Priorities in Medical Research: elite dynamics in a pivotal episode for British health research.

Priorities in Medical Research (PMR) was published in 1988 by a select committee of the House of Lords. The report ushered in an era of NHS research and development (R & D) that lasted from 2001 to 2006. The inquiry's origins lay in concerns about academic medicine in the United Kingdom, yet PMR gave relatively little attention to this subject. Instead the report focused critically on the disconnect between the Department of Health and the NHS in R & D. This, the committee argued, had led to the neglect of research into health services and public health. To sidestep the report's unwelcome proposal for a National Health Research Agency, the department eventually grafted R & D management onto structures created as part of wider NHS reforms. The Medical Research Council successfully pursued a strategy of keeping the committee's attention away from sensitive aspects of its own programme. The final focus of PMR was shaped by an alignment between committee members with an industrial view of research and champions of health services research. The actions of the various actors involved are interpreted using elite models of the state, and the applicability of these models is critically examined.

Rothschild reversed: explaining the exceptionalism of biomedical research, 1971-1981.

The 'Rothschild reforms' of the early 1970s established a new framework for the management of government-funded science. The subsequent dismantling of the Rothschild system for biomedical research and the return of funds to the Medical Research Council (MRC) in 1981 were a notable departure from this framework and ran contrary to the direction of national science policy. The exceptionalism of these measures was justified at the time with reference to the 'particular circumstances' of biomedical research. Conventional explanations for the reversal in biomedical research include the alleged greater competence and higher authority of the MRC, together with its claimed practical difficulties. Although they contain some elements of truth, such explanations are not wholly convincing. Alternative explanations hinge on the behaviour of senior medical administrators, who closed ranks to ensure that de facto control was yielded to the MRC. This created an accountability deficit, which the two organizations jointly resolved by dismantling the system for commissioning biomedical research. The nature and working of medical elites were central to this outcome.

Implementation of collaborative governance in cross-sector innovation and education networks: evidence from the National Health Service in England.

BACKGROUND: Increasingly, health policy-makers and managers all over the world look for alternative forms of organisation and governance in order to add more value and quality to their health systems. In recent years, the central government in England mandated several cross-sector health initiatives based on collaborative governance arrangements. However, there is little empirical evidence that examines local implementation responses to such centrally-mandated collaborations. METHODS: Data from the national study of Health Innovation and Education Clusters (HIECs) are used to provide comprehensive empirical evidence about the implementation of collaborative governance arrangements in cross-sector health networks in England. The study employed a mixed-methods approach, integrating both quantitative and qualitative data from a national survey of the entire population of HIEC directors (N = 17; response rate = 100%), a group discussion with 7 HIEC directors, and 15 in-depth interviews with HIEC directors and chairs. RESULTS: The study provides a description and analysis of local implementation responses to the central government mandate to establish HIECs. The latter represent cross-sector health networks characterised by a vague mandate with the provision of a small amount of new resources. Our findings indicate that in the case of HIECs such a mandate resulted in the creation of rather fluid and informal partnerships, which over the period of three years made partial-to-full progress on governance activities and, in most cases, did not become self-sustaining without government funding. CONCLUSION: This study has produced valuable insights into the implementation responses in HIECs and possibly other cross-sector collaborations characterised by a vague mandate with the provision of a small amount of new resources. There is little evidence that local dominant coalitions appropriated the central HIEC mandate to their own ends. On the other hand, there is evidence of interpretation and implementation of the central mandate by HIEC leaders to serve their local needs. These findings augur well for Academic Health Science Networks, which pick up the mantle of large-scale, cross-sector collaborations for health and innovation. This study also highlights that a supportive policy environment and sufficient time would be crucial to the successful implementation of new cross-sector health collaborations.

Improving accountability through alignment: the role of academic health science centres and networks in England.

