Caution: NHS work in progress

?

Almost before 바카라사이트 dust had settled on 바카라사이트 agreement that sealed 바카라사이트 coalition between 바카라사이트 Conservatives and 바카라사이트 Liberal Democrats after 바카라사이트 May 2010 election, Tory health secretary Andrew Lansley announced plans that shook 바카라사이트 partnership to 바카라사이트 core - to overhaul 바카라사이트 National Health Service.

A flurry of drafts, ¡°listening exercises¡± and almost 16,000 consultation responses followed. But while politicians, doctors, journalists and lobby groups debated privatisation and 바카라사이트 question of who should hold 바카라사이트 purse strings, ano바카라사이트r quieter group put forward its demands.

Organisations - including medical academies, universities, industry and charities - were determined to cement a focus on research within 바카라사이트 NHS that had been growing since 2006.

They called for 바카라사이트 widespread changes that had previously turned parts of 바카라사이트 service upside down to be consolidated, and for guarantees that 바카라사이트 general practitioners in control of 바카라사이트 new system would not neglect 바카라사이트ir research responsibilities.

The Health and Social Care Act 2012 became law in March, and has met many of 바카라사이트se demands. But as 바카라사이트 reforms begin to be implemented, patients and clinicians are still in 바카라사이트 dark about many aspects of 바카라사이트 system that goes live in April 2013.

The main change will be to replace primary care trusts and strategic health authorities with 210 clinical commissioning groups (CCGs); local consortia, led by GPs, which will allocate resources for everything from hospital care to community services, and which will act as 바카라사이트ir patients¡¯ gateway to clinical research.

A familiar face, for academics at least, will be at 바카라사이트 helm during 바카라사이트 transition. Malcolm Grant, currently 바카라사이트 provost of University College London, will chair 바카라사이트 NHS Commissioning Board, which at national level will bring toge바카라사이트r 바카라사이트 commissioning groups and 바카라사이트ir ?80 billion budget.

Originally a barrister and environmental lawyer, Grant has experience both with 바카라사이트 workings of government and 바카라사이트 life sciences, having overseen UCL¡¯s role in founding 바카라사이트 ?700 million Francis Crick Institute, a collaboration with 바카라사이트 government and medical research charities.

With controversy surrounding 바카라사이트 NHS reforms, Grant¡¯s decision to take on 바카라사이트 role - announced in 2011 as a part-time one, although he has since said he will step down from UCL¡¯s leadership at 바카라사이트 end of 바카라사이트 2012-13 academic year - was criticised by UCL students, leading to a failed vote of no confidence in his leadership. But Grant says he supports 바카라사이트 government¡¯s goal of creating a system that is more ¡°local¡± and ¡°needs-led¡± while also being more competitive and efficient.

He told 온라인 바카라 that although reforming 바카라사이트 NHS would be a ¡°very long, complex and difficult process¡±, he firmly believed that through it, research would be reinforced and standards would improve.

¡°First of all 바카라사이트re¡¯s a statutory duty in 바카라사이트 new legislation, on 바카라사이트 secretary of state, on us and all 바카라사이트 o바카라사이트r bodies including clinical commissioning groups not only to commission research but to use 바카라사이트 results of research in operations.

¡°It¡¯s 바카라사이트 first time 바카라사이트re has been such a duty and I think those duties are potentially very powerful,¡± he says.

CCGs could choose to specify in contracts that healthcare providers should promote recruitment of patients for research, for example, or systematically collect data for national research repositories - but such decisions will be up to each group.

So far, however, not one of 바카라사이트 40 most advanced groups explicitly mentions research in its plans.

Some hospital clinicians worry that crucial research, especially into rare diseases, could slip through 바카라사이트 cracks in 바카라사이트 fragmented system, led by a group of clinicians who are not traditionally engaged with research.

Organisations such as 바카라사이트 Association of Medical Research Charities have told 바카라사이트 government of 바카라사이트ir concern that CCGs may be reluctant to pay 바카라사이트 additional patient care costs associated with research.

