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University interventions aim to help heal a 'broken' NHS

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

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.

Readers' comments (4)

  • It is depressing that the focus on research gathers momentum while the medical academic's other role, teaching their students and juniors, is seen as less important. If consultants in the Imperial model are to be 'managed' for academic output on pain of a sacking, then it will be a strong temptation to neglect the training of the future medical workforce. To promote academic excellence is one thing, but to insist that all consultants in an NHS trust must maintain publications of a particular calibre... perhaps this seems a little Stalinist?

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  • I believe this is a step in the right direction for the UK healthcare system. For too long has it been dominated by the divide between bench and bedside, and between academics and clinicians. Yet, this is essentially the key feature that has led to the dominance of the USA in clinical and basic biomedical sciences.

    In contrast to what Dr Papnikitas has written, I believe that a strong focus on research does not temper with the training of the future medical workforce. In fact, I am of opinion that it will serve to enrich the training of future doctors. By having more NHS doctors with research interests, it will have a knock-on effect on the medical students - they would be more likely to be interested and involved in medical research.

    How then, might one encourage physician-scientists to do more teaching? There are at least two ways around this: One, the university tenure committee should include teaching undergraduate/graduate level classes as part of the hiring contract. Two, the university should provide more attractive monetary benefits for clinicians to undertake teaching of medical students. The latter method has been adopted by Harvard Medical School last year to encourage clinicians from he Longwood Medical Area hospitals and the Massachusetts General Hospital to take time off their clinical/research work to teach/tutor the medical students.

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  • Arrogance masquerading as science

    Smith makes some sense in the way that he chooses to prioritise areas of research strength at his Institution. Nearly every other research Institution does the same. But I do take exception to his remarks about dermatology in general. He pokes fund at a fictitious journal called the European Journal of Skin Allergies, and prescribes a stripping of research sessions for those colleagues who dare to publish in it, with the implication that all such journals are of a poor standard.
    He then goes onto say that some areas of medicine, such as dermatology, rheumatology and gynaecology - which rarely appear in top journals - will disappear from Imperial, and “that sort of research should be done by GPs,". Here, there is a not-so-subtle implication that dermatology research is second rate and that “that sort of research” ought to be done by GPs, further implying that GPs are only fit for second rate research. Perhaps it was not intended as such, but the remarks are clearly insulting to GPs and academic dermatologists.
    The remarks perpetuate prejudices that some sorts of medicine like renal, reproductive medicine and oncology are proper science and “better” than topics like dermatology. Yet the evidence suggests that despite a very small academic dermatology base, UK dermatology has contributed disproportionately to the global dermatology literature. Our group for instance, has published ever year in top general journals such as the Lancet, the BMJ, New England Journal of Medicine and Nature, and we have raised over £6miilion in non-commercial “blue chip” external research income over the last 5 years, probably because our University has recognized that all disciplines can become top quality when supported and allowed to develop. I have heard the “my science is better than yours” types of remark so many times in my career, that I now take it all with a pinch of salt. But arrogance masquerading as science cannot go unchallenged. What matters is that clinical research is of the highest quality and that it provides real benefits to our patients. I am glad I am not working at Imperial.

    Professor Hywel Williams
    NIHR Senior Fellow and Director of the Centre of Evidence-Based dermatology at the University of Nottingham

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  • Professor Smith’s views on the quality of UK research in gynaecology, dermatology and rheumatology may well apply to basic science - he was a gynaecological basic scientist before he moved into university administration, so he should know.

    But he is misinformed if he thinks that the UK is falling behind in clinical research in these or any other areas. Clinician scientists have to decide whether the bright ideas that come out of laboratories actually do more good than harm in the real world. Too often the early trials that precede licensing only measure short term or surrogate outcomes. It is a slow and laborious business to perform the definitive trials that show whether the treatment is really worthwhile taking into account all the effects measured over a long enough period. The “Stalinist” NHS may not be as user friendly for patients as the insurance-based systems of health care in Europe or the US. But it is actually quite good at that sort of clinical research.

    Most of it is done by ordinary clinicians, working wherever the treatment is best delivered, which may be in primary or secondary care, and co-ordinated by a few relatively cheap, albeit scientifically rigorous, clinical trial units. I’m delighted to hear that Imperial will not be engaging in this sort of research.

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