Service Delivery Research: Researcher-Led or Manager-Led?

The implication behind much Service Delivery Research is that it is researcher-led. After all, it is called “research”. But is this the correct way to conceptualise such research when its purpose is to evaluate an intervention?

For a start, the researcher might not have been around when the intervention was promulgated; many, perhaps most, service interventions are evaluated retrospectively. In the case of such ex-post evaluations the researcher has no part in the intervention and cannot be held responsible for it in any way – the responsibilities of the researchers relate solely to research, such as data, security and analysis. The researcher cannot accept responsibility for the intervention itself. For instance, it would be absurd to hold Nagin and Pepper [1] responsible for the death penalty by virtue of their role in evaluating its effect on homicide rates! Responsibility for selection, design, and implementation of interventions must lie elsewhere.

But even when the study is prospective, for instance, involving a cluster RCT, it does not follow that the researcher is responsible for the intervention. Take, for instance, the Mexican Universal Health Insurance trial.[2] The Mexican Government promulgated the intervention and Professor King and his colleagues had to scramble after the fact, to ensure that it was introduced over an evaluation framework. CLAHRCs work closely with health service and local authority managers, helping to supply their information needs and evaluate service delivery interventions to improve the quality / efficiency / accountability / acceptability of health care. The interventions are ‘owned’ by the health service, in the main.

This makes something of a nonsense of the Ottawa Statement on the ethics of cluster trials – for instance, it says that the researcher must ensure that the study intervention is “adequately justified” and “researchers should protect cluster interests.”[3]

Such statement seems to misplace the responsibility for the intervention. That responsibility must lie with the person who has the statutory duty of care and who is employed by the legal entity charged with protecting client interests. The Chief Executive or her delegate – the ‘Cluster Guardian’ – must bear this responsibility.[4] Of course, that does not let researchers off the hook. For a start, the researcher has responsibility for the research itself: design, data collation, etc. Also, researchers may advise or even recommend an intervention, in which case they have a vicarious responsibility.

Advice or suggestions offered by researchers must be sound – the researcher should not advocate a course of action that is clearly not in the cluster interest and should not deliberately misrepresent information or mislead / wrongly tempt the cluster guardian. But the cluster guardian is the primary moral agent with responsibility to serve the cluster interest. The ethics of doing so are the ethics of policy-making and service interventions generally. Policy-makers are often not very good at making policy, as pointed out by King and Crewe in their book “The Blunders of Our Governments”.[5] But that is a separate topic.

— Richard Lilford, CLAHRC WM Director

References:

  1. Nagin DS & Pepper JV. Deterrence and the Death Penalty. Washington, D.C.: The National Academies Press, 2012.
  2. King G, Gakidou E, Imai K, et al. Public policy for the poor? A randomised assessment of the Mexican universal health insurance programme. Lancet. 2009; 373(9673):1447-54.
  3. Weijer C, Grimshaw JM, Eccles MP, et al. The Ottawa Statement on the Ethical Design and Conduct of Cluster Randomized Trials. PLoS Med. 2012; 9(11): e1001346.
  4. Edwards SJL, Lilford RJ, Hewison J. The ethics of randomised controlled trials from the perspectives of patients, the public, and healthcare professionals. BMJ. 1998; 317(7167): 1209-12.
  5. King A & Crewe I. The Blunders of Our Governments. London: Oneworld Publications, 2013.
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One thought on “Service Delivery Research: Researcher-Led or Manager-Led?”

  1. Thank you for this. I would be interested in your view as to who’s responsible for the science and ethics of the cluster randomised age extension triall. Originally it was going to be an assesment of the size of the anticipated benefit of a programme half rolled out as not enough government money. Later, (with an unchanged design and still no informed consent) it flipped into a trial of an intervention with equipoise as its underlying justification. What would be most interesting is your assessment of the quality of both the original and revised protocols – neither of which seem to have been peer-reviewed. Is this good or bad science? Please have a look here for the ongoing saga and protocols (obtained only after asking via FOI) over four installments. https://www.healthwatch-uk.org/news/83-age-extension-trial-of-mammography-screening-update-june-2015.html

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