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NIHR Workshop on Surgery Research

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NIHR Workshop on Surgery Research 9 February 2012 – PowerPoint PPT presentation

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Title: NIHR Workshop on Surgery Research


1
NIHR Workshop on Surgery Research
9 February 2012
2
Session One Research in Surgery
9 February 2012
3
Challenges and Opportunities in Surgery Research
Professor Jane Blazeby
9 February 2012
4
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5
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6
  • A good surgeon needs,
  • The eye of an eagle, heart of a lion and hand of
    a lady
  • 15th Century English Proverb

7
Spend of the MRC/NIHR on non-surgical surgical
research in 2008/9
8
A paucity of surgical RCTs
9
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10
Operations for morbid obesity
US Bariatric centres of excellent 2008/9 De
Maria E. www.surgicalreview.org
UK National Bariatric surgery registry NBSR
www.dendrite.org
11
BYpass
BAND
12
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13
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14
Difficult to select outcomes
  • Technical outcomes
  • Measuring recovery
  • Complications poorly defined

15
Operator expertise culture
16
MRC Framework
17
  • Research infrastructure, CTUs Hubs

18
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19
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20
  • Trainee-led Surgical Research Collaboratives
  • Lessons learnt from the ROSSINI trial
  • Mr Thomas Pinkney

21
Inclusion All patients undergoing
laparotomy Exclusion Laparoscopic-assisted
surgery Blinded wound reviews Pre-discharge
(5-7 days) at 30-33 days Funded by NIHR
Research for Patient Benefit programme
22
(No Transcript)
23
Other research collaboratives
  • London LSRG
  • South West SPARCS
  • Mersey MERGS
  • Yorkshire
  • Kent/Maidstone
  • Trent
  • Cardiothoracic collaborative
  • Yorkshire orthopaedic group

24
Opportunities
  • Feasibility work/studies (RfPB, HTA)
  • Program research, RCTs (NIHR HTA)
  • Clinical academic pathways, NIHR PhDs.

25
Where theres a will theres a way
26
Thank you
9 February 2012
27
(No Transcript)
28
Engaging and Supporting Surgical Research
Research Design Service
Andy Barton
9 February 2012
29
The NIHR Research Design Service (RDS) supports
researchers to develop and design high quality
research proposals for submission to NIHR and
other national, peer-reviewed funding
competitions for applied health or social care
research.
30
www.rds.nihr.ac.uk
To offer fit for purpose advice and support
on research design and methodology to researchers
making funding applications To increase the
number and proportion of high quality
applications for funding
31
  • RDS Purpose
  • To help researchers develop and design high
    quality research proposals for submission to
    national, peer-reviewed funding competitions for
    applied health and social care research
  • To provide consistent national coverage, with a
    focus on NHS-based researchers applying to NIHR
    Programmes
  • To offer access to a range of expertise in
    research design and to refer to other sources of
    expert advice on the applied health and social
    care research system

32
  • Delivering the service
  • Almost all university-based
  • Central Co-ordinating Centre
  • Number of sites
  • Team of Research Design Advisors
  • Access to more specialist advisors
  • Close links with other services, eg CTUs
  • Some training but limited
  • Support for Public and Patient Involvement

33
  • Helping to build successful grant applications
  • Self care information
  • RDS Direct telephone/email queries
  • Primary care face-to-face discussions
  • Secondary care involving other RDS staff
  • Tertiary care other specialist input
  • Follow-up care fixable faults and
    troubleshooting

34
  • RDS national figures
  • 2009/10
  • 2335 projects
  • 217 outline applications (62 short-listed)
  • 662 full applications (35 funded)
  • 2010/11
  • 2328 projects
  • 311 outline applications (54 short-listed)
  • 839 full applications (37 funded)

35
  • Support infrastructure Where the RDS fits
  • (CLAHRC) Research Question
  • RDS Study Design
  • CTU Funding Application
  • CLRN
  • Study Execution
  • CTU Analysis
  • Dissemination
  • (CLAHRC) Implementation

36
  • Find out more
  • Visit
  • www.nihr.ac.uk/infrastructure/Pages/infrastructure
    _research_design_services.aspx

37
Thank you
9 February 2012
38
(No Transcript)
39
Engaging and Supporting Surgical Research
Clinical Research Networks
Dr Jonathan Gower
9 February 2012
40
  • The Role of the NIHR Clinical Research Networks
  • To provide a world-class research infrastructure
    embedded in the NHS to support the successful
    DELIVERY of clinical research studies across
    England