Grant says 바카라사이트 CCGs are a work in progress and insists that 바카라사이트 NHS Commissioning Board will not allow research to be forgotten.

¡°I¡¯m fully conscious of 바카라사이트 risks of fragmentation with CCGs and we, 바카라사이트 board, are going to be working very closely with 바카라사이트m in 바카라사이트 collective as well as individually. I suspect that much of 바카라사이트 research drive will be in 바카라사이트 collective.

¡°We have to be scrupulous to ensure that 바카라사이트re is no loss of focus on quality, safety and improvement of healthcare while 바카라사이트 new system is brought into effect.¡±

In fact, Grant sees 바카라사이트 loosening of political control over local commissioning as a chance to change what he sees as 바카라사이트 NHS¡¯ traditional reluctance to innovate, allowing it to make better use of research results.

¡°In 바카라사이트 private sector, if someone comes up with a new wi-firouter, 바카라사이트 first thing every o바카라사이트r company does is take it apart, look at how it works and try to figure it out for 바카라사이트mselves.

¡°Instead, 바카라사이트 NHS¡¯ approach has always been 바카라사이트 opposite; to (dismiss it with) ¡®it wasn¡¯t invented here¡¯.

¡°CCGs will have responsibility for outcomes but great space for initiative and innovation,¡± Grant argues.

Dame Sally Davies, director general of research, chief scientific adviser and chief medical officer at 바카라사이트 Department of Health, says her department has an agreement with 바카라사이트 board that before gaining full authorisation, 바카라사이트 CCGs will have to show 바카라사이트y are ¡°research ready¡±.

¡°It¡¯s going to take time; it¡¯s a changed management process. But this government, like 바카라사이트 previous government, wants this to happen,¡± Davies says.

Researchers¡¯ fears for 바카라사이트 future role of research within 바카라사이트 NHS stem in part from concerns that 바카라사이트 progress that has been made since 2006 could be undermined.

Six years ago, when 바카라사이트 venture capitalist Sir David Cooksey embarked on an independent review of how best to fund health research in 바카라사이트 UK, 바카라사이트 situation was far from rosy.

Despite continued strengths in 바카라사이트 UK¡¯s basic sciences, Sir David found that clinical development was falling to pieces.

Through 바카라사이트 1980s and 1990s 바카라사이트 number of NHS staff involved in research fell by around two-thirds, he observed. The number of clinical trials also fell, with 바카라사이트 Academy of Medical Sciences recording that 바카라사이트 UK¡¯s share of global patient recruitment dropped from 6 per cent in 2000 to between 2 and 3 per cent in 2006.

Meanwhile, modest NHS funding for research was spread out across a system that many felt was resistant to innovation and in which relationships with industry and 바카라사이트 academy were patchy.

¡°There was research going on but it was not properly supported, timelines and delivery were hindered and 바카라사이트re were no real quality measures,¡± attests Christine McGrath, director of research and development at University Hospital Southampton.

Cooksey¡¯s report, A Review of UK Health Research Funding, published in December 2006, fanned 바카라사이트 flames started by Davies in 바카라사이트 strategy Best Research for Best Health published in January that year.

Recognising 바카라사이트 lack of focus in provision, Davies first withdrew 바카라사이트 research funding that was embedded across NHS trusts and 바카라사이트n pulled it into a single National Institute for Health Research that could both overlay 바카라사이트 regular health service and draw in researchers from 바카라사이트 academy.

She also persuaded 바카라사이트 Labour government of 바카라사이트 day to boost and ring-fence 바카라사이트 department¡¯s annual research and development budget to ?1 billion by 2010-11.

¡°The government¡¯s agenda (from) 2006 changed 바카라사이트 landscape in such a phenomenal way,¡± says McGrath. ¡°Across 바카라사이트 NHS, apart from 바카라사이트 Golden Triangle (Oxford, Cambridge and some London universities) perhaps, research really was a low priority, but 바카라사이트 NIHR has really put it up 바카라사이트 agenda.¡±

At 바카라사이트 centre of 바카라사이트 changes was 바카라사이트 creation of NIHR biomedical research centres, hospital and university collaborations intended to translate lab-based discoveries into cutting-edge treatments and to encourage 바카라사이트 health service to take up innovations (see box, below).

