Studying the Organisation and Delivery of Health Services

Research Methods

Pauline Allen, Nick Black, Aileen Clarke, Naomi Fulop, Stuart Anderson

• Publisher: Routledge
• Year: 2004
• eBook ISBN: 9781134516636
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

First Published in 2001. This is the first book to combine research methods from a range of social science disciplines and apply them to health service research. Health service delivery and organisation is a growing and increasingly important area of research not readily amenable to methods used to evaluate health technologies.

Chapter 1
Issues in studying the organisation and delivery of health services

Naomi Fulop, Pauline Allen, Aileen Clarke and Nick Black

Why study the organisation and delivery of health services?

Throughout the world, societies are striving to determine how best to organise their health systems and deliver services. Increasingly, there is a recognition that the development and evaluation of new therapies and diagnostic tools is only part of the answer to better health care. As we enter a new era of biological understanding of disease following the mapping of the human genome, the demands on the way we organise services will become even greater. This pressure will be enhanced by the rising expectations of consumers and greater access to information. It is essential, therefore, that in parallel to biomedical research and health technology assessment, we advance our understanding and knowledge of how best to organise and deliver health services. Without this, we run the risk of failing to realise the potential benefits that health systems can provide.

In addition, the need to be more responsive to the needs and wishes of those who use health care is increasingly being accepted. The traditional tendency for service organisations to prioritise staff needs over consumers’ needs is no longer acceptable, regardless of whether the system is publicly or privately financed.

All of these pressures have led governments to recognise the need to increase their support for research that can help to improve the way we organise and deliver health services. While this is not a new area of study, the previously disjointed, ad hoc activities that characterised such research are giving way to a more strategic approach, with national programmes of research in some countries. This, in turn, will require a growth in both the volume and quality of research. To achieve these, the tendency for fragmentation between the very disciplines that can make key contributions must be overcome.

The aim of this book is to go some way towards meeting these challenges. It is aimed at researchers and research funders in the field of health services delivery and organisation who need to be familiar with the range of methods required. They may be experts in one particular field but need to have a working knowledge of how other methods can contribute. Alternatively, they may be new to this field of enquiry. Given the necessity for multidisciplinary working in this area, it is important that researchers and funders are aware of the range of appropriate methods and the types of questions which different methods can address; and further, they need to understand that different methods will generate different insights in the light of the theoretical perspective of the relevant discipline.

A further aim of this book is to explore the extent to which multidisciplinary working can be achieved – whether some disciplines can work together, or whether some disciplines are inherently incompatible. Although we cover a wide range of disciplines and methods, it is not comprehensive – by necessity we have not been able to cover all those which may appropriately be used (for example, anthropology and geography have not been included).

The last two decades have been termed the Era of Assessment and Accountability by Arnold Relman, ex-editor of the New England Journal of Medicine (Relman 1998). They were marked by the adoption of scientific management, health technology assessment and the acceptance of evidence-based medicine based on clinical guidelines. While all these developments have contributed to maintaining a working relationship between funders, providers and the public, it is clear that the pressure on health systems persists and is likely to increase. It is time to enter the next era of health care, one in which we attend to the way we organise and deliver services, with much greater involvement of the public and consumers: an era of research on service delivery and organisation (SDO).

In this chapter, first we outline the development of research on the delivery and organisation of health services. Second, we discuss what we call some ‘fundamentals’: these are the key terms and debates concerning researchers generally, and applying to research in this field. These include matters of epistemology (theory of knowledge), and the relationship between disciplines and methods. Third, we present a brief description of each chapter. Finally, we use an example of an issue in health service delivery and organisation (how best to deliver orthopaedic care) to illustrate how the different disciplines and approaches can be applied.

The development of health service delivery and organisation research

Research on the way health services are delivered and organised is part of the broader field of health services (or systems) research which has become well established in the UK, North America and parts of Europe in the last twenty years. Health services research aims to ‘produce reliable and valid research data on which to base appropriate, effective, cost-effective, efficient and acceptable health services’ (Bowling 1997). It is not a scientific discipline in itself but an area of applied research that draws on a range of disciplines and perspectives, including anthropology, economics, epidemiology, history, medicine, nursing, political science, sociology and statistics. It concentrates on the study of health services or systems rather than on the state of health and disease of individuals and of populations. Unlike clinical research, which has traditionally focused on individual patients in relation to their treatment and care, health services research adopts a population perspective. Questions considered by health services research include: How much health care should we have? How should services be funded? Who should receive health services? and How well are services being delivered? (Black 1997).

The interests of different stakeholders in health services have led to the growth, development and increased expectations of health services research. Funders of health care sought help to address the problem of cost containment; health care professionals, particularly doctors who have come under pressure to defend themselves against those who argued that many clinical interventions were unproven, ineffective, or even harmful (Cochrane 1972; McKeown 1979; Illich 1976), have sought scientific evidence from health services research to defend their practices; and users of health services have looked to this research to support their growing demands for more information about the care they receive.

These pressures have led to two tendencies. First, the focus of health services research has tended to be on health technology assessment (HTA). Second, the emphasis on the randomised trial, although necessary, has ‘retarded the development of a broader view of evaluation’ (St Leger and Walsworth-Bell 1999). This focus has, until recently, underplayed the importance of research on how health services are managed, organised and delivered. This is not to say that research on these issues has not been carried out in the last twenty years. On the contrary, many good examples of SDO research exist. Research has been conducted on different funding systems, such as different methods of paying for health care in the USA (Newhouse and the Insurance Experiment Group 1993) and general practitioner fundholding in the UK (Mays et al. 1997); the basis for resource allocation within a health care system (Carr-Hill et al. 1994); the nature of organisational structures within health systems, such as internal markets (Allen 1995); the impact of organisational change on health care providers (Shortell et al. 2000); evaluations of different models of care such as community mental health teams (Tyrer et al. 1998) and hospital-at-home services (Fulop et al. 1997); the appropriateness of the use of acute hospital beds (Victor et al. 1993); analyses of interactions between health care professionals and patients (Stimson and Webb 1975; Strong 1979); and the impact of different approaches to management, such as the impact of the introduction of general management (Strong and Robinson 1990).

