Moves to get the NHS fighting fit

Claire Sanders looks at how the relationship between universities and the National Health Service can be improved in such a way that both sectors will benefit

The relationship between universities and the National Health Service is central to the success of both - yet it is rarely understood or valued.

But if Labour's second term in office, expected to begin this morning, is to be a success it has to work. The NHS plan, published last July and billed as the last chance to save the NHS, depends on it. It is a highly political battleground. Labour's plans for the NHS and, in particular, its university for the NHS featured prominently in the election campaign.

Ministers are only just realising that if they are going to save the NHS they need the universities on board. In March, the secretaries of state for health and education met for the first time to discuss the relationship.

The importance of the NHS for universities is equally underestimated. "The NHS is the biggest single employer of graduates and the second biggest funder of universities after the funding councils," said Sir Martin Harris, vice-chancellor of the University of Manchester and chairman of the Universities UK health strategy group. "For some universities, as much as a third of their funding now comes from the NHS."

If the NHS plan proves a liability, universities could find themselves embroiled in the government's efforts to resurrect it. In particular, medics fear a secret agenda to move the funding of medical students from the higher education funding councils to the Department of Health.

"The attraction for [the DoH] is greater central planning - the ability to produce specialist doctors, trained primarily as technicians, quickly. We would vigorously resist the move. It would render our qualifications meaningless internationally. We educate people to think and would not want to be training barefoot doctors for the NHS," the head of one prestigious medical school said.

For universities to deliver on the NHS plan, a highly complex and fast-evolving set of relationships have to work smoothly. Universities and the NHS have to deliver on what is called the tripartite mission - that is education, research and service (patient care). And for the first time they have to do it across a number of subject areas including nurses, midwives, professions allied to medicine and health scientists as well as doctors and dentists.

A summit meeting was held last October. It involved officials from the DoH, the Department for Education and Employment, the Higher Education Funding Council for England and Universities UK. This led to the meeting between ministers to discuss the university/NHS interface in March.

Janet Finch, vice-chancellor of Keele University and the UUK lead representative on the health professions at the summit, said: "The meeting was significant because it showed the commitment from the top to getting this relationship right. For too long, officials in the two departments had not been coordinating policies."

Professor Harris is equally adamant that there is now a push from the top. "Five years ago, the then Committee of Vice-Chancellors and Principals published a report on the contribution of universities to the NHS. It fell like a stone into a still pond. That has now changed," he said.

Next month, the UUK is expected to publish another major report on the area - giving full recognition for the first time to the importance of nurses and other health professionals.

The report is timely. In March, the Nuffield Trust published a highly critical report of the NHS/university interface. Like many such reports to date (at least 14 since 1987), it focused mainly on the interface between medical and dental schools and the NHS.

Called University Clinical Partnership: A New Framework for NHS/University Relations , it concludes: "The context of NHS/university relations has... outgrown the current framework. The NHS is predominantly focused on service, whereas in universities the priorities are research and education... There are... very few incentives to align research, education and clinical service strategies."

It made a number of proposals for clinical partnerships to overcome these problems. And it recommended that the ten key principles set out in 1990 to underpin NHS/university relations should be revised to include a greater service element. This would make them more applicable to nurses and other health professionals.

Professor Finch said: "To some extent this has already been done with the publication in October 1999 of a report on the partnership between universities and the NHS on nursing and other health professions."

Professor Harris said: "I believe that the commitment from the top to making the relationship between universities and the NHS work is going to make a significant difference. But I would be concerned at an over-centralised approach. You cannot expect a model that works well in Newcastle, for example, to be appropriate in London."

As well as getting the framework right for this relationship, universities have to produce - they have to educate the huge increase in student numbers envisaged in the NHS plan and they have to deliver on research.

The education challenge

Universities are expected to deliver increases in medical, nursing and other health student numbers against a fast-changing funding regime and highly complex quality assurance arrangements.

In late March, Hefce, acting on proposals in the NHS plan, announced the results of the latest bidding exercise for 1,000 extra medical school places. Medical intakes have increased by about 50 per cent since 1998.

Michael Powell, executive secretary of the Council of Heads of Medical Schools, is confident that universities can deliver on these numbers, but with a significant proviso. "We need the applicants. Over the past six years, the number of home applicants has fallen by almost 20 per cent," he said.

There is yet to be research on why applications have fallen, but the student-funding regime and the widely publicised stresses faced by the medical profession - particularly junior doctors - are believed to play a key part. The NHS has a careers section that many heads of medical schools believe should be doing more to promote medicine as a career, similar to the Teacher Training Agency for teachers.

Professor Finch said: "For a long time, students may have been put off medicine as there were few places and the area was so competitive. We need to get across the message that there are now more places and we are looking for a wide range of talented people."

Medical schools also need the staff to teach these new students. The DoH has announced a scheme to provide funding and a more secure career path for clinical academics, but in certain subject areas there is a shortage of academics coming through. The NHS plan proposed an increase of 5,500 nurses and 4,450 therapists and other health professionals entering training each year by 2004.

Professor Finch said: "The new workforce development confederations, which came into place this April, will be contracting with universities to decide numbers.

"We need to work with them to ensure a planned and realistic approach. It cannot be done unless more funding is put in."

In March, the National Audit Office published Educating and Training the Future Health Professional Workforce for England . Sir John Bourn, controller and auditor-general, called for joint responsibility for providing practice placements, more effort to reduce dropout rates (they averaged one in six students, in line with all university courses, but were as high as 20 per cent on some courses) and the need for more investment if expansion were to be sustained.

