Health research systems in change: the case of 'Push the Pace' in the National Institute for Health Research.

BACKGROUND: Those running well-organised health research systems are likely to be alert for ways in which they might increase the quality of the services they provide and address any problems identified. This is important because the efficiency of the research system can have a major impact on how long it takes for new treatments to be developed and reach patients. This opinion piece reflects on the experience and learning of the United Kingdom-based National Institute for Health Research (NIHR) when it implemented continuous improvement activity to improve its processes. DISCUSSION: This paper describes the structure and work of the NIHR and why, despite is successes as a health research system and ongoing local continuous improvement, it believed in the value of an organisation-wide continuous improvement activity. It did this by implementing an approach called 'Push the Pace'. Initially, the organisation focused on reducing the amount of time it took for research to transition from an early concept to evidence that changes lives. This scrutiny enabled the NIHR to realise further areas of improvement it could make - additional goals were increased transparency, process simplification, and improved customer and stakeholder experience. We discuss our experience of Push the Pace with reference to literature on continuous improvement. CONCLUSION: Continuous improvement is a cycle, an activity that is done constantly and over time, rather than an act or linear activity (such as Push the Pace). We believe that the work of Push the Pace has initiated a strong commitment to a culture of continuous improvement in the NIHR. This is significant because culture change is widely recognised as immensely challenging, particularly in such a large and distributed organisation. However, our biggest challenge will be to enable all staff and stakeholders of the NIHR to participate in the continuous improvement cycle.

Carbon cost of pragmatic randomised controlled trials: retrospective analysis of sample of trials.

OBJECTIVE: To calculate the global warming potential, in carbon dioxide (CO(2)) equivalent emissions, from a sample of pragmatic randomised controlled trials. DESIGN: Retrospective analysis. Data source Internal data held by NIHR Evaluation, Trials and Studies Coordinating Centre. Studies included All eligible pragmatic randomised controlled trials funded by the NIHR Health Technology Assessment programme during 2002 and 2003. MAIN OUTCOME MEASURE: CO(2) equivalents for trial activities calculated with standard conversion factors. RESULTS: 12 pragmatic randomised controlled trials involving more than 4800 participants and a wide range of technologies were included. The average CO(2) emission generated by the trials was 78.4 (range 42.1-112.7) tonnes. This is equivalent to that produced in one year by approximately nine people in the United Kingdom. Commuting to work by the trial team generated the most emissions (average 21 (11.5-35.0) tonnes per trial), followed by study centres' fuel use (18 (9.3-32.2) tonnes per trial), trial team related travel (15 (2.0-29.0) tonnes per trial), and participant related travel (13 (0-46.7) tonnes per trial). CONCLUSIONS: CO(2) emissions from pragmatic randomised controlled trials are generated in areas where steps could be taken to reduce them. A large proportion of the CO(2) emissions come from travel related to various aspects of a trial. The results of this research are likely to underestimate the total CO(2) emissions associated with the trials studied, because of the sources of information available. Further research is needed to explore the additional CO(2) emissions generated by clinical trials, over and above those generated by routine care. The results from this project will feed into NIHR guidelines that will advise researchers on how to reduce CO(2) emissions.

Setting the future policy agenda for health technology assessment: a specialty mapping approach.

BACKGROUND: There is a need for innovative methodologies to identify and prioritize topics for health technology assessment (HTA). A pilot project to evaluate the methodology for specialty mapping was undertaken in the area of child and adolescent health. Two case studies are presented, in the area of sexually transmitted infections and acute pain. METHODS: The methodology comprised sequential stages, based on principles of systematic review. A "stakeholder model" encouraged wider participation. Key stages included identifying the topic area and setting the scope; developing a care pathway; searching for clinical guidelines/guidance, and evaluation literature; synthesis and mapping of literature to the "nodes" of the care pathway to highlight gaps; prioritizing the topics with stakeholders; and referring priorities to the appropriate agencies. RESULTS: A total of thirty guidelines/guidance documents and sixteen evaluation studies were mapped across the two case studies. In some nodes of the care pathway, more literature was mapped than others, suggesting important gaps in research and policy guidance. Sixty-two policy questions were identified and were rated by stakeholders in prioritization workshops. The highest priorities have been considered by senior committees for likely commissioning as research or guidelines/guidance. CONCLUSIONS: This is one of the few published examples of innovative methodology to identify and prioritize topics for HTA. Specialty mapping can make a positive contribution to the policy agenda, with several research and policy gaps being fed into existing prioritization channels. Adequate time, resources, and capacity is required particularly in engaging stakeholders and developing a care pathway. Implementation of specialty mapping in other topic areas with on-going evaluation is recommended.