HIGH FLYERS THINK TANK
National Research Priorities Strategic Forum
The Shine Dome, Canberra, 26-27 June 2002
Priority setting: The NHMRC experience
by Alan Pettigrew
Alan Pettigrew is the inaugural Chief Executive Officer of the National Health and Medical Research Council (NHMRC). He has had a long association with the NHMRC, including as a member of the Research Committee, Chair of the Grants Committee and the Grants Access and Awards Committee, and as a member of the Medical Research Committee and its Executive. His former positions include Deputy Vice-Chancellor (Academic Planning and Resources) at the University of New South Wales and Executive Dean (Faculty of Biological and Chemical Science) and Pro Vice-Chancellor (Biological Sciences) at the University of Queensland. He has served as a Board member of UniQuest Ltd and as a member of the Mater Medical Research Institute Development Council.
It is a pleasure to be here and I am certainly learning a lot as we pass through this particular phase of the priority setting process.
To give you a flavour of how the NHMRC is approaching this issue and has approached it in the past, I need to first draw upon the fact that the NHMRC is established as a statutory organisation according to its Act. In the Act it says that the NHMRC is charged with the responsibility of raising the standard of individual and public health throughout Australia. It is charged with doing that through three different ways:
- fostering the development of consistent health standards between the States and the Territories;
- supporting medical and public health research and training throughout Australia; and
- giving consideration to ethical issues relating to health.
So we are there to provide advice, we are there to support research and we are there also to consider and advise on ethical issues relating to health. That sets the environment in which NHMRC has to work.
In order to do that, the National Health and Medical Research Council has two principal committees established in the 1992 Act. They are the Australian Health Ethics Committee, whose membership is prescribed in the Act, and the Research Committee, with details of its composition also prescribed in the Act. But the Council has also established, under ministerial approval, the Health Advisory Committee and the Strategic Research Development Committee.
So this is the organisation which has to look at national priorities in a research sense but also in the context of its Act and its overall responsibilities across the board.
The other contextual issue which faces the NHMRC is, of course, that there is data available on what NHMRC research should be supporting, in terms of improving health for all Australians. This is some data published by the Australian Institute for Health and Welfare, from their Health 2000 report, which shows the Australian burden of disease across major disease groups as they were in this country in 1996. For each disease area, there are two columns. Basically, the darker blue column relates to disability of the population, and the lighter blue column refers to lives lost. You can see that for cardiovascular disease there is a lower level of disability relative to the burden of disease causing death in the country. But just go down a couple, down to mental illness, and you will see that the disability line there far outweighs the death line. That is, not many people die of mental illness, apart from the suicides et cetera, but the disability burden in the country of people who are alive is very high in that particular area. So there are contextual differences, even within different disease areas, that we have to pay attention to in directing our efforts to improve outcomes in these areas.
So then the priority contexts for the NHMRC are the national burden of disease, and out of that has emerged the national health priority areas. These are constructed by the National Health Priority Action Council, and the formula which is used basically aggregates data across the sort of graphs shown above. We can account for 70 per cent of the burden of disease in Australia across the six national health priority areas:
- cardiovascular disease
- cancer
- injury
- mental health
- diabetes
- asthma
Each of these disease areas, each of those diseases, in addition to just being a major problem for the country in terms of health, is multifactorial. There are many, many factors which impinge and lead to that burden of disease, and each of those factors needs some attention.
So how is the NHMRC approaching this? First of all let me just describe for you what is happening with the Research Committee at the present time. The Research Committee's overall funding strategy supports and underpins the activities of the Research Committee.
We are responsible for improving the health of Australians, through research, across all disease areas in the Health portfolio. We are there to fund excellence, and the choices between what research to fund and what not to fund are really through the Research Committee, based on selecting on the basis of excellence: the best and the most creative people and the best and most creative research. We like to fund as a major player globally so Australians can participate on the international stage, such that they can bring information back to the Australian scene and implement change in the Australian health care sector. We are providing sustained mechanisms to develop and to maintain excellence – that is, trying to underpin national capacity, not only through supporting people in our Fellowship scheme and our medical research force but also through supporting facilities in whatever way we can. Another key strategy in the Research Committee's activity is to consult with the people who apply for the money.
