As part of her research on academic health organisations, Dr Catherine French (Collaborative Learning and Partnerships Programme Lead, NIHR CLAHRC NWL), with Professor Naomi Fulop (Professor of Health Organisation and Management at the Department of Applied Health Research, UCL) and Professor Ewan Ferlie (Department of Management, King’s College London), published a review entitled ‘The international spread of Academic Health Science Centres: A scoping review and the case of policy transfer to England.
We reflect on learning from this review:
“The most complex organisations in human history” was how management guru Peter Drucker described Academic Health Science Centres (AHSCs), partnerships between universities and healthcare providers, which are spreading internationally. Their organisational complexity contrasts with the simplicity of their mission statements: to integrate research, education and patient care with the aim of improving patient and population health outcomes. In our review of the literature on AHSCs, we suggest some useful social science approaches to help us understand and navigate their complexity.
Despite increasing attention to the problem of translating biomedical research knowledge into clinical practice, the policy worlds of research providers and research users remain broadly separate. Universities and health care providers operate in different domains with different incentives, funding sources and accountability structures.
Universities are independent entities, have income from a wide range of sources and operate in global networks. They are incentivised to generate research income and contribute to scientific knowledge through publishing in peer reviewed journals, and to train healthcare professionals of the future.
Health care providers are more likely to have some form of governmental accountability and operate at a local or national level. Through a variety of different mechanisms, they are funded to provide clinical care to individuals and populations.
Bringing these two distinct entities together has been a goal since Flexner’s landmark 1910 report on Medical Education called for US medical schools to be affiliated with universities and for medical curricula to be underpinned with science. Now the concept of AHSCs has evolved to be an international public policy response to the important question of how best to mobilise clinical research into practice.
The literature on AHSCs as an organisational form has been dominated by a focus on organisational models and the extent to which academic and health service governance arrangements are integrated – i.e. who is in charge? Is it the university Vice Chancellor (or their designate) or hospital CEO? Many AHSCs have changed governance arrangements over time, but as Kastor reflects in his tale of the ‘turmoil at Penn and Hopkins’, structures change less because of inherent faults in governance arrangements and more because of financial issues and conflicts between senior executives.
Whether an AHSC is successful in achieving its mission or not depends more on the abilities of its people and their relationships with each other than how they are governed. Governance models are shaped by the individuals who operate them and there are no ideals – they are influenced by local context and personalities. In England, network models prevail. Universities and hospitals are completely different statutory entities and full merger is very unlikely in the current policy climate. Instead they have intertwined shared histories through medical education and are held together by a complex mesh of shared boards, honorary contracts, rental agreements and good will. The oft used aphorism –‘when you’ve seen one Academic Health Science Centre, you’ve seen one Academic Health Science Centre’ sums up how the complexity of these relationships leads to a diversity of models.
There has been much less written on the social and political contexts in which AHSCs operate. In our review we suggest how social science approaches could contribute to the development of the AHSC mission, including understanding the international epistemic communities in which they operate, the relationships between professionals and managers and how boundary theory may inform how best to work across organisational, geographical and professional boundaries.
So what makes a successful AHSC? What would you do if you started with a blank slate? We were constantly asked these questions during our empirical research on AHSCs. It’s a moot point. Every organisation is shaped by the political and organisational environment in which it operates, and the individuals who operate within it, who are shaped with the culture of their science and professions and their relationships with each other, and their history. There are no blank slates.
However in our research we have come across teams making a success of integrating research, education and patient care. What makes these teams standout is partly context driven – they operate in areas of clinical care where research is moving at a fast pace and there are regular clinical trials making a difference to patients’ lives. Financial stability of the specialties also worked wonders – charitable endowments brought freedom to operate beyond organisational constraints. However what appears to make the real difference is leaders, – ‘boundary spanners’, who are able to navigate organisational as well as professional and knowledge boundaries.
These leaders, be they scientists, clinicians or managers, have the ability to build teams who are comfortable operating at the boundaries between research and practice and see research as integral to improving care for patients. Such leaders not only have an in depth understanding of the basic, clinical and applied research within their specialty and clinical practice, but also the skills to build relationships to negotiate through the politics of their respective academic and healthcare organisations.
So how can we understand how to improve AHSCs? Structural change is one thing. Taking hearts and minds with you when people are incentivised in different ways is quite another. If Drucker was right and AHSCs are the most complex organisations in human history, we need to learn not only from academia but also be able to share best practice globally to develop a deeper understanding of the cultural and political factors which influence the success or otherwise of AHSCs.
French, Catherine E; Ferlie, Ewan, Fulop, Naomi J (2014) The international spread of Academic Health Science Centres: A scoping review and the case of policy transfer to England. Health Policy, Volume 117, Issue 3, 382 – 391.