Following his keynote address at the NHS Research and Development (R&D) Forum on 24 May, Peter Brindle believes our NHS should stand out as the most evidence informed healthcare system in the world, with NHS R&D at the heart of making this a reality. Peter is R&D Programme Director at Avon Primary Care Research Collaborative, Leader – Commissioning Evidence Informed Care at the West of England Academic Health Science Network, Evaluation and Commissioner Liaison Lead at NIHR CLAHRC West and a GP.
Let’s aspire to something big: Our NHS should stand out as the most evidence informed healthcare system in the world, with NHS R&D at the heart of making this a reality. At its heart – through being the trusted bridge connecting the research world with the NHS and the service world.
Let’s imagine a world in which the culture of the NHS is one of continuous improvement in finding better ways of doing things, and getting better at doing them. One in which health researchers work with patients, commissioners and those who deliver care, in teams tackling major health issues: in other words, a world in which research maximises its impact. A world in which research really counts.
The need for an evidence informed NHS
Why is this important? We hardly need reminding but our NHS is facing plenty of challenges. There is an expected £30 billion NHS funding shortfall by 2020, 96 per cent of acute trusts are in deficit, there are more pensioners than there are children, and 15 million people are living with a long term condition and needing 70 per cent of the healthcare budget. It is estimated that about 20 per cent of resources are spent on over use, under use or misuse of treatments and probably only about half of healthcare decisions are based on clinical evidence.
So we have a health system with ever-growing pressures and a near desperate need for doing things differently. But especially because resources are so tight, we can’t afford to waste time and money on changes just because we hope or believe that they will make things better. No, now more than ever we need to focus our efforts on the best evidenced interventions, stop the things that are not helping, and evaluate the impact of the changes made. In other words we badly need applied health research.
Happily, about £1 billion gets spent each year by the National Institute for Health Research (NIHR), at least a billion more from the medical research charities and plenty more still from the research councils, EU funding and the pharma and med tech industry. But there is no point in spending these large sums if it does not have an impact on our patients who are on the receiving end of our challenged health system. No one has money to waste and there is a growing recognition that research is not making the impact that funders want.
Reasons for sub-optimal impact
Why might this massive research effort not be having the impact we need? There are many reasons for this but I think these are some of them:
- The questions that researchers are trying to answer are perhaps not always the questions that resonate with clinical and managerial NHS staff
- A traditional reliance on the ‘push’ of ‘excellent’ research in the expectation that it will snapped up by evidence users
- An over reliance on the traditional and medically orientated ‘hierarchy of evidence’, with meta analyses of randomised controlled trials at the top and everything else below, leading an under recognition of the importance of the social sciences in helping us understand why things do or don’t work
- This in turns leads to inappropriate status being given to ‘gold standards’ and expensive, time consuming and reductionist research methods. This is matched by insufficient recognition of the opportunity cost of pursuing researcher-defined ‘high quality’ research rather than considering the value that research brings to the evidence user. Who should define the ‘gold standard’ anyway – the evidence user or the evidence producer? The customer or the manufacturer
- Research findings are not always packaged well or appropriately disseminated – something that is hard for researchers to do without access to the right networks and contacts in the service world
The missing link
These reasons for research not having the impact we are hoping for, come about because research is being developed in relative isolation from the environment that it is expected to influence. Getting research evidence into practice depends upon the vast workforce in health and care who commission, provide and deliver healthcare innovations. It is these people – clinicians and managers who are largely not engaged in research and have never heard of the NIHR, who lie between the research and it making a difference to our patients. They are the ones that implement it. This is the crucial point: it doesn’t matter how important research findings might be, unless the evidence is incorporated into practice and makes a difference to patients.
If the impact of research is limited by poor engagement of the majority of the service workforce, how can we fix it? The first thing to do is to recognise that that we are talking about two very different worlds with different drivers, culture and language, requiring the research community to put themselves in the shoes of those they hope will use the evidence they produce. The best way of facilitating this is for a much stronger emphasis on the co-production of research – getting the evidence generators and the evidence users together from the beginning of the research pathway at priority setting and idea development, right the way through to the interpretation of the results and the dissemination of the findings.
