information more problem based m~d person and .district related, linking events in the |ire of individuals and thus making our decisions more "consumer oriented".
3. Different motivations Thirdly, academics and practitioners seem t o feel they have contrasting needs and different .conceptual approaches to planning. However, planning requires four different kinds of activities. (a) "'Problem identification" is a convenient starting point and it is based in the establishment of units of analysis (people, resources, o r services)that can be quantified. This information, frequently only descriptive, provides the content of most area and district profiles at present. (b) "'Problem hlterpretation". This is the analysis of the needs, the deficiencies of services to cope with these needs, and the type of changes required. Here, academics can be .extremely valuable, with their interest in the demands and needs of populations, their familiarity with statistical analysis and the availability of computer based data systems at most universities. (c) "Policy analysis". This activity, which havoJves the linkage of all information available, using data based on the experience of shnilar systems and especially judgements .from experts, is decision specific and necessarily performed in a short time period. Here, the role of the academic is probably much more limited. (d) "'Policy evaluation". It is especially in this fourth stage where opportunities for collaboration are always present. Evaluation requires specific research methods. Most of the techniques used at the present are still cumbersome, costly and time consuming and come from several independent disciplines. This requires an interdisciplinary team, something always difficult to organize, but becoming more common in academic departments of community medicine. There are already, of course, some examples of cooperation between academics and practitioners (in information and planning) in England. One type is cooperation between University computer centres or departments of Electrical Engineering and the National Health Service, with the Universities mainly contracting to provide computer and systems analysis skills and resources. A second type is cooperation between the National Health Service and Medical Schools through departments usually of Medicine, ~Pediatfics and Obstetrics and of Community Medicine with academics participating in the collection, analysis and interpretation of information in their relevant subjects. Five priority areas in which this cooperation should be enhanced (considering only .the terms of reference of information and planning), could be the following: (a) Studies of cohorts of patients going through the system. (b) Development of new outcome measures, using indices more sensitive to changes in medical care. (c) Analysis o f tasks and skills of medical and paramedical personnel. (d) Studies in primary care with hypothesis testing. (e) Better understanding o f inter-relations between hospitals and community. In all these areas the opportunities for cooperation and innovation are very great° From the point of view of the academic, his ability to help policy makers will be improved
Academics, practitioners and health polio'
53
when his role in planning is clarified. This has other byproducts since, for teaching and research activities, their relationship with services can only be beneficial. Perhaps this could help to change the traditional models o f medical education into "'needs'" derived models, more ecological, more preventive and with more contribulion to society by st~udents and staff alike. The impact that this way o f thinking may have on these students when they become members o f medical committees and planning teams is potentially extremely imporlant. This may affect the health and social services in a way that no operational programme can do. For example, in some departments o f Community Medicine students are encouraged to do field projects relating to problems o f the Teaching Areas in which the Universities are situated. Many of these studies have been requested by Health Authorities, and some o f the findings used. Although these ideas are not new and joint honorary appointments o f academics in the N.H.S. are now the rule rather than the exception, many o f them have been accepted, more for personal reasons than because o f the possibility of effective cooperation. It also happens of course that some of the authorities do not appear to be really interested in using the academics in these appoinlmen~, to their full potential Even though the staffing of many University departments is very .meagre and therefore help will be limited in these cases, a joint appointment should reinforce a relationship which must necessarily be two-directional with practitioners also taking a much more active role in teaching and research than at the present. At the moment, many of these appointments involve individuals, and not necessarily the institutions where they are working. Thus, the relationships should also be institutional more than personal and alternative structures should be created to link those responsible for planning and information and ¢hose for teaching and research. Perhaps, in this way, practitioners and academics will learn to harmonize decisionmaking with the development o f research for policy purposes in a coordinated time scale. References I. See for example editorials of the International Journal of Epidcmiology (1977) 6, Nos. 2 and 3. June and September. 2. Nuffield Provincial Hospital Trust (1973). List of D.H.S.S.-promoted research and development current in 1972/73. Oxford University Press. 3. D.H.S.S~ Handbook of Research and DevMopment (1976).-London: H.M.S.O. 4. D.fLS.S. Handbook of Research and Development (1977). London: H.M.S.O. 5. D.H.S.S. Annual Report 1975 (1976). Cmnd 6565. London: H.M.S.O. 6. Williams, B. (1977). Appfications to regional research committees in 1976 and lheir outcome. British Medical Journal ii, 945-974. 7. Williams, B. (1977). Applications to regional research committees in I976 and their outcome. British Medical Journal ii, 946.
Academics, Practitioners and Health Policy Carlos J. M. Martini* -M.D., M,P.H.~ M.Sc,, M.F.C.M.
