This report is very welcome and timely. The contributions of modern science and technology to the quality of modern healthcare are everywhere visible. They include non-invasive imaging, minimalist surgery and new anaesthetics, stents and statins, genetic testing and new techniques and treatments for cancers. There is much more to come as we head into the era of personalised medicine in which diagnostics and treatments are moulded with much greater accuracy around the individual.
Less obvious, but equally as important, has been the contribution of the social sciences, as evidenced by the examples in this report. Healthcare is enormously expensive. Relatively few nations have even a basic model of universal healthcare coverage that provides equity of access to an entire population, let alone with the NHS promise of being free at the point of clinical need. And no such nation has a model that is economically sustainable well into the future, given demographic changes and rising costs, as science enables us to perform life-saving procedures that were previously impossible, and as public expectations rise accordingly. Across all of these domains lie the social sciences.
More importantly for healthcare systems across the world is the improvement of population health, primarily through the prevention of ill-health, but also through shifting presentation, diagnosis and treatment further upstream, so that healthy lives are prolonged and healthcare becomes more than simply a patch and repair service for acute and chronic conditions.
This report proposes a number of steps towards a more coherent and focused approach in linking the social and behavioural sciences to these ends, and is to be warmly welcomed and applauded. It’s a strong case and there is an urgent need.
Sir Malcolm Grant CBE FAcSS
Chair, NHS England
The Campaign for Social Science was set up in 2011 to inform public policy, build coalitions and engage in measured advocacy. It sprang from the Academy of Social Sciences, which now has a fellowship of around 1,100 eminent academics and practitioners across universities, business, government and civil society. 42 learned societies are also members, representing over 90,000 social scientists in all walks of life.
In 2015, ahead of the last general election, we published The Business of People, to highlight the contributions of the social sciences to the myriad economic, social and environmental challenges which confront the UK and the wider world.
This successor report – The Health of People – represents a timely intervention in policy and public debates about the health and wellbeing of our society. From transforming health services to influencing health-related behaviours, the report makes clear that too much of the potential of social science still lies untapped. And it makes a set of clear recommendations to improve the provision, transmission and uptake of research evidence in ways that can make tangible improvements to population health.
I would like to extend my warmest thanks to those who have devoted time to the project over the past year, especially to Professor Susan Michie FAcSS, who expended considerable time and energy in expertly steering the report through to completion, and the members of her Working Group, as well as to our Review Group, whose experience and insights provided a valuable reality check on our conclusions. Let me also thank Sharon Witherspoon MBE FAcSS and Daniela Puska of the Campaign team, and Professor Jon Glasby FAcSS, a member of our Board, all of whom made important contributions to the drafting of the report and management of the project.
Finally, we are grateful to Ziyad Marar and colleagues at SAGE Publishing for their ongoing partnership and for publishing the report; and to the Association of the British Pharmaceutical Industry (ABPI), British Psychological Society, Cancer Research UK, Nesta, Society for the Study of Addiction, and Wellcome Trust for their generous support.
We are in a period of transition, both within the NHS and wider health system, and across UK universities and research. Reports like this, and the wider efforts of the Campaign to demonstrate how social science can help to meet our shared priorities, have never been more urgently required.
Professor James Wilsdon FAcSS
Chair, Campaign for Social Science
[email protected]
SOCIAL SCIENCE AND NEW WAYS OF CONFIGURING SERVICES
So far we have been looking at changing the behaviours of health professionals and illustrated some of the ways in which the social sciences have contributed. But there are also system-level changes for which robust social science evidence could make a difference.106 While the translation of organisational change into improved health is mediated by changes in individual behaviour, it is important to understand how changes in social settings work at multiple levels. This can inform the types of organisational change, such as incentive structures and opportunities for those behaviour changes, which can alter the behaviour of health professionals. Behaviour is not only relevant as a mediator; it is often a key part of the organisational intervention itself, for example, in improving communication and team-working.
The ways in which health services are delivered in the UK are increasingly recognised to be key to improving population health. Partly this is a result of financial pressures and the drive for efficiency, and partly it is because the UK’s ratio of doctors to the population is low relative to EU comparators.107 Approaches suggested to improve service delivery include widening the responsibilities of the existing non-medical workforce,108 addressing reasons for retirement and emigration of doctors,109 changing recruitment numbers for particular medical specialities,110 and the greater use of digital technologies (for example, Skype consultations). A programme of rigorous evaluation of new ways of delivering services is especially important given the rise in the proportion of the population with long-term health conditions, and with complex co-morbidities.
For many long-term conditions, we are a long way from having models of active and easy-to-attend services in community settings that promote a step change in patient behaviours and outcomes. Reconfiguring complex continuing services for chronic conditions will require a programme of focused work.
