The age of austerity dawned soon after the global financial crisis of 2008 took hold, and governments have since wrestled with how to cut back on public spending without damaging key services such as healthcare. In the UK, there is growing concern that budgetary cutbacks will negatively impact the ability to support long-term medical research projects, which are a key strength among the scientific activities in which the country excels.
Much of the UK’s strength in medical research stems from the funding it receives through both government agencies and charitable donations. Medical research charities funded over £1bn in medical research projects in 2011, and the government’s Charity Research Support Fund supports many projects by covering indirect costs of research such as heating and lighting laboratories in universities so that charities can pay for scientists and materials. So far, the Charity Research Support Fund is protected until 2015, but the research community is concerned about whether the government will continue to find the right balance between the long-term needs of research and short-term political goals, and worry that funds for research could be diverted to delivering immediate care through the National Health Service (NHS).
“The main issue is that when you look at medical research you are looking at it in the long term, not simply jumping in and out. You may have to wait up to 20 years before you see it making a difference to patients. When you compare that to the political environment you find that governments are often working within five-year planning frameworks,” says Dr. Iain Frame, Director of Research for Prostate Cancer UK (see featured image above).
“There is a drive to do science that is immediately applicable, but medical research does not work that way—just ask the pharmaceutical companies. There is a short-term focus to funding. Britain was always good in this area because it did some of the best blue-sky research, but very few [researchers] get the chance to do that now,” says Gillian Murphy, Deputy Head of the Department of Oncology at the University of Cambridge.
For Frame, the danger is that the austerity measures might lead to changes in a medical research funding structure that, for now, works effectively. “The UK is fantastic at research and the National Institute for Health Research has a great program of funding through the Medical Research Council. It is a beautiful model for research to get to where it needs to be, which is ultimately bringing benefits to patients, but at what point do you prioritize funding to make patients lives better now rather than investing in future benefits?” remarks Frame.
The Road to Reform
Reform of the NHS is part of the UK’s austerity measures as it accounts for a large proportion of public spending. The stated goal is to drive £20bn of efficiency savings in the NHS by 2015 to free up money for patient treatments and investment in new technology. The worry is that this goal might be too bold and funds may have to be diverted from research.
“The UK government is not bad at funding health research and the three-yearly budget reviews have seen funding relatively protected. However, saving £20bn from the English NHS without significant cuts in the service it offers seems absurd, so there has to be a risk that some of this money will have to come out of resources that support research. We need to embed the idea that research is a core part of the business, part of our every day work, and that it could lead to cost reductions in the future,” says David Cameron, Professor of Oncology and Clinical Director at the Edinburgh University Cancer Research Centre, who is also Director of Cancer Services for NHS Lothian.
If cuts were to come they would be felt in the budgets of the National Institute for Health Research (NIHR) and the Medical Research Council (MRC). The NIHR operates a clinical research network of NHS and Foundation Trusts throughout the UK, and from April 2014 it will have distributed £280m per year to hospitals and surgeries to pay clinical research costs in the NHS. Last year, over 630,000 patients took part in clinical research studies supported by the NIHR Clinical Research Network. The MRC exists to fund a broad spectrum of medical research from fundamental lab-based science to clinical trials, and in all major disease areas. It also works closely with the NHS to encourage and support research, produce skilled researchers, and both advance and disseminate knowledge and technology to improve quality of life and the UK’s economic competitiveness. So far, NIHR and the MRC budgets have ostensibly been protected, though some researchers fear this may change. “We may see cuts at some point in the future [and] if you cut back on basic research now it will impact clinical research in the future,” says Frame.
Even so, the MRC continues to fund key projects, including the award last year of £25m to kick-start what it calls an “industrial revolution” in regenerative medicine as part of the UK Regenerative Medicine Platform, which is also supported by the Biotechnology and Biological Sciences Research Council and the Engineering and Physical Sciences Research Council.
“There were several factors behind this initiative. The first was the potential health importance—effective tissue regeneration has proved enormously beneficial in the haematopoietic system, and the potential value in other tissues and locations is obvious. The second was the quality of the science base—with strong groups and centres of excellence in developmental biology and differentiation, stem cell science, cell imaging, biomaterials, and medical engineering—as well as strengths in relevant clinical disciplines. The third was the complexity of the field and its interdependencies,” says Declan Mulkeen, the MRC’s Chief Science Officer.
