Cure at a cost

January 20, 1995

It is five years since the Government launched its National Health Service reforms. These have had an impact not only on patient care, but also on academic medicine.Today, we highlight the pressures and changes which the health care revolution has brought to higher education, and examine how these may develop. Tony Culyer explains the thinking behind his task force's report, while other academics outline the educational trends in medicine, nursing and other allied subjects.

Health research is under threat. Some threats are obvious, at least to those who research in this field. But there is a more fundamental threat that is not at all obvious. It comes from a form of the two-culture syndrome - the culture of those whose responsibility it is to commission and deliver medical care to patients; and the culture of the research community.

Both are fishing in the same pool of finance and, unless each learns to appreciate a good deal more about the other, communicate effectively, and then commit themselves to a joint endeavour, there can be only one outcome - NHS research will wither. Many claim to be proud of our record in health research. The danger is real that we will have little to proud of, save another past, another history, another record of success turned sour.

Research supported by the NHS is of two broad kinds. One is medical; the other is broadly referred to as "health services research", which has in the past been a Cinderella in terms of resourcing. The settings of the activities researched are also broadly two: research in institutions such as university hospitals; and research into community services, such as GP practices and the community work of the professions allied to medicine. The second setting has also been a Cinderella - particularly inappropriate bias as care settings have increasingly shifted towards the community.

The main driver for NHS research is the need for research coming from the NHS itself. NHS-funded research programmes do not support fundamental research in either medical or social science subjects, unless these were of major significance to the NHS itself. There is thus a distinction, which is bound to be fuzzy at the margin, between the sort of research core funding by the funding council, and that which builds on it funded by the NHS, the research councils, and the medical research charities. This is the basis of the "dual support" system.

The NHS funds two types of research activity. It funds its own programmes, where priorities are set by the director of research and development on the advice of the central R&D committee, divisions within the Department of Health, and regional directors of R&D. Second, it funds on a selective basis the NHS costs of patient-based research funded by non-commercial research sponsors.

NHS funding of R&D has been complex, and only partially driven by the nature of the activity in question. The main streams of funding have been these: the Service Increment for Teaching and Research (SIFTR) allocated to regions according to the numbers of medical and dental undergraduate student; some "tasked" NHS executive funding for service support for R&D in general practice; ad hoc regional funding for service support costs of research conducted in NHS settings; other bits of discretionary regional funding; special but temporary research funding arrangements for the London Postgraduate Teaching Hospitals; the explicit funding of the department's and the NHS R&D strategy's programmes of research; and the implicit research funded by institutions whose medical and other staff engage in research not funded from other sources.

Probably the most deep-rooted problem is SIFTR, effectively a general subsidy for teaching hospitals. Non-SIFTR funding is an ad hoc measure to remedy the inaccessibility of this funding to research hospitals which have no undergraduates. But SIFTR excludes also district general hospitals and all other settings of care and research. Its lack of selectivity has meant that legitimate discontent was voiced both by researchers, whose experience has frequently been that the money was not targeted at the institutions level on supporting their activity, and by central managers, who really have no idea of what these funds are purchasing. Also long-standing has been the special arrangements that have protected the London Postgraduate Teaching Hospitals. Poor accessibility of research funding to other centres, including research based in community care settings, is an old problem.

A further long-standing problem has been lack of coordination. There is no top level at which those principally responsible for supporting health research can meet, share plans, avoid duplication, and plan for the joint support of research teams.

At the grass roots level, much "research" is conducted that has no relation to national or regional needs for R&D, and whose quality is largely unmonitored.

The NHS reforms also highlighted deficiencies in research funding mechanisms. The more successful purchasers are at negotiating contracts delivering what they ask, of a quality they require, and at the tightest price they can negotiate, the less discretionary cash is available for implicit research within provider institutions and the greater the reluctance of providers and purchasers to pick up the service costs of research patients in clinical trials, especially those conducted through several collaborating centres. Success in one internal market (patient care) has become prejudicial to success in another (research).

There are long-standing communication gaps between the NHS and the research community. Health authorities and trusts, even before their separation, tended to take a short-term view of research, wanting "quick and dirty" solutions to the particular puzzles that confronted them.

Moreover, many have interpreted what is essentially service development - an essential task of local management - as research, which it is not. There have been two distinct cultures, with little opportunity for the one to inform the other of its needs or to collaborate effectively, and a vocabulary whose meanings are not shared. The gaps have been intensified by the NHS reforms, which intensified the short-termism of the NHS and offered no mechanisms for useful mutual collaboration.

All this is contrary to one of the main thrusts of the NHS reforms and the NHS R&D strategy - the adoption of best (cost-effective) practice through dissemination and implementation of reliable R&D results and getting substantial reductions in the enormous and arbitrary variations observed in clinical practice.

The task force proposals set out to meet these problems. Several recommendations aimed at improved coordination of R&D policy centrally (via a forum for the funding bodies and a revamped central R&D committee to advise the director of R&D) and ensuring that purchasers and providers were better heard in central and regional processes through which R&D priorities for NHS research support are settled. Another set was directed at the separation and ring-fencing of R&D support so that health R&D could be identified, managed, accounted for and protected from being squeezed out by the internal market.

The recommendations involve putting all NHS R&D funding into a single stream and distributing it in the form of project and programme support, service-cost support, and research facilities support.

Another set was directed at creating an institutional framework through which researchers could justify their claims on resources, do so in competition with other researchers, and be accountable for the R&D contracts they won.

A fourth set was directed at opening funding mechanisms to Cinderella settings and disciplines, so that able teams would not be prejudiced in competition with the traditional R&D institutions.

A fifth set was directed at technical matters, ensuring a common basis of R&D costing, appropriate quality assurance and assessment, minimising the bureaucracy, and ensuring a manageable adjustment to the new arrangements.

The aims of transparency and openness can all too easily be sabotaged by those whom these virtues threaten. There is also a danger that the effectiveness of the proposed mechanisms, none of which is without financial cost, might be severely compromised by that fashionable but foolish form of political correctness which condemns all NHS spending not redounding to the immediate benefit of patients. This can only create under-investment in the human resources needed to implement the recommendations.

Research, especially high quality research, needs to be driven by the ultimate benefit it brings to patients. But the process of targeting funding where the best judgement suggests that it will do most good can never be costless. There is a trade-off between short-term patient benefit and greater future benefit. This trade-off should be biased towards the future partly because there is so much in current practice whose true benefit to patients is either highly uncertain or simply unknown, and partly because of the fast rate of introduction of new ways of doing things and of new ways of doing things that previously were simply not possible.

Research in the NHS matters not because of national pride. Research matters only when it is of high quality and is expected to yield important benefits to clients, some of which may come in the form of stopping them from becoming clients in the first place. NHS research is in this sense utilitarian. It is not for the private benefit of researchers indulging their fav-ourite hobby but for the usable knowledge that may benefit all.

Tony Culyer is deputy vice chancellor at the University of York, a member of the central R&D committee of the NHS, and was chair of the NHS taskforce whose report, Support for Research and Development in the NHS, was published by the Department of Health in September.

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