41
NIHR Clinical Research Networks
NIHR Clinical Research Networks
NIHR Dementias Neurodegenerative Diseases
Research Network
NIHR Diabetes Research Network
NIHR Medicines for Children Research Network
NIHR Mental Health Research Network
NIHR Comprehensive Clinical Research Network
NIHR Stroke Research Network
NIHR Primary Care Research Network
NIHR National Cancer Research Network
42
Covers the whole of England Covers all
healthcare sectors Covers all areas of clinical
need Support delivered through 25 Comprehensive
Local Research Networks (CLRNs) All the Research
Networks work closely together to deliver
benefits for researchers and patients
43
  • What the NIHR Clinical
  • Research Network provides
  • Access to experienced Research Management and
    Governance staff
  • Access to a local network of dedicated skilled
    research support staff (eg research nurses)
  • Support to service departments such as pharmacy,
    radiology, laboratories
  • Dedicated research time for clinicians
  • Access to free training opportunities
  • A local and national support network to ensure
    the successful set up and delivery of research
    projects

44
  • What the CCRN budget
  • is being spent on in 2011/12

243m 85 of the total CRN budget Funding level
being maintained
45
  • Specialty Groups
  • CCRN portfolio broken down into 24 different
    specialties
  • Each led by a Specialty Group set up to harness
    the enthusiasm and expertise of researchers in
    the specialties that they are dedicated to
  • Membership through nomination of Local Leads from
    the CLRNs (now over 500)
  • To actively engage with the research community
    and other stakeholders to make the most of what
    the Clinical Research Networks have to offer
  • National coordinating function linked to local
    networks to ensure the successful delivery of
    studies to time and target

46
The number of studies in each Specialty Group
47
  • Surgical Research
  • Cross-cutting theme extends across cancer,
    cardiovascular disease, musculoskeletal, nervous
    systems disorders, ENT, GI, Injuries and
    Emergencies
  • Around 70 active studies on the portfolio funded
    by NIHR and NIHR partnership organisations
  • Multidisciplinary vascular, heart,
    orthopaedics, GI, neuro-, plastics, head and
    neck
  • Historically under-represented in the research
    arena
  • A complex area to do research in
  • BUT

48
  • NIHR CRN support
  • to surgical research
  • NIHR has established a Specialty Group for
    Surgery
  • Excellent cross-talk across disciplines
  • A real focus of enthusiasm and advice
  • A vehicle through which to develop partnership
    working
  • 1.6m of additional network funding directed
    specifically to support surgical research in
    addition to the significant disease-specific
    support (cancer, cardiovascular etc)
  • Supporting GRIST (Growing Recruitment into
    Interventional and Surgical Trials)
  • Identifying the barriers and finding solutions,
    making a difference

49
The Surgical ResearchSpecialty GroupSSpecSurri
50
Recruitment into Surgical Research Studies
51
Where recruitment is taking place
52
  • Practical help we
  • can offer
  • Advice about deliverability
  • Patient numbers, patient pathway
  • Consent rates
  • Resources required
  • Identification of research active centres with
    the commitment and expertise in specific areas
  • Help with securing support through the CLRNs
  • Ongoing study overview
  • Unblocking local blocks
  • Help to find new recruitment sites
  • Identifying national blocks and addressing these

53
  • How to access help
  • Visit the Specialty Group stand in the
    Marketplace
  • Pick up a Surgery Specialty Group flyer
  • Contact the Surgery Specialty Group Lead for your
    CLRN
  • The CLRN where the CI resides offers a Lead
    Network Service to help CIs set up multicentre
    studies quickly and effectively across multiple
    CLRNs

54
Thank you
9 February 2012
55
(No Transcript)
56
Session Two Developing Surgical Research Projects
9 February 2012
57
What makes a good NIHR application?
Professor Jonathan Michaels
9 February 2012
58
  • Is the research question in remit?
  • Is the research question within the remit of the
    themed call, and
  • Is the research question within the remit of the
    specific NIHR programme being applied to?
  • Talk to the programmes concerned or consult the
    NETSCC or CCF web pages www.netscc.ac.uk/funding
    or www.ccf.nihr.ac.uk for advice

59
  • Is the question important?
  • The need for the research
  • How much will patients or the NHS benefit from
    the proposed research or healthcare technologies.
  • Is there a clear trajectory into patient benefit.
  • Has the research question been explained clearly
    and the importance of topic made (e.g. burden of
    disease, impact on service / population, gaps in
    the knowledge identified and how this research
    will address these gaps)

