Applying a Health Network approach to translate evidence-informed policy into practice: A review and case study on musculoskeletal health

Given the current international and national data on chronic disease prevalence, future projections, and the associated health sequelae and healthcare costs [1‐3], which clearly demonstrate an exponential escalation that is economically unsustainable, optimisation of healthcare delivery in this area is a health policy and whole-of-government imperative [4‐6]. Three specific challenges are faced by policymakers in trying to optimise healthcare delivery, including (i) identifying effective evidence-based interventions to address health problems; (ii) identifying how to best integrate these into health systems; and (iii) identifying how to best drive these changes across health systems [7]. Although there is a significant body of high-level evidence demonstrating ‘what works’ in clinical practice, for example through clinical trials, clinical practice guidelines, and Cochrane systematic reviews, far less evidence is available to guide how to successfully translate such evidence into policy and widespread practice [7]. While the uptake of evidence to inform policy in some circumstances may be rapid; for example, the removal of government subsidies for vertebroplasty procedures for osteoporotic vertebral fractures in Australia in response to two recent randomised controlled trials [8, 9] and a meta-analysis [10] which demonstrated no clinical benefit for the procedure; this policy response is reactive and less preferable than a standardised, incremental approach to evidence translation into policy. Notwithstanding the knowledge gap in effectively translating evidence into policy, the literature on the effectiveness of various strategies for achieving evidence integration and translation is growing. The Cochrane Effective Practice and Organisation of Care (EPOC) Group has completed 92 systematic reviews of interventions designed to improve the delivery, practice, and organisation of health care services, and protocols for a further 49 systematic reviews in this field [11]. Further, the Health Systems Evidence database contains over 4000 systematic reviews, evidence briefs and other syntheses of research evidence on governance, financial and delivery arrangements within health systems, and interventions designed to support change in health systems [12].

In a review of literature on evidence integration and translation in health care policy, Mitton et al. [13] identified a number of key strategies for achieving evidence integration, including i) face-to-face exchange between decision-makers and researchers (for example to gather information on current practices, develop relationships and broker involvement in change implementation); ii) the use of Networks and/or Communities of Practice; iii) capacity-building within health services and health delivery organisations (for example, enhancing capacity to implement health promotion programs, providing training in critical appraisal of research literature); and iv) use of steering committees to harness strategic input from local experts into future research and evidence-informed policy development. Notably, because the focus of these strategies is on the establishment of bilateral communication and stakeholder involvement, the development of trustworthy relationships between research partners was identified as a central factor to their success. The same factor was also identified by more recent primary research [14, 15] and consensus opinion [16], and mirrors the benefits of involving stakeholders in policy development [17]. Haynes et al. [15] recently reported data derived from policymakers on the barriers and facilitators to effective engagement with researchers. Identifying trustworthy researchers who understood the political environment and government processes was a key challenge discussed. Given this pivotal role of relationship building, how can meaningful and effective relationships be forged between stakeholders, be fostered, and be used to drive translation of evidence into policy and practice?

One strategy to help build and strengthen critical relationships between stakeholders in healthcare is to target the disconnect between evidence and health policy and practice through the use of a Health Network or Community of Practice (CoP) approach [18, 19]. A network is a partnership, collaboration or alliance between individuals and/or organisations that are connected in some way, such as through shared interests, professional roles, or organisational linkages [20, 21]. A CoP uses the Network model to develop a collective, or ‘community’, to share information, solve problems and drive innovation in an area of common interest and understanding [22]. Given the greater accessibility to health services now provided by information and communication technologies such as telehealth, eHealth, and edoctor, the concept of a CoP has expanded beyond the traditional face-to-face forum to include virtual CoPs, potentially reducing some of the geographic barriers and competing work and lifestyle commitments which limit opportunities for face-to-face encounters for consumers and healthcare professionals [23, 24]. The formation of virtual CoPs may also open opportunities for exchange in developing nations and between jurisdictions [25].

