- Email: [email protected]
The future of health research in the UK
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Correspondence
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and performance targets on patients’ care and outcomes, about patients’ experiences and satisfaction, and about the methods of doing Health Technology Assessment research, Service Delivery and Organisation research, and policy research as well as straightforward clinical research. If we don’t do rigorous, independent research into health service issues facing the UK, policymaking will get even further distanced from evidence, to all our detriments. However, the fact is that this type of health services research is almost completely missing from MRC’s portfolio, as was shown in detail in the UK Clinical Research Collaboration’s analysis of spending profiles.2 Horton recommends handing NHS R&D’s project and programme funding over to the MRC, but without a complete and radical overhaul of MRC’s funding strategy and practice, and not just some tinkering with a systematic review stream, this could mean curtains for policy-related health services research in the UK. I am Director of the Medical Care Research Unit funded by the NHS Policy Research Programme, Chair of the Health Technology Assessment (HTA) Programme Commissioning Boards, Deputy Director of the HTA Programme, and was Deputy Chair of the Medical Research Council’s Health Services and Public Health Research Board and Deputy chair of the MRC Clinical Trial Cross Board 2002–06.
Jon Nicholl j.nicholl@sheffield.ac.uk Medical Care Research Unit, School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK 1 2
Horton R. Health research in the UK: the price of success. Lancet 2006; 368: 93–97. UK Clinical Research Collaboration. UK health research analysis. London: UKCRC, 2006.
Richard Horton’s entertaining and provocative comparison of the MRC and NHS R&D programme is both of doubtful validity and unnecessarily divisive.1 To compare the performance of a new organisation with one that has existed for almost 100 years and has four times as many resources at its disposal is questionable. Additionally, to ignore the different 728
but complementary aims of the two further undermines the comparison. The NHS R&D programme was set up, on the recommendation of a House of Lords Select Committee, containing former medical school deans and leaders of industry, to strengthen public health and health services research.2 Their concern was the lack of applied research to support improvements in the effectiveness, efficiency, and organisation of the NHS. During its first decade it has made substantial contributions to achieving these goals not only through systematic reviews of existing research evidence but also through primary research on the effectiveness of interventions, their costeffectiveness, and how best to deliver and organise services. Although there is scope for improvement, nationally and internationally, the programme is well respected and its outputs valued by policymakers. It has pioneered methodological developments in health services research, systematic reviews, health technology assessment, and research on the organisation and delivery of services. The last of these was unique when established in 1999. Horton’s main criticism of the NHS R&D programme is that it is subject to political interference. If that results in a public funding body prioritising issues of concern to the public, practitioners, patients, and their carers (rather than those of researchers) then it should be welcomed not denigrated.3 Such choices are inherently political and it is entirely appropriate that most of the research funded by the NHS should be commissioned. Equally, it is appropriate for biomedical research funded by the MRC to be largely investigator-led. Whether or not a single fund is created, there will be a continuing need for two fundamentally different approaches to allocating funds reflecting the two contrasting but complementary research paradigms of biomedical and health services research. NB is responsible for the NHS National Coordinating Centre for Service Delivery and Organisation R&D Programme, and a member of the MRC Subcommittee on Evaluation.
Nick Black [email protected] Chair, Health Services Research Network, London SW1E 5DD, UK 1
2
3
Horton R. Health research in the UK: the price of success. Lancet 2006; 368: 93–97. Black N. A national strategy for research and development: lessons from England. Annu Rev Public Health 1997; 18: 485–505. National Coordinating Centre for Service Delivery & Organisation R&D. National listening exercise: report of the findings. London: NCCSDO, 2000.
Richard Horton’s Comment linked to the Cooksey review of the UK health research system1 did good service in highlighting many of the system’s strengths, but crucial gaps in the analysis resulted in some flawed conclusions. First, the Comment underplays the effect NHS research has had in providing support for decisionmaking: detailed assessments indicate that the projects funded can provide evidence to inform a wide range of decisions.2,3 The Health Technology Assessment programme, for example, not only has a major role in the work of the National Institute for Health and Clinical Excellence, but also informs the decisions of other bodies such as the National Screening Committee.3,4 Second, although there are difficulties in achieving desired levels of impact on decision-making, it would be wrong to repeat the mistakes of 25 years ago and think that the problems can be solved by transferring funds for more needs-led research back to the Medical Research Council (MRC).5 The result of that change was the discontent throughout the 1980s that led eventually to the creation of the new NHS R&D Strategy in 1991.5 Lessons from history show that the different tasks of the MRC and the NHS research programmes require their own organisational structures.5 The Cooksey review could make a major contribution to improving the effects of UK health research by highlighting the further support www.thelancet.com Vol 368 August 26, 2006
Correspondence
required, in areas such as agendasetting and knowledge brokerage, to ensure the better functioning of a needs-led research programme embedded in the health-care system. The Health Economics Research Group receives core funding from the Policy Research Programme of the Department of Health.
