Conceptual Framework

All research should be underpinned by a conceptual framework. My current and future research programme is driven by three factors: supra-national issues, national issues, and my personal research interests.

I have a strong commitment to improving the quality and accessibility of health services. The ultimate objective of my research is to help health-care systems deal with some of the many problems and challenges they are currently faced with.

Supra-national issues

Healthcare systems throughout the developed world are faced by similar challenges. Some of these challenges include:

•  the steadily increasing expenditure on health services

• maintaining the population’s access to health care while at the same time curtailing this growth in health care spending

• the increasing proportion of the population from older age groups

• the increasing prevalence of chronic diseases

• determining the most appropriate balance between primary and secondary care

• controlling how new medical technology is introduced and ensuring maximum benefit is obtained from it

• ensuring that health services are of high quality

• ensuring that effective systems are in place to regulate health professionals

Traditionally, research in these areas has been very nation-specific, with relatively few attempts to carry out cross-national studies. However, if many of the challenges faced by health care systems are similar, then it is likely that countries can draw upon each other’s experiences in developing methods of dealing with these challenges. Hence, over the last two years, I have spent a substantial amount of time meeting and liaising with academics and policy makers from a number of countries, including the United States of America (USA), the member states of the European Community, and New Zealand. This has resulted in the development of a number of cross-national studies. In the first instance, the main focus of this work has been collaboration with researchers from the Primary Care Departments and Health Services Research Departments at the University of California, San Francisco, USA and Johns Hopkins University, Baltimore, USA.

In collaboration with my US colleagues, I have already completed the first of these studies, in which I examined specialist referral rates among primary care physicians in the USA and the UK. This study had a number of innovative features. In particular, it was the first study in the UK to take into account differences in case-mix (i.e. the severity and prevalence of disease) among the patients registered with different general practices. The study was very well received by policymakers in the USA, who were particularly impressed by some of the population-based information available in the UK (which is in marked contrast to the USA). My colleagues and I now plan to carry out a number of other cross-national studies around the areas of the role of incentives in changing physician behaviour; the effectiveness and value of different methods of controlling access to specialist services (‘gatekeeping’); and the impact of changes in the primary care workforce on the delivery of services and health outcomes. Over the next few years, I envisage a steady expansion in this cross-national research programme.

National issues

As well as the generic challenges faced by healthcare systems, there are other challenges that are more unique to the NHS in England. These include:

• implementing the recommendations of the NHS plan and of the National Service Frameworks

• reducing socio-economic inequalities in health status and in the use of health services

• ensuring that NHS R & D is in line with NHS priorities (Needs & Priorities in NHS R & D).

Over the last few years, I have worked closely with colleagues in the Office for National Statistics and the Department of Health to help meet some of these challenges. My main initial task has been to develop methods of measuring chronic disease prevalence rates, monitor how these are changing over time, and measure the quality of healthcare provided by primary health care teams. This work has been supported extensively by the Office for National Statistics and the Department of Health. Much of it has been published in peer-reviewed journals and in the government’s own health journal, Health Statistics Quarterly. The next phase in this programme of work is to devise a strategy for maximising the value of the information collected by the NHS from primary care.

Personal research interests

My own research interests are in:

• health policy

• the organisation and delivery of health care

• chronic disease management, particularly cardiovascular disorders

• the use of information for policy, planning and research

• developing innovative methodologies for primary care and public health research using clinical and administrative databases

Through these interests, I have acquired good methodological and technical skills, and this has allowed me to carry out research on many different topics. I have always tried to apply my skills on important research questions, and major public health and health policy issues. My research record in these areas has resulted in me becoming a national authority and I have often been invited to provide expert advice to government departments and other organisations. For example, I have been invited to join the IT Expert Group of BioBank UK, the joint MRC and Wellcome Trust initiative to develop a long-term 500,000 patient cohort study.

Current Research Program

My current research programme is comprised of a number of different areas including chronic diseases, health policy, and public health. 

