The golden triangle and the golden rule

Take the train to one of the UK’s main university cities and, as you near the station, there’s an impressive view of a major biomedical campus with state of the art buildings and towering cranes – the latter signalling continuing investment. This is a leading example of the so-called golden triangle where health, academia and the private sector co-locate, believing that this will energise and accelerate the bench to bedside translation of research into clinical practice.

But visit the site and you’ll also see evidence of the golden rule at work – whoever has the gold makes the rules. Here, as on many similar campuses across the UK, those shiny new buildings including the ones under construction belong, in the main, to the non-NHS occupants. In this case the major hospital at the core of the campus occupies buildings, the majority of which are 50 years old. Interestingly a shopping complex on the edge of the city, some 10 years younger, is up for sale – one option is to repurpose it as a life sciences research centre.

Back on the biomedical campus the NHS trust has long-standing plans to replace its past their sell by date facilities. But the pace and scale of these developments are governed by the NHS’s Kafkaesque business case approvals process and, ultimately, the Treasury’s death grip on investment – the capital departmental expenditure limit (CDEL). Each government spending department has a CDEL set by the Treasury which, in the case of the Department of Health and Social Care is then allocated to NHS trusts (in future via integrated care systems).

All good if this ensures prudent management of the economy, however – “The most obvious problem facing the NHS relating to capital is that the annual CDEL is not currently high enough and has not been for the past decade” (Rebuilding Our NHS: Why It’s Time to Invest: NHS Providers). But it’s worse than that because even trusts with cash in the bank or with access to the proceeds of asset disposals are unable to spend beyond their CDEL limit. No wonder a councillor, hearing of how CDEL is delaying a planned NHS development in her area remarked; “It’s absolutely crazy, and not the right way to plan for any kind of public services”. (Bedford Independent 8 June 2022).

Another trust sought to leverage the high value of its city centre sites through an innovative approach to provide new NHS facilities including space leased to life sciences and MedTech partners. This would have fostered the day-to-day, serendipitous interaction between scientists and clinicians which is seen as key to successful collaboration in facilities such as the Crick centre. But you can guess what happened when the Treasury heard about it.

Frustrations such as these are commonplace and impede the creation of golden triangles. While there is no shortage of enthusiasm, the physical realisation of collaborative models requires that the NHS can match the capital investment agility of its private sector and academic partners. Just over a year ago the government published what it described as a “bold and ambitious vision for the future of clinical research delivery” (The Future of UK Clinical Research Delivery) where there is a reference to breaking down barriers. Perhaps it’s time for someone to send the Treasury a friendly reminder.