We often hear talk of how to make research 'core business' in the NHS, how to embed the principles of evidence based practice on the front line and encourage services to invest in research more regularly. With current structures, I wonder, however, how realistic this is?
Hi, my name is Sarah Williams. I am the Associate Director of Research and Clinical Effectiveness at Solent NHS Trust. As we mark the National Institute for Health Research’s (NIHR) 10th anniversary, would like to share my thoughts on making research ‘core business’ in the NHS.
The spread and scope of health and care research has undoubtedly grown substantially - particularly in smaller Trusts. Much of this is due to ring-fenced funding for the National Institute for Health Research, distributed to NHS organisations. I lead on clinical research for Solent NHS Trust, a community and mental health provider and am in absolutely no doubt that the NIHR have been critical to our increase in research activity, in giving us the resource and structure, the space and authority to support staff to be involved in research; and the drive to ensure the accessibility to patients grows year on year. It has also clearly articulated the clear link between research activity and better patient outcomes, and whilst the majority of the resource has gone to large acute teaching Trusts, it has quite definitely enabled and empowered smaller organisations.
Whilst immensely grateful, I am increasingly of the view that the unintended consequence of this protection is the separation of research from everyday practice, an elitist sport rather than an integral part of service delivery and growth. Should the NIHR lose funding, it seems highly unlikely that many Trusts will feel inclined or able to pick up the bill given other financial pressures.
In the large teaching hospitals with research units and centres, this may not be felt so keenly. But these centres are not the real world of research in the NHS. It is a bubble. Most other Trusts have a different reality; where research is a 'nice to have' but in which the research team only survives because it is passionately self supporting and separately funded. It isn't considered a core and critical function. In an NHS landscape that is driven by targets and regulatory ratings, and which has to try to save money with increasing demand, this is understandable. And given we are really rubbish in the research world at demonstrating tangible, current and enduring value (financial or patient), it is arguably forgivable.
At my very core is a belief, however, that research is an extraordinary thing…and it shouldn't be exclusive. Research is, after all, a core part of the NHS constitution and should be open to everyone. The impact on patient care is significant and comes in a variety of forms - most obviously as a direct result of having access to new interventions.
I am convinced, however, that most of the enduring and embedded impact on patient care and outcomes doesn't come as a result of the individual trial, it comes as a by product of a service being research active. Being involved in research raises the game of a service and enthuses staff. It embeds an improvement and 'can do' culture; it attracts excellent and passionate clinicians; it helps to motivate and retain and develop those that are already there. It creates a positive buzz, and importantly, it gives staff the skills to use data, use evidence, understand what is working, what isn't. It gives an attractive edge in a tender bid, and commissioners tend to love it. It also makes sure that there are links with universities, who are training our workforce of the future. It gives us a formal method of sharing what we know and what we have learned nationally and internationally. In short, it is pretty much win win, and the return on investment is considerable (although not always immediately visible).
The evidence is overwhelming, right, so why isn't everyone doing it? Quite simply I think because there are too many other things to worry about and because there are no direct consequences of not doing it.
I recently listened to the Nursing Director of NHS Improvement talking about a study in her PhD recently where she asked ward sisters to rate different activities in order of importance - research came something like 22nd out of 24 options. When pressed they reported they'd like to, but there wasn't time and it 'wasn't really their job'. Later that week, I listened to another Director from NHS Improvement talking about their "Single Assessment Framework", the means by which provider Trusts will be rated in the near future - an indicator of what makes a 'quality/ good' trust. Research didn't feature at all. Amongst all the institutions represented, the NIHR was missing. Just as striking is the complete absence of research and innovation in most Sustainability and Transformation Plans.. our local one doesn't mention it. How on earth can this be? And what a missed opportunity. The benefits are so obvious and there is such a critical need for good evidence, especially at a time of massive system change, why don't we mandate it and use it as a marker of quality? Why isn't the NIHR banging on the doors of NHS Improvement and NHS England and demanding inclusion? Why don't they want to be an integral part of the NHS?
Now is the perfect time for us as part of the NIHR to be insisting that we are part of that framework - if we genuinely want research to be part of 'core business' we need to be at the table with the other core agencies. The NHS is changing - there will be new models of care, and we need to be ready for that.. and as it enters its teenage years, the NIHR is in such a strong position. It has had a lovely childhood, protected, nurtured, celebrated and loved, but I would argue that it needs to step out into the wider world of care and become indispensable. Those of us who live with these creatures called teenagers know that whilst they can be rather irritating, we wouldn't be without them. In fact, they are completely essential to our functioning and growth - they challenge, open us up to new ideas, don't let us stand still, explain new technologies and language. Generally indispensable and great fun.. they keep us relevant and slightly uncomfortable about becoming too comfortable..
And that is what research and the NIHR can now do for the NHS and for care... they can make sure research is considered essential,... that even though people will be irritated by the need to do and be involved in research and to use evidence well to inform change, soon it will become something they can't live without. Let's make research core business by making it a fundamental marker of an outstanding organisation... for all Trusts, not just those with the big research facilities.
Let's allow research to grow up, spread its wings and challenge the status quo. It will be uncomfortable and may feel risky, but it is the only way that research will become part of everyday business in the NHS and care sector, and therefore the best way for it to perpetuate and spread, attract and develop great staff, and continue to be a beacon for healthcare provision worldwide.
If you would like to engage with me on these musings, or any other related topic, get in touch. My details are:
Dr Sarah Williams, Associate Director for Research & Clinical Effectiveness