When the then Commonwealth Minister for Health, William (Billy) Hughes defined the role of the newly formed National Health and Medical Research Council (NHMRC) in 1936, he noted that:1

The new Council had 15 members and an initial research budget of £30 000.1 Like its immediate predecessor, the Federal Health Council,1 it was embedded within the structure of the Federal Department of Health.

Today, almost 70 years later, an announcement on changes to the governance of the NHMRC is imminent. The pathway that the Australian Government chooses to take to modernise the NHMRC is as critical for the Australian community as the decision that marked its establishment.

In 1992, empowered by an Act of parliament, the NHMRC became a statutory body. It has an annual research budget of close to $400 million, and is governed by a council of about 30 members who are elected every 3 years.2 However, its scope and function have remained unchanged, as witnessed by the Council’s current mission statement: “to ensure that excellence in research, research and health ethics, and health advice improves the health of all Australians.”2 Now, 5 years into the 21st century and at the end of another NHMRC triennium, questions are being raised about whether the NHMRC can meet the challenges of delivering its mission in the new century.3 There is a view that the time has come for the NHMRC to modernise and mirror itself on the National Institutes of Health in the United States, the Canadian Institute of Health Research, and other organisations such as the Wellcome Trust in the United Kingdom.3 The attributes these organisations share include a high public and political profile, dynamic leadership, effective and accountable governance, strategies to achieve clearly defined goals, and a cadre of health and research professionals who communicate consistently and widely with other research and health organisations, universities, and the private sector. In contrast, the mould and modus operandi of the NHMRC have remained largely unchanged over the past 30 years.3

The three areas of responsibility of the NHMRC are ethics of research, health more generally, and health and medical research. The ethics component of the NHMRC function is world class, but recently the other areas have drawn increasing, albeit muted, criticism.

There are perceptions that the NHMRC

• is arthritically conservative and has difficulty in establishing a national and international profile;

• is tangled up in Canberra’s bureaucratic culture of self preservation and political manoeuvring; and

• is bereft of executive power because of a lack of clarity in the roles of the Chair of Council and the Chief Executive Officer, with the latter having conflicting reporting responsibilities (Box 1).4

There are also perceptions that the purpose and strategy of the NHMRC are driven by crowded committees that have an apparent consensus orientation and undercurrents of the tensions that exist between investigator-driven curiosity research and practice- and policy-driven priority research; and that it has difficulty recruiting and retaining suitable staff.4

Furthermore, there have been assertions that the NHMRC’s

• health advice is protracted and bogged down by red tape and statutory requirements; that its

• processes for policy development and priority determinations are slow and at times suboptimal — as instanced by the recent attempts to develop a policy on chronic disease5 and enact one of the Australian Government’s four National Research Priorities proclaimed in 2002: “Promoting and maintaining good health”;6 and, finally, that it

• has no overt accountability to society for its policy and research directions and its expenditure of what is essentially the public’s money.

In some ways it casts an image of an elitist organisation, but overriding all is a sense that its governance and structure is outmoded.3,4

What can be done?

A radical option I would suggest is for the NHMRC to shed all its functions except health and medical research and in so doing emulate the National Institutes of Health, the Canadian Institute of Health Research and the UK Medical Research Council. But the Australian research psyche shuns the revolutionary in favour of incremental change.

In this context are the excellent governance recommendations advanced in the report Sustaining the virtuous cycle for a healthy, competitive Australia4 delivered to the government nearly a year ago, but which have elicited no response. The review recommended that the NHMRC should be an independent and stand-alone entity, directly responsible to the Federal Minister for Health. It also recommended that it should be governed by a small board of 10–12 members, who could be drawn from society as well as the public health, medical research, and private sectors. The board should be led by a dynamic Executive Chair who might also assume the responsibilities of the Chief Executive Officer (Box 1).

Added to this framework, there should be a delineation of the organisation into separate but cohesive units, with overriding responsibilities for research ethics, national health, health research, and medical research. These separate units should be staffed by health and research professionals recruited and retained by challenging work, attractive career pathways, and remunerations not hobbled by public service guidelines.