60
  • Is the research feasible?
  • Is the presentation and/or methods appropriate
    for the research question?
  • Design complexity
  • Recruitment rate
  • Centres
  • Eligible patients
  • Patient consents
  • Patient follow-up
  • Expectations of service providers / patients
  • Experience, track record of research team

61
  • The science
  • Sample size
  • Effect size
  • Outcomes
  • Must be appropriate for programme applied to e.g.
    HTA patient centred, i4i healthcare technologies
  • Composite measures (e.g. QALYs) or surrogates
    depending on programmes
  • Useful to look at completed or on-going research
    on the programme websites

62
  • The science
  • Stage of development of technologies
  • Especially for complex interventions
  • Some programmes support developmental or
    exploratory studies where there is a clear path
    to the evaluation
  • Some programmes supports pilot or feasibility
    studies leading to major applications to other
    NIHR funding streams (e.g RfPB)
  • Development of innovative medical devices or
    technologies that address unmet clinical needs
    (e.g i4i)
  • Can include qualitative or quantitative research
  • Comparators
  • Best alternative, treatment as usual, placebos

63
  • Infrastructure and Support
  • Research team appropriately multi-disciplinary
    and sufficiently experienced. Roles and
    responsibilities of each member clearly
    described.
  • Involvement with an RDS / CTU from an appropriate
    stage in the research development
  • Involvement with appropriate research networks
  • INVOLVE

64
  • Costings
  • Is the research realistically costed and does it
    offer value-for-money?
  • Is it costed within the limits of the proposed
    programme e.g. RfPB up to 250K over 36 months.
  • Is the cost to address the disease / health issue
    in question justified, and does the topic clearly
    account for the cost requested?

65
  • Other advice
  • English for mixed audience
  • Clinical, methodologists, patient and public
  • Tell the story well for the non - expert
  • Plain English summary
  • Follow the application guidance notes.
  • Visible headings
  • (e.g. sample size, outcomes, technologies)
  • White space there should be some (use
    paragraphs)
  • Flow diagrams
  • PROOF-READ SUBMISSIONS CAREFULLY!

66
  • Feedback from funding boards/committees
  • Feedback from funding boards at all stages is
    meant to be helpful to the applicants
  • Applicants should respond to all areas
    highlighted as necessary by the funding board

67
  • Common pitfalls
  • Inconsistent accounts of planned research
  • Incorrect or inconsistent numbers e.g. sample
    size calculations or missing entirely.
  • Apparent lack of awareness of major or related
    work in train
  • Insufficient detail, or muddled detail
    particularly in the methodology sections even
    at full proposal
  • Gaps in expertise on the research team even
    after feedback from funding board

68
  • Common pitfalls
  • Inadequate detail given on the health issue or
    demonstrations of benefit to patients
  • Inadequate detail given on the intervention to be
    evaluated or the medical device or technology to
    be developed.
  • Application has not stuck to programme remit
    and/or the call
  • Application has not paid enough attention to
    board feedback between outline and full proposal
  • Unrealistic / inaccurate costings (both under and
    over-costing)
  • Submissions have not been proof-read

69
  • Patient and Public Involvement
  • Patient and public involvement is of key
    importance
  • Researchers need to involve patients and the
    public during the development and delivery of the
    research project
  • Patients and public will be involved at all
    stages of the assessment process (referees, board
    members)
  • Funding boards will explicitly look for evidence
    of appropriate patient and public involvement

70
Thank you
9 February 2012
71
(No Transcript)
72
An Introduction to the NIHR programmes
Professor Tom Walley
73
Decline in clinical research in surgery
  • Service demands
  • Lack of equipoise
  • Lack of expertise in clinical trials
  • Easier ways to keep RAE/university happy
    (consent, regulation of clinical trials etc)
  • But
  • Lack of information to inform practice
  • Professional (eg RCS, ASGBI) enthusiasm for more
    clinical research

74
Call for Applied Research in Surgery
  • Application forms available on 23 February.
    Closing date 25 May 2012
  • Particular interests
  • Surgical procedures
  • Alternatives to surgery (surgical comparators)
  • Patient safety/experiences
  • Devices
  • Organisation of services

75
What is applied research?
  • Research with the capacity to improve patient
    outcomes and NHS services
  • Clinical research (not only trials)
  • Not
  • Discovery science
  • Animal
  • See remit of participating programmes - if in
    doubt ask

76
Participating programmes
  • CCF programmes
  • Invention for Innovation Programme (i4i)
  • Programme Grants for Applied Research Programme
  • Programme Development Grants
  • Research for Patient Benefit Programme
  • NETS programmes
  • HTA
  • EME
  • HSDR