Department of Community Hea/th. Queen's Medica/ School Nottingham University The aim of this paper is to discuss the need for collaboration in Health Services Planning, between academics in community medicine and community physicians, working at different levels of the National Health Service. Some of the reasons for the .actual deficiency in participation of academics in health policy issues are analysed with emphasis on the different life styles and motivations of these professionals. The type of activities in planning, where academic participation can be more valuable, are menlioned, and specific areas, like health services evaluation, information systems and the analysis of the interactions between hospital and community services are proposed as providing some of 'the most feasible opportunities for collaboration. Introduction Although few would disagree that collaboration between academics in community medicine and practitioners could be very useful in health policy issues at area and district levels, this is still not as frequent in the U.K. as ought to be expected (the very important contributions of some academics at National or Regional levels is specifically excluded from this discussion). Practitioners include not just community physicians but all other medical and non-medical personnel involved in administration and planning. Examples of possible areas for collaborative study which will be discussed more fully later, include the whole field of medical care evaluation, allocation of resources between hospital and community care, and the development o f information systems for planning purposes. This lack of collaboration is partially due to the inherent difficulties of these areas, but also to at least three other possible causes. 1. Lack o f il~terest 01 some o f lhe subject :'~reas Many academics in community medicine ace not interested in information systems and planning and there is a lad¢ o f emphasis on these subjects by research teams, both iJ;sidc and outside Universities. Epidemiotogy is a discipline,which prot~abty has, in the U.K. at least, one specialist in every academic department o f community medicine and is the basis, with statistics, o f what these departments teach undergraduates. The epidemiologist :knows how di'sease and population interact and how .disease pa'tterns have been evolving over time. Most epidemiologists however, are interested in the past, not the future, while health services planners are interested in the future and not the past. Perhaps one o f the most exciting advances in epidemiological method at present is the potential ability, to predict future events. For instance, the whole philosophy of high risk strategies is based on this possibility. But in spite of several .meetings of the International Epidemiological Association and many publications in which the relevance of epidemiology to planning has been proposed, ~ not many epidemiologists are interested in health policy issues.
*At the .present Professor and Director, Division of Community Health School of Medicine, University Of Colorado, U.S.A. 0038-3506/79/010050+04 $01.00[0
~ 1979 The Society of Community Medicine
Academics, practRioners and health polio3'
51
Acknowledging the importance of the understanding o f the natural history o f disease, the main challenge these days in still the identification and quantification o f prognostic factors. In this the health service system should be treated as one of a set of environmental factors affecting health status and health behaviour in the exposed population. For this type of approach epidemiologists would require to increase their interest in consumers o f the service and decrease their dedication to diagnosed cazes. Furthermore, if we look carefully at ~he publications in the last 4 or 5 years, in the main ep.idemiologicai journals, both here and in America, we will see that most place emphasis o n independent rather than dependent variables, that most are descriptive o f the system and its use, and that there is not too much interest yet in the interactions o f the system and testing o f alternative policies. In the area of health services research carried out by academics the situation is similar,. Looking at research projects financed by D.H.S.S. of which lhere were a total 449 different projects at 1 April 1972, e only 35 or 8 ~ can be included truly within this categc~ry o f health services research (where the planning, organization, staffing, financing, management, operation, .maintenance, use and evalution of health services were part of the main objectives). Another 29 or 6 ~ were related to nursing activities, and by contrast, 80 projects or I8 ~ h a d incidence, prevention and treatment of specific illness as their main objective. In 1976, 3 and in 1977,4 the situation had not changed. It is extremely difficult to determine precisely how many individual projects o r activities were in the area o f Health Services Research, but out of 680 different projects in progress in 1976, a only 10 ~'~seem to be directly related to -this area (although many others are of course relevant in some way to the provision of health services). Funding by other sources is even more infrequent, Under the locally organized research schemeS~in England and Wales o f the 290 new research proposals accepted in 1976, only 48 or t 4 ~o were on health services research/epidemiology. It has been mentioned that some regional committees did not support research in this area. 6 Under :this scheme, p~anning and monitoring activities should be funded, but it appeared in some cases "even when the titles of proposals suggested methodological innovations that migh~ have become generally applicable, some regional committees rejected them as inappropriate", r
2. Contrasting life styles The second possible obstacle to collaboration is a mutual misunderstanding of the potential contribution o f practitioners and academics. The main questions .here .are no longer "what is known" and "how to collaborate", but how to bring the executive life style into any kind of productive contact with the research and innovation life style. This can best be expressed by the two differing perspectives: voiced by the academic on the one hand, who comments, "'the important issue is to understand, to know what to ask, and how to evaluate innovations"; while the practitioner on the other hand comments "there is too much data which is not needed and we don't want to be confused by all these facts, our decisions have to be made at once and on the basis o f experience and social policy". This latter poi-,at~.is well taken for, indeed, the N.H.S. has been ~haped, at least until recently, by a series'of historical determinants and the use, in most places, of the combination o f two differeht decision making approaches to our planning activities. The first decision making approach uses information based on a network of experts (persons who know). The second approach is based on routinely published data. In both o f these models, the data available and the problems are not always associated. Most of the data is usually cross-sectional relating to special groups in the population and, in many cases, corresponds to different geographical areas and time periods.
