Select Committee on Science and Technology Minutes of Evidence

Examination of Witnesses (Questions 280 - 299)



  Q280  Lord May of Oxford: So, from the point of view of the NHS budget, comparing the cost of looking after people who could have been in much better shape if they had had better care, you are suggesting that, even in purely brutal cost-effective terms, it is better to spend more money on this?

  Professor Lees: Let us look at the numbers. The use of statins to prevent stroke may cost about £20,000 to prevent one stroke; to treat a stroke when it has occurred—one, average stroke patient's time spent in hospital, looking at the hospital cost—is maybe £10,000 to £15,000. To give acute treatment with something like thrombolysis, at £400 for one patient's treatment (you need to treat around eight to get the benefits), it is £3,000 or £4,000. So you are saving money by getting in there early and doing as much as you can. I am not saying that is all you need to do—

  Q281  Lord May of Oxford: That is not the only consideration, but it is interesting way of looking at it.

  Professor Lees: And it certainly will not work for everybody, but this is a very important, very cost-effective argument.

  Q282  Chairman: While you have the floor, do you want to continue on the priorities in scientific channels?

  Professor Lees: I think the priority is to apply what we have already learned. We have learnt a lot about prevention, and we still have people out there in the pubs and clubs smoking—and perhaps that will change shortly—but there is a very powerful thing that we could do to help reduce or delay stroke and heart disease. It will help other conditions as well. We have learnt about acute treatment, we have learnt that stroke unit care does make a difference but we have not yet worked out how to get everybody into these units; we have learnt that we can examine stroke and tell: "Is it ischaemic or haemorrhagic?" In fact, there are indications that both can be treated by different mechanisms early, but we are not yet applying that. We have learnt that by using imaging we can discover much more about the mechanisms that are going on and, therefore, we can discover whether some of the mechanisms that seem to work in animal experimentation could be useful for stroke—whether these do apply and, therefore, we could target our research and our treatments better in that. However, we have huge barriers to research, and stroke particularly. Barriers include the fact that stroke is a heterogeneous disease and that by the time somebody has a stroke they are already reasonably old and they may well have other conditions. These other conditions and the variation in care they get make an enormous difference to the outcome, so we need very large trials; trials of thousands of patients to give us an answer. There are barriers to running multi-centre trials, particularly in the UK. A research assessment exercise measures us as academic clinicians on our individual contribution to authorship of papers, our contribution to the grants that we get, and only one or two people can get credits for that but we need hundreds of people all round the country contributing work to these trials. They get no credits for that so they are disadvantaged as soon as they take part. Hospital managers are not encouraged; there is no incentive for them to put patients into trials because it tends to be more expensive to put patients into trials; they have to spend a bit more time with the patient and a bit more on imaging costs, so there is disadvantage there. We need to start giving ourselves incentives to take part in this sort of research.

  Q283  Baroness Walmsley: You talked about the multi-centre trials. Do the people in all the different centres have to deal with their local ethics committee? So have we got multiple ethics committees as well, or is it done in one place?

  Professor Lees: Let me declare a conflict of interest here. I chair the Multi-Centre Ethics Committee for Scotland—the one that deals with Adults With Incapacity. There is no question that we have simplified the ethics procedure, to some extent, but we have done it at the cost of increasing the amount of bureaucracy in many other ways: the forms that have to be filled in now run to some 60 pages. This is partly due to the Central Office for Resrach Ethics Committees, the organisation that has taken over the running of the ethics system. We have a very cumbersome form-filling process and we have to go through the R&D departments in individual hospitals, whereas before perhaps they were not involved. We have all the European Clinical Trials Directive mandates on the numbers of forms that have to be filled, and if it is an academic study you still need to have huge organisation there to be able to report what we call serious adverse events—which, in most cases for a stroke trial, are things that would happen anyway to the patient—nothing to do with the treatment we are researching but all to do with the complications that arise anyway. So we have an enormous bureaucracy which is not all of our own doing in the UK (some of it is thrust on us by Europe), but we have applied it in a way that makes life very difficult. There are very many people who would be interested in multi-centre research who are now saying, "I just do not have the resources to do this. It is too complicated".

