GP & PHCRED Conference July 2005

1. GP & PHCRED Conference July 2005 Australian Primary Health Care Research Institute Nicholas Glasgow

2. Aims • By the end of this session: • Reflected more on the nexus between evidence and policy • Clearer about APHCRI’s focus and approach • Had opportunity to ask questions

3. Overview • Professor Nicholas Glasgow • Overview of the research evidence and policy • Mr Robert Wells • Research Evidence and Policy – Reflections on a career • Dr Bev Sibthorpe • Research Evidence and Policy - Case studies • Professor Nicholas Glasgow • Research Evidence and Policy – The Evidence and APHCRI’s Response • Professor Jonathan Lomas • Commentary

4. Because what you told me is absolutely correct but completely useless Where am I? The problem Yes, how did you know? You must be a researcher Because you don’t know where you are, you don’t know where you’re going, and now you’re blaming me You’re 30 metres above the ground in a balloon You must be a policy maker Yes. How did you know?

5. GP & PHC Research activity • Welcome announcement by Parliamentary Secretary to the Minister for Health and Ageing, Christopher Pyne for continued support of PHCRED • Increasing research and evaluation activity • Growth of this conference • PHCRED activities • RACGP developments • Success in competitive grant rounds such as NHMRC • APHCRI • Primary health system level focus • Policy relevance important • Complex (non linear) relationships between evidence and policy • How do we engage with this complexity?

6. Use of Research Evidence by Policy Makers Nicholas Glasgow

7. Method • Comprehensive search of the black and grey literature relating to research dissemination, uptake and utilisation in primary health care policy • Supplemented by personal communications with key contributors to this literature including: • Professor Jonathan Lomas at the Canadian Health Services Research Foundation • Professor John Lavis and • Professor Nicholas Mays • Relevant systematic reviews were identified

8. Method • A publication was judged to be a systematic review if there were explicit statements within the paper which: • articulated the question • clearly summarised the strategy used to identify relevant studies • indicated how the identified studies were assessed for inclusion/exclusion • summarised and synthesized the results Greenhalgh AT, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of Innovations in Service Organisations: Systematic Review and Recommendations Milbank Quarterly 2004; 82: http://www.milbank.org/quarterly/8204feat.html (Accessed April 2005)

9. July 2005 SupplementJ Health Services Research & Policy • Synthesizing evidence for management and policy-making • Volume 10 Number 3 Supplement July 2005 • http://select.ingentaconnect.com/rsm/13558196/v10n3x1/contp1-1.htm

10. Key review before the supplement • Innvaer S, Vist G, Trommald M, Oxman A. Health policy-makers perceptions of their use of evidence: a systematic review J Health Serv Res Policy 2002; 7:239-244h • Facilitators • Personal contact between researchers and policy makers • Timeliness and relevance of the research • Research that included a summary and clear recommendations • Good quality research • Research that confirmed current policy or endorsed self-interest • Community pressure or client demand for research • Research that included effectiveness data

11. Barriers • Absence of personal contact between researchers and policy-makers • Lack of timeless or relevance of research • Mutual distrust, including perceived political naivety or scientists and scientific naivety by policy-makers • Power and budget struggles • Poor quality research • Political instability and high turnover of policy-making staff

12. A policy maker reflects on evidence and policy Mr Robert Wells

13. Evidence-based Rational process Balancing of interests Long term perspective Open & accountable Objectively evaluated Reactive Ad hoc responding to specific interests Short term horizon Secretive Spin Policy

14. Systematic Methodical Accurate Objective Analytical Detailed Curiosity driven Irrelevant Slow Technical Narrowly focussed Research

15. A researcher reflects – case studies from APHCRI Dr Bev Sibthorpe

16. Key review before the supplement • Innvaer S, Vist G, Trommald M, Oxman A. Health policy-makers perceptions of their use of evidence: a systematic review J Health Serv Res Policy 2002; 7:239-244h • Facilitators • Personal contact between researchers and policy makers • Timeliness and relevance of the research • Research that included a summary and clear recommendations • Good quality research • Research that confirmed current policy or endorsed self-interest • Community pressure or client demand for research • Research that included effectiveness data

17. APHCRI’s approach Professor Nicholas Glasgow

18. Overview • Getting past “two communities” • What is evidence? • What does “use” of evidence mean? • How do systematic reviews and synthesis fit in? • What does APHCRI see as an applied research cycle? • What does this mean for APHCRI's work?

