"More, More, More" sang chart-toppers Andrea True Connection in 1976, in a context entirely unconnected with health and social care research. But perhaps this phrase sums up much of the late 1970s and ‘80s in the UK and beyond, an era of changes which continue to affect us all. It was a time when fortunes were swiftly made and sometimes lost, companies were often swallowed by competitors and large numbers laid off, as outdoing others became increasingly important, short-term gain emphasised over longer-term benefit.
There were swift advances in technology, making it easier to do things on a larger scale, without always enough thought about the consequences. Pop videos frequently showed scenes of lavish wealth, though a few satirised such social trends. It could feel as if, for celebrities and organisations, bigger and brasher was assumed to be better.
Back then, I recall an increased emphasis in the private sector on planning, performance and productivity, often using rather crude measures, with aspects of quality occasionally thrown into the mix. This influenced the public sector and to some extent voluntary sector. The effects were not wholly negative: it was often helpful to be clearer about what a team or organisation was trying to achieve and why, working out how to do this with the resources at hand, celebrating when this happened and reflecting on the reasons when it did not.
But I believe some of the results were damaging, for instance the spread of the notion that keeping people in a state of constant insecurity, afraid of being publicly shamed or losing their job or funding, boosted efficiency. A focus on short timescales and ruthless competition, the idea that what could not be counted did not really count and over-confidence in being able to predict what good (if any) might come out of a search for knowledge or truth were also unhelpful, in my view. Such trends had an influence on research and, in turn, involvement.
By the ‘90s, it might have appeared to be a golden age of knowledge in health and care, with numerous peer-reviewed articles published in journals each week. But, while some reflected excellent work on important topics, this was not always the case. In a much-quoted piece in the BMJ (formerly British Medical Journal) in 1994, statistician DG Altman wrote that “We need less research, better research, and research done for the right reasons.” He pointed to the pressure on researchers, including doctors, to carry out research for which they were ill-equipped, even if seriously flawed. “The issue here is not one of statistics as such. Rather it is a more general failure to appreciate the basic principles underlying scientific research, coupled with the ‘publish or perish’ climate.” In research as in other walks of life, having more is not necessarily a good thing.
Twenty years later, also in the BMJ, former editor Richard Smith wrote that similar problems remained, though “ethics committees are now better equipped to detect scientific weakness and more journals employ statisticians. These quality assurance methods don’t, however, seem to be working, as much of what is published continues to be misleading and of low quality. Indeed, we now understand that the problem doesn’t arise from amateurs dabbling in research but rather from career researchers.”
This was not down to individual failings but wider systems and research culture; Smith quoted “2013 Nobel Laureate Peter Higgs describing how he was an embarrassment to his Edinburgh University department because he published so little. ‘Today,’ he said, ‘I wouldn’t get an academic job. It’s as simple as that. I don’t think I would be regarded as productive enough.’ Producing lots of flawed research trumps a few studies that change our understanding of the world.” Often studies failed to address questions that mattered, methods were sometimes inadequate and there was a bias towards reporting positive outcomes.
By then, the need for greater patient and public involvement in research was more widely recognised, due in part to the efforts of NIHR (the National Institute for Health and Care Research, as it is now known) and some especially determined service user researchers, public contributors and others in the research world. This was extremely valuable, yet happening against a background which often made it harder to sustain and deepen involvement and avoid tokenism.
Even when research was reasonably reliable, a production-line approach was still far from uncommon, resulting partly from what is funded and easier to get published in “high impact journals”. This could get in the way of exploring what was of greatest concern to patients, service users, carers and communities most likely to face preventable ill health or substandard care and acting on findings. And it could drive gifted and committed researchers to quit. Skillful and dedicated research teams, bringing together staff and contributors with relevant lived experience, often produced excellent work which improved practice – but sometimes this required considerable effort to meet expectations from on high without being sidetracked, which could be exhausting.
In 2020 Wellcome published disturbing findings from a survey of researchers and series of local consultation events. “84% of researchers are proud to work in the research community, but only 29% feel secure pursuing a research career… 78% of researchers think that high levels of competition have created unkind and aggressive conditions… Just over half of researchers (53%) have sought, or have wanted to seek, professional help for depression or anxiety… The system favours quantity over quality, and creativity is often stifled,” it found. Inequalities were widened and a long hours culture was widespread.
“Everything counts in large amounts,” sang Depeche Mode forty years ago, in a caustic take on the society of the day. “It’s a competitive world.” This is perhaps even truer today – and it affects research. Some senior investigators have managed to carve out resources and space for involvement; and certain programmes such as ARCs are longer-term, which can enable relationships to be built. Yet even in such conditions, funding is tight.
Years of austerity, the Covid-19 pandemic and cost-of-living crisis have added to the pressures on those managing, conducting, supporting and involved in research.
And timescales and expectations from funders and other powerful figures (or what researchers think they might want) can get in the way of making more than minor changes in response to what contributors say, even the points that may seem valid. It can also increase the temptation to pay more attention to the views of those public members who do not rock the boat, which may get in the way of a swift and streamlined process. Meanwhile researchers who put a lot of time into involving people more fully may have less time to write papers for the kinds of journals which will increase the chances that they, or their colleagues, will having a job in a few years’ time.
More diverse involvement is also being rightly encouraged and bringing rich benefits. But it can add to an already exhausting workload, especially since it may take more time and resources to build trusting relationships with people new to research and under-served groups, provide induction and meet their access needs.
Health and social care research is still deeply satisfying to many who play a part in it. Yet the environment does not always make it easy to make good use of people’s experience, skills and knowledge in a way that is respectful and caring rather than exploitative or draining.
Sometimes I imagine a research world in which there was less pressure to churn out gigabytes of publications of the kind favoured by top journals, a lower quantity of output perhaps but targeted at where it might make most difference. This might be of varying kinds: negative or uncertain as well as positive findings would be valued, with willingness to learn from mistakes, transparency over data and time to plan, explore and weigh up different perspectives.
Emphasis would shift away from a one-size-fits-all model in involvement as well as research, with varied approaches among diverse people. There would be time to build the connections among researchers, service users, carers, service planners and providers which could make it easier to implement what worked but also identify what did not, at least in some settings. Less might be done but more achieved. Meanwhile, perhaps, we can continue to ask searching questions and not get swept away by what might feel like endless demands for “more, more, more!”