  Q284  Baroness Walmsley: Is it done differently in England?

  Professor Lees: England and Scotland have exactly the same system; the only difference on the incapacity issue in Scotland was that research not involving drugs goes through a single designated committee rather than going through any of the general committees.

  Professor Weissberg: It is difficult to know where to start. From the British Heart Foundation perspective, I guess there are two major roles that the BHF play traditionally. Let me just explain that the division of our spend is approximately £50-£55 million on research and about £15-£20 million on care and education. So the remit is to fund the very best of the fundamental research and clinical trials that are requested and required but, also, to plug the gaps in clinical care. As an example of that (and I mentioned heart failure earlier on) the Heart Foundation has funded, through the New Opportunities Fund, 155 nurses to look after patients with heart failure, because in effect hospitals do not have the resources to do it. If you have a nurse who can visit a patient at home and change the diuretic dose you can keep that patient out of hospital, whereas if you do not that patient ends up getting into end-stage heart failure and coming in as an emergency with all the risks that go with it. The organisation's spin on this is that we are interested in   the fundamental research underpinning cardiovascular disease but, also, the clinical care that is required. I would echo the points made here by my colleagues that there are two aspects to improving health care. One is applying the very best of available medicines and evidence-based medicines and evidence-based procedures, and I am afraid the UK is extremely poor at doing so. We have known for about 15 years now that thrombolycis, these clot-busting drugs, save lives in heart attacks and the quicker you give it the more effective it is. Only now, though, have we got to a position where patients are getting it within about 30 minutes of the onset of their symptoms. It takes a long time in our system for new evidence to be adopted and to be translated. I think in terms of trying to prevent morbidity in the elderly, one aspect—as has been said already—is applying best practice quickly and efficiently within our health system, and we have not been very good at doing that.

  Q285  Chairman: Can you say why?

  Professor Weissberg: Generally, cost, because all of the things you have heard about involve up-front costs. Again, we have all put forward economic arguments and mentioned "Is there a saving, ultimately, to be made?" The answer is yes, there is, but not to today's budget in that hospital. That is the way, I am afraid, the NHS looks at it; they are looking at this year's budget in this hospital: "If I keep a heart failure patient out of that bed somebody else's patient is going to fill it". So the bed is still filled, the work is still there, but in terms of future cost to the NHS there is a large saving, but we do not seem to have the flexibility to build that into the system. I think there has also been, if you like, an inherent caution, which has not necessarily always been bad in UK medicine, in that we do wait for the evidence to be pretty overwhelming before we apply it, and I think that is a benefit to the publicly-funded system; you cannot splash money around on new techniques and new drugs if you do not know that they work, but we need the clinical trials to show that they work and—more importantly—once the trial is over we need to implement that best practice very, very quickly. To pick up on one of the other things that was mentioned earlier on, which is imaging, imaging is becoming increasingly sophisticated. Time was, not so very long ago, if you had a stroke nobody wanted to image you, and speaking as a non-stroke specialist I think that is probably right. Nowadays, if you go to the right places, as has been suggested, and you get into the scanner very quickly you will have an image taken of where your stroke is and what is the vascular disease underlying it and, if you are luckier still, somebody will intervene on that and open up that blood vessel. However, there has been a leap of technology away from catheter based, x-ray based imaging which means inserting a tube into a vessel, infusing a dye and taking an x-ray picture—which was invasive, moderately dangerous, costly and required a lot of staff—to very slick, non-invasive techniques based on Magnetic Resonance Imaging, position emission tomography and CT scanning. As has been said, although most hospitals certainly have CT scanners now and eye scanners what they do not have is access, rapidly enough, for patients who need acute management; they tend to be used for the chronic condition, and even then you will wait, in some hospitals, six or nine months to have your back MRI image or a joint MRI image because of the backlog. I would echo what has been said about the implementation of what we already know. That would go a huge way towards offsetting some of the future problems that we have. As I said, from the point of the BHF, we are very interested in the pipeline of what might come along in the future and so we are particularly looking at strategies that might either prevent or deal better with disease that comes along. Another example which I have not mentioned are the ventricular-assist devices. These are mechanical pumps that can take over the work of the heart and have traditionally been used to tide patients over for transplantation. In other words, if a relatively young person with devastating heart failure has been deemed worthy of a transplant but there is no donor, a mechanical device is put in, which is basically a mechanical pump, which does the work of the heart until such time as the transplant can take place. These devices have been problematic because they cause complications, but they have reached a level of sophistication now where one can consider starting to put these devices into people with a view to sustaining them long-term and taking over the heart, and that is a technology which is advancing at quite a rate. I think, if you like, with ventricular-assist devices we are about where we were with pacemakers when I first started putting pacemakers in: they were the size of your fist, with wires about that size that you, somehow, had to manipulate under the skin into the heart, and now they are the size of half a matchbox with a very fine fibre which can be inserted in a matter of half-an-hour and the patient can go home the same day. I think the assist devices are liable to move in the same direction.

