Increased pressure on resources has seen the development of health care that is based firmly on scientific proof. Olga Wojtas meets John Swales, the academic charged with carrying forward a pioneering new medical research strategy at the Department of Health.
Medical research is facing uncertain times. Funding for the National Health Service's five-year-old research and development programme is being overhauled in a radical reorganisation. Funds that have previously come through the Service Increment for Teaching and Research will now come into a single research funding stream, which subsumes eight former sources. Universities have generally welcomed the single funding stream as promoting the importance of research in the health service.
Stephen Dorrell, secretary of state for health, says the programme will revolutionise patient care. "The task for health services is to take advantage of the burgeoning progress of science, both to advance the treatment of disease and to devise realistic approaches to its prevention. If that commitment is to be delivered, health services need to invest in research and development," he says.
"It is no longer sufficient to rely on clinicians reading articles in learned journals. They need ready access to research results - an 'effectiveness index' on tap, as it were - and we need to make a serious commitment to ensure the results of modern medical science are made easily available to practising clinicians."
This pioneering approach, aiming to ensure health care is based on high-quality research, was spearheaded by Sir Michael Peckham who this month left the post of director of research and development for the Department of Health after five years. The new NHS strategy is the first of its kind in the world, and Sir Michael is now to become a consultant to other governments as well as heading a new science and health forum at University College London.
Under his leadership, research priorities have been determined by a Central Research and Development Committee through a "problem-led" rather than a "science-driven" approach. There is anxiety among academics that this approach could mean funding is skewed in favour of NHS work.
But medical schools must find it reassuring that Sir Michael's successor as director of research and development is a seconded academic - John Swales, professor of medicine at Leicester University since 1974.
Professor Swales was originally the sole academic staff member in the Leicester department, but built it up until he latterly headed a team of seven professors. He has been closely involved with the current DoH moves as a member of Sir Michael Peckham's CRDC and as chairman of the Culyer Implementation Group, which followed the Culyer Task Force's radical proposal of the single research funding stream. He insists the funding change will not have a significant impact before April 1998 and that "even then, it won't be cataclysmic".
Medical schools are involved in a survey of research costs and income in all NHS trusts. There will be an initial levy on health authorities in April to set up the single research budget, but funding will continue in the present way for 1996/97, with the full levy coming into effect in April 1997. The following year will see the establishment of a new quality assessment system. However, both the DoH's funding working group and competition and assessment working group are chaired by academics, respectively Alan McGregor, professor of medicine at King's College Hospital, and Sir Michael Bond, immediate past chairman of the higher education funding councils' joint medical advisory committee.
Universities have been appalled at the prospect of having to go through a second research assessment exercise, but when Sir Michael Bond's group draws up its proposals next autumn, it seems set to make as much use as possible of existing measures, minimising the need for a major review. And Professor Swales himself, giving evidence to the House of Lords select committee on science and technology, warned of the long-term implications of core funding based on assessment, if the system became draconian enough to destroy clinical research at a major institution.
This would be disastrous for the development of what I believe essential - the creation of a wide research culture in the NHS." In his evidence to the select committee, he was also alarmed by any rigid funding system that would hamper curiosity-driven, pre-protocol research, and recommended there should be non-earmarked money to support early studies and "early people".
Professor Swales wants to see closer integration between clinical research, basic research and health service research. And that demands greater understanding on the part of health-care providers and of higher education. "Whatever shifts of resources take place, each party has to recognise the needs of the other. Integration has to be the watchword because one side cannot work without the other."
The NHS has itself been commissioning research in areas where it feels existing or planned research does not meet its needs, such as the quality of life in residential care for elderly people who are mentally ill, the mental health of the NHS workforce, and social and ethnic variations in heart disease. Professor Swales would like to see much greater recognition of this work. "Because in the early days the DoH was not perceived to be strong in research, the research community has been very slow to recognise the extent of this work or its high quality.
"It's just as stringently peer-reviewed as academic work." He is particularly concerned about the lack of parity between higher education and the health services in career structures. Clinical academic careers are becoming increasingly pressurised, with research time being eroded by NHS service demands as well as by administrative and teaching duties.
Professor Swales is insistent that there has never been a greater need for scientific assessment of medical provision, given the increasing pressure on health services worldwide as a result of medical advances, the ageing population and increased public expectation. And he is optimistic that improving communication between higher education and the health service, and encouraging them to work together more closely, offers great opportunities to medical academics.
"The most striking thing in clinical medicine has been the development over the past couple of years of evidence-based care. People say it's a slogan, and the term may disappear, but it was recognised by all levels of management in the health service that with pressure on resources, you've got responsibilities to choose the most appropriate forms of health care," he says.
"And how do you know what is most appropriate? That can only be based on scientific evidence." In the Harveian Oration he gave last term to the Royal College of Physicians, Professor Swales told his audience that in the past it was possible to say that a particular procedure or drug was likely to be of proven benefit and should therefore be used. The fundamental and exclusive need was for more scientific data.
But now, the capacity for beneficial work in both science and medicine exceeds funds available. This leads to dangers of inefficiency and inequality. Inefficiency is the failure to obtain the best possible benefit from a feasible treatment, while the inequalities in health between different social groups are already well documented. Scientific research is only just beginning to wrestle with such broader issues, Professor Swales says.
As chair of the CRDC advisory group on cardiovascular disease and stroke, setting out priorities for research, he found himself under fire from medical colleagues for considering such issues of importance and value to the health service. One critic attacked the report because it expressed views that were not those of consultant cardiologists, and complained that epidemiologists, public health doctors and "people like that" had been involved.
Professor Swales is unrepentant. If the health services are to be effective, they must assess the relative value of what they can offer. And this is not a simple decision, since they are no longer in a position to accept everything that is shown to be of proven benefit. But he also stresses that while clinical professionals can inform this judgement, they cannot make it. While science can illuminate the question, it cannot provide all of the answers, he believes. "Science is a matter of observation and experiment. There are boundaries to science, and value judgements lie outside those boundaries. Who actually operates the value judgements? That can only be society."