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The Academic Health Science Centre undertakes three important missions:

  • they treat patients

  • they conduct research

  • they teach the next generation of clinicians

The AHSC model, as a structured and integrated organisational form, is most developed in the US, Canada, Netherlands, UK, Sweden and a few others, and emergent in other countries.

They are a distinct and probably unique type of organisation, quite expensive to run (annual revenue streams on the order of €2 billion or more), very complex and home to a diversity of stakeholders. Often, AHSCs are thought of simply as teaching hospitals in a loose affiliation with universities but this underpowers their role.

The AHSC represents the most robust model of an institution that could be seen as sitting at the nexus of innovation and entrepreneurialism in health sciences. They essentially own the challenges facing us in the biomedical and treatment arenas, and have access to, or indeed may own, their own research capacity to solve those problems – they can be seen as both producer of new knowledge and consumer of it. And through their role in the intergenerational transfer of knowledge (i.e. teaching), they can influence future priorities, and clinical treatment practices within healthcare systems. As large and potentially well connected organisations, they have the potential to access considerable sums of start up capital, and spin-out a variety of new companies.

Not all teaching hospitals have the capacity to be an AHSC. Not all universities become an AHSC simply by linking their medical schools to a hospital, anymore than simply bolting on some labs to a hospital creates productive research capacity.

Virtually all countries, and regional economies, prioritise biomedical research probably within at least their top 5 areas of investment – despite frequently have significant deficiencies. While thinking that an AHSCs may be seen as the best local solution, local capacity can be lacking or weak. A critical worry is that AHSCs will be created from small, dysfunctional, and poorly performing institutions into large dysfunctional and poorly performing institutions, wasting public money, frustrating researchers and would-be entrepreneurs, weakening treatment capacity, and failing to deliver the innovations.

Internationally, AHSCs should be seen as sitting at the top of the healthcare pyramid, providing care from the simplest up to the most complex, and with unique expertise. While challenging to national/regional innovation strategies (which are often parochial in perspective), AHSCs should be at the forefront of international collaborations and integral to globalisation of knowledge transfer and evidence-based care.

Therefore, creating an AHSC as a driver of innovation and home to entrepreneur is not to be undertaken lightly.

One aspect of the AHSC that is particularly important to conceptualise and operationalise effectively is how they commercialise their intellectual property as a result of being both owners of problems, and creators of solutions to these problems. Risks here include inappropriate de-risking of research, premature efforts at commercialisation, confusion over ownership of the work itself, and conflict between institutional components on the methods to choose. These all track back into the AHSC itself, and how it is governed and how the executive suite and board, decide what can and cannot be done, or done well.

The paper draws on the author’s professional experience of working in an AHSC, working with an AHSC in thinking through their commercialisation strategy, and comparative policy research on commercialisation of research and strategies.

What is an Academic Health Science Centre?

AHSCs come in many forms. Understanding why particular arrangements are needed is important to ensuring that AHSCs are not created out of poorly performing component institutions. They are not simply an aggregation logic for pooling knowledge and capabilities. AHSCs can be vertically integrated providers through to a confederation of autonomous institutions. In some countries, the structure of AHSCs is accredited, mandated or otherwise designated, while in others, they emerge as a logical and rational solution to various research/ treatment/ teaching challenges. In addition, AHSCs also form networks for further collaboration.

Depending on national funding systems in higher education and in healthcare, AHSCs may have to deal with a large number of government ministries or agencies (in addition to health and higher education: social/community care, research councils, labour, industry/commerce ) which may be at differing levels in government (national/federal, state, local) as well as charitable and international sources. With this comes a diversity of public supervisory and oversight arrangements, which unsurprisingly may conflict on a number of levels: research priorities, service delivery objectives, degrees of institutional autonomy, and not to ignore the diversity of political interest which may complicate this further.

And within this mix, the challenge of coordination looms very large, to accommodate the autonomy of constituent parts, public accountability and institutional mission.

How should AHSCs organise themselves to conduct research and development for commercialisation?

AHSCs should be understood as accelerators of innovation. In virtue of owning the problems, they can disseminate new practices, enhance the evidence base for treatment options, and alter the very structure of service delivery itself.