In April, the three NHS education and training levies for funding nurses and other health professions, as well as undergraduate and postgraduate medics, were merged under one unit in the DoH. Although they still operate separately in practice, officials are working on closer integration.

"We would be concerned if there were to be transfers of funding away from medical education," Mr Powell said.

The quality regime for medical, dental, nursing and other health courses is also in need of streamlining. Students have to come out fit to work on a hospital ward, meeting the requirements of the professional bodies and meeting the academic requirements of the university. Adding to the complexity, the regulatory bodies are themselves undergoing reorganisation.

Norma Brook, who has just been appointed chair of the shadow Health Professions Council, which will replace the Council for Professions Supplementary to Medicine next April, said: "I am committed to continuing discussions with the Quality Assurance Agency on how to streamline quality regimes."

And, on top of all this, Labour wants a core curriculum for medics, nurses and other health professions to help break down what health secretary Alan Milburn has called "tribalism" within the NHS. It is not yet clear what is meant by this, although a number of universities have started to develop joint courses in areas such as ethics and communications.

The research challenge

For medics, nurses and other health professions, the problem is to deliver quality research, to teach and to care for patients at the same time. All of these subject areas did badly in the last research assessment exercise.

For nurses, the problem is acute as nursing traditionally has had no research-funding stream. It does badly in the RAE and is therefore not awarded money. This creates a vicious circle.

Paul Turner, executive officer of the Council of Deans of Nursing, said:

"We are lobbying Hefce for a capability fund."

A report on nursing research for the DoH and Hefce is expected from the Centre for Policy in Nursing Research at the London School of Hygiene and Tropical Medicine this summer.

After the last RAE, a number of measures were put in place to help health-related subjects. Some of the units of assessment for medical and medical-related subjects now have a number of sub panels. These include members nominated by the DoH, non-academic users of the research, as well as academics. In the last RAE it was argued that these units were too broad and that papers were not being considered by experts or users in the field.

Long-standing funding problems remain. Medical schools argue that their research overhead costs are not being met under the dual-support system of funding.

The modernisation of the NHS and research and development funding, currently being undertaken by Sir John Pattison, director of research and development at the DoH, will help to ensure that money intended for research in the NHS is not used for patient care. Sir John is consulting on a research governance framework in the NHS and a new funding regime that will see two funding streams - support for science (infrastructure funding) and support for priorities and needs (individual projects).

CASE STUDIES

Oxford

Ken Fleming heads the medical sciences division at Oxford University, one of the five divisions created to streamline administration.

On the research side, the medical sciences bring in about £75 million of external research funding to the university, out of a total of £120 million. About £28 million of this is from the Wellcome Trust alone.

"This is why the issue of overheads is so crucial to us," Dr Fleming said. "If grants from departments and research councils do not cover overheads, the university has to find the money from elsewhere - and when this accounts for such a large percentage of funding, this is a problem."

The university has the fewest medical students of any school in the country, but is steadily expanding. By 2006, 160 students should be graduating each year. Thirty of these will be graduate-entry students.

"Like all medical schools, we have problems attracting staff in an international market. We need to offer significantly higher salaries and clear career pathways," Dr Fleming said.

"At the moment, clinical academics are expected to teach, research and treat patients without being properly rewarded for their efforts, or being allotted sufficient time for each activity."

Teesside

Last year, the secretary of state for health, Alan Milburn, opened an £8 million building for the University of Teesside's School of Health. This was a joint initative between the NHS and the university.

The school now accounts for nearly a quarter of the university's funding. Its student numbers have doubled in the past four years, with nearly 1,000 full-time nursing students as well as professions allied to medicine, social work and clinical psychology. It offers a range of postgraduate programmes for the latter professions as well as for doctors.

"The relationship between the university, the NHS and other agencies is essential," said Paul Keane, director of the school.

The school has what Mr Keane described as excellent working relationships with the area's six NHS trusts, two health authorities, more than 250 independent providers of healthcare such as nursing homes, voluntary agencies and all the social work agencies. It is also developing links with the medical schools at Newcastle and Durham.

The Quality Assurance Agency praised the school last year for the way that it organised student placements, the practice elements of its programmes and the evidence-based learning undertaken by the students.

To encourage research, the school has set up a postgraduate institute for health.

STUDY FACTS

Ten key features of univer-sity-NHS partnerships

• Students on university courses in health-related subjects totalled some 200,000 in 1998-99 (full time and part time) out of a total student population of 1.8 million
• The higher education sector, in partnership with the NHS, provides virtually all the pre-registration education for the nation's doctors, dentists, nurses, midwives and other professions allied to medicine (Pams)
• Universities provide most of the clinical and basic medical science research that the future of the NHS depends on. This research is funded from a variety of sources, including the funding councils, the NHS, research councils, the Wellcome Trust and the other medical-research charities
• There are now 28 UK medical schools, including the four new schools announced in the past two years: 21 in England, five in Scotland, one in Wales and one in Northern Ireland. They offer undergraduate and postgraduate education. Other universities also offer postgraduate provision
• There are 14 dental schools in the UK
• More than 70 UK universities offer first-degree and diploma courses in nursing and/or midwifery. Among other healthcare Pams, the largest university provision is in physiotherapy (28 universities), radiography (24) and occupational therapy (21)
• Universities spent about £630 million in 1997-98 from block-grant and fee income on health professions and education and research
• The NHS contributes nearly £2 billion a year to the costs of educating these students and to their continuing professional development
• Universities make a significant contribution to postgraduate training and continuing professional development in all the health professions
• Universities' clinical academic staff contribute substantially to patient care and to the organisation and development of patient services.

Source: Based on UUK briefing note, Winter 2000