Super trusts: unite and conquer

Academic health science centres are the new black. They bring together world class research bodies and clinical centres in a single organisation, aiming to gain a place on the world stage.

Entering this arena of the supertrust is UCL Partners, a partnership of five London-based institutions: University College London, Great Ormond Street Hospital for Children trust, the Royal Free Hampstead trust, Moorfields Eye Hospital foundation trust and University College London Hospitals foundation trust. Its aim is to lift the capital into a field of "international research hubs" that includes Toronto, Singapore and Boston.

UCL Partners, so the hype has it, will focus on treating major diseases that affect populations in London, the UK and worldwide. By promoting a strategic approach to medical research and healthcare across the member organisations, the supertrust intends to deliver significant improvements in health for Londoners; this can then be shared throughout the world.

Operational since last month, it intends to build on existing links between member organisations (such as with Great Ormond Street Hospital through the UCL Institute of Child Health) that have already led to medical breakthroughs or improved access to treatment.

Its strategy is to become one of the top six academic health science centres in the world, whose clinicians and researchers create spin-off companies that provide new treatments and generate jobs and wealth for local economies.

With five leading names involved, why is the supertrust named after UCL? Because, says University College London Hospitals chief executive Sir Robert Naylor, while the partnership includes internationally renowned hospitals, UCL is the leading biomedical university in Europe, the best UK university for health research and one of the world's top 10 overall.

"UCL is the element that brings us all together," he says.

While foundation trusts were once promoted as the crme de la crme of healthcare, as every trust is now expected to become one, some trusts want new ways of staying one step ahead. Imperial College Healthcare trust set up shop as an academic health science centre last year and King's College London has announced plans to create an as yet unnamed organisation with Guy's and St Thomas', King's College Hospital and South London and Maudsley foundation trusts. But Sir Robert is keen to point out that this is not a game everyone can play.

"The Department of Health is concerned that we don't get every hospital declaring itself as an academic health science centre and it wants to protect the brand. It is going to establish a peer review process," says Sir Robert.

In his next stage review final report in June, health minister Lord Darzi said those organisations with self-designated academic health science centre status will be subject to review by a panel of experts that will include international members. UCL Partners is now starting a process of internal peer review of eight research areas before going for external appraisal next spring.

Premier players

The emergence of the new organisations seems to clearly mark a shift in the trust hierarchy similar to the creation of football's Premier League. But Sir Robert believes the relevant league tables are international ones.

"There's a league table for medical schools worldwide and this year's results place Harvard at the top while UCL is number 13. The ones above it are all American except one in Tokyo."

While his organisation will remain a foundation trust, he stresses that UCLH is "not in competition with other foundation trusts... we are in competition with other excellent teaching hospitals".

NHS London director of strategy Paul Corrigan says that as the new wave of academic health science centres are comparing themselves with the best in the world, "and the point of world comparators is to succeed in world terms", such institutions are "different from the NHS, which has historically compared itself with itself".

But there may be as yet unknown consequences regarding the majority of London's child health and ophthalmology services being strategically controlled by one board.

Mr Corrigan indicates the partnership's future depends on the maturity and approach of its partners. "The only way it will work is if the institutions cede a proportion of their interests to the partnership on some issues. The partners would have to recognise their interests would best be served by the wider organisation for certain things. But you need to be clear up front. You cannot stumble into this."

However, Mr Corrigan does not believe the model is the only answer for delivering excellence.

"It's about how we move innovation in a much speedier way from bench to bedside, rather than shutting off institutions that do research from institutions that do service. There are research institutions that are not striving to be world class but can link research to practice. It does not necessarily have to be world class research."

He also refutes suggestions that the centres are likely to concentrate increasingly on research and specialised care, leaving the routine elective work to other trusts. "There is no way they will do this," he says. "If you go to Partners Healthcare [in Boston], you will find they do basic elective work and they are trying to find ways of doing basic elective work better."

Wider reach

The UCL Partners board will include the chairs and chief executive of the four trusts and UCL.Great Ormond Street chief executive Jane Collins says her organisation did not need to become part of UCL Partners to join the trust "premier league", but the move will ensure its research work reaches a wider audience.

"People would probably say that we were already in that premier league, but that brings with it the responsibility of supporting others and we do that," says Dr Collins. "We do lots of outreach and one of our responsibilities is to work with district general hospitals so research can be put into practice to ensure that all patients who could benefit from a certain treatment will get it."

Moorfields Eye Hospital foundation trust already has UCL's institute of ophthalmology on site and "operates as a mini academic health science centre already", says chief executive John Pelly.

"We already have experience of working in this very integrated way with an academic partner. What UCL Partners does is build on what we already have across a wider geographical patch and across a broader range of academic disciplines than is already possible.

"We're already the only ophthalmology trust in the UK. This is not altering our individual organisational position, but will hopefully make us stronger."

But he believes that ultimately all successful foundation trusts will want to be part of academic health science centres. "Who knows what might be in years to come, but there is no [current] alternative status to foundation trusts."