52
C. J. M. Marthfi
These two models are usually the basis of "strategic" plans. However we now know much more of .the cultural, demographic and environmental determinants of disease and of the existence of vulnerable groups in the population. This knowledge is not yet fully used to make our systems of information more problem based m~d person and .district related, linking events in the |ire of individuals and thus making our decisions more "consumer oriented".
3. Different motivations Thirdly, academics and practitioners seem t o feel they have contrasting needs and different .conceptual approaches to planning. However, planning requires four different kinds of activities. (a) "'Problem identification" is a convenient starting point and it is based in the establishment of units of analysis (people, resources, o r services)that can be quantified. This information, frequently only descriptive, provides the content of most area and district profiles at present. (b) "'Problem hlterpretation". This is the analysis of the needs, the deficiencies of services to cope with these needs, and the type of changes required. Here, academics can be .extremely valuable, with their interest in the demands and needs of populations, their familiarity with statistical analysis and the availability of computer based data systems at most universities. (c) "Policy analysis". This activity, which havoJves the linkage of all information available, using data based on the experience of shnilar systems and especially judgements .from experts, is decision specific and necessarily performed in a short time period. Here, the role of the academic is probably much more limited. (d) "'Policy evaluation". It is especially in this fourth stage where opportunities for collaboration are always present. Evaluation requires specific research methods. Most of the techniques used at the present are still cumbersome, costly and time consuming and come from several independent disciplines. This requires an interdisciplinary team, something always difficult to organize, but becoming more common in academic departments of community medicine. There are already, of course, some examples of cooperation between academics and practitioners (in information and planning) in England. One type is cooperation between University computer centres or departments of Electrical Engineering and the National Health Service, with the Universities mainly contracting to provide computer and systems analysis skills and resources. A second type is cooperation between the National Health Service and Medical Schools through departments usually of Medicine, ~Pediatfics and Obstetrics and of Community Medicine with academics participating in the collection, analysis and interpretation of information in their relevant subjects. Five priority areas in which this cooperation should be enhanced (considering only .the terms of reference of information and planning), could be the following: (a) Studies of cohorts of patients going through the system. (b) Development of new outcome measures, using indices more sensitive to changes in medical care. (c) Analysis o f tasks and skills of medical and paramedical personnel. (d) Studies in primary care with hypothesis testing. (e) Better understanding o f inter-relations between hospitals and community. In all these areas the opportunities for cooperation and innovation are very great° From the point of view of the academic, his ability to help policy makers will be improved
Academics, practitioners and health polio'
53
when his role in planning is clarified. This has other byproducts since, for teaching and research activities, their relationship with services can only be beneficial. Perhaps this could help to change the traditional models o f medical education into "'needs'" derived models, more ecological, more preventive and with more contribulion to society by st~udents and staff alike. The impact that this way o f thinking may have on these students when they become members o f medical committees and planning teams is potentially extremely imporlant. This may affect the health and social services in a way that no operational programme can do. For example, in some departments o f Community Medicine students are encouraged to do field projects relating to problems o f the Teaching Areas in which the Universities are situated. Many of these studies have been requested by Health Authorities, and some o f the findings used. Although these ideas are not new and joint honorary appointments o f academics in the N.H.S. are now the rule rather than the exception, many o f them have been accepted, more for personal reasons than because o f the possibility of effective cooperation. It also happens of course that some of the authorities do not appear to be really interested in using the academics in these appoinlmen~, to their full potential Even though the staffing of many University departments is very .meagre and therefore help will be limited in these cases, a joint appointment should reinforce a relationship which must necessarily be two-directional with practitioners also taking a much more active role in teaching and research than at the present. At the moment, many of these appointments involve individuals, and not necessarily the institutions where they are working. Thus, the relationships should also be institutional more than personal and alternative structures should be created to link those responsible for planning and information and ¢hose for teaching and research. Perhaps, in this way, practitioners and academics will learn to harmonize decisionmaking with the development o f research for policy purposes in a coordinated time scale. References I. See for example editorials of the International Journal of Epidcmiology (1977) 6, Nos. 2 and 3. June and September. 2. Nuffield Provincial Hospital Trust (1973). List of D.H.S.S.-promoted research and development current in 1972/73. Oxford University Press. 3. D.H.S.S~ Handbook of Research and DevMopment (1976).-London: H.M.S.O. 4. D.fLS.S. Handbook of Research and Development (1977). London: H.M.S.O. 5. D.H.S.S. Annual Report 1975 (1976). Cmnd 6565. London: H.M.S.O. 6. Williams, B. (1977). Appfications to regional research committees in 1976 and lheir outcome. British Medical Journal ii, 945-974. 7. Williams, B. (1977). Applications to regional research committees in I976 and their outcome. British Medical Journal ii, 946.
