Mention Johns Hopkins Hospital or the Massachusetts General Hospital, and most doctors will recognise these as leading teaching hospitals of the Johns Hopkins School of Medicine and the Harvard Medical School — both consistently ranked in the top 10 medical schools in the United States.1 Both hospitals are exemplars of excellence in the teaching hospital’s functions of patient care, medical education and clinical research.

While Australia’s teaching hospitals may not have the same international status, the best of our teaching hospitals are recognised as providers of complex and high-quality care, suppliers of the nation’s medical and health professionals, and leaders in clinical research. Indeed, a recent review of the status of medical research in Australia acknowledged both its high quality and international standing.2 However, it appears that the standing of this research in Australia’s teaching hospitals is under threat.

In this issue of the Journal, Penington, a leading academic and Chairman of the not-for-profit company Bio21, which links the University of Melbourne with its teaching hospitals and research institutes, argues that Australia’s teaching hospitals are in danger of slipping behind other nations such as the US, Canada and the United Kingdom in the calibre of their clinical research.3

The immediate concern is that the prevailing administrative emphasis in our teaching hospitals now revolves around service delivery and quantitative performance indices that ignore quality of services. Cecil Helman, general practitioner and social commentator, wrote:

In this environment, the importance of research and its supporting frameworks have dropped below the bureaucratic radar. Furthermore, Penington argues that support for research in teaching hospitals has fallen victim to “cost shifting” and “buck passing” of responsibilities between bureaucracies as to who is responsible for the infrastructure sustaining research and development (R&D) in teaching hospitals.3 A new channel or dedicated funding is needed.

The UK has recently witnessed an orderly series of inquiries that have culminated in the UK Government corralling the National Health Service research budget of around £1 billion and forming a new funding body — the National Institute for Health Research — for translational (aiming to connect research to actual patient care) and clinical research programs. An international panel has awarded comprehensive biomedical research centre status with major funding to five major medical research centres — University College London, Imperial and Kings Colleges, and Oxford and Cambridge universities. These are the super medical research universities in the UK, and will be internationally highly competitive in translational research done in a clinical setting (Edward Byrne, Executive Dean, Faculty of Biomedical Sciences and Head of Medical School, University College London, personal communication).

The overarching vision is for health research to be performed by the best people, in the best facilities, and focused on the immediate needs of patients and the public. Paramount in this vision are partnerships with industry, and the central roles of universities, granting bodies and research charities.5 An example of this vision in action is the partnership of the Medical Research Council, the Wellcome Trust and Cancer Research UK in a new institute in central London with a building cost of about US$1.5 billion. This institute will perform mainly basic research, but there is a firm requirement that there be clinical research links to the large hospitals in its proximity, particularly those affiliated with University College London (Edward Byrne, personal communication)

The issues raised by Penington3 are just part of the story. With the recent increase in the number of Australian medical schools and in medical student numbers, there is also a pressing need for more teaching hospitals, ideally linked in a “hub and spoke” configuration with general practice, which has now been given a greater role in medical education.6

If this is to be achieved with the best possible outcome, it is important that there be specific guidelines and a quantifiable framework for what actually constitutes a teaching hospital, and what may be acknowledged as acceptable variability within this framework.

Teaching hospitals have one common characteristic — a commitment to medical education in partnership with university medical schools and clinical colleges. But they can differ in many other ways.7 These include: the size and scope of resident staff; the number of fellowships or advanced training positions; the standing of R&D in the hospital; the facilities and infrastructure to support R&D; the level of integration of university staff in the hospital; the number of academic staff as heads of services; the mix of special clinical services offered; the extent and depth of diagnostic laboratory services; the mix and complexity of clinical care; and so on. The organisational structures of university presence in our teaching hospitals also vary, borrowing extensively from either UK or US models.8,9

It is a given that descriptors like the ones outlined above need to be refined and quantified so that teaching hospitals can be stratified, and key performance indicators can be developed and measured. These parameters might then be the basis of evidence-based and comprehensive remuneration schemes by state and federal agencies, allowing for rigorous accountability of the flow of money.

The Australian community needs access to the best health care, benefiting from advances in medical science and technology. The way forward is to borrow from the UK experience of independent and focused inquiries that have resulted in clear expositions and recommendations for action. It is time to confidently answer the question of whether or not our teaching hospitals perform to the level of their international counterparts, and to prevent the deterioration in clinical research capacity signalled by Penington.3