Richard Smith, MD, Associate Editor, British Medical Journal.
A National Health Research Policy: Needed to Shift the Emphasis of Research
(BMJ, October 1, 1988)

Last week's report on the nation's health spelt out clearly how poorly Britain has done with many public health measures. The report came as no surprise; it is well-known that Britain has performed badly with, for example, immunization, cervical screening, mammography, preventing coronary-artery disease, and reducing inequities in health. One key reason for the failure is probably the absence of a national health policy on health and of a national policy on health research to underpin it. A recent World Health Organizations conference in Tampere, Finland showed how Britain's lack of nationally-agreed policies on health and research is causing us to be left behind many other countries in Europe. 

In contrast to Britain the European regional office of the World Health Organization does have a clear policy, and in 1985 it published 38 targets for health in the year 2000 (2). Few countries, if any, will achieve all these targets, but their existence gives countries the chance to plan coherently. The European Office soon recognized that countries would need to conduct research to help get close to these targets: research to provide new knowledge, to measure whether progress is being made, and to work out the blocks to progress. The conference in Tampere was held to publish two documents on the sort of research that needs to be done (3,4). Research policy for Health for All is aimed at policy-makers and suggests how they might re-orient research programmes (1); Priority Research for Health for All makes specific suggestions to researchers on the sort of work that might be done (4). 

In a nutshell the aim is to make the health-research programmes more relevant to ordinary people and to those such as doctors who use the results of research. WHO does not want to knock down traditional medical research but rather to build up public health research, research into life-styles and health promotion; collaborative research among medical scientists, social scientists, and economists; and health-services research. In most countries in Europe, including Britain, medical research is conducted primarily under the auspices of the Ministry of Education rather than the Ministry of Health, which is one of the factors reducing the relevance of the research. The authors of the books, which were widely circulated before being finalized, are also concerned that the consumers of the results of health research - patients, doctors, nurses and other health workers - are often widely separated from the researchers. This not only further reduces the relevance of the research but also delays the implementation of the results. 

This diagnosis of the ills of medical research is close to that reached by the House of Lords Select Committee on Science and Technology in its report on priorities in medical research (5), and the clerk of the committee, Douglas Slater, was in Tampere to talk about the committee's findings. The committee did not mention WHO's proposals in its report (although it had seen them) but advocated a National Health Service Research Authority to make sure that some of the problems it identified were tackled. The government has not yet responded to the report, but the idea of the special health authority seems to be a dead duck (6). Perhaps what is needed instead is a national health-research policy. 

As WHO emphasizes, such a policy would have to be developed by all those who would be concerned - researchers, the bodies that fund research, health workers and health authorities. Ideally, it would grow out of a national health policy, which should itself be based on the targets of health for all in the year 2000. Britain has associated itself with these targets (7), and [target] number 32 calls for the setting up of a research policy WHO suggests that the policy should establish goals; identify priorities, neglected subjects of research, and manpower and training needs; allocate resources according to priorities; and encourage the uptake of research findings. Experience from Japan suggests that the very process of drawing up such a policy would stimulate research (8, 9). 

British doctors reading this might think that it is all "typical WHO gobbledegook and fantasy", but the conference heard how Finland, The Netherlands, Spain, Hungary, Ireland and Yugoslavia have already been through many of these steps. The Dutch research policy has just been published (p 816) in English (10), and Dr. Kimmo Leppo from the National Board of Health in Finland told the conference how Finland developed a research policy in the 1970s that made many of the shifts subsequently recommended by WHO. The extraordinarily high standard of epidemiology and public health research in Finland is one practical result, as may be its infant mortality, which is the lowest in the world. Britain has also set a high standard in traditional epidemiology but has done poorly at translating the results into practice. 

There are more obstacles to establishing such a policy in Britain than the natural reluctance of the British to think in abstractions. Firstly, the targets of the 'Health for All' programme are not well known and the government is doing little to encourage their dissemination. This is not surprising when the first target is to reduce inequalities in health by a quarter; in Britain we are going in the opposite direction. Secondly, as several speakers at the conference emphasized, shifts in the pattern of health research are hard to achieve without extra money. If funds are going to have to be taken away from biomedical reserach to fund public health research then the research establishment - the Medical Research Council - is going to sabotage the plans. Thirdly, governments everywhere - and certainly the British government - are unenthusiastic about health services research because it illustrates their failures. They much prefer scientists to mess around with rat mitochondria. 

Finally, a research policy might be especially difficult to achieve in Britain because medical research is effectively being "privatized": industry and the charities are funding more reserach than the government (12, 14). But, although this diversity may make the task of developing a policy more difficult, it also makes a policy more essential. 

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1. Smith A, Jacobson B. eds. The nation's health: a strategy for the 1990's. London: King Edward's Hospital Fund.

2. World Health Organization Regional Office for Europe. Targets for health for all. Copenhagen: WHO, 1985. 

3. World Health Organization Regional Office for Europe. Research policy for health for all. Copenhagen: WHO, 1988. 

4. World Health Organization Regional Office for Europe. Priority research for health for all. Copenhagen: WHO, 1988. 

5. House of Lords Select Committee on Science and Technology. Priorities in medical research. London: HMSO, 1988.

6. Anonymous. Intercalating medical research. Br Med J 1988; 195:1802

7. Delamothe T. First United Kingdom healthy cities conference. Liverpool. Br Med J 1988; 296:1117-20. 

8. Irvine J, Martin BR. Foresight in science: picking the winners. London: Printer, 1984. 

9. Smith R. Peering into the bowels of MRC. Part 1- Setting priorities. Br Med J 1988; 296:484-8.

10. Department of Health Policy Development. Health research policy in The Netherlands. Rijswijk, The Netherlands; Ministry of Welfare, Health and Cultural Affairs, 1988.

11. Townsend P, Davidson N, Whitehead M. Inequalities in health. Hardmondsworth; Penguin, 1988.

12. Wells N. Crisis in research. London: Office of Health Economics, 1986.

13. Smith R. Is research to be privatized? Br Med J 1988;296:185-8.

14. Smith R. The funding of medical research; going up or going down? Br Med J 1988;296:267-70. 

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