Does the separation of research and care hold back healthcare improvement?
by Robert Peveler, Clinical Director for NHS Engagement, NIHR CRN
and Peter Bower, Specialty Lead for Health Services Research, NIHR CRN
With all the complex demands of delivering safe and effective health and care services, it is easy to regard research as an 'optional extra', but this would be to lose some of the considerable, but less well known, gains from making research an integral part of healthcare. A striking feature of the recent crisis has been the speed at which research into effective treatments and vaccines targeting the Covid-19 pandemic has been delivered recently in the UK, but these benefits extend beyond the management of a crisis.
One element facilitating the unprecedented pace and scale of Covid-19 research that we have seen in the UK has been the infrastructure of the National Institute for Health Research Clinical Research Network (NIHR CRN), which exists to deliver high-impact research that is integrated into NHS care, and has a mission to increase research delivery year on year. Yet the leaders of many healthcare providers and national bodies often think quite separately about care and research delivery, seeing them as competing priorities, with research yielding to service pressures. In the pandemic we have seen unprecedented co-operation as part of the response, but there is some anecdotal evidence that baseline attitudes have not fundamentally changed. We aim to show that considering research instead as an integral part of service delivery can have far-reaching and long-lasting benefits for both.
The first point to make is that there is evidence that providers of health and care which are more intensively involved in research produce better clinical outcomes, even for patients who are not directly enrolled in research trials. The quality of this evidence was reviewed at a recent workshop led by NIHR (1) which included research-active clinicians, policy makers and patients. Drawing on a landmark review published in 2013 (2), and studies published subsequently, the workshop found that the weight of evidence supports a relationship between research activity and improved outcomes. Unanswered questions remain, however. Does all research improve outcomes, or is it restricted to certain types? At present, the evidence is stronger for interventional research than for observational studies. Is there an optimum 'dose' for research to show this benefit? And, is the relationship between research activity and outcomes found in all clinical settings? At present, the supporting evidence is mostly drawn from hospital settings, although work is now underway to test this in primary care.
There is also debate about the possible mechanisms that might underlie this effect, as understanding these is important if we are to maximise benefit. One possibility is that research-active organizations encourage their clinicians to be aware of current thinking and best practice for all the care they provide. Another is that delivering care in research studies encourages systematic and consistent delivery of care more widely across an organization.
We know that future improvements in care will rely heavily on evidence generated by current research. During 2020, the Covid-19 pandemic demonstrated what can be achieved when research is prioritized: 'Urgent Public Health' studies were completed in record time, and swift progress was made in discovering effective treatments. The fact that the CRN was already in place was fundamental to the swift response, enabling over 130 000 participants to be recruited across these studies in just 8 weeks, and similar rapid progress is being made for vaccine trials. In the RECOVERY trial, recruitment was disproportionately high in many smaller Trusts, often supported by clinicians not previously involved in research. This enables the benefits of research participation to be spread more widely and include staff and patients outside traditional research centres.
Another potential benefit is that staff participation in research may improve recruitment and retention of the workforce. There is a national and global shortage of health professionals, and strong candidates for posts have choices about where they work. Opportunities to participate in research can add greatly to the attractiveness of a post, and every employer needs to appeal to as wide a range of candidates as possible.
Finally, research can also provide additional income and substantial savings on the costs of treatment. Research which meets quality standards in England will be recognized by adoption to the NIHR portfolio, and organizations helping to deliver such research will receive support from their local CRN. A recent report commissioned by CRN and produced by KPMG highlights the financial benefits that trusts can expect (3).
We hope that, from the foregoing review, most healthcare leaders will come to understand that integrating research into care can have major benefits, and that thinking of research and care as two separate, independent and potentially competing activities is outdated. They are two sides of the same coin. The events of 2020 have shown what the health and care system, in partnership with research, is capable of, but there is a risk is that this progress may not be maintained in the longer term. Helping leaders to think about research and care in a more closely integrated model should consolidate these gains, and ensure that they are not lost in future. As clinical services are restored and developed, leaders should look for any and all opportunities to build research into existing and future care delivery systems. A good place to start is a conversation with your local CRN team, who are always eager to discuss research developments with healthcare leaders, and can provide a range of support to these activities.
References:
1. https://sites.google.com/nihr.ac.uk/evidence-base-for-impact-of-cl/home
2. Hanney S, Boaz A, Jones T, Soper B. Engagement in research: an innovative three-stage review of the benefits for health-care performance. Health Services and Delivery Research 2013, 1, 8.