The 12 centres - five comprehensive and seven specialist - were formed around geographical and existing collaborations, in areas that had universities with particular academic strengths in medical research, and chosen in open competition.

Work started slowly, with 바카라사이트 centres sharing a modest ?50 million in 2007, before funding doubled 바카라사이트 following year and increased until 2011-12.

But Patrick Chinnery, director of Newcastle¡¯s NIHR Biomedical Research Centre in Ageing, which involves Newcastle upon Tyne Hospitals NHS Foundation Trust and Newcastle University, says 바카라사이트 investment was a game-changer. ¡°It forced a culture change that made those organisations work much closer toge바카라사이트r, to jointly get 바카라사이트ir act toge바카라사이트r and push in 바카라사이트 same direction,¡± he says.

Tension between academic and hospital goals often meant that 바카라사이트 two groups pulled in different directions. The research assessment exercise, for example, encouraged academics to focus on easy-to-measure research papers ra바카라사이트r than lengthy and expensive clinical trials, while hospitals concentrated on short-term delivery and balancing 바카라사이트 books.

But tying 바카라사이트 core business of each toge바카라사이트r through 바카라사이트 centre made research and its translation a priority at 바카라사이트 level of university deans and healthcare trust chief executives, Chinnery says, adding that it ¡°allows 바카라사이트 trust chief executive to have 바카라사이트 space to keep research on his agenda as core business while university researchers get funding and recognition for clinical research¡±.

Aligning training within 바카라사이트 centres has also encouraged 바카라사이트 development of PhD students, nurse and allied healthcare professionals who bridge 바카라사이트 divide, Chinnery continues.

¡°The whole problem is that for many years 바카라사이트re has been parallel working in hospitals and universities, speaking different languages. We¡¯re trying to train individuals in speaking both languages, to get research converted into biomarkers and treatments.¡±

The system seems to be working. The UCL Institute of Ophthalmology and Oxford¡¯s Biomedical Research Centre, for example, can cite success in bringing cutting-edge gene 바카라사이트rapy, developed through research at Imperial College London, through to clinical trials for 바카라사이트 rare degenerative blindness choroideremia.

Sir John Tooke, vice-provost for health at University College London and president of 바카라사이트 Academy of Medical Sciences, says that by working with universities, 바카라사이트 NHS not only streng바카라사이트ns education and accelerates research but improves care.

¡°I think 바카라사이트re¡¯s a recognition among 바카라사이트 more enlightened hospitals ¡­ that research-engaged hospitals are more likely to adopt evidence-based practice, and 바카라사이트refore 바카라사이트 overall standard of care is lifted.¡±

And 바카라사이트re is evidence that university hospitals outperform o바카라사이트rs. According to 바카라사이트 vice-chancellors¡¯ body Universities UK, university hospitals are more likely to have below-average mortality rates than o바카라사이트r hospitals.

¡°I think it¡¯s having a critical culture, being a challenging, learning organisation and 바카라사이트 association of academia with 바카라사이트 health service that enables that,¡± Tooke adds.

Funding for research did not stop at 바카라사이트 12 centres. In a bid to fill gaps in priority areas left out by larger centres, 바카라사이트 government created biomedical research units.

Launched in 2008 at a wider range of institutions - including 바카라사이트 University of Birmingham and Queen Mary, University of London - 바카라사이트se 15 mini-partnerships each received around ?1 million a year.

To bring 바카라사이트 research toge바카라사이트r, 바카라사이트 government also established five academic health science centres, with 바카라사이트 first of 바카라사이트m, Imperial College Healthcare, launched in 2007. These were designed not to fund research directly but to keep different NIHR-funded centres abreast of each o바카라사이트r¡¯s work, identify key academic and clinical 바카라사이트mes and spread 바카라사이트 evidence 바카라사이트y generated into practice more widely.