77
NIHR Evaluation, Trials and Studies (NETS)
programmes
NETSCC
Health Services and Delivery Research
Established 2012
HSDR
Public Health Research Established 2008
Health Technology Assessment Established 1993
HTA
PHR
Efficacy and Mechanism Evaluation Funded by the
MRC and NIHR Managed by NIHR Established 2008
EME
78
The NIHR Health Research System
Faculty
Associates
Investigators Senior Investigators
Trainees
Universities
Research
Infrastructure
Research Projects Programmes
Clinical Research Networks
NHS Trusts
PatientsPublic
Research Schools
Clinical Research Facilities, Centres Units
Research InformationSystems
Research GovernanceSystems
Systems
79
Basic Research
Development Pathway Funding
MRC
Efficacy Mechanism Evaluation
Invention for Innovation
Biomedical Research Centres
This pathway covers the full range of
interventions - pharmaceuticals, biologicals,
biotechnologies, procedures, therapies and
practices - for the full range of health and
health care delivery - prevention, detection,
diagnosis, prognosis, treatment, care.
Biomedical Research Units
Patient Safety and QualityResearch Centres
Research for Innovation,Speculation Creativity
Research for Patient Benefit
Health Services Delivery Research
National Institutefor Health Research
Programme Grants forApplied Research
Public Health Research
Health Technology Assessment
Collabs for Ldrshp in Appl Hlth Res and Care
Ctr for Reviews Dissemination, Cochrane, TARs
National Institute for Health Clinical
Excellence
Guidance on Health Healthcare
NHS Evidence
Access to Evidence
NHS Institute for Innovation Improvement
Support for the NHS
Strategic Health Authorities
Duty of Innovation
Primary Care Trusts
Healthcare Commissioning
NHS Providers
Patient Care
80
NIHR as a system
Clinical Research Networks
  • Joint calls
  • Facilitating researchers, speeding review
  • Transfers between NIHR programmes
  • Active collaboration between programmes
  • Directors' meetings
  • Meeting with networks

CCF i4i PGfAR RfPB
NETSCC HSDR HTA EME
81
Which programme? Visit the market place
  • EME exploratory trials, less pragmatic, phase
    2-3, efficacy, mechanisms if possible?
  • HTA systematic reviews, large multicentre
    pragmatic trials or other studies (phase 3-4),
    effectiveness in the NHS
  • HSDR organisational, patient experience,
    qualitative or other
  • i4i - translation of bright ideas for new
    high-tech products into methods of prevention,
    diagnosis and treatment 100-300K
  • PGfAR- 2m for up to 5 years, awards made to NHS
    bodies
  • RfPB max 250k for up to three years

82
Themed Call on Research in Surgery
  • Watch the website for dates
  • Engage collaborators, CTUs, RDS as soon as you
    can
  • Closing date for outlines (vary by programme, not
    RfPB)
  • May 25th
  • Closing dates for fulls (vary by programme)
  • October
  • Final funding decisions
  • March 2013

83
Thank you
84
(No Transcript)
85
NIHR-funded Surgical Research NIHR RfPB Award
Holder
Matt Costa
86
Research for Patient Benefit
  • Its main purpose is to realise, through
    evidence, the huge potential for improving,
    expanding and strengthening the way that
    healthcare is delivered for patients, the public
    and the NHS....
  • Very broad remit
  • Mental Health
  • Hospital Medicine
  • Primary Care
  • But, all of the research is about direct benefit
    to the patient...

87
Warwick Arthroplasty Trial
  • A Randomised Controlled Trial of Total Hip
    Arthroplasty Versus Resurfacing Arthroplasty in
    the Treatment of Young Patients with Arthritis of
    the Hip Joint
  • Design A single-centre, two-arm, parallel group,
    assessor-blind randomised controlled trial with
    11 treatment allocation
  • Participants 126 adult patients with severe
    arthritis of the hip joint suitable for a
    resurfacing arthroplasty of the hip
  • Interventions Total hip arthroplasty
    replacement of femoral head and neck. Hip
    resurfacing arthroplasty replacement of the
    articular surface of femoral head only i.e. the
    neck remains intact.
  • Main outcome measures Hip function at 12 months
    post-operation, assessed using the Oxford hip
    score (OHS) and the Harris hip score (HHS).

