The incentives for elite biomedical research have become decoupled from basic health needs

www.nesta.org.uk/feature/health-design/incentives-elite-biomedical-research-have-become-decoupled-basic-health-needs/
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It’s two years since Richard Jones and James Wilsdon published The Biomedical Bubble - a review of research and investment in the UK which showed how policy and funding are dominated by the bio-medical industries, and how we are not investing nearly enough on the preventative side, despite the evidence showing that public health across the UK remains largely determined by socio-economic inequalities, which have been highlighted by COVID-19.

Looking back, the authors say the report was intended as a “provocation” yet they recall their surprise at some of the reactions. They weren’t demanding the disinvestment of bio-medical research, just a more balanced approach to funding in the context of the launch of UKRI – the national research and innovation agency – and Theresa May’s announcement of a target of 2.4 per cent of GDP to be spent on research and development by 2027.

There had been a lot of debate about the structure of UKRI and its strategic potential,” recalls Wilson. “The government argument was that by bringing all this capacity under one roof it could take an unprecedented holistic view of the entire research system. So we were saying, okay, now UKRI is up and running, how will this work?”

In fact, the report began with a litany of the great successes of the UK’s bio-sciences but it went on to question – as others had done - whether things quite were now quite as rosy. “When it comes to pharma and biotech, we were writing at a time when the industry was having serious problems,” recalls Richard. “We drew on some other people’s work – particularly Jack Scannell - to highlight the collapse of research and development productivity.”

More than 80 per cent of the spending of research councils and medical research charities fell into areas dominated by basic and translational biomedical research - though this was not necessarily benefitting either the wealth or the health of the nation as a whole. For instance, not so useful for issues around obesity. The pharmaceutical industry was profitable, but its research was “steered by economic and market conditions which don’t obviously map onto societal goals.” Its major market was the USA, where a lack of health care reform inflates the prices of drugs. With a research model geared towards betting on ill health and overseas policy failure at the expense of more cost-effective preventative interventions, it was time for a re-think.

'All of this is ultimately about competition for resources. People make arguments to secure resources by moving between different arguments about economic and health benefits. It’s like a cup and ball trick.'

Where are we now? COVID-19 has been a huge shock to our public health system and economy and has launched a debate about what we could have done differently. Jones and Wilsdon think it is too early to jump to conclusions.

“I don't want to say ‘well you know the current crisis proved what I thought was right all along’” says Jones. “I think there will be stuff on different sides of the ledger about what our public health system has done, and what it hasn't. You will be looking at the disadvantages that we went into the crisis with – the health inequalities. Clearly there was a correlation of the severity of the disease with pre-existing conditions, type two diabetes and obesity. We need to understand to what extent the unhealthy position we started in affected our ability to deal with the virus effectively.

“I think we'll look at how much attention we gave to doing research to make sure that we have a public health system that worked. Much of the discussion about the pandemic has been about behavioural and social science; maybe that helped, maybe not. That question would be important.”

He thinks there will be questions about the diagnostic side of things, “clearly we have an industry that wasn't able to deliver testing on a large enough scale quickly” - and the supply of PPE, the “unglamorous” end of the health industry “that we outsourced to some other parts of the world.”

He is unequivocal about social care: “I think we can say that right now - the neglect of the social care sector had massive and tragic consequences.”

Change will require clarity of purpose and what Wilsdon calls “untangling.” The biomedical bubble Jones and Wilsdon described is a complex, enclosed system in which – for a skilled lobbyist - the arguments for investment in research can be made to flow back and forth between health benefits - for the whole population or specific groups - and economic benefits - whether that is in relation to the creation of new jobs, fitness to work and productivity gains, cost savings for the health service, or net income from the domestic and global sale of pharma and tech products and services.

“All of this is ultimately about competition for resources in a resource constrained system,” says Wilsdon. “People make arguments to secure resources in various bits of the system, by moving between these different arguments about economic and health benefits. Often the argument moves very quickly. It’s like watching a cup and ball trick. You have to keep an eye on it.

“COVID-19 shows that the links between the public’s health and what is researched are weaker than some advocates would suggest. That’s the argument we made and which Michael Marmot made ten years ago - and again recently. But look at how marginal Marmot’s thinking has been to government policy relative to those from the biomedical side. And therein lies the problem.”

Jones argues that we are not helped by the current categorisation of sectors of economic activity. “The idea of a Life Sciences sector is a category error - it conflates quite different things,” he says. “There’s a biotech and pharmaceutical sector, which is an important export industry and is a big contributor to the economy. Then there's a health and social care sector both inside and outside of the NHS, which is a gigantic chunk of the economy. And there's another sector which supplies lots of stuff to the health and social care sector apart from pharmaceuticals. And these three things are not the same. But not only do people gratuitously conflate them, they don't recognise that there are tensions between them.” They each have different health and/or economic goals.

'We need to understand to what extent the unhealthy position we started in affected our ability to deal with the virus effectively.'

This conflation of arguments and activity silences outlying voices and encourages the concentration of research resources within a narrow range of influential bio-medical institutions in the so called ‘golden triangle’ of London, Oxford and Cambridge. The government in turn looks to the expertise of a small pantheon of scientists who have come through them.

