Health and medical research has been at the forefront of many peoples’ minds of late – and not only because of the recent NHMRC grants announcements.
Universities Australia and others have been sounding the alarm (see here and here) about the possibility of a funding freeze affecting many research grants. This has been widely foreshadowed (including by New Matilda and the SMH) as part of this morning’s release of the Federal Government’s Mid-Year Economic and Fiscal Outlook (MYEFO) statement.
Meanwhile, in the article below, Professor Lesley Barclay, director of the University Centre for Rural Health based at Lismore in northern NSW, responds to the recent consultation paper from the McKeon Review. She urges researchers to do a better job of ensuring their work makes a difference.
We need more research embedded in the health system
Lesley Barclay writes:
We are surrounded by requests to consider directions for health and medical research (HMR), at national level, state level in New South Wales and now in my own institution, the University of Sydney.
Given global financial instability and concerns about balancing budgets, I believe it is crucial that researchers are politically astute in their comments and responses. I have chosen to do so informally and my aspiration is to contribute to debate and a vision for the future of health and medical research.
This commentary makes three propositions. The first that health and medical researchers and clinicians, policy makers MUST be better engaged for a more strategic future. This engagement occurs at the macro level of government but also at the micro level of individual.
The second is that applied or clinical researchers reconceptualise their industry as a service, their colleagues as clinicians, consumers and policy leaders and establish research teams and use research methods accordingly.
The third proposition is that rurally located small research teams make a difference and are necessary.
The comments made here are not only stimulated by recent or current reviews of HMR but also follow participation in grant panels this year. My experience is based on more than 20 years of clinical and health services research and participating as a reviewer of grant applications, a member of panels and two terms on NHMRC Council.
Over these many years of contribution I have treated research funding institutions with respect, affection and at times despair.
The Consultation Paper from the McKeon review of HMR is forward-thinking. I believe the seven priorities identified are sound and position research for the future. While some need ‘tweaking’, I cannot believe that fellow clinical researchers operating in a contemporary world imagine that isolated research endeavours that are not embedded in the health system (see point 1 in the McKeon review) are acceptable.
Yet a minority of the many grants I reviewed this year involved consumers, policymakers or organisations that deliver health care as part of the team. Again, a minority looked at mixing methods that enabled the context in which a randomised control trial was undertaken to be investigated or understood; or used a participatory or iterative approach that enabled their work to become informed by or embedded in the health system. Too few grants integrated clinical researchers or policy makers identified training positions to build capacity in the health service itself.
I also despair of the inability of many researchers to demonstrate application, translation or dissemination of their work beyond the conventional publication route (I do note that there are exceptions to this rule but they remain far too few).
Too many of us apparently still feel that publications are enough, instead of contributing our efforts through clinical or health system leadership, professional associations, guidelines, standards, technical advice, and international contributions or by training others.
Too few researchers were part of teams working to improve health care. It may be a limitation in the way many researchers describe their work in their grants applications – but a minority manage to demonstrate this and describe it concisely and well.
Embedding clinical research and researchers themselves in the health system is necessary so research is ‘trusted’ and used for good decision-making and planning. It also allows researchers to be responsive to trends. This means establishing priorities and rebalancing clinical research and basic sciences with health services research, health economics and epidemiology (again mentioned in the Consultation Paper).
The advances in genomics need to be seen alongside the extra ordinary advances being made by epidemiologists and others using large databases and longitudinal data sets, increased capacity of health economists to establish community preferences and choices for health expenditure, and the importance of health services and ‘translation’ research.
As a rural-based researcher I welcome recognition of the importance of rural and remote health services research in McKeon’s priorities (Recommendation 11:7). This could ensure that the poorer health outcomes of over 30% of Australians who live outside major centres needs are better understood and met.
This requires purposively designed health services that manage distances, investigate and test use of limited workforce and optimising skill mix. This rural redesign of health services must also address the ‘underspend’ in rural and remote health care where outcomes are worse than for other Australians.
The McKeon Consultation Paper emphasises embedding research and researchers at the macro level of the health service. This is well described.
The importance of embedding research at the micro level; for example though individuals, clinicians and joint appointments, and the importance of the relationships between clinicians, policymakers and researchers at this level is not as well addressed. I argue, for rural Australia, this is as important as establishing the large Integrated Health Research Centres they propose that are admirable in their capacity to aggregate and concentrate research endeavour.
I am the Director of a rurally-based University Centre for Rural Health. We have a small team and very limited budget to support researchers as our main goal is educating a rural health workforce. We are funded by the Commonwealth predominantly to do the latter.
Despite our size and lack of resources – grants, tenders that are rurally or remotely based – our work is highly credible thanks to good international linkages and research partnerships, and excellent national and metropolitan links. We lead two NHMRC grants and are as chief investigators on four others, as well as on two Australian Research Council grants. This ensures jurisdictional, national and international leadership- particularly in the area of rural, remote and Indigenous health.
More importantly for our survival we make a difference locally. We undertake numerous smaller funded investigations and tenders evaluating local health service innovation and transformation, rural workforce and skills to meet contemporary standards and expectations, we inform and support decision-making and our work is imbedded in health system improvement and leadership in two jurisdictions. At the micro level our colleagues are not only researchers but also clinicians, policymakers and agencies responsible for the health care of rural and remote Australians.
The approach that the McKeon Consultation Paper takes at the macro level not only informs and supports a better functioning health system, it also serves to reveal the value of research and research skills to the health system and takes them out of their previous isolation. It also acts as insulation. When our contribution is revealed and becomes evident we cannot be seen as extraneous or a luxury, easily shed in times of budget crisis.
Is more difficult to establish rural or remotely located research teams and insulate or absorb their costs in larger institutions or funding systems. Similarly there are risks that the urban located and functioning Integrated Health Research Centres will focus on macro concerns and relationships with rural or remote problems ignored or become marginalised, despite a lack of equity in health outcomes and expenditure for our rural and remote Australian population.
Let’s move forward with recognition that small is also beautiful, that the principle of engagement of researchers with health services involves every level of the health system and that research methods and teams need to reflect this.
• Lesley Barclay is chairperson of the National Rural Health Alliance Council, and director of the University Centre for Rural Health based at Lismore in northern NSW.
• The Conversation: McKeon Review should consider wellbeing of the health system