A story very relevant to research support for the NHS in 2021
Research in secondary care (house number 2) is very different from primary care (house number 1).
Primary, House Number 1, is opposite Secondary, number 2, in Research Street XR123AY
Number 1 is a financially tight household asked to take on a research lodger. They are keen to help with research so clear out the dining room and move the dining table into the lounge.
They live from day to day in Primary House Number 1. Every penny is accounted for and there are increasing house expenses. Any residual pays the house owners some income which they use on food and living expenses for themselves. If things remains stable the residual is better than many others in the street, except perhaps number 2.
This residual pot goes down if the wrong decision is made. Indeed many households they knew well, like theirs, in the street have closed in the last five years. The residual pot has not gone up for anyone for at least 10yrs and when it did (a new contract 2003) it was invested in the household.
Number 1 is busy with household budget, going to work, and looking after a large family who work in healthcare in the house. However they are in charge of the house, make decisions, can act quickly and are flexible in approach.
Number 1 is asked to pay the research lodger directly with money given to them, but has the risk that they have to pay their rent or a lump sum to leave their lodging if this money stops
In Secondary house number 2 they are fortunate to have a spare room and put their research lodger there. The owners have an endowment from a relative in the house next door, number 3, which means each person can still keep a steady income irrespective of how much is spent on the house.
Number 2 has support from the large house number 3 next door who is happy to run their household budget. Number 2 has a relative in number 3 who looks after the family of healthcare workers at their house so they only have to look after the family when they have big problems. However, number 2 has to check with number 3 before they can make changes and this is hard to do as they have to convince the larger number 3 house as well and they do not always agree.
Number 2 is not worried about how to pay the money for the lodger, as number 3 says they will cover the rent or lump sum if the money stops.
Number 1 and 2 are asked to help out with the research the lodger is doing. This is in return for money to get another worker to replace their time.
However, everyone knows those living at Number 1 are more efficient than any new worker so their household income drops because they are funded by work done (Quality outcomes framework). The new worker has an income that is fixed so does not need to work beyond their hours and leaves the house at night.
Number 1 also has to look after the family and organise the house budget so has to pay themselves for extra help, or work harder still. Their income drops and they have to reduce their own personal food and clothing expenditure
In Secondary number 2 they are supported by number 3 who agrees to take on any extra work number 2 can’t do. The personal income for number 2 does not drop if they are replaced by the new worker, so they look at taking on more new workers for research. Indeed number two is, in many cases, paid directly as well with a protected regular payment (PA). Number three is also looking after the family and house budget so that is not a concern.
What will help get research support in Number 1?
Could we provide equivalent support of a number 3 (NHS Trust or CCG ) to number 1 (Primary Care). But then those in number 1 become salaried, are less flexible, have less control and are less cost effective.
Could we fund the accommodation, and time out with increased funding to cover the other roles (family or list of patients) and management of budgets, personnel and the organisation. There needs to be sufficient funding to cover actual costs and leave some income to fund other parts of the house (practice).
Or do we fund more than one research worker and their accommodation through an organisation combining two or three households or more (Primary Care Network additional roles or the Local CRN). With sufficient household funds to cover actual costs and some set overheads for work done. Perhaps having a more experienced researcher so that the owners (GPs or other healthcare workers) have more defined limited and specific roles on patient research recruitment organised by the researcher.
And at the core of this analogy is the fact that the contract between the NHS and each GP is one of an independent contractor. GPs are paid from what is left over when all services have been funded. If a GP takes on a researcher or research work it must be adequately funded and the risks allowed for. If a GP takes on the risk of employment or a research study they put their GP practice and literally their own house on the line. Across the UK in 2019 many practices closed because of this risk and a fall in income.