Nor is leaving elective work to one side an option for his trust, he stresses. "We could not survive if we only took specialised tertiary care and research. The core of our work is primary and secondary care, while our biomedical research centre is trying to address the most common causes of visual impairment, [so] we need a large group of people with those conditions under our care.

"We have easily the largest patient base in the world for ophthalmology, which is why our research efforts are effective. We're not changing our clinical and research strategy in that sense."

However, a new trust hierarchy could also lead to fears that beleaguered district general hospitals will be left further out on the sidelines.

But Royal Free Hampstead trust chief executive Andrew Way believes such organisations will continue to play an important role.

"We have a responsibility as trusts to spread out our abilities and skills but at present we do not currently work in a way that would allow this, hence the expectation that we would develop this as part of an academic health science centre." He emphasises that UCL Partners is not in a race with Imperial or any other of the emerging centres.

But are these new organisations in danger of losing out overall if they go head to head in a battle for resources and superiority?

"There is always a risk of that, but having talked to some of the players, I don't think it will happen, although people like competition and their share of glory. But there is also realism and a real desire to continue to compete internationally. We need to compete internationally, but collaborate to some extent," says Dr Collins.

She adds: "There have been some preliminary discussions with King's and Imperial. Let's say there are two to three academic health science centres in London. There is a recognition among a number of us that we would have to work together to compete with places like Boston [Partners Healthcare] because they are bigger. We need to make sure we are even better at producing research. That would be resolved better in collaboration to compete for international funding, where the critical mass is very important."

UCL Partners, meanwhile, is collaborating with the London School of Hygiene and Tropical Medicine on infection control work while it considers whether to become a founding partner or an associate member.

"There are other hospital trusts (in London), most notably Barts and the London and St George's, but they are much smaller. They will have to decide whether to try to make it on their own," says Sir Robert. "Most of us believe they will want to join one of the three other groups."

Barts and the London school of medicine and dentistry warden Sir Nicholas Wright was recently disappointed not to have been awarded a National Institute for Healthcare Research biomedical research centre with Barts and the London trust. But he says plans to set up an academic health science centre with the trust remain - "and we have no plans to join anyone else's".

Sir Nicholas adds he would not rule out a partnership with UCL or another institution along the lines of the Boston Partners Healthcare model. But they turned down an approach to join UCL Partners. "At this juncture we don't know the benefits. They mentioned the merging of funding streams, but for a medical school like us that would be problematic. There are far too many unknowns."

Meanwhile, those involved with plans to create a third academic health science centre based around King's College London say it will be the UK's largest. Robert Lechler, vice provost for health schools at King's College, says its model is likely to be somewhere between the UCL model and what is being done at Imperial Healthcare, where services and research are aligned after a merger.

"In our view what we have embarked on in south London is a little more complex and quite distinctive," explains Professor Lechler.

UCL dean of biomedical science Ed Byrne says the important issue is to fast-track the development of innovations emerging from UK medical research, something that remains difficult in the UK. While English universities have been "fantastic at basic research", says Professor Byrne, the country has been relatively poor at taking this and addressing it to clinical outcomes.

It is likely to be another five to 10 years before we find out whether academic health science centres are the missing ingredient. The effects they have on the NHS trust hierarchy may emerge much sooner.

The creation of a supermodel

UCL Partners, which became operational last month, will be responsible for more than 3,500 scientists, senior researchers and consultants, with a combined annual turnover of around£2bn.

It plans to focus initially on nine areas of research: neuroscience, cardiac, cancer, paediatrics, ophthalmology, infection, immunology, transplantation and women's health.

Last year, Imperial College Healthcare trust, also in London, formed what it called the UK's first academic health science centre when Hammersmith Hospitals and St Mary's trusts merged with Imperial College London. But rather than go down a similar route, UCL Partners has adopted what it calls a "splinter" model. UCL dean of biomedical science Ed Byrne explains: "We want to be in the top half dozen [centres] in the world and for us the best model is a splinter model, where universities and hospitals have a shared partnership to make sure teaching and research work together. It's not any more successful than a merger model, but the needs of a specific partnership may be met more by one rather than the other."

Professor Byrne points to Harvard Medical School's partnership with Partners Healthcare as the prime US splinter model. "Universities tend to go for splinter models when the universities and the partners are very complex. If you have one or two partners it may be feasible to merge governance but we have not gone for a merger model."

A guarantee-limited company is being set up to identify areas where UCL Partners is, or is aspiring to be, world leading. The company will run UCL Partners and be responsible for developing the major themes.

The recruitment of an independent chair is well advanced and a chief executive should be in place by early next year. The board will include equal representation from all partners.

"UCL Partners is a strategic body rather than an organisational body. The worry is that if you're not managing the strategic body correctly people can drop in and drop out," says Great Ormond Street Hospital trust chief executive Dr Collins. "Having an independent chair of UCL Partners is key. We would hope to get someone who is an expert in a relevant field and has the integrity, personality and skills to ensure we do what we say we will."

Royal Free chief executive Andrew Way adds: "The risk is that we create a bureaucracy that is self-serving. We want it to be very tight."