It is an interesting observation, when you look at the research that is funded by the Research Committee based on excellence, to see where the funding goes. Across the broad health areas listed above, the ones in grey are the ones which I listed previously as being those areas which make up 70 per cent of the burden of disease in this country. That is, there is a natural accretion of researchers into the areas of most importance in health care in the country. This is not a guided thing; this is actually just happening out of the research community itself. And 49 per cent of the total number of project grants in 2002 are directed towards those six key areas of health care.
Back in 1999, the Wills review was released and the government accepted all but one of the recommendations of that review. The outcome of that has been an impact on the NHMRC in terms of changing the direction of how we go about supporting health and medical research in the country. We were asked to provide an effective health and medical research sector, to look at the issue of priority-driven research in a particular area of concern to the Wills review, we needed to link better with industry, and we needed to get a better public investment in a well-managed research sector. So the strategic directions which emerged out of that review in '99 are going on at the present time and we are couple of years into the process of change.
That change of strategic directions has included changes in the shape of research funding, so that there is an increased emphasis on longer and larger grants, giving our best researchers a more secure base upon which they can develop their ideas and bring through their results, and at the same time to improve national capacity. National capacity is referred to most often in NHMRC circles as being the national capacity in terms of people with skills to do the research. In order to lift our game in certain areas, we have had to facilitate support, clearly, in the clinical research, population health research and, more recently, health services research.
We are tasked with improving awareness and capitalisation of IP as it applies to our sector, and with facilitating appropriate commercialisation of research. We have done that by working with other agencies and releasing interim guidelines on intellectual property management, for example. We are charged also with improving our international links, because that will be a facilitation of better outcomes in this country by being able to adopt strategies that are used elsewhere. And we generally need to improve the linkages between research, health policy development and, indeed, health outcomes on a patient-by-patient basis and on a sector-by-sector basis.
This is a brief example of the time course of events of change in the NHMRC. The first column on the left shows the distribution of funding, in percentage terms, across what we call enabling grants – these are basic capacity-building grants – people support, program support and project support. As the cake is being doubled from 1999 through to 2004, these are the changes that are currently in train. The changes were actually set before this graph was drawn, obviously, in the year 2000, but you can see that by changing our greater emphasis onto longer and larger grants, through our program grants system, it takes quite a deal of time for that doubling of funding to actually flow through into that sector, simply because of the number of applications that come in. They are five-year grant awards. You do one lot, you then add another lot, you add another lot, and so on and so forth. The complicated accounting principles that go into this are driving us crazy, I have to say, and when we interact with DoFA, as was mentioned earlier this morning, we have an interesting time in dealing with these particular matters.
But the point I wish to emphasise here is that change coming from the Wills review is taking time to flow through the system. As the money is ramped up over that five-year period, the ramping-up actually leads to a longer-time course of events than just the five-year period.
So what are we doing within that, in terms of our new program grants, again emphasising increased scale, scope and duration of support for medical and health research? It is interesting that in the first round of applications for our new program grants, these are some of the examples that you see here of new program grants that were awarded in the areas of national health priority that I mentioned earlier.
There were 16 new program grants, and this list shows some of the programs that were awarded across those areas. There are another group of program grants soon to be announced, and they too fall into the national health priority areas in large measure. Again this is an example of the community of scholars themselves in health and medical research knowing where the important questions are, and making an attempt to get research going in those areas.
