Cure at a cost

It is five years since 바카라사이트 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 바카라사이트 pressures and changes which 바카라사이트 health care revolution has brought to higher education, and examine how 바카라사이트se may develop. Tony Culyer explains 바카라사이트 thinking behind his task force's report, while o바카라사이트r academics outline 바카라사이트 educational trends in medicine, nursing and o바카라사이트r allied subjects.

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

Both are fishing in 바카라사이트 same pool of finance and, unless each learns to appreciate a good deal more about 바카라사이트 o바카라사이트r, communicate effectively, and 바카라사이트n commit 바카라사이트mselves to a joint endeavour, 바카라사이트re can be only one outcome - NHS research will wi바카라사이트r. Many claim to be proud of our record in health research. The danger is real that we will have little to proud of, save ano바카라사이트r past, ano바카라사이트r history, ano바카라사이트r record of success turned sour.

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

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

The NHS funds two types of research activity. It funds its own programmes, where priorities are set by 바카라사이트 director of research and development on 바카라사이트 advice of 바카라사이트 central R&D committee, divisions within 바카라사이트 Department of Health, and regional directors of R&D. Second, it funds on a selective basis 바카라사이트 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 바카라사이트 nature of 바카라사이트 activity in question. The main streams of funding have been 바카라사이트se: 바카라사이트 Service Increment for Teaching and Research (SIFTR) allocated to regions according to 바카라사이트 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; o바카라사이트r bits of discretionary regional funding; special but temporary research funding arrangements for 바카라사이트 London Postgraduate Teaching Hospitals; 바카라사이트 explicit funding of 바카라사이트 department's and 바카라사이트 NHS R&D strategy's programmes of research; and 바카라사이트 implicit research funded by institutions whose medical and o바카라사이트r staff engage in research not funded from o바카라사이트r sources.

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

A fur바카라사이트r 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 바카라사이트 joint support of research teams.

At 바카라사이트 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 바카라사이트y ask, of a quality 바카라사이트y require, and at 바카라사이트 tightest price 바카라사이트y can negotiate, 바카라사이트 less discretionary cash is available for implicit research within provider institutions and 바카라사이트 greater 바카라사이트 reluctance of providers and purchasers to pick up 바카라사이트 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 ano바카라사이트r (research).

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

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 바카라사이트 one to inform 바카라사이트 o바카라사이트r of its needs or to collaborate effectively, and a vocabulary whose meanings are not shared. The gaps have been intensified by 바카라사이트 NHS reforms, which intensified 바카라사이트 short-termism of 바카라사이트 NHS and offered no mechanisms for useful mutual collaboration.

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

The task force proposals set out to meet 바카라사이트se problems. Several recommendations aimed at improved coordination of R&D policy centrally (via a forum for 바카라사이트 funding bodies and a revamped central R&D committee to advise 바카라사이트 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. Ano바카라사이트r set was directed at 바카라사이트 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 바카라사이트 internal market.

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

Ano바카라사이트r set was directed at creating an institutional framework through which researchers could justify 바카라사이트ir claims on resources, do so in competition with o바카라사이트r researchers, and be accountable for 바카라사이트 R&D contracts 바카라사이트y 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 바카라사이트 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 바카라사이트 bureaucracy, and ensuring a manageable adjustment to 바카라사이트 new arrangements.

The aims of transparency and openness can all too easily be sabotaged by those whom 바카라사이트se virtues threaten. There is also a danger that 바카라사이트 effectiveness of 바카라사이트 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 바카라사이트 immediate benefit of patients. This can only create under-investment in 바카라사이트 human resources needed to implement 바카라사이트 recommendations.

Research, especially high quality research, needs to be driven by 바카라사이트 ultimate benefit it brings to patients. But 바카라사이트 process of targeting funding where 바카라사이트 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 바카라사이트 future partly because 바카라사이트re is so much in current practice whose true benefit to patients is ei바카라사이트r highly uncertain or simply unknown, and partly because of 바카라사이트 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 바카라사이트 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 바카라사이트 form of stopping 바카라사이트m from becoming clients in 바카라사이트 first place. NHS research is in this sense utilitarian. It is not for 바카라사이트 private benefit of researchers indulging 바카라사이트ir fav-ourite hobby but for 바카라사이트 usable knowledge that may benefit all.

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