In complex systems such as health, and especially in the context of chronic disease where system reforms are inherently multifaceted, Networks offer a potential solution to informing and implementing organisational change, and facilitating the alignment of evidence-informed policy and practice. This is achieved principally through the engagement of multidisciplinary stakeholders to form working relationships in order to identify and develop solutions to system barriers. While the concept of a Network model is not new, its application to influencing organisational change in the health sector in an integrated and formal manner is an emerging field of interest for researchers and policymakers [18]. Evidence to substantiate the effectiveness of Networks in tackling clinical health issues is accumulating [20, 26‐32], and a similar Network approach has been adopted in other fields, for example environmental science [33]. While discrete Networks such as clinical Networks, policy Networks, and service management Networks may evolve naturally, these Networks are potentially siloed due to disparate perceived stakeholder interests and varying scopes of influence or professional training focus. Siloed Networks may be less effective in bridging evidence-policy-practice gaps across the broader health continuum because their goals, activities and functions are perceived to be independent of one another. In contrast, the sphere of influence, and therefore effectiveness, of a multidisciplinary (or multiple-stakeholder) Network may be substantially greater [18, 30, 32, 34] because collective efforts and diverse skill sets can be harnessed towards a common goal. The aim of this paper is to provide an overview of Health Networks in Western Australia (WA) and to describe a case study of the application of a multidisciplinary Health Network model to the development of evidence-informed policy and service delivery for consumers with musculoskeletal health conditions.

In Australia, musculoskeletal health is recognised as a National Health Priority Area, attributed to the profound social and economic burden of conditions such as osteoarthritis, rheumatoid arthritis, osteoporosis and pain of musculoskeletal origin [41, 42]. In recognition of the social burden of musculoskeletal health conditions, a suite of evidence-based and consumer-centred musculoskeletal Models of Care has been developed by the WA Musculoskeletal Health Network. These Models of Care serve as a platform to improve service delivery in musculoskeletal health, specifically for inflammatory arthritis, spinal pain, elective joint replacement surgery for osteoarthritis, and osteoporosis [43‐46], and complement a National Service Improvement Framework [47] as well as Models of care from other states, particularly New South Wales (NSW) [48‐50]. Consistent with broader policies for chronic diseases [6, 51], the WA Models of Care for musculoskeletal health provide recommendations concerning the delivery community-based, interdisciplinary care for consumers and carers across the care continuum. For example, the establishment of community-based, multidisciplinary rheumatology/musculoskeletal health services was identified as a key recommendation in the Inflammatory Arthritis Model of Care [43]. This recommendation highlights a substantial change in historic service delivery in the public health system for this clinical area. In WA, public rheumatology care has been delivered primarily in the tertiary hospitals for residents of the metropolitan area. Establishment of community-based services promotes the transition of care from tertiary hospitals to community facilities to improve ease and equity of access to care, improve cost effectiveness, and ease pressure on tertiary hospitals. Here, we present the implementation of this initiative as a case study to demonstrate the application of a Health Network approach to achieving translation of evidence into policy and practice.

The WA Musculoskeletal Health Network (http://​www.​healthnetworks.​health.​wa.​gov.​au/​network/​musculoskeletal.​cfm), one of 18 WA Health Networks, was established in 2006. The strategic direction of the Network is guided, through consultation, by a multidisciplinary (including consumers and carers) Executive Advisory Group (EAG) of 17 members. Activities undertaken by the Network (e.g. developing Models of Care or other policies, undertaking specific projects, developing business cases or policy implementation plans) are performed by multidisciplinary working groups which are convened from the broader Network of members and are led by a clinical ‘champion’ or clinical lead. These working groups report to the EAG. The EAG and working groups are supported by a dedicated Network officer/manager from the Department of Health, within the Division of System Policy and Planning. The Networks do not have access to recurrent funding. At September 2012, there were 3075 stakeholders registered with the WA Health Networks, of which 2713 (88.2%) receive regular communication about Network-related activities. 546 stakeholders are registered with the Musculoskeletal Health Network and 503 (92.1%) receive regular communication about Network activities (Table 1). Models of Care have been developed by the Musculoskeletal Network since 2006, with the most recent Model of Care published in 2011. The Network has also contributed to the development of state-wide strategic frameworks addressing chronic diseases [6, 51].