Therefore, a critical issue for an AHSC is how they go about commercialisation, that is, operationalising the acceleration and dissemination of innovation and how they enable the entrepreneurial nature of researchers.

Particular challenges arise when higher educational institutions and healthcare organisations are state owned and run, with the result that staff (academics and researchers) are public employees or civil servants. This has the potential to create difficulties for individuals who may wish to be entrepreneurial yet retain their relationship to those issues which sparked the innovation in the first place.

Problems in this area have been raised by the French government with respect to the visibility and commercialisation of national research from state-owned laboratories and from the universities themselves. Institutional restrictions on commercialisation can create conflicts as in the UK where the universities pursue one approach while NHS hospitals use NHS/Department of Health commercialisation strategies.

External sources of seed capital are faced with constructing sensible funding arrangements in this environment. This has led institutions such as Karolinska in Sweden or Imperial Innovations in the UK to create an entrepreneurial subsidiary to deal with the commercialisation process. We are a long way from simple technology transfer here.

What are implications for policy: on research, on commercialisation and on higher education?

At some level, AHSCs are ill-defined in the European context, what their characteristics are, how they are organised and perform. Sensible investigation is needed to identify the performance, role and function of AHSCs in Europe, and to understand whether they are in fact a nexus of innovation or a quagmire of bureaucratic interference.

We need lessons and cases to draw on to understand how to structure appropriate innovation policies that may require the formation of high performing AHSCs that can be breeders of entrepreneurs. We also need to think beyond biomedical research as the potential scope of AHSCs includes innovations in systems and ways of working, health information technology and software, medical devices and not just medicines and so on. This nexus of innovation is very broad.

As someone who sees the challenge of AHSCs through both the institutional as well as policy lens, some key areas of priority are implicated and which are presented as conclusions:

  • Funding of AHSCs is not quite the same as funding the constituent parts, so national policies need to be harmonised if AHSCs are to become effective accelerators of innovation and enablers of entrepreneurs. This will raise coordination challenges for governments as the incentives they deploy may come from different pots of money with differing purposes.

  • Institutional design is important and only suitably high performing institutions should comprise an AHSC; this has implications for whether a national accreditation system should be used (England), or policies and initiatives to advance the role of AHSCs (Canada).

  • Commercialisation design is important and plays to national policies on public ownership of publicly funded research, whether state-owned research infrastructure should be disposed off to non-state ownership, with corresponding implications for the employment status of entrepreneurs. National taxation and entrepreneurial policies can be remarkably short-sighted and counter-productive; we really need to understand how bad some national legal frameworks are, and how good others are. AHSCs will be embedded in these legal frameworks, so how productive they can be is linked.

  • We really need to understand how national policies can encourage the introduction of high performing AHSCs where none exist, or prune the numbers of AHSCs if they have proliferated without also achieving high levels of (international) recognition and performance, or enable existing AHSCs to be real drivers of innovation.

NOTE:

Presented at the 2012 Entrepreneuriship conference in Maastricht in March 2012: see here for more details.

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Title page to Locke's Some Thoughts Concerning...

Some New Thoughts on Education are needed

The new Government’s plans to scrap SHAs by 2012 in an effort to slash NHS administration costs will have ‘major ramifications’ for the future of GP training, and could see budgets cut, warns the GMC. From the GP Bulletin, Pulse, 1 June 2010.

As Mark Twain said, rumors of his death, etc. the issue is overstated as always.  Fear replaces optimism as vested interests worry that they won’t be getting their education funding. But what was it doing with the SHAs in the first place? The creation of some form of market in health professions education, tied in some way to supply management does not in the end ensure a steady and flexible supply of health professions, any more than a similar system would ensure a reliable supply of geologists or accountants. The higher education system fails to evolve in response to the funding, as it is quite separate from the students or the continuing professional development needs of practising professionals.

It is good, though, to know that some see merit in this change as it will, in the end, clarify the purchaser/provider issues and redefine the necessary oversight of the health system. GPs and other health professions, though, do need to be assured that funding is in place to ensure that the programmes they need are properly funded, and accessible in ways that meet their requirements. It is, perhaps, no surprise that the revalidation argument fell at the final hurdle on the issue of a doctor’s time to do revalidation (having had some involvement in this issue in the past, I had calculated the full-time equivalents required to run the system, as well as the time it would take just to read the documents involved — but no one it seems had actually tried to read the paperwork, conduct the required activities with an eye to a clock!).