For Mulkeen, there is no doubt that medical research should be a key focus of investment in the UK, and that the government is playing a central role in supporting this research. He disagrees with those who claim that government funding is falling in real terms. “Government has maintained medical research funding in real terms, with some provision for inflation to maintain spending power over the current three-year period. Science funding overall has seen far fewer cuts than other areas of public spending. Capital funding for equipment and facilities was cut back sharply for both medical and non-medical research, at first. Over the last two years, however, the government has been able to release more capital for science—for areas including regenerative medicine, use of health data sets, and medical bioinformatics,” he explains.
“Of course, it is not only the public sector that is affected—some, but not all, UK medical research charities have seen their spending power reduced. Sustained government support does not mean that there is no challenge facing medical research. Protected or not, for now, the economic downturn greatly increases the need to show that medical research has been a good investment in terms of its societal benefits and its economic benefits—and also, to show that the future returns from public funding will be as great, if not greater,” he adds.
Mulkeen readily agrees that if medical research funding were to be cut significantly as part of a government spending review then it could have serious consequences for the UK, now and in the long run. This is a sector in which the country should maintain, or build upon, its undoubted strength. “Over the last decade, in the UK and many other countries, medical research has been challenged to accelerate the pace with which discovery translates into clinical gain or new commercial products. The strategies we are pursuing involve several approaches, and also aim to develop closer partnerships with the private sector, and to increase private investment in health R&D in the UK. It is vital to carry on building both the public and private sector commitment to increased translation—and cuts would threaten both public investment and private sector confidence,” he remarks.
“We should also think of the research community’s confidence and ambition. For early career scientists, and for those who have not yet chosen a scientific career, cuts obviously send the wrong message. But for all researchers, there is a risk that sustained cuts in funding for running costs or for new equipment and facilities lead to less ambitious or less imaginative science,” he adds.
While Mulkeen has a positive stance on the government’s strategy for funding medical research, others are more sceptical about the current situation and more fearful for the future. “Whatever is said, the budget for the MRC has been decreased. The NIHR has started to reallocate more into treatment than into research, though they may say that research funding has not fallen. The changes are going on in the background, so the public doesn’t see it. The number of drug trials sponsored by pharmaceutical companies in this country is falling year on year because of red tape and the increasing cost of doing research here,” says Kieran Breen, Director of Research and Innovation at Parkinson’s UK.
“The NHS is the envy of the world, but it is not being used as well as it could be. The UK could be at the fore of drug research and the UK has the infrastructure for it, but if the funding is taken away from research to go into NHS running costs then there will be a detriment to the economy and to healthcare costs in the long term,” he adds.
For Breen, the immediate costs of medical research projects should be viewed in a different perspective, and seen as ways of potentially saving money in the future. “The problem with cutbacks in clinical research funding now is that it highlights a very short-sighted view of healthcare. If we don’t understand, diagnose, and treat conditions like Parkinson’s disease better then it affects the health of the nation and increases the cost to the health service. The government does not think about the long term, it thinks as far as the next election in 2015, not about what the NHS will cost in 2025. Less money for research now means a bigger bill for the health service, especially as the population gets older. If you fund research now you can reduce the cost of the NHS,” he says.
Charities Hit Hard
A substantial amount of research funding in the UK comes from research charities, which spent over £1.2bn in the UK last year. Some of these are now feeling the pinch, particularly those reliant on fundraising, which may see contributions fall as people have less disposable income. Others are more insulated, such as Prostate Cancer UK, which has been able to increase its research spending thanks to its association with the Movember campaign. Others, such as Cancer Research UK may face huge cuts over the next three years.
The MRC’s Mulkeen notes the pressure on charities to come up with more immediate applications from research projects. Some feel this could undercut the true value of medical research, which lies partly in so-called ‘blue-sky’ projects, which investigate a topic for its own sake to see what insights can be gained, rather than pursuing specific goals. “The bigger charities are focused on translational goals, which can have an immediate application, but they are cutting back on smaller blue-sky project grant schemes. We are seeing that with the Medical Research Council and Cancer Research UK, amongst others. The loss of ability in the UK to do those projects is a real problem. The translational push has been overdone with the aim of getting patents quickly, so we need to step back and fund modest but deserving projects alongside the blue-sky projects,” says Murphy.
“The risks are immediate. We will see in the next five-to-ten years a loss of capacity to do basic medical research. The UK needs to invest in young scientists. Schools are not encouraging the study of science, undergraduate study is weak and at post-doctoral level there are very few opportunities for researchers to support themselves because government funding is being cut. We are worried to see colleagues in universities unable to support research and giving up,” continues Murphy.