The NHMRC Board and its units should be supported and advised by appropriate committees, including an overarching health and research advisory council of 10–15 members, addressing strategies, policies and priorities for the nation’s health and for curiosity and priority-driven health research. The latter need to focus on the prevailing national health problems in Indigenous health, disease prevention, chronic disease and health care delivery. The NHMRC should also develop innovative approaches to forging research partnerships, such as those pioneered by the Canadian Health Services Research Foundation and the Health Research Council of New Zealand. The overriding aim should be that all policy and practice must be supported by evidence, and, in the absence of evidence, this should be acquired through research. The activation of ad-hoc working committees (Box 1) should be on a needs basis. Ideally, these would be task- and outcome-focused, time limited and made up of experts drawn from an approved “College of experts”. Out of necessity, this College would be continually rejuvenated by “young blood”.

This modern NHMRC could also shed some of its current functions. Health advice, particularly regarding acute threats to the nations’ health, could be the business of an Acute Response Taskforce of experts, including representatives from federal, state and territory health departments. Australia’s response to the bovine spongiform encephalitis threat is an exemplar of this approach. The ad-hoc Taskforce would obtain its research capacity from the NHMRC. The NHMRC’s role in clinical guidelines development and dissemination could be devolved to the National Institute of Clinical Studies, as is the case in the UK, where elaboration of guidelines is a function of the National Institute of Clinical Excellence.7 Long overdue questions as to the purpose of guidelines, the processes for their development and dissemination, and the nature of the final product, need to be addressed.

The Board could take a radical approach and assess the success of its sponsored research not only by the traditional methods of published articles and granted patents, but also by asking “what exactly is society getting for its money?”8 Three UK bodies — The Medical Research Council, The Academy of Medical Sciences (a non-grant-giving body that promotes medical science) and The Wellcome Trust — are addressing the question of the societal value of health and medical research, to justify escalating government expenditure on this research and convince the public that these vast amounts of money contribute to individual and national health.8 The Board could even be so bold as to invite the public and policy makers to determine research priorities.9

These suggestions for modernising NHMRC governance have one purpose: to ensure that the organisation is clearly accountable to the Minister and is dynamic, flexible, adaptive, effective, and in tune with the 21st century. The recent achievements of the National Institutes of Health10 and Canada’s Institute of Health Research11 indicate that, with the right individuals and culture, all this is achievable. Above all, these changes would fulfil the goal of Billy Hughes that: “Research must be actively pursued and developed and as fast as new knowledge is acquired it must be applied.”1

However, all this discourse on modernisation is academic in the absence of a commitment by the Australian Government to provide appropriate research funding for the NHMRC with built-in annual growth. After all, who would want to lead an enterprise that by world standards is static or falling behind?

Postscript

Three days after this editorial was published online on 4 September 2005, the Federal Minister for Health and Ageing announced that from 1 July 2006, the NHMRC will become a fully independent statutory agency within the Health and Ageing portfolio, and that this change “will streamline the council’s governance arrangements and improve its ability to respond to emerging health and research priorities”.12 The newly announced governance structure (Box 2) — a hybrid of the recommendations made by the Grant Report4 and those of the 2004 report of the National Audit Office on NHMRC governance13 — is undoubtedly an improvement compared with the present governance arrangements. There is a clearer delineation of responsibility, and accountability in management, advice and strategic development.

However, there are good reasons for the medical and research community to vigorously oppose the suggested governance structure. It will potentially place the NHMRC under the complete control of the Minister and, indirectly, his political or departmental advisors. Under these circumstances, only a very strong CEO, a person with considerable power and influence, would be able to take the NHMRC and its agenda forward, and people of this calibre are hard to find.

To improve the proposed new NHMRC governance structure, there should be a Board, a small statutory body operating in classical corporate governance mode, with the CEO responsible to the Chair and the Board, and the CEO corporately responsible to the Minister. In the new governance structure as depicted in Box 2, the Management Advisory Committee would be omitted and the Board would be placed between the CEO and the Minister, with an advisory connection between the Council and the Board.

A framework for the modernisation of the NHMRC has been put in place. But, with the potential for political control of the modernised NHMRC, will it become “dynamic, flexible, adaptive, effective, and in tune with the 21st century”? There are 9 months remaining before the new governance structure is activated. During this time, the government might reconsider the governance issue and put in place a structure that will ensure the NHMRC’s independence. For advice on this matter, there is a wealth of interest, expertise and experience available, and the time has surely come for the government to move beyond the GOBSAT (Good Old Boys Sat Around a Table) principle. By embracing a commitment to consultation, communication and change, modernisation of the NHMRC might ultimately be achieved. But it will require leadership and a clear vision, and a commitment to what is good for the community rather than for politicians.