From bench to bedside: linking clinical and research medicine

Reducing all of the extraordinary complexity associated with performing medical research, providing medical training and delivering healthcare to a single numerical ranking on a league table is a fraught undertaking. However, it seems, it has also become a necessary one for medical school leaders in these globally competitive times.

England is currently in the throes of a major reorganisation of its leading university medical schools and their associated teaching hospitals. Several American-style Academic Health Science Centres (AHSCs) have either recently come into being or are currently undergoing a process of formation.

The main driver for encouraging the formation of AHSCs is the desire to create genuinely world class centres of innovation in UK healthcare, which will drive the adoption of new treatments within the UK National Health Service (NHS) and globally. Their emergence is part of a wider reform of the NHS, led by Ara Darzi, an influential surgeon-cum-politician.

The AHSC model is also gaining traction in other parts of Europe as well. The Karolinksa Institute in Stockholm also aims to migrate to an AHSC structure, citing the same reasons as its English counterparts.

In Ireland, where Iraq-born Ara Darzi, received his medical training, the model has been introduced at University College Dublin (UCD), which has formed Dublin Academic Healthcare with its affiliated hospitals, the Mater University Hospital and St Vincent’s University Hospital. However, all of the country's medical schools, including UCD, University College Cork, Trinity College Dublin and the Royal College of Surgeons in Ireland, are also partners in a separate entity, Molecular Medicine Ireland (MMI), which aims to coordinate biomedical research and education on a country-wide basis.

While the overarching goal is to improve the quality of outcomes in research, medical education and patient care, assessing peformance will, inevitably, involve hard quantitative measures. The most compelling - and, arguably, the most reductive -  measure of all involves entry into the ranks of what are considered the world’s top medical schools.

That, believes Lynn Carlisle, Deputy College Secretary (Health), at King’s College London, is the whole point of the exercise. “If you don’t aspire to be one of the best in the world then there’s no point in doing it,’ she says. King’s is in the process of forming an as yet unnamed AHSC with its three affiliated hospitals in south-east London, Guy’s and St Thomas’, King's College Hospital and South London and Maudsley. “We have papers going to the four partner organisation boards this month, with proposals on branding and governance.”

UCL Partners, which encompasses University College London (UCL), Great Ormond Street Hospital for Children, Moorfields Eye Hospital, the Royal Free Hampstead and University College London Hospitals, came into being in September. Just over twelve months ago, Imperial College London formed the UK’s first AHSC, Imperial College Healthcare, along with five hospitals, Charing Cross, Queen Charlotte’s and Chelsea, Hammersmith, St Mary’s and the Western Eye. The formation of AHSCs is also underway in Manchester and in Warwick.

These organisations are, in the main, operating from positions of strength, at least within a European context. It’s not as if the likes of UCL or Imperial College are languishing in the lower reaches of any international ranking. “I think we’re in the premier league, but it’s not one of the top three universities,” says Ed Byrne, Executive Dean at UCL Medical School. King’s College has “further to climb”, admits Carlisle, but is gaining recognition as one of the world’s top ten medical schools is the goal.

The main tool for achieving this goal is the creation of new governance structures, designed to integrate more coherently the research, education and clinical care activities of the participating institutions. “The single inviolable rule, however their governance is set up, is everyone in the entity takes responsibility for the triple mission,” says Byrne.

“The thing that distinguishes the University of California, San Francisco, or Columbia from the major UK university hospitals is they’re much more uniform in their ownership of the triple vision.”

UCL Partners is adopting a partnership - or, in American parlance, a split - model, whereby the participating institutions all remain independent but operate under the auspices of a joint board. “The individual partners control their own assets,” says Byrne. The larger AHSCs in the US follow this model, he says, citing Harvard University Medical School and the University of Pittsburgh, as examples.

The key to success will be for UCL Partners, which begins life with a combined budget of around GBP 2 billion, treats 1.5 million patients per annum and employs 3,500 scientists, senior researchers and medical consultants, to these massive resources working together.

A search for a chief executive will get underway shortly; an independent chair has been identified, but not yet appointed. Around ten theme directors will form another important management layer underneath. Each will be responsible for the triple mission in one of ten clinical areas in which UCL Partners either is, or could be, world class.

King’s College and its affiliated hospitals are also adopting a partnership model, says Carlisle. “We've decided we will not merge – that’s one decision we took early on.” Such a move, she says, would have placed undue emphasis on the integration process. King’s is looking to the Johns Hopkins University in Baltimore as a role model.

King’s senior team went on a visit there earlier this year. “They operate on a devolved powers model,” Carlisle says. A single board governs the entire system, although individual hospitals retain their own boards as well. King’s and its partners will operate through units called clinical academic groups, which are thematic areas with a single management structure and budget.

Defining success, and being able to measure it, are core elements in the migration to an AHSC structure. “We’re developing very precise parameters around that,” says Byrne. Research and education metrics are obvious; clinical metrics are less so. “We have some very good ideas on the table, but it is a work in progress,” he says.

All of these fledgling AHSCs will have to pass a formal designation process run by the UK's Department of Health. This will include a peer review conducted by an international panel, chaired by Alan Langlands, Principal and Vice Chancellor of Dundee University, Scotland. Successful applicants will be granted AHSC status next March. But the actual bedding down of the new structures will be an ongoing process.

The Karolinska Institute also wants to climb the world league tables. “We would rank ourselves among the five top schools in biomedicine in Europe,” says its president, Harriet Wallberg-Henriksson. “Of course we would like to be among the top five in the world.” But the dual structure under which the Karolinksa Institute operates at present is a barrier, she says.

Its two university hospitals, which merged into one organisation in 2004, are controlled by the local authority in Stockholm, whereas the medical university itself is under state control. Hospital staff are not incentivised to perform clinical research, Wallberg-Henriksson says. Even the hospital director’s performance is not measured on this parameter.

Stockholm County and the Karolinksa have set the partnership process in train, however, by establishing Stockholm Academic Healthcare System, which integrates research and education into a joint structure. But, as in the UK, the transition to a full AHSC structure will be an ongoing process.

Meanwhile, Ireland’s his nationwide ethos is in part due to the lack of scale of any individual institute and to the country's historical weakness in biomedical research and in postgraduate training. “We have pockets of expertise of international significance,” says Ruth Barrington CEO of MMI.

Extending that expertise and strengthening the country's research infrastructure is the MMI’s goal. But smaller countries like Ireland will have to compete harder than ever for the mobile talent and funding that Europe’s fledgling AHSCs will undoubtedly target over the next decade. For all the criticism that international league tables attract, getting to the top of the tree provides not only a certain pulling power, but also a hallmark of quality.