  Q286  Baroness Walmsley: I would like to ask to what extent your priorities are recognised by government. Do you think there is a good link between science and policy development? Do you think things could be done any better and, if so, what would be the benefits?

  Professor Weissberg: I will talk about cardiovascular rather than cerebrovascular and stroke, in that it has been a government target through the National Service Framework, and that is one of the reasons that the times, as I have already mentioned, in getting heart attack patients treated have come down because it has become a government priority, they have put money behind it and so things have started to happen. If you like, it shows what can be done when the right impetus is put behind it. There are coalitions of funders for research: one, in particular, is the Cardiovascular Research Funders Forum, which is a coalition of the Department of Health, the BHF, the Wellcome Trust, the MRC, and the Stroke Association (I think that is probably it) who meet relatively regularly to discuss strategy and areas of research that are of importance. I think we have got a way to go yet to make sure that that then gets translated into implementation and funding but at least the infrastructure is there to do that. I think, from the cardiovascular point of view, we have been fairly lucky over the years. I think stroke has been, unfortunately, left somewhat behind. I do not know whether my colleagues would agree with that.

  Professor Fentem: I think there are a number of points worth making as regards stroke. Stroke research has benefited from the NHS research and development programme, there is no doubt about that, and they enabled us to pick up some quite important projects in relation to rehabilitation. The other area which is rather important and which we have not touched on this afternoon is the question of research capacity. I came to see Lord Warner in December and Lord Warner said to me: "If I gave you £10 million would you know where to spend it?" The answer is that we would have a bit of difficulty in spending it in some of the areas which are our priorities, for the reason that stroke is quite a new discipline. As I said at the outset, 20 years ago nothing much was happening for stroke patients; stroke research is therefore relatively new, certainly compared with the research into heart disease. The result is that there is a capacity-building exercise that is needed in order to have the researchers around who were capable of undertaking this work. It is a great pleasure to be able to say that the NHS have, at last, picked that up. The Stroke Association is one of the strands of their support that they have given. We have had bursaries to help build research capacity for some years, but the NHS have now picked that up. Indeed, the level of support that was provided for such people was, I think, particularly generous, which is slightly surprising.

  Q287  Chairman: It is not often we hear it said!

  Professor Fentem: So far as the MRC are concerned, it is only 18 months since stroke was listed in their strategy. There was a meeting 18 months ago of their overall research strategy committee and at that committee it was agreed that stroke would appear in the strategy. It is not easy, either, to disentangle what portion of the brain sciences programme is relevant to stroke. So there is a sort of fairly artificial exercise which goes on, as reported in Hansard as to exactly how much money is spent on stroke research. The hard facts are, I think, that the Stroke Association spends about £2 million, the MRC probably about £4 million and over a period of time of perhaps 10 years, the NHS has spent £15 million. That is against the £100 million spent annually on cancer and larger sums of money that Peter Weissberg is now able to spend on heart disease. We are now a member of the Cardiovascular Funders' Forum but in the paper that I submitted, my Lord Chairman, I pointed out that I was a member of the Funders' Forum for Research in Ageing and Older People. That, I have to say, has been particularly disappointing. I hoped that that would be the research component of, if you like, the National Service Framework for Older People, but it did not prove to be that. Of course, the reason it did not work or has not worked so far is that there was not enough money on the table. We were a collection of very small charities: Help the Aged have about £5 million a year they spend, we have £2 million, and that is in contrast with the £100 million that the cancer charities brought to the table—maybe it is nearer £200 million now, I cannot remember. So there was no prospect that we would have some quick wins and make a big impact on research into ageing. That is a big disappointment. So I suppose, in summary, some good support may come from the NHS, particularly now with the National Stroke Clinical Research Network but not so good in relation, at least, to the Funders' Forum.

