Prof. Neil Small: Partnerships in health research - Winter 2009

In recent years the rationale for the NHS supporting research has been a subject of much debate, culminating in 2006 in both the White Paper Best Research for Best Health and A Review of UK Health Research Funding, also known as the Cooksey Report. These heralded a change in the assumptions and organisational structure for NHS research and this change has implications for universities as they seek research collaborations with the NHS.

Partnerships in health research

The Medical Research Council retains its basic science remit but NHS funding is now much more overtly focussed on applied research. A little more difficult to understand, but of considerable significance locally, was a decision that money previously given to NHS organisations to provide research support (the Levy) would be allocated not to organisations but to specific studies. If a study was peer reviewed and funded by an approved source, such as a Research Council, the National Institute for Health Research or a major charity, then it would be classified as an NHS Portfolio study and would be eligible to receive research support costs - these cover costs to the NHS of undertaking research and are additional to money awarded via a research grant. In the past large NHS teaching hospitals received the bulk of the NHS levy; they will now get nothing. Thus an opportunity opens up for new players to emerge in NHS research. Bradford Teaching Hospitals NHS Foundation Trust, for example, increased its annual funding from non-commercial sources from about £500,000 in 2005/6 to £1,800,000 in 2007/8.

The new organisational structure for NHS research funding sees a National Institute for Health Research (NIHR) that oversees a series of Clinical Research Networks designed to increase recruitment into clinical trials in key areas of health; the University leads on Stroke research.

The Patient Safety and Quality Research Centre at Bradford co-ordinates grants for major pieces of research which includes obesity. There are also research projects funded in a number of categories including Research for Patient Benefit, Service Delivery and Organisation, Invention for Innovation, Health Technology Assessment and the NHS Physical Environment Research and Development Programme (an area of successful collaboration between Professor Beggs at the University and Bradford Hospitals). All constituent parts of the new structure focus on the benefit to patients that will result from the research; that benefit must be achievable quickly. In addition Collaborations for Leadership in Applied Health Research and Care (CLAHRC) have been set up in seven locations in England; Bradford (working collaboratively with Leeds and York) has one. Our local CLAHRC includes emphasis on the translation of research into practice and the improvement of NHS information systems so that they generate research-quality data.

NHS Trusts that had little involvement in research now have the potential to develop because of the need for proposals that sit close to service delivery concerns. They can be reassured that a study taken into the portfolio will be fully supported financially. They are likely to be the lead partners because this reassures funders that the research concerns are close to practice and that findings can be readily implemented. Universities need to consider how they can bring added value to collaborations that will be led by NHS organisations. They need to emphasise: the skills that are central to applied research; mixed methods; and a focus not just on identifying what works and why it works, but also on the system change that is required to cement innovation into routine practice. About 30% of Department of Health research spend will be on treatment evaluation and another 30% on health service delivery concerns. The role of NHS Trusts as lead organisations in the new NHS research environment is evident in Bradford where the Bradford Institute for Health Research has been set up. It is located on the Infirmary site and includes both research teams and research support and governance functions. It exists as a collaboration between the three NHS Trusts in Bradford, representing Acute, Primary and Community Care, and the Universities of Bradford and Leeds.

An example of a major research study which has developed within this new NHS research context is Born in Bradford. Officially launched in October 2006, but which in practice began in spring 2006, this study has the former and current Bradford University Chancellors, Baroness Lockwood and Imran Khan, as patrons. Born in Bradford's establishment was in response to the very high levels of infant mortality and childhood illness evident in Bradford. It is a study based in the NHS, incorporating Bradford Acute Hospitals, NHS Foundation Trust and Bradford and Airedale Teaching Primary Care Trust. At its centre the Universities of Bradford and Leeds are represented on the study executive. Professor John Wright (Director of Bradford Institute for Health Research) is Principal Investigator while I take the academic lead. Funding, now amounting to over £7 million, comes from a range of different sources: the European Union, the Welcome Trust, the NIHR via programme grants, CLAHRC funding, and disease-specific charities. In addition the study is an NHS Portfolio study so service costs are available via that route.

Infant mortality and inequalities in child health are central concerns of the NHS nationally and locally. Between 1996 and 2003 infant mortality (deaths in the first year of life) peaked at 9.1 per 1000 live births in Bradford, almost double the 5.3/1000 recorded in England and Wales overall. (There has been some improvement since this peak but relatively worse figures for Bradford persist.) Half of Bradford's 5500 births a year are babies born to mothers of Pakistani origin and for these infants mortality figures are even higher. Subsequent patterns of illness in children are also generally higher in Bradford. Born in Bradfordis designed to first investigate why, and then to offer routes to intervene to effect a change. It is, in essence, an applied research study that can be understood by Best Research for Best Health. It additionally seeks to improve the way routine data are collected, analysed and used in the NHS. For example, data on rates of growth in infants have always been collected but they need to be collected systematically and rigorously to be useful in generating research data that can then influence practice; doing this is central to Bradford's CLAHRC. It has the aim of attracting leading academic researchers to this city - academics have always come to Bradford because of its ethnic mix. However, now they can contribute to an overall programme that is designed to ensure findings are made available in such a way that they can be acted upon locally. This aim is succeeding: Born in Bradford has academic partners that include colleagues from universities in Bristol, Loughborough, York, Durham, Edinburgh, London (Imperial College and the London School of Hygiene and Tropical Medicine) and Leeds.

The logistics of undertaking the Born in Bradford study are challenging - every pregnant woman planning to have her baby in the Bradford Royal Infirmary from March 2007 has been invited to join. The fathers have also been asked to sign up. The target is to sign up 10000 babies of which we currently have over 6000. More than 80% of mothers invited to join say yes. We take samples of blood from mother and baby and saliva from fathers; these together constitute a bio-bank with tremendous potential as a research resource. Baseline questionnaire data are collected and we obtain NHS routinely collected data. The aim is to follow babies as they grow to relate the circumstances of their birth to the subsequent health experiences they have. For example, one focus will be on patterns of growth and on subsequent obesity (this is supported by our NIHR programme grant).

We know some of the fundamental things about patterns of infant mortality and child health; the most important determinant is poverty. We know that Bradford is a poor city, one of the most deprived in the UK, and we know that within it people from Pakistan are disproportionately disadvantaged. In this sense some of the basic science has been done. What we need to know before we can do anything practical is to understand the nuanced interactions in this city of all the different factors: poverty, ethnicity, environment, behaviours, genetics and how services are provided. These factors may have an impact on babies and children. We then need to consider how the understandings of the results can be translated into interventions. It is this that makes Born in Bradford an example of the sort of research study that fits well with the new NHS. In addition to this, in relation to the University of Bradford, there is some symmetry in our aspirations. Born in Bradford is centrally engaged in confronting inequality in one of its starkest and most disturbing manifestations that babies are five times more likely to die in the first year of life in the poorest fifth of society compared to the richest. Its findings cannot be implemented without embracing the strengths of diversity in the city. Perhaps Born in Bradford would expand the University mission statement to capture the idea of discovery as well as application: "making knowledge and making knowledge work".

Born in Bradford has a website, www.borninbradford.nhs.uk, with access to the detailed protocol for the study and up-to-date material on recruitment. The questionnaires we are using and the details of our partners are also available.

Neil Small
Professor of Health Research
School of Health Studies