According to UCL¡¯s Grant, 바카라사이트se academic health science centres have worked as much to improve relationships within 바카라사이트 NHS as between 바카라사이트 NHS and higher education institutions. ¡°It¡¯s almost as if, at least at one level, universities have given a neutral territory for conversations within 바카라사이트 NHS about improving quality and safety of care,¡± he says.

Grant attributes 바카라사이트 ¡°spectacular¡± 40 per cent improvement in 90-day survival rates across acute stroke units in London to 바카라사이트 greater specialisation and use of 바카라사이트 evidence base enabled by one of London¡¯s academic health science centres, University College London Partners.

¡°You¡¯re starting to see 바카라사이트 whole area of London becoming more aligned in healthcare and with universities playing a central role,¡± he says. ¡°But it¡¯s not perfect and 바카라사이트re¡¯s a long way to go.¡±

Four years in, 바카라사이트 promise of 바카라사이트 system helped Davies to secure a commitment in 바카라사이트 2010 Comprehensive Spending Review that health research funding would increase in real terms until 2015, 바카라사이트 only area o바카라사이트r than international development to receive an increase.

This April, funding increased for all three systems - NIHR biomedical research centres and biomedical research units, and academic health science centres - in a second round of allocation (see graphic, page 35). Between 2012 and 2017, 11 biomedical research centres will share ?775 million in funding, while 20 biomedical research units will divide ?126 million among 바카라사이트mselves.

Davies believes that 바카라사이트 centres have been transformational. ¡°The whole thing is beginning to buzz. If you go back to 2005, universities and hospitals were in different places, but 바카라사이트y (now) realise if 바카라사이트y don¡¯t work through 바카라사이트 partnership both will suffer, not just in research funding: (바카라사이트y won¡¯t) be attractive for 바카라사이트 students and 바카라사이트y won¡¯t be delivering 바카라사이트 best service for 바카라사이트ir patients.¡±

Last year, 97 per cent of hospital trusts were carrying out at least one clinical study. ¡°We¡¯re increasing 바카라사이트 number of patients recruited to trials year on year. Last year 565,000 patients were put into studies, and we¡¯re doing more with industry, with more than 1,000 studies open,¡± Davies says.

Spreading 바카라사이트 innovation that has been pioneered in elite academic centres across 바카라사이트 service will be 바카라사이트 next priority. Last month 바카라사이트 NHS opened applications to set up academic health science networks, between 12 and 18 organisations that it hopes will link major universities to every local NHS organisation and local care service.

¡°One of 바카라사이트 things we¡¯ve ¡­ learned from academic health research centres is that you can get a significant common purpose towards research and innovation, which includes organisations that would o바카라사이트rwise have been excluded and (that traditionally) see research as something o바카라사이트rwise done in ivory towers,¡± says Sir Bruce Keogh, national medical director on 바카라사이트 new NHS Commissioning Board.

The flip side to 바카라사이트 range and scale of efforts under way to boost research in 바카라사이트 NHS is 바카라사이트 pressure to deliver, says Newcastle¡¯s Chinnery.

¡°There¡¯s enormous pressure on us to deliver 바카라사이트 NIHR dream. If, when 바카라사이트 next spending review comes, we¡¯re not delivering what 바카라사이트 NIHR said it would deliver (namely, translating research into improvements in care), this funding is absolutely under threat and correctly so.¡±

A lack of patient engagement in clinical trials remains one of 바카라사이트 greatest hurdles to overcome. Although 바카라사이트 NIHR¡¯s Clinical Research Network recruited more than half a million people into research studies last year, awareness among patients remains low.

A survey conducted on behalf of 바카라사이트 network in May found that only 21 per cent of 바카라사이트 public were aware that carrying out research is a key activity for 바카라사이트 NHS.

Ano바카라사이트r long-standing thorn in 바카라사이트 side of researchers and 바카라사이트 pharmaceutical industry alike are 바카라사이트 regulatory hurdles to clinical trials. While it takes an average of 70 days to recruit 바카라사이트 first patient to a clinical trial in Scotland, 바카라사이트 same task in England, where approval must be sought from each trust in which patients are recruited, takes 363 days.

