Analysis: Clinical friends are good

A healthy partnership between universities and the NHS is essential to the reform of healthcare and to Labour's widening participation agenda. Claire Sanders reports on two such alliances.

The Leeds way
Health-related activity, including the biological sciences, accounts for a third of the £250 million turnover of Leeds University. Leeds is keen to develop this work further and to promote its university-health partnership as a model for the rest of the sector.

Peter Noble, the university's director of health development, said: "We want to create the university hospital of the future."

Last December, the joint strategy board for health met for the first time. It is a strategic partnership between the university, the local National Health Service and, crucially, the local authority, enabling an overview to be taken of health as well as of social work.

When Mr Noble was appointed from the NHS in 1998 to oversee the expansion of Leeds' health provision, he faced problems.

The medical school in particular had received disappointing research assessment exercise scores (nothing higher than 3a) and poor teaching quality assessments.

This was not a situation that vice-chancellor Sir Alan Wilson could allow to continue. "It was a gamble appointing me," Mr Noble said. "I was a general manager in the NHS, used to a more command-style economy."

Hugo Mascie-Taylor, medical director of the Leeds Teaching Hospitals NHS Trust, said: "The appointment of a trained manager was crucial. It was one step further down the path of corporate management - rather than relying on individual links."

A number of other developments also helped to pave the way for the establishment of the joint strategy board. In the mid-1990s the university created a faculty of health, embracing the schools of medicine, dentistry, psychology and healthcare studies and the Nuffield Institute for Health.

The trust was created at the same time. It is the country's largest acute trust, serving the whole of Leeds and the West Yorkshire conurbation. The university realigned its structures to reflect the new acute, community and primary-care services, with academic units linking teaching and research within clinical service.

And since 1996, the university and the NHS have shared an integrated research and development strategy. Leeds believes it was the first in the country to appoint a single individual to the post of both university faculty dean for research and NHS director of research and development.

Mr Noble argues that the collaborative approach has already produced clear results. The medical school is set to expand by 20 per cent, following a successful bid to widen participation in partnership with the University of Bradford. It achieved three 5s and three 4s in the 2001 RAE and bid successfully for the National Cancer Research Network coordinating centre and the NHS Translational Cancer Research Network.

The university was successful in bids to establish the Leeds Institute of Molecular Medicine and the Leeds Institute of Genomics, Health and Therapeutics. It also placed a successful bid in collaboration with universities and trusts across the Yorkshire and Humber region to house a regional hub for medical intellectual property rights.

Mike Smith is the man responsible for research policy in the trust and the university. "I originally worked for the NHS, but it became increasingly apparent that a joint post would bring about the sort of cooperation that was required between the university and the NHS," he said.

Professor Smith said the creation of a single trust in Leeds made his post possible. "My post puts flesh on the bones of the strategy of cooperation."

The university and the NHS are about to make another joint appointment for a senior research manager.

David Cottrell, director of learning and teaching (medicine) at the university, sees the expansion of the medical school in partnership with Bradford as crucial to the success of the university health partnership. "Bradford has a good track record in widening participation. It increased its intake of minority ethnic students on to its nursing course from 6 per cent to 19 per cent and simultaneously cut its dropout rate," Professor Cottrell said.

The two universities are targeting school pupils before they take their GCSEs, encouraging them through a mentoring system to stay at school. "We can't guarantee people places," Professor Cottrell said, "but we can give them a fighting chance."

Chosen students will be able to take a foundation year and then a year of Bradford's clinical science degree before entering year one, or, in some cases, year two of the Leeds medical degree.

"The approach is in tune with NHS thinking on multi-professionalism, giving flexible entry into different professions rather than wasting talent," Professor Cottrell said.

Peter McWilliam, dean of the School of Healthcare Studies, is also overseeing expanding student numbers.

Leeds is unusual for a Russell Group university in having a large school of nursing. It admits 390 pre-registration nursing students, another 40 midwifery students and 42 diagnostic radiographers a year.

"We can take the numbers, but the big bottleneck is in student placements. Hard-pressed NHS staff, with one eye on waiting lists, find it hard to take on students," Professor McWilliam said.

But he believes there has been a "radical shift" in university and NHS relations.

"We've moved from a purchaser-provider relationship to more of a partnership," Professor McWilliam said. "My local relationship with the West Yorkshire Workforce Development Confederation is good."

Karen Garner is the human resources manager for medicine and dentistry at Leeds. She works with the NHS on joint contracts and appraisal systems and to implement the Follett report (see opposite) The Follett report followed the inquiry into the Alder Hey body parts retention scandal. It recommended a number of changes to ensure clear lines of accountability and appraisal for those working for both the NHS and the university.