Some other additional things that are happening as the research capacity initiatives are: increasing support for facilities and equipment, increasing support for maintenance of databases in health care, our program in medical genomics facilitates people in that sort of discipline by aggregating equipment and skills in a certain area, a program in population health research, which is really designed to build our capacity of people to deal with those sorts of issues, and a joint health services research program, again more research being emphasised into getting health services research underpinning health policy across the country. And our international cooperation is important with a few of the organisations with which we are interacting at the moment.
The Strategic Research Development Committee, as the second of our two research committees, was established in 1997 by the NHMRC to develop strategic capability in health areas of identified importance to Australia, where the research effort is currently underdeveloped and/or underresourced. There appeared to be gaps in the way in which investigator-led research was coming through. How could we support some of these areas which we believe might be underdone?
This was the first set of activities that were undertaken after 1997. An interesting one that I wish to highlight on that list is the second bottom dot point. At that time, in 1997, there was a lot of interest in Hepatitis G, and the SRDC put some money behind some research into that area and found, after some good evidence-based research was done, that it was not an emerging health problem. So there was no point in directing a lot of effort into that potentially emerging problem.
Likewise, Lyssavirus. Who'll remember the death of the stable hands at Hendra, in Queensland, about that time? It was hitting the press and we thought we had a major problem, so there was an attempt to address that issue on an immediacy basis by looking at some research in that area. Fortunately, that issue has not emerged as a major health problem for the country.
So that was the first triennium of the Strategic Research Development Committee. At the end of that triennium they then undertook a review of the priority setting that they had been undertaking.
This list of dot points is the questions that were put out for public consultation. Groups, individuals, organisations were asked to write in; there were meetings held, working groups, workshops, all the sort of thing that you would undertake through public consultation, and the questions that were asked were these sorts of questions listed here.
Everybody had to try and work out what was the balance of the issues that would then lead through to the setting of priorities. As a result of that consultative process across all of those different sorts of questions and their interactions, there came five priority areas for the new triennium starting in 2000. Those areas are defined as: Ageing, Systems of care for chronic disease, Mental health, Indigenous health, and Oral health. Within each of those identified priority areas, there is a set of an extra four priorities which overlie each of the previous five. These are health issues, rural issues, health inequalities and palliative care.
So these are the major approaches that SRDC is taking, through this current triennium. We will see some outcomes of that research effort and that concentrated approach to supporting research there, but I can assure you that the outcomes of some of this research will not flow through for another five or more years.
Some evidence on why ageing, for example, was picked: expenditure on health needs of people aged over 65 at the time when this study was done accounts for the numbers that you see there. Why mental health? Well, the bottom there was that it is costing approximately $2 billion per annum in the Australian health care sector, so some extra research effort into mental health was deemed to be worthwhile.
So we get to this issue which has been facing the Council through this year: how do we set the balance appropriately between investigator-driven research, which in the health sector is approaching the national health priority areas anyway, and priority-driven research, which is directed towards areas where we feel there might be a need for some extra support? Looking internationally, we find that the US National Institutes of Health claim that their direct research or priority-driven research accounts for 30 per cent of their expenditure. The Canadian Institutes of Health Research have been reported as saying that their level of priority-driven research is sitting at around 9 per cent. The NHMRC, when we look at the national priority areas that are supported by the SRDC through its process, and add to those the national capacity-building areas of the Research Committee, then we are spending up to about 12 per cent of our budget so far on priority-driven research. That will increase because of new programs that are coming on stream, but it won't increase up to the 30 per cent mark at this point in time.
The important consideration which has come out of Council's deliberation in the last few weeks is the following point, which is a point I have tried to emphasise through the discussion of research which is driven by investigators. The impact on outcomes is a specific criterion for the peer review process assessing the merit of project applications. When the impact on outcomes is assessed by peers against the quality of the research which is coming up in an application, then the question of setting the balance between investigator-driven and priority-driven is simplified. You get the best experts assessing, 'How is this research going to impact on a definite improvement in outcome for health?' out of the research which is before them to be considered.