Stephen Hanney [email protected] Health Economics Research Group, Brunel University, Uxbridge UB8 3PH, UK 1
2
3
4
5
Horton R. Health research in the UK: the price of success. Lancet 2006; 368: 93–97. Buxton M, Hanney S, Packwood T, Roberts S, Youll P. Assessing benefits from Department of Health and National Health Service Research & Development. Public Money Manage 2000; 20: 29–34. Hanney SR, Gonzalez-Block MA, Buxton MJ, Kogan M. The utilisation of health research in policy-making: concepts, examples and methods of assessment. Health Res Policy Syst 2003; 1: 2. http://www.health-policysystems.com/content/1/1/2 (accessed Aug 7, 2006). National Screening Committee. Commissioning and responding to research. http://www.nsc.nhs.uk/uk_nsc/uk_nsc_ind. htm (accessed June 29, 2006). Kogan M, Henkel M, Hanney S. Government and research: thirty years of evolution. Dordrecht: Springer, 2006.
Richard Horton in his comprehensive review of the recent achievements of the MRC and NHS R&D, against the background of the UK Chancellor’s proposal to amalgamate their budgets, concludes that “their aspirations are more likely to be realised by fusion into a Single Fund: independent of government”.1 Horton does not, however, suggest how any new organisation might be both accountable for a budget in excess of £1 billion yet able to have political and scientific independence. Any medical research agency must of necessity work with and in the NHS, and use its clinical staff and facilities under the patronage of the Department of Health. Horton points to the past uneasy relationship between the NHS Director of R&D and ministers, and to the leakage, with the acquiescence of these same ministers, of a substantial part of the NHS R&D budget into NHS service delivery. www.thelancet.com Vol 368 August 26, 2006
The present proposition for a new Single Fund for medical research is the latest in the history of government support for medical science going back to the creation of the Medical Research Committee in 1913—a history that records the tensions between scientific curiosity and independence, the needs of society in general and health services in particular, funding arrangements and sufficiency, and general oversight and control. The Ministry of Health was set up by Act of Parliament in 1919 to bring together under a single ministry all the present and future health responsibilities of government. One special reason, advanced by the medical profession, for its creation was to ensure that new medical knowledge should be rapidly translated into practice. Responsibility for the Medical Research Committee was, however, deliberately not transferred under the Act for three reasons: first, the remit of the Committee covered the whole of the UK not just the England of the new ministry; second, the Committee worked freely with other departments of government; and third, because of the danger that an “active minister” might attempt to influence the research or any conclusions from research which might conflict with the policies of the ministry. The Committee was therefore recreated as the Medical Research Council with a Royal Charter under the Privy Council. The MRC was answerable to the Lord President, who was always a senior member of the cabinet; furthermore, it was chaired by a member of the House of Lords and one of its two lay members was always a Member of Parliament. This model was followed subsequently when the other research councils were set up. The scientific freedom afforded by this arrangement for accountability allowed the MRC to address issues such as the effects of smoking and the testing of nuclear weapons on the health of the population.
These arrangements continued until a Minister for Science was given responsibility for the research councils in 1959. This short-lived ministry was absorbed into the new Department of Education and Science in 1964. Still later the research councils were transferred to the Department of Trade and Industry where they presently lie in the Office for Science and Innovation. The Ministry of Health was not initially concerned with medical research, but from 1940 the Chief Medical Officer was a member or an assessor of the MRC. Under the 1946 NHS Act the minister was required to provide facilities for clinical research. Although the ministry had developed a small policy research programme to support ministers in the 1960s, it was unprepared when, after the Rothschild report in 1971, it was designated a “contractor” for research and a quarter of the MRC budget was transferred to it. This was a complete failure. The Department (as it had been redesignated) was unable to identify its research needs and passed the money back to the MRC. After a few years the pretence was abandoned and the budget returned to the MRC. In 1988, the House of Lords Committee on Science and Technology strongly recommended that both the Department and the NHS should have their own research programmes. Two years of inaction followed, the Lords returned to the charge in 1990, and the NHS R&D programme was born a year later. One of its early fruits was the Culyer report of 1994, which laid out a strategy for funding research and the support of research within the NHS. This led to a stocktake of research and a valiant attempt to identify the NHS costs of the infrastructure for clinical research. These infrastructure costs, as Horton notes, amount to 80% of the NHS R&D budget. These funds, however, are for the most part so embedded within NHS Trusts that it has proved impolitic or impossible to release them to be used strategically to support changing priorities in research. 729
Correspondence
We do not have the rights to reproduce this image on the web.