The authors undertook a review of Network-related activities over the last three years which aligned to the Network objective of delivering evidence-informed health services to consumers with musculoskeletal health conditions. The review focused on outcomes and the processes used to achieve this objective in the context of: i) development of policy; ii) procurement of funding; iii) stakeholder engagement, specifically the identification of partnerships with individuals or organisations which have been associated with policy or project outcomes; iv) publications; and v) projects undertaken by the Network which aligned to implementation of Models of Care. The review was informed by operational reporting undertaken by the Network officer, discussions with leaders of Network working groups, reports from working groups, reports from the EAG, and information gathered from a large stakeholder forum held in 2011 [52].

The review identified a range of activities undertaken by the Network which aligned to development and implementation of the Models of Care for musculoskeletal health, particularly in the areas of establishing services, workforce development and encouraging active self-management by consumers.

In WA, four Models of Care have been produced for musculoskeletal health [43‐46], all of which are now at the stage of implementation and are supported by broader policy frameworks [6, 51, 53]. Broader policy frameworks provide the added advantage of raising the profile of Models of Care within government and better integrating them with the broader health policy directions. Implementation projects are being led by local clinical leaders in the areas of spinal pain, inflammatory arthritis, osteoporosis and elective joint replacement surgery for osteoarthritis. The projects are supported by the broader Network and the government officers. We present a specific case related to the implementation of the Inflammatory Arthritis Model of Care [43].

Over a three-year period since the completion of the Inflammatory Arthritis Model of Care, strategies to address specific policy implementation challenges have been used to drive implementation of this Model of Care (Table 2), and others. The outcomes of applying the Health Network approach to implementation of this policy are summarised below.

Across the four Models of Care, many of the Network projects were integrated to achieve the broad aim of improved access to, and delivery of, services for consumers with musculoskeletal health conditions. The strategy to integrate Network-led projects enables an incremental and coordinated approach to more successfully addressing challenges around health system redesign. This exemplifies the value of moving from silos of independent activity in clinical, policy and research arenas, to a co-ordinated approach facilitated through a Network model. Examples of other Network-led projects linked with recommendations in the Models of Care and which are purposely linked to the community-based rheumatology service are summarised below.

While the implementation stage of the WA Models of Care varies, overall, the use of a Network approach has contributed to the success of developing and implementing recommendations from these policies. The Network approach we describe for developing evidence-informed policies and their translation into practice has achieved some important outcomes for WA. For example, in addition to achieving specific health system improvements in musculoskeletal health, most notably for inflammatory arthritis [54, 55] and spinal pain [56‐59, 62], and influencing national health reform debates and strategies in these areas [42, 63], the WA Models of Care are now recognised as critical components to health-related policy, planning and funding decisions in WA. Specifically, Models of Care are used by non-government organisations to set strategic directions and inform development of business cases, by state health services to improve existing clinical service models or establish new models, by state infrastructure and clinical services planning divisions to reach decisions on the locations and facilities required to deliver services [64], and in state funding allocation decisions. Similar outcomes are being realised in NSW with the development and release of Models of Care for musculoskeletal health in that state through the NSW Musculoskeletal Network [48‐50].