To improve healthcare delivery, regional NHS directorates have set up ‘Vanguard’ areas to experiment with new ways of configuring services. In Scotland, the Scottish Collaborative Innovation Partnership Process (SCIPP) examines some of the same issues. These include better integration of primary and acute care; enhanced healthcare within care homes; multi-speciality providers for common conditions within communities; and reconfiguration of urgent and emergency care. Some of these changes in healthcare delivery have been subject to some degree of piloting (setting up an experiment, and collecting objective evidence about operation and outcomes), such as the work of the Central London Clinical Commissioning Group.114 Social scientists have been involved in the design of each of these evaluations. i
Case Study
Service reconfiguration: How social science insights inform best practice
NICE Guidelines spell out the health checks and services that newly diagnosed diabetics should get, and an NHS National Service Framework for Diabetes gives further guidance on what this should mean for service delivery. Yet the National Audit Office has found that the majority of diabetics are still not receiving all of the specified care processes, and fewer than 4 per cent of newly-diagnosed diabetes patients were recorded as having taken up a structured education programme.[111] This is not merely a question of individual behaviour but of how local services support those with new diagnoses to take up the programmes and those with longer-standing diagnoses to adopt the diet and other behavioural changes required to manage their condition. Integrated practice units for joined-up diabetes care are now being implemented, for example, in the inner-London borough of Camden.[112]
A successful reconfiguration of services has also taken place around the delivery of care to those who have recently had strokes. Research suggested that referring stroke patients directly to care in a specialist stroke unit that could provide immediate assessment by specialist teams, brain imaging and thrombolysis when appropriate, and acute rehabilitation services, was the single biggest factor that could improve outcomes after stroke, even if patients had to travel further to reach such units. In London, evidence based on statistical modelling and informed by a social science team, who considered a wide range of evidence about the importance of specialist care, was used to reconfigure patterns of provision to ensure that all patients could reach such units within 30 minutes and that only units providing care 24 hours a day, seven days a week would be used. In Manchester, a slightly different model was used, with units offering less comprehensive care also being used as a first port of call. In London, some units that were providing less comprehensive care were closed, while none were in Manchester. Analysis showed that deaths and length of hospital stays were reduced in London, while Manchester did not see a similar reduction in death rates.[113]
There are also already a number of initiatives to improve the links between services and research, including social science research,[115] such as the GP Access Fund for pilots to improve access, networks listed in the NHS Improvement Directory,[116] and the NHS Innovation Accelerator.[117]
Many but not all of these projects and programmes have involved evaluation and programmes for rolling them out more widely.[118] However, it is not clear that these initiatives add up to more than the sum of their parts – that there is a strategic setting of priorities, cumulative learning and attention to issues arising from implementation. Social science could be better used to evaluate pilots and devise implementations in an iterative manner. The Health Foundation’s proposed Improvement Science Institute is one way to address this. More strategic ‘implementation labs’ would be another, as set out in the recommendations of this report.
The social and behavioural sciences have expertise in the study of and support for implementation across a range of services, including health, education and social services. Evidence has shown that successful implementation of interventions depends on social processes and interactions, and interventions cannot just be copied like a recipe book. What may work in one social setting or culture may not work in another. Understanding the reasons for this is vital in informing successful implementations in new settings. Changes in service delivery rest on a complex combination of institutional practices and cultures, incentives and regulatory changes. (See the journal Implementation Science for current evidence and thinking in this area.)[119] But using the theories, evidence and methods from the social sciences to greater effect in this arena means we need to have the right capacity for this type of work and ways of ensuring they are brought to bear in a focused way.
Implementation research is becoming a cornerstone even of behavioural economics with significant programmes of research devoted to understanding the relevant conditions for change for particular issues in particular settings, including incentives for change.[120] There are similar national and international initiatives in children’s and education services.[121]
In a devolved healthcare system, with local healthcare Trusts and Commissioning Groups and different national ways of organising care, variation in ways of providing services will be normal and desirable. Using these variations to look at whether they may give rise to different outcomes can provide useful evidence for improvement.[122]
However, local experiments may not result in generalisable lessons or strategic focus, and will not in themselves provide cumulative learning about what changes may make the most difference. Understanding the settings and the conditions that affect complex interventions or reorganisations requires a range of evidence: understanding the ways in which people actually work, as well as understanding the ways in which opportunities and motivations may be changed in the routine working environments involving the whole range of staff (rather than the more highly-motivated staff who tend to participate in studies). Resources to pilot different ways of working should ideally be planned and reviewed with strategic attention, so that local pilots test key variables in ways that may allow generalisation.
Without this process of piloting and evaluation, we risk failing to exploit opportunities to enhance the effectiveness of existing ways of changing behaviour. For example, audit and feedback aims to improve patient care and outcomes through careful review of healthcare performance against explicit standards. It is widely used to monitor and improve NHS care, including in national clinical audit programmes. Audit and feedback is one of the more effective interventions to change health professional practice.[123] Cumulative meta-analysis of audit and feedback trials indicates that effect sizes stabilised over 10 years ago, suggesting a lack of cumulative learning on how to improve effectiveness.[124] There are opportunities to systematically embed audit and feedback trials within national clinical audit programmes as part of an ambitious international ‘meta-laboratory’.[125]
The social sciences have much to offer here, both methodologically and in generating substantive hypotheses that can be tested. Only in this way can local, one-off experiments look beyond ‘what works’ in a single location to the question of how and why some service innovations work in some settings and not in others.[126]
None of these insights is new, of course, and variations in healthcare practices provide in themselves a fruitful field of inquiry. But there is growing recognition of the importance of social and behavioural science not only to help explain these variations but to help reduce them to improve healthcare practice. The time is right to move beyond considering these issues on a project-by-project basis and build a more robust infrastructure to propose, examine, evaluate and help promote social and organisational change in service delivery to improve the nation’s health.
These initiatives are different from the place-based NHS Sustainability and Transformation plans. While these involve reconfiguring services and changing ways of service delivery to integrate provision, they are driven in part by the need to seek cost efficiencies.