“The geographical concentration of power leads to the concentration of resources, not necessarily for any sinister motive,” says Jones. “But this distorts perspectives. If your view of the world is conditioned by the train line from Oxford to Paddington and then the tube to Whitehall you don't get much contact with people who might live in different parts of the UK, where the health problems are very different.”

He expresses bewilderment at a funding system in which the money from the National Institute for Health Research (NIHR), which comes primarily from the Department of Health and Social Care – “that is absolutely supposed to be about dealing with the clinical translation of research into real health” – is concentrated in Oxford and London.

Wilsdon argues that the narrow perspectives and backgrounds dominate advisory committees and translate to an “unconscious” problem with “group think.”

“This is not unique to biomedical science. It happens when you don't get diversity in the room,” he reflects. “You can probably see aspects of it in the thinking during the early part of the pandemic in terms of the modelling assumptions made on the behavioural side.

And then with SAGE – it’s a scientific advisory group in a pandemic without public health people on it! It's bizarre. The people come from a narrow cast list of institutions, backgrounds and disciplines that I think leave them vulnerable to regional, socio-economic and cultural blind spots, and blind spots in terms of other forms of disciplinary and practise-based expertise, which as it turns out have been paramount in the current situation.”

'We’d been telling ourselves that we've got such a brilliant world leading bio-science system. We just weren't paying enough attention to what was happening elsewhere.'

The Biomedical Bubble, a report written for Nesta, recommended the creation of a “National Institute for People Powered Health”, the antithesis of the bubble, that would draw on patient and community participation to improve the effectiveness of the health and social care system, and lead on preventative approaches to address the wider determinants of health. Nesta developed this idea and has been continuing to advocate for a similar body. What do the authors think now?

Jones believes that such a body would need to reflect what COVID-19 has shown us about our health and social care system from this crisis. “In some ways it did turn out to be enormously adaptable and it was able to respond impressively,” he says. “And we've now got some very fast efforts to develop vaccines. I don’t think people understand how hard that is to do. If the Imperial team makes an RNA vaccine, that will be a big tick against some of the recent developments in elite success for advanced bio-science - though we may find that our capacity for manufacturing these, or other advanced medicines, may run into a bottleneck.

“But there's gigantic holes. In a rational world we would come out with a better, more joined-up system that linked public health, social care and acute and primary healthcare in a much closer way and we would design a research and innovation system to support that.”

Wilsdon cautions against an institution that might become an “additional point of concentration in the system.” He doesn’t think that “just putting it in Manchester or wherever” is enough: “It needs to catalyse activity through the system. But if the idea becomes a focal point for more ambitious investment in these agendas, yes, that’s attractive. That's what was appealing to us.”

They are both struck by the role hubris about our research capacity has played in the pandemic. Wilsdon talks about his recent experiences giving evidence to the Home Affairs Committee with epidemiologists from Hong Kong and Singapore, where SARS shaped policy and health systems so they were able to react quickly to COVID-19.

“We’d been telling ourselves that we've got such a brilliant world leading bio-science system in various ways and we just weren't paying enough attention to what was happening elsewhere,” he says. “This is another feature of the biomedical bubble – an epistemic blinkeredness that has a techno-nationalistic dimension.” We’ve been too focused on generating our own knowledge - finding our own ‘world beating’ solutions.

Jones winds up our discussion by reflecting on the way that COVID-19 has exposed our lop-sided approach to public health. “Our debt to the expertise of the clinical staff in the NHS is obvious now,” he says. “But I think there’s a lot of other expertise – notably in public health departments in local authorities across the country – that we’ve failed to draw on. Central government’s haven’t shared data with the people who were best placed to use it. Expertise in public health may be less glamorous than academic bioscience, but that’s what we needed.”

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Richard Jones (left) is Professor of Materials Physics and Innovation Policy at the University of Manchester; he is an experimental soft matter physicist. He is the author of more than 190 research papers, and three books, including Soft Machines:nanotechnology and life (OUP 2004), and has written extensively about science and innovation policy.  He was PVC for Research and Innovation at the University of Sheffield from 2009 to 2016, was a member of EPSRC Council from 2013 – 2018, and chaired Research England’s Technical Advisory Group for the Knowledge Exchange Framework.  In 2006 he was elected a Fellow of the Royal Society in recognition of his work in the field of polymers and biopolymers at surfaces and interfaces, and in 2009 he won the Tabor Medal of the UK’s Institute of Physics for his contributions to nanoscience.  He is an Associate Director of the Research on Research Institute.

James Wilsdon (right) is Digital Science Professor of Research Policy at the University of Sheffield and Director of the Research on Research Institute (RoRI), a global consortium of research funders, academics and technologists working to advance transformative & translational meta-research. He is also vice-chair of the International Network for Government Science Advice (INGSA). An interdisciplinary social scientist, he works on the politics, governance and management of research systems, and the relationship between evidence and decision-making. His recent publications include, with Richard Jones, The Biomedical Bubble (Nesta, 2018).