"Before Follett came out, we had already embarked on a job plan review," Ms Garner said. "This was a joint process with the NHS and the postgraduate deanery - which oversees the training of junior doctors."

The review found that some staff were working largely for the NHS and other staff were working largely for the university, but that their position was not reflected in their contracts.

"Staff were transferred so that everyone could work more efficiently. We make joint appointments and have joint job descriptions, but we needed to do more work on mapping lines of accountability. This was particularly important for the NHS, which has gone through a series of organisational changes," Ms Garner said. The impact of the new contracts for consultants and doctors is still unclear.

The university and the NHS are also working towards joint appraisal. "Appraisal for the NHS tends to mean weeding out those who can't do their jobs, whereas for the university it is more about personal development," Ms Garner said. "We are trying to marry the two approaches." A national scheme is being drafted and awaited.

To ensure good communication, the university has set up a Health Information Project, and Mary Renfrew, director of the Mother and Infant Research Unit, is overseeing it.

"This is a big university, and we want to ensure that our NHS and local authority partners know who to liaise with," Professor Renfrew said.

The project will consist of a large database, which will be a "portal" on the health activities of the university.

"It is not so difficult outlining the teaching activity, but bringing together all the research in both the university and the hospitals is more difficult. Eventually, anyone interested in health inequalities, for example, will be able to pull out who is working in that field," Professor Renfrew said.

But the path to a partnership is by no means smooth. The medical school has been without a dean for two periods, making collaboration more difficult.

This July, Ed Hillhouse will leave Warwick University for Leeds to take up the post. The last dean left in October 2001. "The shortage of clinical academics is a national problem," Mr Noble said.

Dr Mascie-Taylor said: "It has to be acknowledged upfront that the NHS is concerned primarily with delivering patient care, and the university is concerned primarily with research and teaching.

"Once that is acknowledged, we need to look at the areas we have in common and at how best to work together. These areas are growing, and there is now a new level of trust between universities and the NHS."

The Peninsula Medical School
When it comes to working with the local National Health Service, the Peninsula Medical School has one big advantage - it is new.

"We are free to align ourselves with the healthcare needs of the 21st century," said John Tooke, dean of the school.

"The government has put the patient at the heart of its reforms of the NHS, and the Peninsula Medical School reflects this - from how it relates to its NHS partners through to its curriculum and research priorities," he added.

The structure of the school, a collaboration between the universities of Exeter and Plymouth, reflects the reforming NHS.

The school's ruling body includes representatives from the newly created Strategic Health Authority for Devon and Cornwall, the three local acute trusts, the three primary-care trusts as well as representatives from public health, mental health and social care.

Pat Bailey, head of administration, said: "We treat all our NHS partners equally."

John Bligh is the associate dean responsible for the curriculum. "We contacted all the clinicians in the area and asked them what should be in the new curriculum," he said.

The syllabus contains 200 case presentations. Students at Peninsula, the first 1 of whom arrive this autumn, will learn through a problem-solving approach. Each case is structured to ensure that students cover a particular area of medicine.

"Research has shown that students learn facts far more efficiently this way than just sitting through a lecture," Professor Bligh said.

The school has employed a core team of lecturers whose research skills lie in the education field.

Each case study will put the patient's experience at the heart of the student's experience, and in keeping with this philosophy students will meet patients from day one.

"Students will be out in the community from the first day of their course, meeting patients in family centres, GP's surgeries or in mental health trusts," Professor Bligh said.

In common with other medical schools, students at the Peninsula Medical School will first go on the wards in year three. Before that, they will learn in the new Clinical Skills Centres.

"We have highly realistic models on which students will practise," Professor Bligh said.

"We will not have cadavers here, our experience is based on living patients."

Plymouth has a large school of nursing, and over time the two schools will share aspects of their curriculum.

"Our medics will also learn many of their clinical skills from nurses either out in the community or in the skills centres. We will be building a healthy respect for team-working," Professor Bligh said.

The school has established a series of posts called community clinical sub-deans. These will be the schools' links with the health community. Their tasks will be many and varied, ranging from assisting with community placements to assisting with special study units - these are units that allow students to research areas of particular interest to them. The units will make up 30 per cent of the total final assessment.

Students will be closely assessed throughout the course, and observations on their professional behaviour and judgements will feed into final assessments.

The school's students are carefully selected to ensure that they reflect the population of the Southwest.

