Our experience of covid-19 has brought so many truisms—”nothing will be the same again”—”the new normal”—”post-covid world”, most implying a negative connotation and in many spheres that is definitely the case. But in the context of UK research could it be a good thing? Could covid-19 be the reset button that UK research needed? I believe that it could and that we can benefit from the overturning of the status quo, the recent loosening of bureaucracy, structures and careers to build a fairer, stronger and more resilient research sector for the future.
Clinical research has often been regarded as one of the jewels in the crown of the UK’s academic and business achievements, combining as it does commercial enterprises, the NHS, medical foundations and charities, not-for-profit organisations and of course UK universities. However, there is evidence that the jewel is fading and its setting is coming loose, particularly in the experiences and attitudes of clinical academic trainees. Recent evidence from surveys by the Royal College of Physicians and Wellcome suggest that trainees are unhappy.
Of these, the Wellcome survey was the most damning of research culture. Concerns include responding to external incentives that seem to focus on quantity of outputs and “narrow concepts of ‘impact’, rather than on real quality”. Competition is escalating, job security is reduced, and they feel they are just part of the output machinery. Nearly a quarter of junior researchers felt pressured by their supervisor to produce a particular result and 70% of all survey respondents including senior researchers felt stressed on an average working day. How did it come to this?
In addition, there are many people hoping for a research career whose hopes are dashed by the lack of available posts at the end of training. If all the academic trainees—about 5% of the trainee workforce, a similar percentage to the senior workforce—converted to academic positions that would be acceptable, but there appears to be a cliff-edge drop off in those who have academic training but have to take up non-academic NHS positions. It is a major loss to research if their skills are not used or under-used at the point of joining the consultant workforce.
There are other underlying flaws in UK research—the concentration of research around particular clusters of universities and teaching hospitals, the uneven funding model with its heavy reliance on major charities and foundations, the lack of research parity across diseases and medical conditions, and the status gap between Nobel-prize winning research and clinical audit/bedside data collection.
Over the past two months, the research world has been turned upside down—we have been both hidebound and spellbound. Hidebound in that some 90% of existing research has been paused, spellbound as new opportunities and funding streams have opened up. Boundaries between the NHS and academia have been removed in the joint effort to tackle the epidemic. Clinical academics both with and without clinical commitments have volunteered to move to directly caring for covid- and non-covid patients. Labs have been repurposed over a period of days to provide testing facilities. Regulatory bodies have moved with hitherto unheard of lightning speed to green-light research and provide ethical approval, while providing the same level of scrutiny needed for patient safety and consent. The time from a written proposal to starting a trial has shrunk from months to days. Our challenge is to maintain these flexible and invigorating arrangements and not reverse into our old practices.
The RCP has long argued for research to encompass all NHS Trusts, not just those with a formal attachment to a medical school or history of research activity. We have stressed the importance of researching diseases close to where those diseases are most prevalent. New research published in BMC medicine on geographical inequalities in recruitment to research suggest that “around 12% of current recruitment activity would need to be redistributed to align with disease prevalence.“
During the epidemic, some of the hospitals not generally associated with research trials have been very quick to respond and offer patients for trials, including in places like Stoke and Dudley for the RECOVERY trial—this is encouraging and we need to ensure this continues into the future.
The rapid return of clinical academics to the frontline during the crisis shows their willingness to support the NHS, and they will experience feeling valued by the public and colleagues in a way that clearly was not always present in a research career given the results of the surveys described above. As they return to academia we need to ensure that they continue to feel valued and supported, and to begin to address the underlying problems of undertaking a career in research. I recently wrote to the regulatory bodies for clinical research to set out the key issues they need to address including additional time and funding for those returning to complete their research, the need for a flexible approach, and how the assessment of their training will be considered to take into account the time spent in clinical practice.
If we were able to show the same flexibility and consideration for all trainees, in the future they might feel more valued. Are there new models we could develop that would continue to allow career flexibility, in particular for those clinicians who would like to do some research within their consultant practice, but who are not supported to do so? And can we maintain the lower barriers established in the crisis between clinical practice and research to make portfolio careers easier?
The economic stasis caused by the pandemic has thrown into sharp relief the limitations of some of the current funding models for research in the UK. In particular the large charities like Cancer Research UK, British Heart Foundation, who rely on public funding for the money they invest in research, have been hit hard and expect to lose millions of pounds this year, which may endanger many trials and cause a hiatus of at least a couple of years before we all hope the revenue streams like shops, marathons, fun runs etc will be open to them again. Foundations and organisations funding research from the ongoing interest from large funds will suffer from the stock market collapse.
Will this be the wake-up call we needed to have a root-and-branch review of the value of what we are funding? If difficult decisions need to be made because we can’t afford everything that came before, now is the time to regroup, reduce, and streamline. With the microscope pointed at us, we will have to justify our research more, be more transparent about its benefits to patients, and priorities may prove to be very different in a covid-19-endemic world.
We have been shown a glimpse of a new world, and some of it is an improvement. Barriers have been broken down, systems are more flexible, hurdles to research have been jumped, and everything has moved faster. Let’s preserve that spirit, to shore up our research sector through this difficult time and come out with leaner, stronger, and more flexible ways of working that will make the academic career worth pursuing again.
Cheng-Hock Toh is a professor and consultant in haematology in Liverpool. He is the academic vice-president for the Royal College of Physicians London, national specialty lead for haematology in the National Institute for Health Research Clinical Research Network, and president of the British Society for Haematology. Twitter @CHToh1
Competing interests: None declared.