Now to the national research priority exercise. What are the opportunities? Well, these have been repeated by many speakers during this meeting and others outside it. The points I wish to emphasise from an NHMRC perspective are that there is an opportunity for greater cross-agency and greater cross-sectoral participation and cooperation; we could better use our existing and new resources; we could improve the scope for multidisciplinary approaches, especially the social sciences – and I have to put my hand on my heart and say that I think the social sciences and humanities have to be actively engaged in this current process; improved outcomes in research will facilitate improved outcomes in the NHMRC's other roles, namely, providing health advice to the country; and we need to build on a system that supports excellence. It must be founded on excellent research.
So what are the cross-sector, cross-agency things that might be able to be activated? I picked on new technologies as an example. Medical genomics, xenotransplantation, stem cells, medical devices et cetera under the heading of biotechnology, many activities going on within CSIRO funded by ARC, funded by NHMRC, these are the things where we could get some cooperation happening. I would like also just to draw briefly on the information and communication technology side of things, because there was mention earlier of e-health and telemedicine. I am putting in a plug here for CSIRO, who are developing these sorts of issues for health care in the country – the fact that a patient in Mount Isa could be diagnosed with a problem and have their test results sent down a telephone line in real-time ultrasound. So this is an important area of cross-sector engagement that I think we can enter into.
But we should not lose sight also of the risks in national research priorities. In my context, in the health care context, the time frame for outcomes in health research is long. Capacity to redirect funds on a short-term basis is difficult when we have already set a course, as I showed you in that graph earlier, of how we are redirecting funds within our activities. There is the issue of churn, the implications for research personnel as priorities move around. If they move around too quickly, people are going to be very destabilised by such a process. I know Joanne has addressed that issue in several conversations, and I think we need to clarify the issue of three-year reviews for the community.
What happens to non-priority areas? There are potential lost opportunities, loss of capacity, rundown of or failure to build infrastructure, and a loss of morale. The clear problem for me is not being prepared for unexpected – positive and negative – issues on a global scale. I give here some examples.
This is the growth in number of new HIV infections, from WHO data, from various areas of the globe. You can see this is happening between 1980 and 2000, a 20-year span. So things can happen quickly if you don't look out for them. Drug-resistant tuberculosis is another problem which may be on the horizon. It is not in Australia, but look where else it is in the world and see what commercial travel will do for some of these sorts of problems. Then there is environmental change, global warming.
We can see the trend: the red line is moving above a baseline there of zero over the last few years, and there is a further rise in temperature expected. You only have to go back to basic biochemistry to understand what will happen to a bacterium if you turn up the heat just a little bit.
So what are the priority areas for NHMRC? Our vision here is improved health for all Australians. It will be an expectation of the population. There is a link between national health and national wealth, and that is clearly demonstrated by the WHO. It is a multifactorial and multidisciplinary issue, and we require capacity, both in our existing health areas and the emerging health areas.
Our proposals that we are thinking through at the moment are that we should be putting priority behind A healthy start to life – that is, pre- and postnatal, early childhood. Healthy ageing has been mentioned, and I will mention it again as being something which we need to pay attention to. And there has to be a focus on Indigenous health, because it is an immediate imperative.
I get back to the time course issue. If we start putting a priority on pre- and postnatal life, when are the outcomes going to be realised in this country? They may not be realised for at least 20 to 25 years. If you are starting to think about pre- and postnatal life, the outcomes will not be realised until that person has developed into an adult and is contributing to society in the fullness of their maturity. And it goes beyond that, because the outcome will affect the next generation that those individuals actually create.
What are our potential action areas? Functional and population genetics and genomics brings in environmental factors and social factors which affect gene expression, which affects health. Integrated health informatics and information analysis can be from the molecular to the social level, and there is also the issue of tissue and organ development and regeneration as a most recent action in the time scale of health care.
I leave you with this thought. If you get the balance wrong, you will certainly lose direction. If you get the balance really wrong, you will go round in circles.