  Professor Lees: I think it is right that we do not have all that many green shoots that are there, able to spend money. I can certainly find places to spend £10 million very easily. I think we are growing on stony ground—this is the problem—and the three things I would say we really need to do to translate that apparent policy of supporting stroke research into action are, first, to deal with the bureaucracy that we talked about—the red tape, the paperwork—second, to deal with that issue of incentives for multi-centre work (that is both remove the disincentive that if you are doing that you do not get points in the RAE, and add an incentive to the hospitals and the NHS system to encourage research), and, third, let us deal with the infrastructure. That involves two things. One will cost money, and that is putting in more in the way of imaging equipment and more in the way of radiologists and radiographers to run that equipment, but the second part need not cost money, and that is to say it will be government policy that every patient with stroke and every patient with heart attack will, when they come into hospital, be immediately diagnosed. So, for a heart attack patient, that may be that they get their ECG—done, and I think we would think it would be dreadful if you could not get a cardiograph done when you turned up at hospital with chest pain- and for a stroke patient it means an immediate scan. Right at the moment, the target is to get your CT scan within a couple of days—two days, for a condition where the brain is dying over hours.

  Q288  Baroness Walmsley: If I may, my Lord Chairman, I have a little follow-up. All three of you gentlemen have talked in your response to my question about priorities about the structures and systems in place to set the priorities for research, with the exception, perhaps, of Professor Lees. I wonder if you can say something about the structures and systems that are in place to identify the priorities about implementation and best practice, and all those things. In your earlier answers you were lamenting the fact that a lot of the research does then not translate into better practice and systems to actually deliver the results of the research to the patient. Who decides now?

  Professor Weissberg: In theory and in practice it is probably the National Institute of Clinical Excellence these days that decides. So once a new development is recognised out in the medical literature then it goes onto the agenda for NICE to adjudicate as to whether this is value for money within the NHS, and until that point is reached it is nigh-on impossible to introduce a new medical technique or system, even though the evidence is out there, because the funding is not there. The theory is, of course, if NICE approve it then the funding should be made available, but at a practical level we find in hospitals the money has to come out of a pot which is held in the Primary Care Trusts, and most of them are in the red. Even though we hear that NICE has said that such-and-such technology should be instituted across the board it has to be done at the financial disbenefit of that hospital. I will make one other point, though, which is going back to research in implementation: there is no doubt, in my mind, that the very best way to ensure best practice is adopted is to be doing research in that area. If you are doing research into stroke and acute thrombolycis you have to come up with a strategy to get your patients into that hospital to do that research within the minutes that you need. Once you have set that up and you have shown that it works, then generally speaking there is a moral imperative locally to make sure that you follow on. So one should not under-estimate the importance of clinical research in actually progressing clinical practice. It is no accident that the centres of clinical excellence are also the centres of research excellence because those are places that gather the patients up, that put them into research protocols, that brings them outside the rather turgid mechanism of the health service and into a research protocol which allows you to treat them quickly and get an answer. Even if you then have to wait for NICE to agree, it is pretty unusual for you, the local hospital that has discovered that treatment, not to carry on using it.

  Q289  Baroness Murphy: Two things, if I may, following up that. One is, as Professor Weissberg pointed out, the National Service Framework on Cardiovascular Medicine has been very successful in concentrating the health service's mind on the right targets in that area. I wonder why, and perhaps Professor Lees and Professor Fentem might like to comment, the National Service Framework for Older People did not include best practice in relation to stroke. Yes, it has acute stroke units and good things in it but no targets were set and certainly not a very ambitious target.