The University of Edinburgh’s Cameron agrees: “It is a short-term versus long-term problem for the entire NHS, not just for research. What people look for are outputs, but there is a lot of evidence that research has other spin-offs. There are better outcomes for patients treated at hospitals that do research, partly because it raises standards. Blue-sky thinking is also necessary and it can be done within the core business of healthcare, and it will deliver hidden benefits. There are plenty of people out there with innovative ideas, but we don’t have the culture to support them,” he remarks.
For many in the scientific community, the fact that some key projects are being put on hold is a bad omen for the future. “Suffice to say that despite the government’s efforts, we have all been hit as many of our research funders have cut back their funds and that is impacting particularly on smaller groups and Principal Investigators in the middle of their careers,” says Ana P. Costa-Pereira, Group Leader and Senior Lecturer in Cell Signalling in the Department of Surgery and Cancer at Imperial College London’s Faculty of Medicine.
Feeling the Pinch
As the outlook for medical research funding in the UK turns bleak, there is a growing call for the issue to be looked at from a different perspective. “The government says research spending won’t go down, but it has fallen in real terms as it has not gone up in line with inflation. We are now at a plateau but the government should at the very least keep funding constant in real terms. What we really need is an internal review to identify the opportunities that would be missed if we reduce medical research funding now. We need a logical debate with all the interested parties. We need an informed decision, not a knee-jerk reaction,” says Breen.
He cites the number of on-going drug trials in the UK, noting that 450 are for cancer, whereas there are only 37 for Alzheimer’s and 12 for Parkinson’s disease. “We need to prioritize the right areas and age-related conditions are among the most important as the population ages, but the division of funding is way out of proportion. We have to increase spending on age-related conditions in order to bring down the overall spending on healthcare in the long term,” remarks Breen.
Others agree that the problem is as much with the organization and distribution of funding as with the amount of money spent.
“There is a big issue with children’s medical research, which is hugely underfunded. This has a massive effect on the adult population as a lot of the NHS budget is spent on people in the last two years of their life, who are often suffering with problems that started in childhood. There is too much funding at the top and not enough at the bottom, if you like, so you need to turn that pyramid upside down,” says John Shanley, CEO of children’s medical research charity Sparks (Figure 4).
“Of a NHS budget of £110bn only around 6% is spent on children. The big funders of paediatric medical research are the MRC and the Wellcome Trust and then charities like Sparks do what we can. Something drastic must be done because there is a massive problem building up. I’m realistic and of course we have to look after the elderly, but it would be better for the government to look at the allocation of funding. The cake might not get any bigger, but it could be shared out in a better way,” he adds.
In the Hotseat
Though the research community in the UK is eager to point out the potential risks of cutting funding, no one underestimates how difficult the decisions are that politicians have to make. Yet when asked what they would do if they held the purse strings, researchers have a number of suggestions.
“The UK does research incredibly well but we need a joint approach to improving healthcare. To support research you need an overarching framework but the changes in the NHS seem fairly fragmented from a research perspective. We will have to watch and see whether the NHS restructuring will benefit research or impede it. I say again, the UK does research well, but there is an opportunity to mess it up, so let’s not do that,” says Prostate Cancer UK’s Iain Frame.
For the University of Cambridge’s Murphy, there needs to be less emphasis on short-term outcomes. “We need to get a strong base of scientists coming through at all levels. It is not necessarily about getting more money for research. We have to think for the long term, as there is no short-term fix. I’m impressed by some of the changes in the last few years, such as how the NHS and the government fund medical research, as it used to be a complete mess,” she says.
“Now, there is an increasing focus on specifics such as how to diagnose cancers earlier. However, we still need to support research efforts on the basic understanding of biological mechanisms; stem cell research is a good example. There may not necessarily be a specific outcome, but that will come later as our understanding improves,” she adds.
The MRC’s Mulkeen believes the UK has a strong track record that must be maintained. The MRC’s own research funding has led to the formation of over 50 new companies since 2007, and he notes that much of the £40bn therapeutic antibody industry has its roots in basic, publicly funded, MRC research. “Medical research has a very good track record of delivery for patients and for the economy. In terms of scientific achievement, it stands out as one of the UK’s strongest scientific areas. It is also one of the most productive areas, if you relate measurable outputs to funding. Medical research is very important in the UK,” he remarks.
Ultimately, many countries will face the dilemma that researchers describe in the UK, namely balancing the long-term economic and social importance of medical research with the short-term need to balance the budget. Whether the current approach is right, only time will tell.