This sounds reasonably straightforward but doing this properly is extremely hard. If it was easy, it would already be happening. No, bringing together distinct professional groups to create a shared endeavour requires conscious and deliberate efforts. It will rarely happen all by itself. In finding a way forward, we can learn an enormous amount from the successful engagement ofpatients in research activity.
This was not happening by itself and required the setting up of bodies like INVOLVE and the James Lind Alliance to help patients understand the nature of research and for researchers to understand how much better research can be with patients involved from the beginning. The engagement of the NHS workforce in research is about at the level that patient involvement was 10 or 15 years ago, and now it is the bringing together of these professional groups with researchers that requires our efforts in order to trigger a step change in research impact.
The challenge to NHS R&D
NHS R&D teams based in trusts and in CCGs, while also having close relationships with researchers, are ideally placed to bring the research and service worlds together and to drive the co-production of research. It is a challenge R&D teams need to grasp with both hands.
Properly co-produced research will address most of the major blocks to research in making a difference. The questions will be the ones the service world needs the answers to, the methods will be sensitive to the context and appropriate to the resources and time available, while dissemination will be greatly enhanced by the results being framed in an accessible way and shared with relevant networks.
Within the NHS
What specifically can NHS R&D teams do to make this vision of an evidence-informed NHS through engaging service staff in all aspects of research, a reality? Here are some suggestions:
- Promote a culture within their organisations of looking for evidence and evaluating services and interventions. This is not routinely done, but it should be. Make it easy to do and unacceptable to ignore
- Looking for evidence will inevitably lead to finding gaps in the evidence. This is a rich source of NHS-relevant research questions that can be fed into local and national research
- Remind trusts that the point of research is on patient benefit and not just about maximising income
- Drive a culture of improvement in the broadest sense. Breakdown the artificial and illogical silos of improvement science, evaluation and research and strengthen the ‘D’ in R&D. They are all about finding better ways of doing things so let’s pick the right tool for the job
- Find and promote powerful stories of research impact to demonstrate that research is relevant and important. This is not always how NHS staff perceives it
- Highlight the risks of not using research – it is where our evidence for improvement comes from!
NHS R&D teams are also in a good position to broker great relationships between the trusts and CCGs and their local higher education institutions through:
- Reminding academics that it is in their long term interest to build trusted relationships through offering informal advice with evidence appraisal and evaluation
- Recognising the value of ‘impact’ and knowledge mobilisation in university promotion criteria
- Facilitating the co-production of research through the creation of ‘boundary spanning’ posts like researchers in residence and management fellows – individuals who understand the drivers, culture and networks of both the academic and the service worlds, and can act as translators and marriage brokers between them
- Encouraging the formation of Health Integration Teams – academics, clinicians, commissioners and patients working as a team to tackle significant health or service problems
- Creating more joint posts. One of the reasons why evidence based medicine is a standard concept for doctors, is due to the large number of medical academic posts. Lets widen the concept through creating more non-medical, and in particular, more non-clinical joint posts in health research. Why shouldn’t a manager be able to combine service work with time doing research and teaching?
As well as the NHS and academia, the third piece of the jigsaw is research funding. Funders can sometimes find themselves remote from the environment they wish their research to improve. NHS R&D teams are very well placed to help keep them in touch with the NHS and help them recognise the need for greater co-production of research and that this takes additional time and resources – but it is worth it.
Our NHS really needs the help of the health research community like never before and we can’t afford to waste any of the research effort. The key to making the research count is through academics working with the users of evidence – the people who commission or deliver care in the NHS, to co-produce research that the NHS needs.
Through acting as brokers between the service and research worlds, we in NHS R&D have a crucial role in building the truly evidence informed NHS that our patients deserve. Lets make it happen.