  Professor Lees: I am not sure I can answer that question, but if I can throw a question back to you: why was there not a National Service Framework on strokes specifically, given that it is the third leading cause of mortality and is a major medical cause of disability, etc, etc? I think stroke was put in as an after-thought to that. In England, just as in Scotland, we had stroke added to the cardiovascular disease document in much the same way; it is seen as the poor brother or sister.

  Q290  Baroness Murphy: It is all wrapped up in things "elderly".

  Professor Lees: Just tagged on at the end, yes.

  Professor Fentem: I think we should say that Standard Five of the NSF for Older People has had its effect. I had made some notes on what I thought the links were. I have, for my sins, also served as a non-executive director of a PCT, and in the discussion there Standard Five of the NSF has certainly had its impact. One of the most important links has been the publication of the Royal College of Physicians' Guidelines on Stroke, which are evidence based and which have identified those areas in stroke across the clinical spectrum, from acute care to community care, where we have evidence and where we do not. It seems to me that that is a particularly valuable contribution (the recent edition 2004 has just been published), and that has had a tremendous impact on stroke care, and will continue to do so. May I just say, in support of Professor Weissberg, I welcomed John Reid's pronouncement that good research equates with good care, and good research saves lives. It has been demonstrated for cancer and we hope now that we might have the opportunity to demonstrate it for other conditions including stroke.

  Q291  Lord May of Oxford: I want to pick up on something you have just said about the connection between basic, clinical research and the delivery of universally effective care based on that. I do realise that simply counting papers and things is not a reliable measure of the quality of work, and I do realise that there are differences in the quality of work in the different hospitals. Nonetheless, clinical research measured both by quality of papers and measured by relative expenditure on it by conventional methods, is something in which the UK is, for example, well ahead of Canada, which was the one that manages to put things better. Thirteen per cent of the world's clinical medical literature is produced by the UK. I realise there has been a certain amount of decline in this, and I repeat myself that I realise it is not the only measure, but I offer it back to you as something that casts a bit of a shadow over the statement that if you are really very, very good at doing research that means you will be very good at looking after the patients, because it seems to me that our failure is not a failure in the research as such but a failure in the effective delivery of it.

  Professor Weissberg: Perhaps I can respond to that. I was not suggesting it was a failure of research, I was suggesting that if you are prosecuting good clinical research then that necessarily has an impact—

  Q292  Lord May of Oxford: At the place where you are doing it. Therefore, I draw the conclusion, everyone has to be doing the basic research otherwise hospitals will not be doing a good job.

  Professor Weissberg: I am not implying that. I said the centres of excellence that produce the research are doing the best clinical practice, by and large—not totally—and so what I was saying is that those centres that wish and are able to do the research need to be able to do it, and as we have heard there are big barriers to doing that. Going back to Lady Murphy's point about the impact of research, the NSF for Cardiovascular Disease was a somewhat easier nut to crack than, perhaps, many others because we had good evidence. So we could say we know that it saves lives to give aspirin, therefore that has to be one of the goals for the NSF. We know that streptokinase save lives, we know that ace inhibitors save lives and we know that statins save lives, and I would make the point that we know that because of studies done in the UK in our major centres (funded, I have to say, largely by the British Heart Foundation) that have added that dot to the I or cross to the T that says "Yes, this piece of evidence is incontrovertible, we must use it as best practice". It therefore went into the NSF and now the standard of care is vastly better for patients with cardiac disease than it was five to 10 years ago, but it is because we have that body of evidence which came out of the research that allowed us then to apply it. I think part of the problem with stroke has been—and, again, I am saying this not as a stroke specialist but, if you like, as a medical generalist—that even 10 years ago the GP would send the heart attack patient immediately to hospital because he felt they could do something for them, and the stroke patient would stay at home. The hospital was not seeing the immediate morbidity and problems associated with stroke in the way that we were as cardiologists in our coronary care units, and there is nothing like seeing a patient deteriorating in front of your eyes to stimulate you to want to do something about it. I think the problem with stroke has been that stroke patients have largely been left in the community and it is only now that we are starting to realise they are better cared for in hospital. As the pendulum swings towards bringing more and more stroke patients into hospital and sooner then I think the impetus and the whole research agenda will accelerate, and I think that is what feeds into the whole process.