and performance targets on patients’ care and outcomes, about patients’ experiences and satisfaction, and about the methods of doing Health Technology Assessment research, Service Delivery and Organisation research, and policy research as well as straightforward clinical research. If we don’t do rigorous, independent research into health service issues facing the UK, policymaking will get even further distanced from evidence, to all our detriments. However, the fact is that this type of health services research is almost completely missing from MRC’s portfolio, as was shown in detail in the UK Clinical Research Collaboration’s analysis of spending profiles.2 Horton recommends handing NHS R&D’s project and programme funding over to the MRC, but without a complete and radical overhaul of MRC’s funding strategy and practice, and not just some tinkering with a systematic review stream, this could mean curtains for policy-related health services research in the UK. I am Director of the Medical Care Research Unit funded by the NHS Policy Research Programme, Chair of the Health Technology Assessment (HTA) Programme Commissioning Boards, Deputy Director of the HTA Programme, and was Deputy Chair of the Medical Research Council’s Health Services and Public Health Research Board and Deputy chair of the MRC Clinical Trial Cross Board 2002–06.
Jon Nicholl j.nicholl@sheffield.ac.uk Medical Care Research Unit, School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK 1 2
Horton R. Health research in the UK: the price of success. Lancet 2006; 368: 93–97. UK Clinical Research Collaboration. UK health research analysis. London: UKCRC, 2006.
Richard Horton’s entertaining and provocative comparison of the MRC and NHS R&D programme is both of doubtful validity and unnecessarily divisive.1 To compare the performance of a new organisation with one that has existed for almost 100 years and has four times as many resources at its disposal is questionable. Additionally, to ignore the different 728
but complementary aims of the two further undermines the comparison. The NHS R&D programme was set up, on the recommendation of a House of Lords Select Committee, containing former medical school deans and leaders of industry, to strengthen public health and health services research.2 Their concern was the lack of applied research to support improvements in the effectiveness, efficiency, and organisation of the NHS. During its first decade it has made substantial contributions to achieving these goals not only through systematic reviews of existing research evidence but also through primary research on the effectiveness of interventions, their costeffectiveness, and how best to deliver and organise services. Although there is scope for improvement, nationally and internationally, the programme is well respected and its outputs valued by policymakers. It has pioneered methodological developments in health services research, systematic reviews, health technology assessment, and research on the organisation and delivery of services. The last of these was unique when established in 1999. Horton’s main criticism of the NHS R&D programme is that it is subject to political interference. If that results in a public funding body prioritising issues of concern to the public, practitioners, patients, and their carers (rather than those of researchers) then it should be welcomed not denigrated.3 Such choices are inherently political and it is entirely appropriate that most of the research funded by the NHS should be commissioned. Equally, it is appropriate for biomedical research funded by the MRC to be largely investigator-led. Whether or not a single fund is created, there will be a continuing need for two fundamentally different approaches to allocating funds reflecting the two contrasting but complementary research paradigms of biomedical and health services research. NB is responsible for the NHS National Coordinating Centre for Service Delivery and Organisation R&D Programme, and a member of the MRC Subcommittee on Evaluation.
Nick Black [email protected] Chair, Health Services Research Network, London SW1E 5DD, UK 1
2
3
Horton R. Health research in the UK: the price of success. Lancet 2006; 368: 93–97. Black N. A national strategy for research and development: lessons from England. Annu Rev Public Health 1997; 18: 485–505. National Coordinating Centre for Service Delivery & Organisation R&D. National listening exercise: report of the findings. London: NCCSDO, 2000.
Richard Horton’s Comment linked to the Cooksey review of the UK health research system1 did good service in highlighting many of the system’s strengths, but crucial gaps in the analysis resulted in some flawed conclusions. First, the Comment underplays the effect NHS research has had in providing support for decisionmaking: detailed assessments indicate that the projects funded can provide evidence to inform a wide range of decisions.2,3 The Health Technology Assessment programme, for example, not only has a major role in the work of the National Institute for Health and Clinical Excellence, but also informs the decisions of other bodies such as the National Screening Committee.3,4 Second, although there are difficulties in achieving desired levels of impact on decision-making, it would be wrong to repeat the mistakes of 25 years ago and think that the problems can be solved by transferring funds for more needs-led research back to the Medical Research Council (MRC).5 The result of that change was the discontent throughout the 1980s that led eventually to the creation of the new NHS R&D Strategy in 1991.5 Lessons from history show that the different tasks of the MRC and the NHS research programmes require their own organisational structures.5 The Cooksey review could make a major contribution to improving the effects of UK health research by highlighting the further support www.thelancet.com Vol 368 August 26, 2006
Correspondence
required, in areas such as agendasetting and knowledge brokerage, to ensure the better functioning of a needs-led research programme embedded in the health-care system. The Health Economics Research Group receives core funding from the Policy Research Programme of the Department of Health.
