Book review
Improving health services; background, method and applications
Walter Holland. Cheltenham: Edward Elgar Publishing, 2013. 272pp.
The title of this wonderfully informative book establishes an appropriate set of expectations for the reader. Professor Walter Holland could have called his book ‘A history of health services research’ or ‘Reflections on the career of a pioneer health services researcher’. Instead he makes a statement of purpose for health services research (HSR), a statement full of active intent, and sets the scene for a passionate description of why HSR is important.
Improving Health Services is a personal take on HSR, based to a large extent on the author's work in establishing and leading the Social Medicine and Health Services Research Unit at St Thomas's Hospital in London. The unit was established by and embedded within the hospital, with the objective of producing both generalisable knowledge and useful answers to local questions. This model remains common in the United States and it would be good to see it revived in the UK.
Professor Holland has been at the thick of action from the earliest days of HSR in the UK. He evaluated the Conservative government's policy to remove free school milk (‘Thatcher the Milk-Snatcher’), he was an expert member of the Resource Allocation Working Party (RAWP) and made a major contribution to the early measurement of avoidable deaths. Film fanatics may remember Forrest Gump, played by Tom Hanks, a character who had the habit of appearing at seminal moments in US history; Professor Holland didn't just make an appearance in British healthcare history, he helped to mould it.
The earliest days of HSR are described in detail, when the government realised that their policies might benefit from being informed by research evidence, but weren't quite sure how much independence they were happy for researchers to exercise. Professor Holland describes how HSR was seen as the poor cousin of the research world, not quite real science, misunderstood or ignored by the established funding bodies and supported only by a small number of professional leaders, in particular George Godber, England's most famous chief medical officer. He outlines the important role played by private foundations such as the Nuffield Trust, organisations with vision and a willingness to take risks – a role that the Nuffield, the Health Foundation and the King's Fund continue to play to this day.
Many of the past challenges described by Professor Holland may feel familiar to the current generation of health service researchers, though as a specialty it has come a long way in the last two or three decades. As a consequence of the work of early leaders in the field, HSR is now better understood, better funded and is training a growing number of researchers in the wide range of academic disciplines that contribute to the field. It is becoming increasingly good at managing the tension between maintaining the expertise of individual disciplines, and optimising the benefits of bringing these disciplines together. In particular we are seeing increasingly innovative ways of combining the skills of researchers who's preference is to answer the ‘what's happening?’ and ‘does it work?’ questions with those who prefer to ask the ‘how does it work?’ and ‘how do we make it work better?’ questions.
So HSR is growing up but has a long way to go. Much published research in the field has a lower profile and impact than it deserves and many health service researchers still do not work closely enough with policy makers and health service leaders. They are insufficiently engaged with finding effective ways of mobilising evidence and influencing practitioners, by working across the boundary between the scientific method and other ways of knowing. And the health service researcher community does not yet feel like a cohesive or powerful lobbying force. When HSR achieves the same level of political influence as the life sciences community, then it will be judged to have matured.
Professor Holland is a grandee of health service researcher but remains an astute observer and commentator of the health service. Current and future generations of researchers and health service leaders would do well to learn from his passion for evidence-informed policy and practice, and his commitment to ensuring that research is, above all, useful.
- © Royal College of Physicians 2015. All rights reserved.
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