  Chairman: We have quite a number of questions we would like to pursue so I am quite keen to move on.

  Q293  Lord Turnberg: Professor Weissberg, you very helpfully pointed out that the brain and the heart are pretty strong organs and if their blood supply was okay they would do all right, that you should not be worrying about them ageing and that the major problem, at the moment certainly and for a long time to come, is ensuring that the blood supply is okay and preventing atherosclerosis. This is all about preventing disease as against studying the basic biology of ageing. This may be a somewhat philosophical type of question but do you see somewhere in here the problem of doing basic research on ageing brains and ageing hearts irrespective of this disease-related deterioration due to vascular disease? Is this a silly thing to be thinking about now?

  Professor Weissberg: No, it is not but it is quite a difficult thing to do in that it is difficult to get your hands on the organs that you want to study in that particular age group. That is why I mention imaging as being so important, because I think that with more investment in research the non-invasive imaging techniques are beginning to give us a handle on molecular mechanisms and cellular mechanisms in the brain and in the heart, and I think that will then unlock the ability to ask about the ageing process per se in the brain cells and in the myocardium. There certainly already is research going on into the association between atherosclerosis and vascular ageing. One of the prevalent theories at the moment is that a consequence of atherosclerosis, that is the plaque breaking down to cause a stroke or a heart attack, is the failure of the repair mechanism in the vascular wall; that there is a constant tension between the lipid causing inflammation leading to the plaque rupturing and the smooth muscle cells working as repairers keeping that plaque intact and stopping it breaking down, and there is clear evidence that the cells from a plaque, the smooth muscle cells, are senescent. By that I mean if you try to make them grow and divide they do not do so, they have reached the end of their natural lifespan. There is molecular evidence now to show that as cells divide (it does not matter which cell you are talking about) the chromosomes get shorter and shorter and shorter with each division until there comes a point where the cell will no longer divide again, and some cancers occur because that shortening never takes place. There is now evidence coming out in cell biological literature that there may be, if you like, premature senescence at a cellular level. It is not quite the same thing as you are driving at in terms of ageing, but it is trying to get at the fundamental biology of ageing, if that is what you mean. I think there is quite a lot of mileage in that. The other example I would cite is something from my own research group's work, and that is Progeria Syndrome. These are these very unfortunate children that age extraordinarily rapidly and die, usually, at the age of 10 or thereabouts looking as if they are 80 or 90, but they die actually of vascular disease; it is that which causes them to die. It is not in the context of conventional risk factors for atherosclerosis—they do not have high lipids or anything like that—but they do have rampant atherosclerosis which kills them. The genetic cause of Progeria has just been identified as lamin mutations, and that has opened up a whole area of research. Lamin is a protein in the nuclear envelope which binds to a whole host of other proteins, and so that has opened up a whole area of cell biology and molecular biological research asking how do these proteins interact to prevent cells from becoming senescent under normal circumstances? Clearly, if you disrupt one of those proteins that cell becomes senescent very rapidly. So I think there are several indirect ways, if you like, into the biology of senescence or ageing, and I think that is already going on to an extent. Clearly, it is an important avenue of research if one wants to understand the natural process of ageing.

  Q294  Lord Turnberg: Just as a follow-up on that, Professor Lees said we are going to die of one of either cancer, heart attack or stroke. I am not sure he is right because it is quite possible that in a number of years' time most of the common cancers will have been cured or prevented, and if we work on the vascular tree in the ageing process in the way you have described and the arteries remain patent and open and our hearts beat away nicely and our brains continue to function, it may be something else that kills us off. This is where the biology of ageing is going to be of importance.

  Professor Lees: Or the lack of pension!