There is not, of course, a clearly defined boundary between HTA and questions relating to health service delivery and organisation. Indeed, some would argue that it is a false distinction to make, as technical and organisational or social considerations are so interwoven that they should not be studied in isolation (Gibbons et al. 1994). SDO and HTA research complement one another. For example, HTA can provide evidence on the cost-effectiveness of one particular intervention (such as a drug or surgical technique) compared with another, while SDO research would then be required to determine, for example, where the best setting (e.g. primary or secondary care) for the delivery of that intervention would be. Other areas of SDO research include comparisons of different models of care, organisational issues at different levels (such as within teams, departments or entire organisations), and the management of change in health care organisations.

In England, while research on the delivery and organisation of services has been broadly supported in the past, it received a major boost with the establishment of a national government-funded programme in 1999 (http://www.sdo.lshtm.ac.uk). Initiatives in other countries, such as the Canadian Health Services Research Foundation (Lomas 2000) and the Australian Centre for Effective Healthcare (http://www.aceh.usyd.edu.au), have also increased the focus in this area internationally. In the USA, the Agency for Healthcare Research and Quality (http://www.ahcpr.gov) is one of a number of organisations which funds research in this area.

Some fundamentals

Given the wide range of disciplines that contribute to the field of SDO research, it is inevitable that certain methodological tensions will arise. It is important that these are recognised and understood if multidisciplinary working is to be achieved and the potential contribution of research is to be realised. This section will discuss some of these tensions and, as a preliminary matter, it is important to give working definitions of some key terms used throughout this book. These terms, such as epistemology, discipline, paradigm, approach, method and methodology, are first defined briefly below before we discuss their implications for SDO research in the remainder of this section. It should be noted that the definitions provided might seem to underestimate their complexity and contestability, but have been simplified for the purposes of this book.

Epistemology refers to a branch of philosophy concerned with the theory of knowledge. The central questions it addresses are the nature and derivation of knowledge, its scope, and the reliability of its claims. The related term ontology concerns what can be known, that is, the kinds of things that exist. It is important to understand the debates arising from these questions, as they have been highly influential in the development of many of the disciplines discussed in this book.

The term paradigm can be used to describe the ‘world view’ adopted by the researcher, that is, the general theoretical assumptions that members of a particular scientific or research community adopt. These may be either explicit or implicit in the researcher’s work. An example of a paradigm is positivism – research based on the assumption that there is a single reality, i.e. one set of ‘facts’ about the world which may be observed. Thus different paradigms are based on different epistemologies.

A discipline is used to refer to a group of academics with an identifiable perspective or focus, such as economics or sociology. The extent to which a researcher’s training leads him or her to formulate and pursue research questions in a way that differs from that expected of researchers with a different disciplinary background can usefully be considered under three headings: the questions asked, the concepts used, and the research techniques employed. Members of a discipline may all adhere to the same paradigm or to different ones. There are frequently debates within disciplines, such as sociology and psychology, because different researchers within those disciplines use what are seen as competing paradigms (see Chapters 2, 3 and 5).

In this book we use the term approach to describe a way of going about the research process. Action research (Chapter 11) and operational research (Chapter 10) might more accurately be described as approaches to research rather than as separate disciplines. Although action research draws heavily on sociology it does not do so exclusively, and operational research, which has its roots in engineering science, uses a wide variety of methods. The distinct feature for both action research and operational research is that the researcher works with those being researched, both to design research questions and to optimise and implement solutions. The disadvantage of this closer local focus is that generalisability may be compromised. The advantage is that the likelihood of appropriate implementation may be enhanced. Some would say these approaches sit on the border between research and change management, issues discussed further in Chapters 10 and 11.

The term theory is used in a number of ways in research and, once again, different disciplines and paradigms have contrasting perspectives on it. A theory is an explanation, explaining the phenomenon of interest (for example, ‘the organisation’ or ‘leadership’). Theory may provide the focus for the study, an idea for investigation. It can also assist the researcher to formulate and reformulate the problem addressed by the research. A particular theory can be tested by empirical research and its limitations analysed. However, while the positivist tradition sees a clear distinction between the role of theory and data (that empirical research is used merely to test ‘hypotheses’, i.e. theories), other traditions posit a more complex relationship between theory and empirical research. In the latter, research shapes, initiates, reformulates and clarifies theory. An example of this approach is the notion of ‘grounded theory’ proposed by Glaser and Strauss (1967) whereby theory is generated and developed from the data.

Methods refer to particular techniques for under...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Illustrations
• Contributors
• Acknowledgements
• Chapter 1: Issues In Studying the Organisation and Delivery of Health Services
• Chapter 2: Organisational Studies
• Chapter 3: Micro-Level Qualitative Research
• Chapter 4: Epidemiological Methods
• Chapter 5: Organisational Psychology
• Chapter 6: Policy Analysis
• Chapter 7: Economic Evaluation
• Chapter 8: Organisational Economics
• Chapter 9: Historical Research
• Chapter 10: Operational Research
• Chapter 11: Action Research
• Chapter 12: Synthesising Research Evidence