Stephen Leeder: Integrate to diversify

CONTEMPORARY high-level health care is at its most productive when there is interplay among clinical services, research and education.

A service that provides access to patients for research and teaching, for instance, will attract high-quality practitioners to senior hospital positions.

There is international variation in how these partnerships are sustained. For example, in Malaysia, the entire budget of its three principal teaching hospitals is provided by the Ministry of Higher Education.

In Australia, informal relations among universities, research workers (and institutes) and educators have been financed in mixed and informal ways by federal and state health budgets and universities. These arrangements have attracted critical attention in an era when support for activity-based funding of clinical services is gathering strength.

State health departments and ministries are increasingly concerned to see if universities could be (or are) invoiced for the contribution their hospitals and institutions make to the clinical education of medical and health science students. Universities, in turn, are assessing what they might charge for the clinical services provided by their staff.

They wonder how much they will charge for having an imaginative research idea and, if an experiment using resources from health services fails, whether there will be a bill seeking a refund from the research worker.

The Independent Hospital Pricing Authority has been asked to determine the efficient cost of teaching, training and research activities from 1 July 2014, and to advise on the feasibility of moving to activity-based funding or another mechanism for funding based on the volume of activity by 30 June 2018.

A Teaching, Training and Research Working Group now advises on this matter, but does not include representatives of university vice-chancellors or directors of medical research institutes.

Where, in this new world of I-charge-you-and-you-charge-me, is the incentive for translational research where clinical questions are discussed between clinicians and scientists, and findings from laboratories are speedily applied in clinical care? As an alternative to fragmentation, proposals that proceed in the opposite direction — towards greater integration — deserve airplay.

In the latest issue of the MJA, a Perspectives article examines the strengths and weaknesses of the integrated health science centre concept — one that was strongly proposed by the recent McKeon review of medical and health research in Australia, and recently endorsed in the MJA.

The authors of the Perspectives article raise several important points about diversity in academic health centres, the role of the private sector, and the significant challenge of applying effective models of governance.

It is diversity in the academic health centres that exist internationally that permits progressive assessment of their success and failure.

Not all such ventures have worked in the United Kingdom, despite the unified funding available through the National Health Service. Although academic health centres have been established in leading centres in the United States for decades, complexity in governance and management has been a challenge and may prove to be so here.

We should avoid one-size-fits-all expectations.

Further, where is the private sector in the development of such centres? In Australia, where about half of all health care is delivered in the private sector, large private hospitals and the sector more generally — pharmaceutical and device manufacturers for a start — will only be persuaded to buy in if there are assurances of sustainable funding.

Experience with the development of research hubs in Australia suggests that win-win opportunities — such as sharing expensive equipment and information technology systems — must be created for the coalitions to be formed and maintained.

Perhaps most critically, what form of governance will work? University managers, health service providers, clinicians, scientists and teachers (of all clinical professions and not only medicine) will need to be confident that the instruments of governance are secure. There may be broad appeal for having the NHMRC, which has been championing such centres for years, carry out this function (even though it would not be familiar territory).

We are at a tense moment in the history of collaboration among health care, research and education.

On one side, we have the forces of disaggregation and strict costing. On the other, we have demand for more integration and easier concourse among those pursuing research, engaging in teaching and providing clinical care.

Which way will we turn?

Professor Stephen Leeder is the editor-in-chief of the MJA and professor of public health and community medicine at the University of Sydney.

This article is reproduced from the MJA.