"There are pockets of extreme rural deprivation here and we are working with schools in disadvantaged areas," said Judy Searle, associate dean responsible for admissions. "We have started a scheme called 'I can be a doctor too', which will develop over the years."

Forty-seven per cent of the first cohort are mature students, of whom 37 per cent are graduates. The school is looking for a wide range of qualities in its students. "We have not been constrained by A-level results," Dr Searle said.

Rob Sneyd, associate dean for facilities and a consultant anaesthetist, is well aware of the pressures on NHS staff.

"There is understandable anxiety among consultants about how all the new students will be taught. The new consultants' contract will also change working patterns in the NHS and will have an impact on the time consultants have to teach," he said.

The new school has model clinical academic contracts, drawn up before the Follett report, which take account of the need for joint appointments and appraisal. The school also recognises the need for a coordinated approach to research with the NHS, and is launching a project to jointly exploit intellectual property rights held by NHS partners.

Professor Tooke is determined to build the research strengths of the school. "The new medical schools are rather like new universities in respect of their research funding - there is no historical base to build on. We are lobbying the Higher Education Funding Council for England to make good this funding deficit."

The school has received £1.5 million from NHS research and development to fund its research infrastructure.

Russell Hamilton, regional director of NHS research and development, said:

"This funding will allow clinical research of direct relevance to the NHS to flourish."

With new buildings under construction in Plymouth and Exeter, there is excitement about the new school. "We want our students to be tomorrow's leaders in healthcare provision and agents of change," Professor Tooke said.

Major NHS policy documents

December 1997, The New NHS: Modern - Dependable
First white paper on the NHS by new Labour government aimed to abolish the internal market with integrated care. Set in place frameworks for ensuring national standards. Establishment of the National Institute for Clinical Excellence to draw up guidelines for clinical practice.

July 1999, Making a Difference
Set out government's commitment to extending the role of nurses, midwives and health visitors. First acknowledgement that the NHS had to provide quality practice placements and focus on more flexible curriculum.

October 1999, Agenda for Change
White paper proposed a new pay system for staff, due to be introduced over the next two years. It covered complementary reforms to the consultant contract and to the General Medical Services Arrangements for GPs.

November 1999, Supporting Doctors, Protecting Patients
Set out principles of self-regulation, based on putting the patient first. Led to the establishment of the Health Professions Council and the Nursing and Midwifery Council in April 2002. Paved the way for reform of General Medical Council and the introduction of revalidation of doctors. Education providers must comply with requirements of new bodies.

March 2000, Research and Development of a First Class Service: R&D Funding in the New NHS Set out to divide R&D into NHS priorities and needs and set out NHS support for science.

April 2000, A Health Service of All Talents
NHS workforce planning review that recommended new arrangements for workforce development. Called for more team-working across professional boundaries and more flexible courses. Led to establishment of Workforce Development Confederations, which bring together local NHS and non-NHS employers to plan healthcare workforces. WDCs have higher-education representation.

July 2000, NHS plan
Government's ten-year programme of investment and reform. Set in motion further expansion of student numbers across health professions. Called for an NHS Modernisation Board to oversee implementation of plan; and reform of postgraduate medical education through Medical Education Standards Board.

January 2001: Alder Hey inquiry: led to reform of organ retention procedures.

March 2001, Research governance framework
Framework for health and social care research published.

May 2001, Labour manifesto
First mention of the University of the NHS, to provide new learning opportunities for NHS workforce.

July 2001, Bristol Royal Infirmary Inquiry report
Ian Kennedy called for pilot of a common core curriculum and said the public should be more involved in selection of medical students.

August 2001, Modernising Regulation in the Health Professions
Consultation document seeking views on functions of the Council for the Regulation of Healthcare Professionals and extent to which it should cover education.

September 2001, Follett review
Review of arrangements for managing medical and dental consultants with joint NHS-university contracts.

September 2001, Shifting the Balance of Power
Proposed that by 2002, two-thirds of health authorities be replaced by 30 strategic health authorities. NHS trusts and primary-care trusts are accountable to new health authorities.

November 2001, Working Together - Learning Together: A Framework for Lifelong Learning in the NHS
Framework to ensure students can transfer between health courses. Called for common core skills, well-supervised placements and a "skills escalator" for NHS staff.

April 2002, Delivering the NHS Plan: Next Steps on Investment and Reform
Further expansion of health student numbers, but no new expansion of medical schools. Linked health and social care reforms. Called for establishment of single Commission for Healthcare Audit and Inspection, bringing together work of the Audit Commission with the Commission for Health Improvement. Proposed Commission for Social Care Inspection and standards bodies for social care.