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The Stars Were Aligned'? the Origins of England's National Institute For Atkinson et al. Health Research Policy and Systems (2019) 17:95 https://doi.org/10.1186/s12961-019-0491-5 RESEARCH Open Access ‘All the stars were aligned’? The origins of England’s National Institute for Health Research Paul Atkinson* , Sally Sheard and Tom Walley Abstract Background: In 2006, the research and development (R&D) activity of England’s national healthcare system, the National Health Service, was reformed. A National Institute for Health Research (NIHR) was established within the Department of Health, the first body to manage this activity as an integrated system, unlocking significant increases in government funding. This article investigates how the NIHR came to be set up, and why it took the form it did. Our goal was a better understanding of ‘how we got here’. Methods: We conducted oral history interviews with 38 key witnesses, held a witness seminar, and examined published and unpublished documents. Results: We conclude that the most important forces shaping the origin of NIHR were the growing impact of evidence-based medicine on service policies, the growth of New Public Management ways of thinking, economic policies favouring investment in health R&D and buoyant public funding for healthcare. We note the strong two- way interaction between the health research system and the healthcare system — while beneficial for the use of research, challenges for healthcare (such as stop-go funding) could also produce challenges for health research. Conclusions: Understanding how and why England came to have a centralised health service research system alongside a long-established funder of biomedical research (the Medical Research Council) helps us interpret the significance of the English health research experience for other countries and helps English policy-makers better understand their present options. Learning lessons from the features of the English health research system calls for an understanding of the processes which shaped it. Firstly, the publicly funded, nationally organised character of healthcare promoted government interest in evidence-based medicine, made research prioritisation simpler and helped promote the implementation of findings. Secondly, the essential role of leadership by a group who valued research for its health impact ensured that new management methods (such as metrics and competitive tendering) were harnessed to patient benefit, rather than as an end in themselves. A policy window of government willingness to invest in R&D for wider economic goals and buoyant funding of the health system were also effectively exploited. Keywords: United Kingdom, health research system, National Health Service, National Institute for Health Research * Correspondence: [email protected] Department of Public Health and Policy, University of Liverpool, Whelan Building, Quadrangle, Liverpool L69 3GB, United Kingdom © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Atkinson et al. Health Research Policy and Systems (2019) 17:95 Page 2 of 14 Background establishment of the NIHR has been discussed by In 2006, a National Institute for Health Research (NIHR) scholars of health research, but the present study is the was established as part of a group of radical initiatives in first historical analysis, interviewing participants to gain United Kingdom research organisations. NIHR, with a insight into their motivation [5, 8]. 2015/2016 budget of £1037 million, is a virtual organisa- tion within a government department, the Department Methods of Health and Social Care (DHSC), responsible for the All interviews were conducted by PA, joined on three National Health Service (NHS)’s own research and its occasions by SS. Both are historians and have under- support for studies commissioned by others. (Until 2018 taken the Oral History Society’s training in interviewing. the Department was known as the Department of Health Prior to the project, neither interviewer had had contact (DoH).) NIHR is the first body to manage this activity as with the great majority of the interviewees. Thirty-eight a single system integrating clinical research, research interviews were recorded and transcribed, with participants capacity-building and research delivery by the health being a mix of NIHR directors and other staff as well as se- service — a reform that unlocked significant increases in nior figures from government and the world of research, government funding [1]. NIHR is by far the largest granting us exceptional access to decision-makers. Sam- funder of clinical research in the United Kingdom. Ex- pling was purposive, with interviewees selected for our per- amples of NIHR’s wide-ranging impact include clinical ception of their impact on policy-making. We took care to gains, such as the use of tranexamic acid to reduce ser- include interviewees who were involved behind the scenes ious bleeding and death after severe trauma, policy gains, or at more junior levels, rather than focusing exclusively on such as its contribution (discussed later) to the work of those who have been most visible and vocal. the United Kingdom’s National Institute for Health and We also searched and correlated primary and secondary Care Excellence (NICE), and capacity development such historical sources such as policy documents and existing as the establishment of the research leadership develop- analyses with the interviews. Each interviewee received a ment programme [2]. This article is about England, the tailored set of questions and points for discussion; inter- largest of the four countries of the United Kingdom; views were semi-structured and ranged beyond these sub- parallel developments took place in Scotland, Wales and jects when interviewees raised other material of interest. Northern Ireland. (The expression ‘Britain’, used by two Oral history studies adopt a humanities approach rather interviewees, often means the United Kingdom, though than following a social science one such as grounded the- technically it excludes Northern Ireland.) ory. Subjects were interviewed at locations they found This history is of interest to an international audience be- most convenient, either their homes, workplaces or a neu- cause many of the challenges of health research are experi- tral central London location (the Wellcome Library). enced worldwide [3]. An account of the English experience Three interviews had to be conducted by telephone. There may illuminate how the publicly funded, nationally adminis- were no repeat interviews. Audio recording and transcrip- tered character of the English healthcare system has affected tion were used. All participants were also invited to an research and development (R&D). While Walter Holland audio-recorded ‘witness seminar’ in February 2018 at the compared health research in the United Kingdom and the University’s London campus, which 22 attended; its tran- United States of America, few other international compari- script provided a further resource for the project [9]. Wit- sons exist — the present study, while not comparative, al- ness seminars add nuance and debate to the recollections lows an international readership to understand the English of individuals, drawing out greater insight into the motiva- experience better [4]. There has been very little study of the tions behind past events. contemporary (post-1990) history of health research; Sher- Ethical approval was given by the University of Liver- gold and Grant’s review of health research in the United pool Committee on Research Ethics. Participants could Kingdom since 1911 summarises the most relevant litera- choose to be quoted without prior consent, to approve ture [5]. Our work covers the NIHR era in greater detail. quotations used or not to be quoted. Policy interviewing Our goal was a better understanding of ‘how we got calls for an alertness to the interviewee’s agenda and here’ as an aid to current policy-making. To historicise a power imbalances between interviewer and interviewee, policy can help reframe debates, test assumptions, sug- and demands the maintenance of a critical distance; gest alternative courses and help policy-makers under- Berridge discusses these and other methodological issues stand “the way in which their policies will mix into the about the validity of findings and how to avoid some of flow of a society’shistory” [6, 7]. An explicitly historical the pitfalls of policy interviewing [10]. methodology can supply otherwise unavailable insights for contemporary policy development because partici- Results pants are more candid about past activities, seeing The article discusses how NHS R&D interacted with engagement via interviews as non-threatening. The four parts of its surroundings, namely evidence-based Atkinson et al. Health Research Policy and Systems (2019) 17:95 Page 3 of 14 medicine (EBM), developments in public sector manage- guidelines came to be used too by governments and ment, industrial policy and change in the NHS. These other authorities [15]. The United
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