  Q295  Baroness Murphy: The specific research you are talking about, looking at the cellular and molecular level in relation to the ageing phenomenon, has that been yet applied to the vascular system specifically? Do we know whether, as yet, that work has been done or is it still in the pipeline?

  Professor Weissberg: It is being applied to the vascular system. There are groups around the country—my own group in Cambridge has certainly been doing some work on this and I know of about four or five other groups that are funded through the Heart Foundation—that do research on the phenomenon of vascular ageing as opposed to vascular disease progression.

  Q296  Baroness Murphy: Are those two regarded as separate?

  Professor Weissberg: Atherosclerosis is a disease associated with the ageing process but it is not unique to ageing, so it is not inevitable that as you get older you will get atherosclerosis nor is it inevitable that if you are young you will not get atherosclerosis. I think there is a distinction between the disease entity and vascular ageing. If one took atherosclerosis away—and of course it is very hard to do that in our society because pretty much everybody has got some of it—then you are talking about the haemodynamics of the stiff artery because there is no doubt that arteries get stiffer as they get older, and if the main conduit artery, the aorta, is stiff then it transmits much higher pressures to the tissues beyond and they can damage the tissues beyond—the brain, the kidney and the small vasculature—and I think we have been less good at getting a handle on that process. That is beginning to happen, again, partly through the new approaches to imaging and, also, I have to say, because it is no longer unfashionable to say "I am interested in physiology". There was a time, 10 years ago, when you had to be interested in molecules or cells to get any research funding at all, and if you said "I want to do more research on the haemadynamics of how a blood vessel behaves" you did not get funded. Fortunately, that pendulum is beginning to swing back now and we are starting to understand a bit more of the physiology—and we have got to because we are learning a lot about molecules and a lot about the cells but we have got to marry that with the physiology to be able to understand how it all works out. I think there is more work going on in that area.

  Q297  Lord Soulsby of Swaffham Prior: We have heard from you gentlemen about heart disease and stroke and they are, clearly, seen to be priorities in the National Health Service and in the pharmaceutical industries. Is there sufficient co-ordination between clinical medicine and pharmaceutical companies in either the treatment of the conditions or the prevention, and if not how does one bring them together more effectively?

  Professor Lees: I have worked with industry—not in industry but I have worked closely with them—and I think it is clear that industry has contributed enormously to the health service, and vice versa in terms of prevention. So that many of the drugs that have been developed, the statins and the anti-hypertensives and so on—vast numbers of drugs that have been looked at for preventative purposes in thrombin—were developed by industry, and industry benefited by getting the sales of these drugs, to the extent of enormous sums of money. But, I think actually there is still a huge barrier. As far as I can see there is no position where industry comes to the health service and says, "We want to work together to develop something". There is almost the opposite reaction; that if industry wants to work with clinicians to do a trial the health service puts barriers in the way by, for example, increasing the costs. If the Medical Research Council wants to run a trial in a particular hospital then the costs that are applied are those of doing the research itself, the added cost, plus, maybe, a little bit of overhead. If industry comes along, then every test that would have been done anyway in these patients is charged at as much as possible to the industrial company. So it is seen as a way of extracting money from industry to support the health service. Certainly there is nothing in the way of our research assessment exercise or the incentives for anybody to take part in industry-funded research; it is seen as being a bad thing to be doing. Yet, clearly, it is necessary; we have to work in partnership with industry. They very often have access to the compounds at a very early stage of development, they have access to groups elsewhere in the world who are willing to work with you; they can co-ordinate things, they have the facilities for dealing with the bureaucracy of getting compounds into different countries, and so on. So I think it is necessary that we work with them but I do not think we are doing it as well as we should do.

  Q298  Lord Mitchell: It is quite startling to hear that and I just wonder how would you improve it if you could.

  Professor Lees: The research networks that are being set up will help with that because they have been set up with an aim that they will encourage industry research. I think we also have to put something in the way of incentives in place for hospital managers to say "We want you to take part in this"; we have to put it in place with academics to say, "You will be given brownie points in the RAE, or whatever, which will be worth as much as taking part only in Medical Research Council-funded research". I think it is to do with sorting out incentives. Then, I think, we have got to go to industry and say, "Look, if we collaborate closely with you, if we give you the lower rate for conducting research in this country, we expect also to get the drugs sold to us at a lower rate". I think we can work in partnership happily.

