The National Institute for Health and Care Research (NIHR) was established 20 years ago, in 2006. It was a fantastically disruptive innovation at the time, the brainchild of Professor Dame Sally Davies who, as Head of Research and Development in London, recognised that while Research and Development was part of the remit for the UK’s National Health Service (NHS), it was often hard to identify where that research was taking place and the impact it was having. NIHR was created with £1 billion funding from the NHS, with trusts and researchers applying for that funding in response to targeted calls. Funding was allocated on the basis of the quality of the research proposed, rather than on historic block allocations. The result was a large-scale redistribution of Research and Development funding, the growth of applied health research that had direct, near-time relevance to patient care, and demonstrable health, economic and social benefits. Funding from NIHR supports all aspects of clinical research, from the infrastructure required to deliver research in the NHS, the salaries for researchers – at all stages of a research career – as well as funding allocated to individual research projects and programmes. The result has been a transformation of the clinical research funding landscape in England. With an annual budget of £1.6 billion, it is one of the largest funders of medical research in Europe.1
The UK’s science and medical research is world-leading. The ability to test new treatments and diagnostics in the NHS provides an unparalleled opportunity for rapidly testing the efficacy of new treatments and integrating those treatments into clinical care, and NIHR has been fundamental in enabling this to happen. This is best exemplified by our collective response to the COVID-19 pandemic: the national support and coordination of research delivery infrastructure, whereby every single hospital in England and a large proportion of GP practices had capability to deliver COVID-19 vaccine studies and clinical trials. The Randomised Evaluation of COVID-19 Therapy (RECOVERY) platform trial for in-patients with COVID-19, for instance, involved every hospital in England, with over 48 000 patients recruited from 190 sites. Study recruitment was so rapid that, 91 days following drafting of the protocol, the study reported that dexamethasone had reduced death in inpatients by a third and clinical practice was changed across the world, overnight: a practice that has saved an estimated 1 million lives.2
The NIHR has always included mental health in its remit, and indeed has supported a substantial volume of mental health research programmes and projects over the past 20 years. It is therefore disappointing and somewhat paradoxical that, over this same 20-year period, mental health research and clinical care in the UK has not been transformed to the same degree as other areas of medicine. Research is not embedded into clinical practice, and outcomes and life expectancy for our patients have not improved. In fact, life expectancy for those with severe mental illness has gone backwards compared with those without mental illness.Reference Hayes, Marston, Walters, King and Osborn3 The number of mental health researchers in the UK has also declined at an alarming level and is now reaching critical levels – the number of academic psychiatrists (professors, senior lecturers, lecturers) has dropped over the past 20 years, from 330 in 2004 to 206 full-time equivalents today.4 This represents under 2% of the number of consultant psychiatrists in the UK, less than other specialties (3.4% overall), and occurs at a time of expansion of the numbers of both medical schools (from 30 to 46) and medical students. The result is several medical schools without any academic psychiatrists to train the next generation. This decline occurs in the context of considerable NIHR investment in clinical academic training posts over the last 20 years, which makes the lack of senior academic posts for trainees to move into especially glaring.4
Structural reasons for a lack of parity in research funding
There are many reasons why 20 years of NIHR has not resulted in stabilisation or growth in mental health research in England. Mental health research has always been especially reliant on government funding and has been chronically underfunded overall. There are very few dedicated mental health research charities and investment from the pharmaceutical industry has dwindled over the past 30 years, with psychiatry viewed as too difficult and our disorders too amorphous. A report from MQ mental health in 2017 showed that £124 million per year had been spent on mental health research, with this funding remaining flat over the 10 years between 2008 and 2017 – the majority coming from the UK Government, and only 2.7% from public donations. This compares with £612 million per year on Cancer research over the same timeframe, 68% of which came from public donations.5
The NIHR has a remit across healthcare and it is unrealistic to expect it to cover all of one sector’s needs. However, there are systemic reasons why mental health has been particularly disadvantaged in some NIHR funding schemes, with a key factor being the separation of mental health from the remainder of medicine, both physically in terms of buildings and NHS organisations, as well as in terms of staff mix and research culture. A large proportion of NIHR funding (£825 million per year) supports research infrastructure, either through research delivery infrastructure or research centres. One large infrastructure investment, the Biomedical Research Centres (BRCs), when they were first established, were awarded to a single NHS Trust and university partnership, academic centres of excellence with a high volume of world-leading research. The BRC competition therefore largely excluded mental health Trusts who, as organisations separate from their acute Trust colleagues, did not have the volume or range of high-quality research to reach the bar required for BRC funding. The current award of BRCs has changed emphasis to encourage national collaboration and partnership to address this disparity, but this comes after 20 years of minimal dedicated investment. Similarly, the physical separation of mental health Trusts from acute Trusts means a lack of access to clinical research facilities to enable the delivery of research activities and, in particular, trials of novel interventions. In Oxford, we host the only clinical research facility in UK dedicated to mental health research (out of 28), and one of two NIHR BRCs dedicated to mental health research (out of 20).
