The National Health Service (NHS) Trusts in England have provided the setting in which applied health investigators conduct their research. Funding for the NHS to support this work has been provided by the government in the form of block allocations to research-active NHS organisations. Historically, grant awards have been held in associated university accounts rather than managed through the NHS. This is now changing.
In professional terms, the area of interest is the partnership working created among UK Universities and NHS Trusts by the new arrangements for funding applied health research in Best Research for Best Health (BRfBH) (UK Department of Health, 2006). This funding, which will largely be sought by clinical academics (i.e., clinically qualified professionals employed by the higher education sector), will be managed through the partner NHS Trusts. This will necessitate greater coordination and collaboration between higher education institutions (HEIs) and the NHS Trusts.
In practice-related terms, these new awards will require NHS and university research management teams to develop new processes and policies to manage funding, contracts, and projects. From an academic perspective, there is an increasing focus on theoretical and methodological issues of researching concepts and implementing partnerships. This interest has grown, particularly in the social science disciplines, as a result of the government focus on, and, in some cases the mandate for, partnership working.
Thus, the aim of this review is to examine what the academic literature on partnership working suggests may be the opportunities and challenges that health researchers face in light of the BRfBH policy.
Best Research for Best Health
The UK Department of Health launched BRfBH in January 2006 following widespread consultation with stakeholders. This government strategy proposes radical changes in the funding and organisation of clinical research in the NHS and associated university-based medical schools in the UK. The purpose of the policy change is to make the NHS an internationally recognised centre of excellence for research, develop the clinical research workforce, and make patient-focused, applied research a priority. The strategy has 16 accompanying implementation plans that detail, amongst other things, the centralisation of funding, the creation of a National Institute for Health Research (NIHR), and the development of a new clinical research network for England.
Prior to the launch of the new policy, Government consultants identified many barriers to clinical research in the UK, including historical allocation models for NHS research and development (R&D) funding, bureaucratic NHS Trust management practices at the local level, few effective incentives to conduct research in the NHS, a dramatic decline in the number of clinical academics, and the perception by academic researchers that NHS funding and applied research are of lesser value compared to other funding sources.
Funding will now be centralised by incrementally removing R&D funds currently housed within 253 Trusts across the UK. This funding will be made available through various competitive funding streams. NIHR provides the mechanism to meet the expectations of BRfBH, and will direct and oversee ali NHS-funded research in England.
Another aim of the new strategy is to reduce the burden of complicated regulatory systems for researchers through limiting bureaucracy and streamlining the systems for managing and regulating research. However, there is little detail about how NHS Trusts will manage their legal obligation to safeguard patients within this new system, and a commonly expressed concern among R&D support staff is that the new processes will merely add another layer of bureaucracy rather than reduce the burden to researchers. One crucial requirement of the new funding model is that the NHS and academia will need to work in close partnership to access funding streams, as the funds and contracts are awarded to the NHS partner.
Why Change the Way Universities and the NHS have Worked in the Past?
Cooksey (2006a, 2006b) provides a history of NHS research funding and details the reasons why the systems need to change. From the days of the initial Haldane Report (1918) about the machinery of government, through the Rothschild report (1971) and the Culyer Report (1994), the government, and in particular, the Department of Health, have struggled to influence the health research agenda and to afford a high profile to applied research. The Cooksey review suggested mechanisms, structures, and funding arrangements to obtain "maximum benefit for research whilst eliminating duplication of effort" (foreword, p. 1). The primary recommendation was for one funding stream divided between the UK Medical Research Council (MRC) and the new NIHR. Cooksey recognised the need for cohesion amongst these powerful yet discrete health research partners by acknowledging that this maximum benefit and reduction in duplication can only be achieved "... if all those involved are dedicated to ensuring that they work together cohesively in the research continuum" (foreword, p. 1).
Cooksey also recommended additional emphasis on translational research--i.e., translating basic science findings to benefit patients. Cooksey explicitly recommended partnership working between the agencies delivering health research in the NHS, and cited communication and leadership as key factors influencing success of translational research efforts. Strong leaders must facilitate and encourage discussion of research and needs among clinicians, lab-based researchers, and researchers from other key disciplines. This in turn should help develop a culture of trust, mutual understanding and greater cooperation. Cooksey stopped short of recommending a merger between MRC and NIHR, but did strongly recommend seamless delivery of the national health research strategy.
Review of Partnership Literature
In 1997 the recently elected New Labour government embraced partnership working as a political imperative, in contrast to the previous government's emphasis on competition to achieve social outcomes (Glendinning, Dowling, & Powell, 2005).
Partnership working is not a new concept, but the scale of the partnerships stimulated and encouraged by 'New' Labour was unprecedented. For example, Sullivan and Skelcher (2002) identified 5,500 local or regional partnerships initiated or created by government, as well as 60 different types of public policy partnerships. Jupp (2000) observed that the word partnership was used in parliament 6,197 times in 1999, compared with just 38 times a decade earlier.
The 'New' Labour government championed partnership working to revolutionise an increasingly deteriorating NHS. In 1997 (UK Department of Health, 1997), Alan Milburn, then Secretary of State for Health, wrote, "There will be no return to the old centralized command and control systems of the 1970s.... nor will there be a return to the divisive internal market system of the 1990's.... Instead there will be a third way of running the NHS--a system based on partnership and driven by performance" (paras 2.1 & 2.3).
In the foreword to Partnership in Action (UK Department of Health, 1998), Milburn described how needs spanning more than one category (e.g., health and social care) can become lost in "sterile arguments about boundaries" (p.3). He further observed that the needs of organisations took priority over the needs of the very people they were meant to serve.
In 1999, the NHS Act placed a statutory duty of partnership on the NHS and local authorities to work on health improvement issues. In 2000, the NHS Plan defined financial incentives to encourage and reward joint working among Primary Care, Secondary and Tertiary NHS Trusts, and social services. Thus, the framework for partnership working in health research was set.
Definitions of Partnership
There is little agreement among authors on the definition of partnership. Glendinning, Dowling & Powell (2005) said, "use of the term (partnerships) has been promiscuous" (p. 371), and went on to point out the lack of agreement on how the term should be defined. Mackintosh (1992) argued that partnership is a concept in public policy that contains a very high level of ambiguity, with a potential range of meanings subject to conflict and renegotiation. Powell and Glendinning (2002) described partnership as "a rhetorical invocation of a vague ideal" (p.3). The Audit Commission (1998) likewise described partnership as "a slippery concept that is difficult to define precisely" (p. 16).
Lewis (2006) provided a rather more colourful definition of partnership during a speech at the launch of a government white paper: "... the suppression of mutual loathing in the mutual pursuit of government funding" (para 17).
Ling (2000) summarised this lack of agreement by stating, "Commentaries about partnerships exist from a variety of...