27 May 2016
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.
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 and Care 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.
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:
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.
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.
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:
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:
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.