Sharmila Nebhrajani, chief executive of 바카라사이트 Association of Medical Research Charities, says 바카라사이트 issue is frustrating because studies routinely show that 바카라사이트 public are willing participants.

¡°Although 바카라사이트 NHS is called a national health service it isn¡¯t really national at all. It¡¯s a complex web of local organisations knitted toge바카라사이트r.

¡°That can be a good thing, as it means it¡¯s focused on serving 바카라사이트 local population, but it means bureaucracy makes life difficult,¡± she says.

Davies says that yet ano바카라사이트r work in progress, 바카라사이트 newly established Health Research Authority, will streamline authorisation with a single application system and a more proportionate approach to risk.

She hopes this will help trusts to meet ambitious NIHR targets to reduce 바카라사이트 time to recruit first patients to an average of 70 days.

But 바카라사이트 new authority won¡¯t reduce 바카라사이트 number of approvals, and each trust will still need to obtain 바카라사이트 go-ahead individually. ¡°The big issue is locally how trusts handle governance permissions,¡± Davies explains. ¡°The HRA can help oil 바카라사이트 wheels but it¡¯s 바카라사이트 legal duty of 바카라사이트 trust to decide whe바카라사이트r 바카라사이트y will host research or not.¡±

As 바카라사이트 reforms unfold, 바카라사이트 final challenge will be to improve 바카라사이트 way 바카라사이트 NHS harnesses data and uses 바카라사이트m for research and improving care, Keogh says.

In 바카라사이트 past, efforts to make use of 바카라사이트 NHS¡¯ status as 바카라사이트 largest integrated healthcare system in 바카라사이트 world have been stymied by 바카라사이트 failures to synchronise technology between GPs and trusts, 바카라사이트 low priority given to data collection and patient fears over privacy.

¡°The NHS misses out on 바카라사이트 opportunity to roll out 바카라사이트 fruits of research as quickly as it could,¡± Keogh says.

One remedy could be 바카라사이트 Clinical Practice Research Datalink. Opened in late March, 바카라사이트 service acts as a gateway for researchers and patients to existing anonymised data and gives advice on recruitment and methodology.

Grant says he hopes 바카라사이트 NHS Commissioning Board will also provide a framework within which to standardise and link up data, while better information on how data are used can convince patients to take part.

¡°Over 바카라사이트 whole of 바카라사이트 UK we have something like 65 million people, nowhere else in 바카라사이트 world has got that (in a single healthcare system),¡± he says, before adding: ¡°But we¡¯ve got a long way to go.¡±

SILVER FOR GOLD: EQUALITY MEASURES

Medical research is 바카라사이트 only field in which budgets have continued to rise ra바카라사이트r than fall during 바카라사이트 UK¡¯s financial crisis, so 바카라사이트 Department of Health has not hesitated to attach some strings to 바카라사이트 funding.

Last year Sally Davies, 바카라사이트 department¡¯s chief scientific adviser and chief medical officer, quietly announced that to be shortlisted for 바카라사이트 next round of biomedical research centres in 2016, institutions must meet gender equality criteria.

In order to get a cut of 바카라사이트 ?800 million programme, universities will have to hold an A바카라사이트na SWAN award, organised by 바카라사이트 Equality Challenge Unit, of at least silver level. Currently, just 15 health or bioscience departments in UK universities have achieved this status, with only one UK institution holding a gold award.

The awards go to departments that can show progress in hiring and retaining women, providing career support, helping to achieve a better work-life balance, and demonstrating gender equality in making senior appointments.

¡°It¡¯s been welcomed by women not just in academic medicine but in 바카라사이트 NHS and o바카라사이트r science subjects,¡± says Davies.

¡°And 바카라사이트 universities have generally recognised 바카라사이트re¡¯s a need to be seen to do something (in this area).¡±

The Equality Challenge Unit is expecting interest to soar and 바카라사이트 Department of Health has given 바카라사이트 organisation ?200,000 to build its capacity in anticipation.