The case for targeted investment in people and infrastructure
A further major investment in research delivery infrastructure is through the Research Delivery Network, which supports research delivery across every specialty across the country. There are particular challenges in delivering research in mental health services – our clinical services are usually structured by age range or setting, rather than by disorder, such that identifying people eligible for disorder-specific studies requires considerably more effort. Clinical services are run by multidisciplinary teams that usually do not consider research as part of their remit, such that patients are frequently not made aware of ongoing research studies. The proportion of people in NHS mental health services who are offered the opportunity to participate in research remains vanishingly small (42 009 from 3.8 million people in 2024, 1%).1 Mental health Trusts tend to not have the same integration with other areas of medicine, nor with scientists undertaking cutting-edge research, so there is often limited awareness of latest advances or novel treatments and little opportunity for staff to get involved in research.
There have been recent targeted efforts to address these challenges, with the Mental Health Translational Research Collaboration delivery of the Mental Health Mission funded by the Office of Life Sciences and NIHR to increase capacity to deliver clinical trials, and targeted investment from NIHR to build mental health research capacity in areas with little existing research;6 however, considering the scale of NHS activity that takes place in mental health services, and the challenges faced by these services, such efforts need to be on a much larger scale and with sustained and dedicated funding.
The funding for mental health researchers similarly needs a targeted response and substantial investment. Funding for academic psychiatrists has historically been through regional NHS health authorities, recognising the important role and wider population health impact of these posts. Most of these posts are now lost, due to local health service funding pressures. NIHR funding does not, and cannot, compensate for this decline in senior posts, with only a handful of professorship posts funded each year, in open competition across all specialties: in most years there are no posts in mental health. There are no charities or other funders to replace these posts. It is vital that clinical academics are recognised as being fundamental to the design and delivery of mental health services.
The case for a National Institute for Mental Health Research
Research-active clinical organisations have been shown to deliver better outcomes and better care, with improved staff recruitment and retention and enhanced morale.7 Mental health services are no different, and indeed the need is even greater than in other areas, given the prevalence and economic impact of mental illnesses on society. Research is not a ‘nice to have’ option for the NHS: it is vital.
The UK Government has introduced the Mental Health Investment Standard, with a commitment to increase the proportion of spending on mental healthcare. This is extremely important and welcome, but an equivalent commitment is now also required to increasing the proportion of research funding for mental health research in the NHS.
This is needed to fund the infrastructure and people necessary to transform outcomes for our patients. The NIHR was introduced in 2006 and has been transformative for the facilities, staff and research in the NHS. The integration of world-leading science into clinical practice through the NIHR has saved lives and improved lives; there is an increased life expectancy today because of the advances in medical research over this period. There are structural and cultural reasons why the NIHR has not resulted in the equivalent transformation in mental health. These would be addressed through equivalent dedicated resource for research in NHS mental health services. Given the prevalence and the burden of mental health disorders, and the need to develop the mental health research infrastructure across England, a National Institute for Mental Health Research should be established with a separate and equivalent budget to the NIHR.
Acknowledgements
B.R.L. would like to thank Professors Rachel Upthegrove, Peter Jones and Paul Harrison for comments and feedback.
Funding
This study received no specific grant from any funding agency, commercial or not-for-profit sectors.
Declaration of interest
B.R.L. is Head of Department of Psychiatry at the University of Oxford. She was Clinical Director of NIHR CRN Thames Valley and South Midlands from 2014 to 2022, Deputy Director of NIHR ARC Oxford and is in receipt of NIHR funding through NIHR BRC Oxford Health and an NIHR Programme Grant. She is an editorial adviser to the BJPsych editorial board but did not take part in the review or decision-making process of this paper.
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