University interventions aim to help heal a 'broken' NHS

Centres unite medical schools and hospitals to improve healthcare. Melanie Newman reports

June 5, 2008

The National Health Service has been failing the public for years because of the historical divide between university medical schools and hospitals.

This is the view of Steve Smith, the leader of the UK's first Academic Health Science Centre (AHSC), a new type of partnership designed to close the research-practice division.

"The system is broken," said Professor Smith, principal of Imperial College London's faculty of medicine and the chief executive of Imperial College Healthcare NHS Trust.

Although universities' biomedical research is world class, he said, institutions are pushed away by a "Stalinist" NHS. "The consequence is that while we are second only to the US in biomedicine and have four of the top universities in the world in this area, we are way down the table when it comes to clinical outcomes."

Until five years ago, the historic split was accepted by both sectors as a fact of life, Professor Smith said. Then the Government started pouring money into the NHS, spending an extra £40 billion in five years.

"The excuse was always that there wasn't enough money. Then there was more money, but patient satisfaction hardly changed. The excuses ran out," Professor Smith said.

Last year, Sir Ara Darzi, the Health Minister, who is himself a professor of surgery at Imperial, called for research for the NHS across the country to be led by AHSCs, university-hospital partnerships in which teaching, research and clinical care would be fully integrated.

Sir Ara outlined six criteria for AHSCs: integrated governance, internationally recognised excellence in research, integrated funding streams for research, integrated career paths, joint programmes combining research and clinical work, and the commercial expertise necessary to market research developments.

Imperial became the first AHSC last October when its faculty of medicine merged with Hammersmith Hospitals and St Mary's NHS trusts. This year, Barts and The London School of Medicine and Dentistry, part of Queen Mary, University of London, as well as King's College London's Medical School, both announced plans to become AHSCs.

However, Queen Mary's approach to setting up an AHSC differs from that of Imperial. So much so, that Imperial's communications office said that the two approaches were "not comparable".

Imperial's all-out merger model is based on AHSCs in the US, in particular the Johns Hopkins University centre, which figures prominently in health provision and research league tables worldwide.

In the Imperial model, the institution provides the "vision and mission" while the NHS does the "operational stuff", Professor Smith said. Imperial plans to recruit 30 medical professors, who will be appointed jointly by the university and the NHS, by 2010.

Similarly, as of 1 October, all NHS consultants appointed by the trust will be approved by Imperial and will be required to provide an "academic plan" for their work.

At Imperial, medical academics are now judged by the same criteria as everyone else in the research assessment exercise - they are expected to publish in the most prestigious medical journals.

"If your paper only makes it into the European Journal of Skin Allergies, your research sessions will be removed," Professor Smith said. "If we are paying a doctor to do research, it has to be of a particular standard."

This means that research in some areas of medicine, such as dermatology, rheumatology and gynaecology - which rarely appear in top journals - will disappear from Imperial. "That aligns towards the priority of the NHS, which is to move such specialisms out of hospitals. That sort of research should be done by GPs," Professor Smith said.

Imperial's link with hospitals has shown that closer ties between practice and research lead to better patient outcomes.

Since research and practice were integrated at Hammersmith Hospital's renal and transplant centre, death rates after transplantation have fallen and more patients are coming off dialysis.

Unlike Imperial's, the Barts Medical School is not merging with the NHS trust. But Professor Sir Nicholas Wright, the warden of Barts, said that his initiative was an AHSC nonetheless.

"The concept of academic leadership of clinical medicine is more ingrained at Imperial. Merger would be a step too far for us," he said. "There are lots of models of AHSCs. Harvard Medical School hasn't changed its name."

Barts and The London NHS Trust's clinical directorates, previously led by clinicians, have been restructured into 16 units that will be led by academics.

All NHS consultants will be on academic contracts and will have academic line managers, while all academics will have to meet teaching performance standards. Joint directors of research and development and education will be appointed, with the latter responsible for postgraduates and undergraduates in medicine, nursing and professions allied to medicine.

"I've had this in mind since I came here," said Sir Nicholas, a former deputy principal of Imperial's School of Medicine who joined Barts in 2001. Only obstructive managers had prevented him fulfilling his ambitions earlier, he said. "I would have done this anyway, irrespective of Darzi."

Meanwhile at King's plans are under way to form the country's largest AHSC - its the medical school is planning to merge with three NHS trusts, including a mental health trust.

Announcing the plan, Rick Trainor, the principal of King's, said: "The very best health organisations in the world are adopting the AHSC model. There are probably only half a dozen university and healthcare combinations in the world that can genuinely aspire to be world-class AHSCs - and ours is one," he said.

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