19. Key Stakeholders (“communities”) Providers of Primary Health Care services and their organisations Australian Government Policy and Decision Makers APHCRI Hub and Spokes Consumers of Primary Health Care Services and their organisations Research Community

20. Getting past “two communities”

21. The nature of “evidence” • “Research” and “evidence” are words that are value laden and differently understood • What is being sought is valid and reliable knowledge, and wisdom in its application • If innovations within primary health care are going to be conceived, tested and implemented there must be willingness on the part of all players to understand research and evidence through different lenses • Helpful insights will be derived from different research traditions.* *Greenhalgh AT, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of Innovations in Service Organisations: Systematic Review and Recommendations Milbank Quarterly 2004; 82: http://www.milbank.org/quarterly/8204feat.html (Accessed April 2005)

22. The nature of “use” • Direct (engineering, instrumental) use • Research feeds directly into decision making for policy and practice • Symbolic use (mobilisation of support) • to add weight to a particular policy direction • an instrument for persuasion. Findings – or simply the act of research – can be used as a political tool and can legitimate particular courses of action or inaction • Conceptual use (enlightenment) • Even if policy makers or practitioners are blocked from using findings, research can change their understanding of a situation, provide new ways of thinking and offer insights into the strengths and weaknesses of particular courses of action. New conceptual understandings can then sometimes be used in instrumental ways. • Wider influence • influence beyond the institutions and events being studied. Evidence may be synthesised. It might come into currency through networks of practitioners and researchers, and alter policy paradigms or belief communities Nutley S, Davies H, Walter I. Evidence Based Policy and Practice: Cross Sector Lessons From the UK. ESRC UK Centre for Evidence Based Policy and Practice: Working Paper 9. 2002. ESRC UK Centre for Evidence Based Policy and Practice; Research Unit for Research Utilisation

23. Systematic reviews and synthesis • Cogent argument for systematic reviews to be given greater profile as evidence of value to policy makers • There is an emerging science of systematic reviews and synthesis *Lavis JN, Posada FB, Haines A, Osei E. Use of research to inform public policymaking Lancet 2004; 364: 1615-21 *Lavis JN, Davies HTO, Oxman A, Denis JL, Golden-Biddle K, Ferlie E. Towards Systematic Reviews That Inform Healthcare Management and Policymaking JHSRP 2005; v10 Number 3 Supplement

24. Economic assumptions • How you pay (reward) people contains incentives to do (or not do) particular things • Economists speak of the need to align incentives to ensure that that inherent incentives encourage the behaviour needed to achieve desired goals • Are producers of research evidence rewarded for addressing policy questions?

25. Research • Primary • Secondary • Pre Research • Priority setting/review • Questions • Methodologies • Funding • Research training (not just researchers) Dissemination Evaluation • Adoption • (Use • Direct • Symbolic • Enlightenment)

26. Key Stakeholders Providers of Primary Health Care services and their organisations Australian Government Policy and Decision Makers APHCRI Hub and Spokes Consumers of Primary Health Care Services and their organisations Research Community

27. Who’s question(s)? • Policy makers and decision makers in both the Commonwealth and States/Territories; • Providers of primary health care services and the various organisations with which they are linked; • Researchers; and/or • Users of primary health care services and the various organisations with which they are linked

28. Aim for Stream Four • “to systematically identify, review, and synthesise knowledge about primary health care organisation, funding, delivery and performance and then consider how this knowledge might be applied in the Australian context”

29. Seven Topic Areas • Chronic disease management; • Integration, co-ordination and multidisciplinary care; • Prevention and early intervention; • Innovative models for comprehensive primary health care delivery; • Innovative models for the management of mental health in primary health care settings; • Older Australians and health promotion, prevention and post-acute care; and • Children and young Australians, health promotion and prevention

30. APHCRI questions within topics • Questions of two general types • “What do we know about….?” and • “What are the possible options?” • The “What do we know about…?” questions are the focus of the systematic review and synthesis, while the “What are the possible options?” questions build on the results to develop ways forward for Australia’s primary health care system  • APHCRI is interested in specific questions being addressed in each topic area, including questions about funding arrangements (existing and alternative), delivery arrangements and governance arrangements, and performance - i.e. system level questions

31. Why Stream Four? • This systematic processing of knowledge will provide: • A strong basis on which national primary health care policy can be informed, • Clear insights into important knowledge gaps, and • The foundation on which APHCRI can build subsequent streams of activity • The process for Stream Four will: • Strengthen the hub and spoke model – we mean it! • Build capacity in the policy and research communities with regard to primary health care policy relevant research

32. Stream Four Workshops • Four workshops occur during Stream Four • At least one CI from each group • Attendance by members of the DoHA • Allows • Iteration of the questions • Reflection on the results as they start to emerge • New direction to occur • Researchers to focus on the research, policy analysts to focus on policy analysis and both to learn more of the other

33. Miscommunication is real ATTORNEY: Is your appearance here this morning pursuant to a deposition notice which I sent to your attorney? WITNESS: No, this is how I dress when I go to work. ATTORNEY: What gear were you in at the moment of the impact? WITNESS: Gucci sweats and Reeboks.

34. Professor Lomas Comments

35. END