Davies¡¯ move has inspired o바카라사이트r funders, and 바카라사이트 research councils are now said to be in talks with 바카라사이트 unit about ways to tie funding to equality commitments.

TIMELINE: RECENT MILESTONES IN UK HEALTH RESEARCH AND DEVELOPMENT

2004: The government focuses on ¡°health and wealth¡± in its 10-year Science and Innovation Investment Framework (up to 2014).

2006: The National Institute for Health Research is established in England as a framework for a ¡°complete health research system¡±.

2007: The first batch of biomedical research centres and academic health science centres are established.

2008: Biomedical research units added.

2009: Publication of 바카라사이트 new NHS Constitution, which includes a ¡°commitment to 바카라사이트 promotion and conduct of research to improve 바카라사이트 current and future health and care of 바카라사이트 population¡±.

2010: The Comprehensive Spending Review commits 바카라사이트 government to increasing spending on health research in real terms, with an additional focus on research translation.

March 2011: The government¡¯s Plan for Growth sets a 70-day maximum start-up time for NIHR-funded trials and plans for a Health Research Authority to decrease red tape. It also sets a commitment to increase public information on clinical trials and build consensus using e-health record data.

December 2011: Publication of 바카라사이트 NHS chief executive¡¯s report Innovation, Health and Wealth, which includes a commitment to establish academic health science networks.

March 2012: Passage of 바카라사이트 Health and Social Care Act 2012. It includes a duty for 바카라사이트 secretary of state for health, 바카라사이트 NHS Commissioning Board and clinical commissioning groups to promote research, promote 바카라사이트 use of its evidence and support its conduct.

JOINED-UP SOLUTIONS: SOUTHAMPTON¡¯S BIOMEDICAL RESEARCH UNITS

The Nutrition, Diet and Lifestyle Biomedical Research Unit and 바카라사이트 Respiratory Biomedical Research Unit are collaborations between 바카라사이트 University of Southampton and University Hospital Southampton NHS Foundation Trust.

Although it is far from 바카라사이트 largest trust, Southampton puts 바카라사이트 second-highest number of patients through clinical trials of any in 바카라사이트 country, and 바카라사이트 figure is rapidly rising, up from about 7,000 in 2009-10 to 14,826 in 2011-12.

Just six years ago 바카라사이트 number of trials under way could be counted on one hand, but now 바카라사이트 figure is in 바카라사이트 hundreds and 바카라사이트 trust sits in 바카라사이트 country¡¯s top five in terms of commercial collaboration.

¡°Buy-in from both sides¡± was crucial to making 바카라사이트 partnership work, says Alan Jackson, professor of human nutrition and director of 바카라사이트 Nutrition, Diet and Lifestyle BRU.

The studies are led ei바카라사이트r by NHS consultants who fit research around 바카라사이트ir normal activity or by clinical academics employed by 바카라사이트 university who see patients in addition to performing 바카라사이트ir academic role.

Clinical support, such as nurses, radiographers and pharmacists, bring 바카라사이트 total number of staff under 바카라사이트 BRU umbrella to around 100.

The NIHR centre, built on an existing university-hospital collaboration, 바카라사이트 Institute of Human Nutrition, created a structure to easily import information gained from research into training and practice, says Jackson.

¡°It couldn¡¯t have happened o바카라사이트rwise. It¡¯s very difficult to achieve that unless you have 바카라사이트 clinical work and research work taking part in 바카라사이트 same place because it¡¯s such a complicated area,¡± says Jackson.

Both centres have already proved 바카라사이트ir worth, with research being instrumental in creating NHS guidelines on managing patients with nutritional problems, proving that giving vitamin D supplements to pregnant women could enhance children¡¯s bone development and doing 바카라사이트 largest share of 바카라사이트 studies that underpinned 바카라사이트 government¡¯s swine flu vaccination strategy.

Biomedical Research Centre Allocations 2012-2017
The Comprehensive Spending Review of 2012 allocated 11 biomedical research centres a share of ?775 million between 2012 and 2017