  Professor Fentem: I think the question is whether the present arrangements, in fact, are optimal. As Lord May will detect, we have been looking carefully in recent times at the Canadian stroke network. I think there are some features of the network that commend themselves. Whether it is too late to consider them for   this country or not, I am not sure. The pharmaceutical companies actually contribute to the network, so the funding they put in the direction of research goes to the network and is not, therefore, distributed on the basis of contracts with individual clinical academic units, or whatever. That, it seems to me, has something to commend it and we need to move in that direction if we are going to make a real success of the clinical research networks.

  Q299  Lord Soulsby of Swaffham Prior: I was going to come to the clinical networks. It does seem to me that the development of any molecule or any procedure is costly, extensive—10 years or more—and if the pharmaceutical industry is going to be charged for that then that is going to slow things down enormously. The network situation is going to help cure that, is it? Is it going to encourage pharmaceutical companies to come forward with more new molecules and new procedures than they would have done?

  Professor Fentem: I think the question is how do we best engage them in the discussions? We are not at a stage yet where we can see clearly how that will be managed. Clearly, we have made a rather unsteady start to this because whereas the Government has made £100 million available for the next batch of research networks, the money that was discussed that would come from the OST to the MRC to support the research on those networks has not yet been forthcoming. So we may end up, on the present information, with networks but not with the funding for research programmes. A rescue bid could come  from organisations like the pharmaceutical companies, obviously, and so we perhaps do need to work out exactly how we will engage with companies in organising the networks. These would be contracts, in the end, not with individual academic departments but with a network of departments.

  Professor Weissberg: Can I just come in on that? It is an extraordinarily complex interaction between industry and academic and NHS research because, inevitably, industry has a particular agenda, and that is that they want to sell their product, and they want to protect their product. One of the difficulties in trying to do research with industry—and I think it has been well-exemplified recently—is they are very nervous of you trying to do research on one of their products that they do not currently have a licence for, not because they are concerned that if you find that it works they are not going to make a lot of money (they would do) but because they are concerned that if you find something negative (and a good example of that is the inhibitors that were being trialled for bowel cancer and in so doing was the final nail in the coffin for their risk of causing heart disease) it makes industry very nervous of doing any further research, particularly outside their narrow remit if their product is selling well. So it is very difficult to persuade them to think laterally, if you like, with any of the products they have out there. I think we have to recognise that we do need to work with industry. They need us and we need them; it is a matter of coming up with a framework in which we are all comfortable. We are all, as researchers, a little bit nervous at the moment, under the current framework—which is not really a framework on how to interact with industry—as to how we will be perceived in terms of our interaction with that company. So there is a lot of work to be done to try to work out some ground rules there that are mutually satisfactory, but certainly industry needs us. I am sure it is no accident that the money for clinical research in this country has gone up after industry was saying "We cannot do clinical research in the UK and we will have to take it elsewhere." They recognise the need to do clinical research, preferably here, and we recognise the need for them to help us do it. It is a matter of coming up with a framework we are all comfortable with.

  Chairman: We have, effectively, run out of time, and I am concerned that there might be a division bell ringing, in which case several Members of the Committee would have to go, but I would like to get two more questions on the table, perhaps, from Lord May and Lord Mitchell, with responses from Professor Lees—and if you wanted to amplify them thereafter that would be possible.

  Lord May of Oxford: Very quickly, we have been talking about the current recent past—and may I say I completely agree that the research assessment exercise is in more ways than one inhibitory of collaborative research, and let us hope that that is one of the things that might be ameliorated—but looking beyond that, what are the things that you see if you look 10, 15, 20, 25 years ahead? What are the things that you may care to speculate on very briefly now, perhaps, that we might be looking forward to? In particular, you have touched on stem cells earlier but I wonder what you think might be some of the longer term promises, given some of the things that have happened very recently.

  Chairman: I wonder if we could have Lord Mitchell's question, and then perhaps you might make one response.

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