In the end, the simplest solution is to put the funding in the hands of both the students seeking the study a health profession, and in the hands of either the self-employed GP or their employer (the hospital) to decide what to do. With a level playing field on the provider side, this would ensure that the free-ride enjoyed by the private sector ended, and that all providers were properly responsible for both professional development generally, and CPD in particular. One benefit would be improved accountability by the higher education institutions that have come to monopolise this area, regardless of the quality of their offerings or not.

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Primary School in "open air", in Buc...

Education en plein air, Romania

Countries sink vast sums of money in higher education. Why?

Universities and colleges are at their root  ‘schools’, designed to enable the transfer of knowledge from one generation to another. It is where people go to learn how to be a doctor, lawyer, accountant, chemist, engineer, sociologist, and so and so on. What we expect them to do is deliver this knowledge transfer in an efficient and effective manner, to some degree of reliability and standards over time. To do that well, those who teach in these places are also expected to, in one form another, operate at the front line of their profession or discipline. There is really no point learning to be a lawyer from someone who doesn’t know what the meaning of recent court ruling is for civil liberties. So we expect those people to have an inordinate curiosity to know more than the average person would in order to structure the new knowledge, clean out the old, and ensure that we still get lawyers who can defend you in a court or a doctor who recognises you have a disease and knows what to do.

The research agenda has emerged as a big area of university activity, with many academics, perhaps most, have their careers almost trapped within expectations that they will do research and do it well, and be “published in prestigious international journals” (as a head of a higher education institutions once said to me).  Some more senior academics, perhaps the ones with the best understanding of a field, prefer not to teach, but beaver away on their pet research projects, or supervise the energetic activity of their graduate students.

In terms of the demands of the modern world, can the twin objectives of research and teaching co-exist together in the way that have in the past?

In the UK, the various university groups, such as the Russell Group, want greater freedom to set tuition fee levels, so they will get more money — this is the “big idea” that has come from institutions that are supposed to be the elite institutions in the UK, able to think the unthinkable, leap tall problems with a single bound.  I am dismayed at such lack of insight, but also at such self-serving indifference to the problems that lie within the academy.

Will this money go to better teaching? This is doubtful, as universities define themselves more through their research agenda than through their teaching agenda. Indeed, the careers of academics are made, not on the quality of their teaching, but on the steady production of research papers published in journals with a global audience of often a few hundred people, and books that embody the assembling of vast storehouses of information, but often fail to produce anything more than a wind-egg of insight.

There is the view, though, that teaching and research are intertwined; no doubt. But in the modern university, the research side rarely benefits the undergraduates (the focus is on the post-graduates), and higher performing academics are allowed to shrug off their teaching responsibilities, so they can concentrate on what interests them.  Perhaps all research intensive academics should be on soft money, ensuring that they are constantly focused on producing results from their research; this would also require greater sensitivity on the funding side, though, to ensure that good basic and preliminary or groundbreaking research continues to be funded. But at least it would eliminate the sinecure that protects many academics from accountability. But it would address the academic free-rider problem.

Like any clubby group, the universities see themselves benefiting FROM society, but not fully comprehending how they actually provide benefits TO society.

The solution is to break up the cosy world of higher education, like we would with any cartel. We need more contestability in the market for ideas, for teaching and for research.

That means that if students are to pay higher tuition fees, they should expect to get a higher quality learning experience.

That means professors teaching first year students, and graduate teaching assistants finding something else to do.

That means that we need to be able to decouple research productivity from the university’s teaching mission, enabling more free-standing and autonomous research facilities to exist, without the necessity of also carrying a teaching responsibility. It means that some institutions will concentrate on teaching and not be penalised for not doing research.

That means that some universities should go back to being polyclinics, and perhaps even technical colleges, to provide a more diversified educational system for the learners.

That means that we need more ways for students to learn, without the necessity of huge investment in building overheads and campuses,

That means we need smaller, more flexible learning and research-intensive environments, that can respond quickly and flexibly to areas of priority, such as we have seen with systems biology, conservation medicine, and other ways to integrate knowledge across often dysfunctional and artificial academic disciplines.