Stephen Hanney [email protected] Health Economics Research Group, Brunel University, Uxbridge UB8 3PH, UK 1
2
3
4
5
Horton R. Health research in the UK: the price of success. Lancet 2006; 368: 93–97. Buxton M, Hanney S, Packwood T, Roberts S, Youll P. Assessing benefits from Department of Health and National Health Service Research & Development. Public Money Manage 2000; 20: 29–34. Hanney SR, Gonzalez-Block MA, Buxton MJ, Kogan M. The utilisation of health research in policy-making: concepts, examples and methods of assessment. Health Res Policy Syst 2003; 1: 2. http://www.health-policysystems.com/content/1/1/2 (accessed Aug 7, 2006). National Screening Committee. Commissioning and responding to research. http://www.nsc.nhs.uk/uk_nsc/uk_nsc_ind. htm (accessed June 29, 2006). Kogan M, Henkel M, Hanney S. Government and research: thirty years of evolution. Dordrecht: Springer, 2006.
Richard Horton in his comprehensive review of the recent achievements of the MRC and NHS R&D, against the background of the UK Chancellor’s proposal to amalgamate their budgets, concludes that “their aspirations are more likely to be realised by fusion into a Single Fund: independent of government”.1 Horton does not, however, suggest how any new organisation might be both accountable for a budget in excess of £1 billion yet able to have political and scientific independence. Any medical research agency must of necessity work with and in the NHS, and use its clinical staff and facilities under the patronage of the Department of Health. Horton points to the past uneasy relationship between the NHS Director of R&D and ministers, and to the leakage, with the acquiescence of these same ministers, of a substantial part of the NHS R&D budget into NHS service delivery. www.thelancet.com Vol 368 August 26, 2006
The present proposition for a new Single Fund for medical research is the latest in the history of government support for medical science going back to the creation of the Medical Research Committee in 1913—a history that records the tensions between scientific curiosity and independence, the needs of society in general and health services in particular, funding arrangements and sufficiency, and general oversight and control. The Ministry of Health was set up by Act of Parliament in 1919 to bring together under a single ministry all the present and future health responsibilities of government. One special reason, advanced by the medical profession, for its creation was to ensure that new medical knowledge should be rapidly translated into practice. Responsibility for the Medical Research Committee was, however, deliberately not transferred under the Act for three reasons: first, the remit of the Committee covered the whole of the UK not just the England of the new ministry; second, the Committee worked freely with other departments of government; and third, because of the danger that an “active minister” might attempt to influence the research or any conclusions from research which might conflict with the policies of the ministry. The Committee was therefore recreated as the Medical Research Council with a Royal Charter under the Privy Council. The MRC was answerable to the Lord President, who was always a senior member of the cabinet; furthermore, it was chaired by a member of the House of Lords and one of its two lay members was always a Member of Parliament. This model was followed subsequently when the other research councils were set up. The scientific freedom afforded by this arrangement for accountability allowed the MRC to address issues such as the effects of smoking and the testing of nuclear weapons on the health of the population.
These arrangements continued until a Minister for Science was given responsibility for the research councils in 1959. This short-lived ministry was absorbed into the new Department of Education and Science in 1964. Still later the research councils were transferred to the Department of Trade and Industry where they presently lie in the Office for Science and Innovation. The Ministry of Health was not initially concerned with medical research, but from 1940 the Chief Medical Officer was a member or an assessor of the MRC. Under the 1946 NHS Act the minister was required to provide facilities for clinical research. Although the ministry had developed a small policy research programme to support ministers in the 1960s, it was unprepared when, after the Rothschild report in 1971, it was designated a “contractor” for research and a quarter of the MRC budget was transferred to it. This was a complete failure. The Department (as it had been redesignated) was unable to identify its research needs and passed the money back to the MRC. After a few years the pretence was abandoned and the budget returned to the MRC. In 1988, the House of Lords Committee on Science and Technology strongly recommended that both the Department and the NHS should have their own research programmes. Two years of inaction followed, the Lords returned to the charge in 1990, and the NHS R&D programme was born a year later. One of its early fruits was the Culyer report of 1994, which laid out a strategy for funding research and the support of research within the NHS. This led to a stocktake of research and a valiant attempt to identify the NHS costs of the infrastructure for clinical research. These infrastructure costs, as Horton notes, amount to 80% of the NHS R&D budget. These funds, however, are for the most part so embedded within NHS Trusts that it has proved impolitic or impossible to release them to be used strategically to support changing priorities in research. 729