Chronic diseases

I have a large programme of work focused around chronic diseases. This work has a number of objectives, including:

• examining the epidemiology and treatment of important chronic diseases

• examining the association between treatment, complications, and outcomes

• research on planning, monitoring and measuring the quality health services

I have used this programme of work to help train more junior researchers in research methodology. The work has also been used extensively by policymakers. For example, my work on epilepsy is being used in the planned National Service Framework on Long Term Conditions.

The next phase of this work will start early in 2002 and run for three years. In total, about 25 different diseases will be studied in this programme of work and each disease area is targeted to produce at least one-two publications. To help complete this very ambitious and wide-ranging research programme, I have been establishing collaborations with other research groups in the UK with similar interests to my own.

Health Policy

In addition to the international and national research on health policy described earlier, I have some other research focused on health policy. I have received funding from the Department of Health to evaluate the use of different methods of measuring case-mix in primary care. These case-mix measures will then be used to investigate variations in areas such as general practice prescribing, specialist referral, and hospital admission rates. These variations are important because they raise questions about how efficiently and fairly NHS resources are being used. They also have a major impact on health spending because the costs of health care increase dramatically when patients are referred to specialists. In the longer term, case-mix measurement could have a major role to play in resource allocation and performance monitoring in primary care.

In another project, I am collaborating with the Health of Londoners Project Team and London Office of the NHS Executive in developing a longitudinal study of primary care trusts in London. The aims are to determine the separate contribution of supply factors, and general practice and patient characteristics, on health status and the use of health services, at a primary care trust level. For example, one of the questions I will be investigating, which is great interest to the Department of Health, is whether increasing the supply of outpatient services will lead to an increase in general practice referral rates.

Finally, changes in health policy are not always driven by evidence, and when health policy is changed, relatively little is known about the effects of these changes on clinical practice or the delivery of health services. There is considerably more quantitative analysis of policy in the USA, and researchers in the UK can learn from this experience to improve our own research in this area.

Public health research

In addition to my primary care related research, I maintain an active research interest in important public health areas, such as inequalities, deaths from suicide, and cancer epidemiology. For example, one of the key components of the government’s strategy on health is a reduction in deaths from suicide. The commonest method of suicide is drug overdose, but traditionally very little information has been available routinely about the epidemiology of these deaths. I have helped to develop a system of monitoring deaths from overdose, and of identifying high-risk groups, to overcome this limitation. The database developed to do this is now being used extensively for research. Over the next few years, I aim to expand this research through increased collaboration with other researchers.

Methodological work

I also have some ongoing methodological work. In the past this has included the development of methods of measuring the socio-economic characteristics of general practice populations, and the development of databases for research on public health and primary care priorities. In the next few years, I envisage three main methodological developments.

• Firstly, I have established myself as a leader within the UK in the field of using large clinical and administrative databases to carry out evidence-based evaluations of health policy. I would like to further develop this area of work and develop methods of rapidly evaluating changes in health policy.
• Secondly, I would like to develop methods of evaluating the results of randomised controlled trials using primary care databases. 
• Thirdly, I would like to develop methods of evaluating referral guidelines, also using primary care databases. 

Research Collaborators

My research program has involved collaboration with researchers from several institutions in the United Kingdom and overseas. These institutions include:

• Imperial College London
• University College London
• University of California, San Francisco, USA
• Johns Hopkins University, Baltimore, USA
• Medical University of South Carolina
• University of Edinburgh
• UCLH NHS Trust
• Office for National Statistics
• Institute of Neurology
• University of Leicester
• St. George's Hospital Medical School
• Guy's, King's & St. Thomas' Medical School
• University of Nottingham
• Wandsworth Primary Care Research Centre
• Kent, Surrey & Sussex Primary Care Research Network
• Manor Health Centre, Clapham, London
• 3M Health Information Systems, Connecticut, USA
• London Health Observatory
• University of Southampton