What is health services research?

HSR word cloud


So, what is health services research?

Back in March I emailed colleagues to find out how they would define health services research.  I’d posted a link to a recent Hive Blog to my facebook page, and whilst my friends were understandably incredibly impressed with how erudite and cleverly I made connections between Taylor Swift songs and realist synthesis, they were also at a bit of a loss about what kind of research I do…  this was the second time that someone had asked me to more closely define a) what is HSR, as well as b) realist approaches in a nugget/nutshell, so I thought it was about time I wrote something.

I had some great responses from colleagues (see the word cloud!),  and here are some of the highlights – starting in the plainest of English, travelling to the kinds of definitions which I think need further translation and explanation…

Thinking wisely, asking questions and weighing the evidence in order to understand and help decision making by those that work in health and care services. 

We look at things like how people access health and what treatments they may receive and how access, treatment and practices could be better in terms of costs, how effective they are, how accessible they are and how to make them actually happen in the real world.

The use of systematic methods to understand the workings of an aspect of health services, how such health services deliver health-related and other outcomes and how such services may be altered to improve the delivery of such outcomes

What is HSR?  I’ve always wondered… and for a long time I had absoluuutley no idea and just hoped no-one would ask me… to be honest none of my daily out-of-work acquaintances have the even remotest idea what I do apart from be Betty and Danny’s Mummy and that I drive off to work in that far off land what is The University so something like ‘it’s research about health services kind of thing innit?’ is usually enough to get the glazed look and realise that you’ve said enough!  I feel a bit more grown up now (since they put Senior in my title) and like I should have a better answer…  but maybe the simple is always better – this is a bit text book-eze.    How about – ‘HSR involves researchers from multiple disciplines aiming to find out the best ways to deliver, manage and organise the most effective and cost-effective health services and improve the quality of care.’?

Health Service Research involves “informing the decision on how to deliver the Right intervention, at the Right time to the Right Patient, in the Right location, by the Right provider, with the Right Outcomes for the Right cost

The integration of epidemiologic, sociological, economic and other analytic sciences in the study of health services. Health services research is usually concerned with relationships between NEED, DEMAND, supply, use, and OUTCOME of health services. The aim of health services research is evaluation: several components of evaluative health services research are distinguished, viz: Evaluation of structure…., of process…., of output…., of outcome….

Health services research is a multidisciplinary field of inquiry, both basic and applied, that examines the use, costs, quality, accessibility, delivery, organisation, financing, and outcomes of health care services to increase knowledge and understanding of the structure, processes, and effects of health services for individuals and populations.

So what about you?  If you’re down the pub talking to friends (or strangers….), and somebody asks you what you do, what do you say HSR is?

[Obliquely opaque film reference alert… Scarlett Johanson’s recent role as an alien in Under the Skin is creepy and compelling.  I particularly like how she approaches asking people about themselves…. so maybe just be wary if someone follows up asking you about HSR, by asking you if you live alone…..]

University of Liverpool Realist Methods Summer School – Guest Blog from David Blane, University of Glasgow

I know what you did last summer…..

Or rather, I know what you didn’t do.  (And thinking about what didn’t happen can be a useful feature of realist research, but more on that later!).  I know that you didn’t attend a realist methods summer school in Liverpool… because there wasn’t one.

Thankfully, however, there was this year and there will be next year.  So, for those budding realists that missed out, I’m going to share my thoughts on what it was about the summer school that worked (for whom, etc…), and hopefully convince you of the value of attending next year.

In true realist fashion, I’ll start with a C for Context.  The summer school took place in Liverpool, at another C – the recently formed Centre for Advancement of Realist Evaluation and Syntheses (CARES) at the University of Liverpool.  The venue was well suited to this sort of event, with a main meeting room (see photo) and several smaller ‘breakout’ rooms, as well as a central courtyard area for lunch and tea breaks.

It’s hard to think of a more appropriate acronym for a research centre headed by Dr Justin Jagosh  a leading figure in the application of realist methodologies to health services research. Justin really does care – not just about the development of realist research generally, but also about the individual projects that were shared, warts and all, by the participants of the summer school.  His unwavering encouragement (not to mention his patience!) was valued by everyone and can definitely be considered a crucial enabling factor for a successful summer school.

The participants were another key Contextual feature of the success of the summer school.  There were about 20 researchers from across the UK and one each from Australia and Holland.  Most were PhD students, but there were also several teams of researchers, some with many years of research experience.  Most were working in health services research, though the field of international development was also represented, and there was a good mix of realist evaluation and synthesis projects.

What about the M for Mechanism?  As Prof Rumona Dickson, the Director of the Liverpool Reviews and Implementation Group (which CARES sits within), put it, “the idea is a simple one – if you bring a bunch of people together working on similar projects, with protected time and space to work, then good things will happen”.  So, the “program theory” or mechanism is something about having protected time in a supportive environment, i.e. without phones ringing and emails pinging.  Sounds good to me.  If you take the Pawson approach to mechanisms as being “resources and the response(s) to them”, the protected time could be considered one “resource”, but there are several possible others – the sharing of experiences by colleagues, and nuggets of wisdom from Justin, for example.

And there were plenty of nuggets.  On the first day, we had an overview of the logic and key ingredients of the realist approach, and were introduced to the concept of “retroduction” (an approach to scientific inquiry described as the “spark of creativity” associated with the realist researcher!).  On day 2, we worked through examples of realist reviews to explore CMO configurations in more detail.  The questions, “what is actually going on here?” and “why did this intervention not work, for these people, in this context?” were posed, as another way of thinking through potential mechanisms.  Days 3 and 4 provided more protected time and space to work on our projects, either individually or in groups, in rooms designated as either ‘quiet’ or ‘chatty’ (I prefer ‘collaborative’).  We were also presented with the idea, frequently reinforced by Justin, that it’s perfectly normal and acceptable to move from confusion to clarity (and back again!), throughout the process of realist research.  Realist research is an evolving methodology with no prescribed set of rules to follow.  For me, the maxim “one size doesn’t fit all” applies as much to the process of realist research itself as it does to the majority of complex interventions that the methodology has been used to evaluate.  This flexibility (and inherent uncertainty) can be at once both comforting and disconcerting, and takes some time to get used to (a variable “response” to these nuggets of “resource”, perhaps?).

Ultimately, the Cs and Ms that are included in any realist research project will be shaped by the O of Outcome(s).  Indeed, many realist researchers recommend starting with your Outcomes and working backwards, when hypothesizing potential Mechanisms and their enabling or constraining Contexts.  The desired Outcome for most of the summer school participants was simply to make progress with their realist projects.  The general consensus was that this had definitely been achieved: for some, there were “breakthrough” moments; while for others, they simply left a little more confident that they were working along the right lines, and a little more comfortable with the uncertainties of the process.  For me, as the proud (if a little exhausted) father to a six week-old daughter, three nights of undisturbed sleep was perhaps my greatest Outcome!

I’d like to finish by thanking my PhD supervisors for encouraging me to attend the summer school, my funder (the Scottish Government’s Chief Scientist Office) for enabling me to attend, and my wonderful wife Miriam for allowing me to attend.  I look forward to meeting up again with many of the summer school participants, along with other realist researchers, at the 1st International Conference on Realist Approaches to Evaluation and Synthesis, to be held at the same venue in Liverpool between 27th and 30th October 2014.  In the meantime, happy retroducing!