BACKGROUND: As in many countries around the world, there are high expectations on academic health science centres and networks in England to provide high-quality care, innovative research, and world-class education, while also supporting wealth creation and economic growth. Meeting these expectations increasingly depends on partnership working between university medical schools and teaching hospitals, as well as other healthcare providers. However, academic-clinical relationships in England are still characterised by the "unlinked partners" model, whereby universities and their partner teaching hospitals are neither fiscally nor structurally linked, creating bifurcating accountabilities to various government and public agencies. DISCUSSION: This article focuses on accountability relationships in universities and teaching hospitals, as well as other healthcare providers that form core constituent parts of academic health science centres and networks. The authors analyse accountability for the tripartite mission of patient care, research, and education, using a four-fold typology of accountability relationships, which distinguishes between hierarchical (bureaucratic) accountability, legal accountability, professional accountability, and political accountability. Examples from North West London suggest that a number of mechanisms can be used to improve accountability for the tripartite mission through alignment, but that the simple creation of academic health science centres and networks is probably not sufficient. SUMMARY: At the heart of the challenge for academic health science centres and networks is the separation of accountabilities for patient care, research, and education in different government departments. Given that a fundamental top-down system redesign is now extremely unlikely, local academic and clinical leaders face the challenge of aligning their institutions as a matter of priority in order to improve accountability for the tripartite mission from the bottom up. It remains to be seen which alignment mechanisms are most effective, and whether they are strong enough to counter the separation of accountabilities for the tripartite mission at the national level, the on-going structural fragmentation of the health system in England, and the unprecedented financial challenges that it faces. Future research should focus on determining the comparative effectiveness of different alignment mechanisms, developing standardised metrics and key performance indicators, evaluating and assessing academic health science centres and networks, and empirically addressing leadership issues.

Organizational models of emerging academic health science centers in England.

Recent government policy initiatives to foster medical innovation and high-quality care in England have prompted academic and clinical leaders to develop new organizational models to support the tripartite Flexnerian mission of academic medicine. Medical schools and health care providers have responded by aligning their missions and creating integrated governance structures that strengthen their partnerships. In March 2009, the government officially designated five academic-clinical partnerships as England's first academic health science centers (AHSCs). As academic-clinical integration is likely to continue, future AHSC leaders could benefit from an analysis of models for organizing medical school-clinical enterprise relationships in England's emerging AHSCs. In addition, as the United States ponders health systems reform and universal coverage, U.S. medical leaders may benefit from insight into the workings of academic medicine in England's universal health system. In this article, the authors briefly characterize the organization and financing of the National Health Service and how it supports academic medicine. They review the policy behind the designation of AHSCs. Then, the authors describe contrasting organizational models adopted in two of the newly designated AHSCs and analyze these models using a framework derived from U.S. literature. The authors conclude by outlining the major challenges facing academic medicine in England and offer suggestions for future research collaborations between leaders of AHSCs in the United States and England.

Structure, governance, and organizational dynamics of university medical centers in the Netherlands.

PURPOSE: The Netherlands, a country of 16 million people, is home to eight university medical centers (UMCs), institutions that are closely analogous to U.S. academic health centers and play in important role in Dutch society. The authors' purpose was to test the extent to which an analytical framework developed in one setting can be transferred to another and to yield fresh insights into the value and limitations of different theoretical perspectives on organizational design in the specific context of the academic-clinical enterprise. METHOD: The authors applied a conceptual framework originally developed in the U.S. context to analyze UMC structure, governance, and organizational dynamics. Three UMCs, selected for their differences, were used as case studies, and data were gathered through interviews and document review. RESULTS: A multilevel approach is used to present the data. At the highest level, an overview of the composition, functions, and accountabilities of UMC boards is provided. Below this, the authors describe how functional integration for delivery of the tripartite mission is achieved at the sub-board level. Finally, the authors describe some of the detailed mechanisms used to bind together different interest groups within the UMCs. CONCLUSIONS: The authors found that the U.S.-derived framework for analysis required modification for the context of the Netherlands, but that the study validates the view that many challenges involved in the management of the academic-clinical enterprise are international.

Understanding the economic and social effects of academic clinical partnerships.

Partnerships between medical schools and their clinical associates, which we describe in this article as academic clinical partnerships (ACPs), are powerful economic and social actors through their roles as major employers and procurers of goods and services. A broad spectrum of effects extending beyond the tripartite mission shapes the social contract between ACPs and the communities they serve. The authors present a model for identifying and measuring effects across this spectrum and illustrate the model's application with reference to specific case studies set in the United Kingdom. This model categorizes effects into five different domains: economic, human capital, social capital, knowledge, and place. These different effects express themselves along a spatial scale that varies from the very local to the global. The authors describe the theoretical background for each domain, as well as the methods required to identify and measure effects. These methods range from a quantitative economic impact analysis using extended input-output models to qualitative methods to capture social capital and place effects. The authors demonstrate how leaders in academic medicine can use the model to build a holistic picture of the societal effects of ACPs. Evidence of impact is of value to ACP leaders in engaging with both national and local stakeholders, and the approach is likely transferable to different countries.