The new austerity isn’t only about money, it is also about purpose. Given the massive public investment in higher education, is it too much to ask the higher education sector to remind the hard-pressed taxpayer exactly what they are for?

Want to know more? Some suggestions…

The Marketplace of Ideas by Louis Menand (FT review of his book)

Reinventing Universities, a paper by Gowher Rizvi

We must set our universities free by Terence Kealey in Standpoint

Can American Research Universities Remain the Best in the World by Jonathan Cole in The Chronicle of Higher Education


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Edsel

News item in the UK: The sector’s funding body, the Higher Education Funding Council for England (HEFCE), announced (on 1 February 2010) that budgets are to be cut by £449 million for 2010/11.  This includes:

* A 1.6 per cent reduction (£215 million) in teaching funding;

* Research budgets will remain the same as last year;

* A 16.9 per cent cut in capital funding;

* A 7 per cent reduction for funding of special programmes and initiatives.

In a letter to vice-chancellors setting out the budgets, HEFCE said it recognised that the reductions will be “challenging” to institutions.

Now what is to be done? Predictably, the higher education sector in the UK is arguing that this will affect perhaps 200,000 students who won’t be able to get a university education. A few weeks ago, the sector argued that the UK’s place as a top tier home of higher learning was at risk — but that came from the elite Russell Group, which represents perhaps the top of the top universities in the UK.

There are a number of possible ways of thinking about this. A few:

  1. Universities already get a lot of money, and they perhaps could reduce their running costs — think of the disorganised structure of the academic year, think of teaching loads or confused performance management (is it teaching quality, research or publications??), and pretty good employment contracts. (I had one once.)
  2. There are too many universities trying to do too much, and perhaps it would not be a bad thing if some either closed or merged with another institution. The loss of the old polytechnics deprived the higher education system of a sensible alternative. Since comparisons to the US are frequently made, it is worth noting that some of the US’s top institutions are not called “university”, anyway, but ‘institute’ and indeed ‘polytechnic’. One could also look for new innovative institutions to emerge to challenge much that universities do. For instance, research institutions without university links, or which are focused on compelling issues — check out the Santa Fe Institute, for instance. Universities are not the only fruit!
  3. Cutting capital funding is not such a bad thing, given the horrendous financing of a state-sponsored capital funding body. Better universities learn how to build collaborative relationships with sources of capital, than expect their funding automatically to come from the state.
  4. Perhaps too much inadequate research is done, poor deployment of intellectual effort at reaching wider learning communities, responding to new ways of structuring learning beyond the rather tired full or part time dichotomy, and so on.

But of course, the key dilemma remains, what is to be done?

I take an optimistic view, but I would put the challenge at the door-step of the universities.

Rather than complain, prove that 800 years of public and private investment hasn’t been wasted, and come up with sensible solutions that would establish a sustainable approach going forward.  I doubt 200,000 or 200 students would be disenfranchised as a result, new ideas would emerge.

A recent book review in the Financial Times of Louis Menand’s The Marketplace of Ideas, would be a good place to begin some fresh thinking. The reviewer, Christopher Caldwell, notes:

Starting in the 1970s, professors, newly alert to injustices in society at large, took aim at credentialism and departmentalisation in every nook and cranny of American life – except, Mr Menand notes pointedly, their own. The professorial hierarchy continued to rest on a system of arduous PhDs (raising high barriers to entry), “disciplinarity” (denying the authority of the non-credentialed to teach or even discuss academic subject matter), and tenure (jobs for life). It was a system well-suited to monopolising bureaucratic power, but less well-suited to the free flow of ideas. Menand cites a 2007 study to show that, in the 2004 presidential elections, 95 per cent of the social science and humanities professors at elite US universities voted for John Kerry and 0 per cent (statistically speaking) for George W. Bush. Monopolies produce smugness and sameness in universities, just as they do anywhere else.

The title of this blog entry takes from a line in the film Independence Day, where the President says to the Geoff Goldblum character, ” And we’ll see if you’re as smart as we all hope you are” It is now time for the universities with their massive subsidised top-tier braintrust put on their thinking caps, stop playing victim and take responsibility for the solution.  The university-based economists let us down quite badly with failing models of our economies, and we are all paying for it in one way or other. Let’s not see two in a row.