Published research

On a background of relatively low academic output there was much variation with some trusts and many individuals performing strongly. Staff at one trust, the South London and Maudsley NHS Foundation Trust, were more than twice as effective at producing publications than those at the nearest rival, whereas other trusts produced almost no published research in the past 5 years (online Table DS2). Even after correcting for trust size and budget, the South London and Maudsley NHS Foundation Trust was the most productive, producing 7 publications per 100 staff years, followed by Tavistock and Portman NHS Foundation Trust (3 publications per 100 staff years) and then Cambridgeshire and Peterborough NHS Foundation Trust (2 publications per 100 staff years). It is worth noting that the mean number of publications per 100 staff years was 0.73, meaning that on average NHS mental health trusts produce 1 paper per 137 staff years. It would be interesting to refine this further to employed clinicians but these data were unavailable. Of course, most staff would be entirely unproductive in research and probably not encouraged or supported in this regard. The aforementioned productive trusts were not only the most effective trusts at producing research but they also showed the most (absolute) growth in research over the past 5 years. When examined for relative growth, the top performing trusts were Oxford Health NHS Foundation Trust, Sussex Partnership NHS Foundation Trust and Cumbria Partnership NHS Foundation Trust. In fact, annual research output across all mental health trusts has almost doubled over the past 5 years perhaps reflecting success of the NHS research and development strategy or perhaps reflecting wider research involvement in general. Of course trusts with a high research reputation tend to attract highly motivated employees and also offer those employees a high degree of infrastructural support.

Funded research

We also examined ranking according to funded research in the form of portfolio studies. The trusts which demonstrated particularly strong performance were Manchester Mental Health and Social Care Trust as well as South London and Maudsley NHS Foundation Trust, Oxford Health NHS Foundation Trust and Cambridgeshire & Peterborough NHS Foundation Trust. Several trusts do not do well at producing published research but do appear to have attracted successful NIHR portfolio research. These are shown in the bottom right of the quadrant analysis (Fig. 1). These mental health trusts include Cheshire and Wirral Partnership NHS Foundation Trust, Lincolnshire Partnership NHS Foundation Trust, North Staffordshire Combined Healthcare NHS Trust and Norfolk & Waveney Mental Health NHS Foundation Trust. One interpretation is that these trusts have been historically relatively research inactive but are focusing on funded research programmes that might lead to greater productivity over the next 5 years. However, their investment in research has yet to produce significant output compared with other trusts. Trusts in this quadrant may be advised to help their clinicians convert ongoing studies into published work perhaps by offering local training and perhaps support from academics at universities linked with these trusts. Conversely, a number of trusts have relatively poor performance in portfolio research compared with their performance in unfunded non-portfolio research. These are shown in the top left of the quadrant analysis (Fig. 1). A clear example is Leicestershire Partnership NHS Trust which has the worst ratio of funded portfolio activity to (largely unfunded) published output. In these mental health trusts clinicians were actually productive but probably without infrastructural support and without strong success in gaining external funding. Trusts with relatively high productivity outside of portfolio research should examine which clinicians could be further supported locally. It is likely these trusts are over-reliant on clinicians producing research in their own time and in the limited hours given to supporting professional activities. Examples of research support that trusts could consider include dedicated sessions for research, research advice and expertise, support for research administration and governance, appointment of honorary research assistants, availability of good literature searching facilities and online journal subscriptions and links with departments with statistical or epidemiological expertise. It is interesting to ask what separates research active mental health trusts from relatively research inactive mental health trusts? Clinicians and managers in NHS trusts that are research inactive, probably consider research as a luxury which they are unable to support over and above face-to-face contacts. This may be particularly true in the modern NHS focusing on payment by results and foundation status. Clinicians and managers in trusts that are research active would likely take the view that research is an integral part of the NHS and vital to support innovation and helps improve existing practice. Indeed, 93% of the public want their local NHS to be encouraged or required to support research. ¹⁰ Research is part of the NHS core principles. ¹¹ It is supported in the NHS constitution as follows:

In our view, each trust should evaluate its research output, research support and research funding on an annual basis and set up systems that encourage valuable, ethical research.

This analysis of research productivity can only make limited observation of individuals. Further, many staff employed by trusts are not clinicians and would not be expected to engage in research. Nevertheless, it is rare for trusts to achieve more than 3 publications per 100 staff years (equivalent to 100 employees working for 1 year). Indeed, most clinicians are entirely research inactive. This has been previously documented. For example, only 24% of psychology graduates wrote up their research for publication. ^{Reference Cooper and Turpin13} Atkinson & el-Guebaly ^{Reference Atkinson and el-Guebaly14} surveyed 861 members of the Canadian psychiatric association: 8.1% indicated no research activities over the past 2 years, whereas 50 (33.8%) indicated limited commitments to research and 58.1% indicated a major commitment to research activities, and 67.6% of respondents indicated they were mentors to students. Much research in the NHS is unfunded but we were not able to quantify this proportion. Previous findings are that 26%-38% of research is unfunded ^{Reference Silberman and Snyderman15} and of those conducting research without funds, 60% carry out research in their own time. ^{Reference Schroter, Tite and Kassem16}

Research by staff and clinicians employed by mental health trusts is increasing. As a whole NHS trusts are increasingly recognising the value of research, but while some innovative trusts are actively promoting research, others appear to focus only on financial income related to research. For employees, integration of research and clinical practice is correlated with greater job satisfaction and personal satisfaction. ^{Reference Garfinkel, Bagby, Schuller, Williams, Dickens and Dorian17,Reference Hay, Mulder and Boyce18} Underperforming trusts should consider whether greater resources are needed to support relevant research. Clinically relevant research and good-quality audit is an important way to improve patient care by developing and testing new innovations, but too often good work does not get published. The NHS is in a key position to lead on clinical research, but research infrastructure and relevant resources are very variable. Many clinicians from a variety of professional backgrounds have the ability to conduct meaningful research but need the support and encouragement of their employers to do so successfully.