In the context of musculoskeletal health, important outcomes have been achieved in WA which are likely to promote sustainability of the WA Health Network approach and foster an ongoing policy-into-practice research agenda. The sustainability of the Network model itself is most likely related to the achievement of positive outcomes (organizational success), for example the establishment of a community-based rheumatology service and reconfiguration of service delivery in pain medicine units [56]; social inclusion amongst a community of stakeholders (social inclusion) [65]; and emerging evidence for improved consumer health [56, 58], all of which build resilience and foster sustainability for the Network [66]. These outcomes underline the potential system improvements and consumer health gains achievable using a Health Network model with a phased and coordinated implementation approach that involves cross-discipline stakeholders and consumers, and highlight the importance of developing evidence-informed and contextually appropriate policy to enable contextually feasible implementation initiatives [38]. Strategies amenable to Networks may therefore prove successful in overcoming previous attempts by government to tackle specific clinical issues and that have historically been less effective and sustainable.

Implementing health service delivery changes to better address chronic health conditions is challenging due to the complex aetiology of these conditions, the multiple stakeholders required in order to achieve optimal consumer outcomes, and the historic design of healthcare systems to address acute healthcare needs in hospitals rather than long-term healthcare needs in community settings. From an implementation perspective, the Health Network approach is effective because it i) connects stakeholders from across the health sector – researchers, clinicians, consumers, policy-makers and so on, and ii) provides mechanisms and pathways for action. Without the Health Network model, formalised and regular connections between these stakeholders would not otherwise occur, as highlighted recently [15]. In the context of musculoskeletal health, this approach is particularly useful since the majority of service delivery in this clinical area occurs in ambulatory care settings; hence, effective integration among stakeholders across primary care and hospital-based care is critical to achieving seamless service delivery for consumers. The case study described in this paper involved multiple stakeholders, in particular the establishment of a partnership model among researchers, clinicians and policymakers. The effectiveness of the WA Health Network approach is not only attributable to cumulative implementation efforts, that is by integrating several projects, but also reflects successful engagement with local, domain-specific leaders and support from the broader Network. The identification of local, domain-specific leaders, often termed ‘champions’, supported within a distributed leadership framework, is well recognised as effective model to promote change, motivate participation from others and drive complex and multidimensional projects [32, 67, 68] and has also been identified as a facilitator to successful evidence integration and translation in health care policy [13]. This type of organisational model, particularly the support of local leaders, has been shown to be effective across different health areas [69, 70].

The WA Health Network approaches align strongly with the recognised need for research evidence to inform and optimise public health policymaking [71, 72], especially in the context of chronic health conditions [6, 51]. In Australia, the National Health and Medical Research Council (the nation’s main funding source for health research) also recognises this need and now supports partnership projects among research leaders and policy leaders [73], while at a state level, grants are offered to enable the translation of policy into practice through the State Health Research Advisory Council’s Research Translation scheme [74]. While opportunities to explore evidence translation into policy and policy translation into practice are emerging in a research context, and may be supported by a Health Network approach, resources to support broader implementation of evidence-based programs and policy recommendations are less attainable.

As evidence for the strength of Network (or partnership)-based health improvement initiatives accumulates, access to funding opportunities and organisational support, particularly that of middle-management, to drive the implementation of service reforms will be important because effective program implementation is difficult and often requires specific expertise combined with organisational support to achieve sustainable success. For example, the effectiveness of various program implementation initiatives will vary; such that a well-supported, average program may well outperform a poorly supported, high-quality program [75]. Therefore, developing implementation expertise within the Health Networks will be important for delivering innovative and sustainable health reforms in WA, particularly in rural WA [76]. Further the Health Networks will need to constantly adapt and respond to the emerging Australian health reforms and develop innovative means to maintain effective communication between stakeholders, for example through electronic modes of communication, such as social media, as stakeholders’ expectations for modes of communicating change from traditional face-to-face and email exchanges. A further challenge for the Health Networks will be to maintain alignment of the Models of Care with contemporary evidence. A notable limitation of the Network process is the time taken to develop a Model of Care or implementation plan, usually in the order of 1–2 years. While effective consultation is time-consuming, protracted development processes may stymie ability to respond quickly to emerging opportunities and disenfranchise members due to the perception of inaction and unnecessary processes.