88
Why was this application successful?
  • A research question that was obviously relevant
    to patient care
  • A multidisciplinary team methodology as well as
    clinical expertise
  • Heavy patient involvement
  • Simple, pragmatic study design
  • Realistic (and limited) goals, within the
    timescale and budget of RfPB

89
Warwick Arthroplasty Trial
  • Results
  • The hip function of patients following
    Resurfacing Arthroplasty was not shown to be
    better than Total Hip Arthroplasty12 months after
    operation.
  • Overall complications rates did not differ
    between the two groups
  • Resurfacing may be cost effective in some
    patients but this depends upon the long-term
    survival of the implants
  • Conclusions Resurfacing Arthroplasty was not
    shown to be better than Total Hip Arthroplasty in
    the 12 months after surgery.
  • Trial registration. Current controlled Trials
    ISRCTN33354155. UKCRN 4093.

90
What have we learnt?
  • Dont be too clever simple research questions
    and straightforward study designs
  • Clinical engagement is key all of your
    surgeons and allied health professionals must be
    on board
  • No substitute for dedicated research staff
    surgeons are rubbish at recruiting!
  • Take your expected rate of recruitment, halve it
    and then halve it again...

91
What we would do differently next time
  • Patients as co-investigators really important
  • Research Design Service input
  • What can you afford?
  • Qualitative/Mixed Methods, Health Economics etc
    may add to the application but within the budget?
  • Talk to someone who has successfully delivered
    an RfPB project.....

92
NIHR springboard....
  • Track record is important
  • NIHR remarkably supportive and willing to give
    feedback take their advice!
  • HTA funding
  • Distal Radius Acute Fracture Fixation Trial
    (DRAFFT)
  • Wound Management of Open Fractures of the Lower
    Limb (WOLLF)
  • Programme Grants for Applied Research
  • Improving the outcome for patients with fracture
    of the proximal femur

93
Thank you
94
(No Transcript)
95
NIHR-funded Surgical Research NIHR HSDR Award
Holder
Professor Martin Utley
96
Outline
  • A risk model for paediatric cardiac surgery.
  • Building the project and building the team.
  • Selling the proposal.
  • Getting it done.

Numerology tips from a lottery winner?
97
A risk score for paediatric cardiac surgery
that incorporates diagnosis,
is based on national data,
and that can be used for local monitoring
The idea
Victor Tsang
Kate Brown
The team
CCAD
UCL CORU
98
Something for everyone
Experts, expert collaborators, PPI
The idea
Challenge / test / build the idea
Start early!
The team
99
Something for everyone
Experts, expert collaborators, PPI
The idea
Challenge / test / build the idea
Start early!
The team
Value of research to you / patients / NHS
Similar problems / trajectory / spin offs?
The proposal
Aims objectives methods
Roles and responsibilities, Plan B
Realistic timetable
100
Something for everyone
Experts, expert collaborators, PPI
The idea
Challenge / test / build the idea
Start early!
The team
Value of research to you / patients / NHS
Similar problems / trajectory / spin offs?
The proposal
Aims objectives methods
Roles and responsibilities, Plan B
Realistic timetable
The research
Regular and frequent progress meetings
Flag problems / delays
Trouble shooting
101
Summary
  • Benefits made clear
  • A competent, well briefed team
  • A clear plan
  • Risks anticipated and contingency plans in place
  • Effective communication
  • Start on time and dont overrun

Sound familiar?
102
Final lottery tip
You have to buy a ticket.
103
Thank you
104
(No Transcript)
105
NIHR-funded Surgical Research NIHR PGfPG Award
Holder
Mr Peter McCulloch
106
Who are we?
  • Quality, Reliability, Safety Teamwork Unit
    (QRSTU)
  • Research unit focussed on INTERVENTIONS to
    improve SAFETY in SURGERY
  • Based in Nuffield Dept of Surgical Science,
    Oxford University
  • Multidisciplinary team includes clinicians,
    ergonomists, aviation teamwork experts,
    specialist in systems improvement, knowledge
    translation, statistics and health economics

107
Safer Surgical Services
  • Programme of studies to evaluate INTERVENTIONS to
    improve safety and quality in surgery
  • Looking at SYNERGY between approaches and effects
    of CONTEXT and CULTURE on success
  • Based on a 3 dimensional model of safety (system,
    culture and technology)
  • Uses learning from non-medical experience eg CRM,
    Lean, Ergonomics
  • 3 Trusts over 3.5 years, mainly Orthopaedics

108
Application Process
  • Dates and timelines 2 years from start to go.
  • 5/9/08 Final Draft 1.3
  • Notes on reviews 28/11/08
  • Response to review 8/01/09
  • Response to further reviews 19/01/09
  • Full application 09/06/09
  • Resubmission 25/08/09
  • Final resubmission 22/09/09
  • Outline, full application revision so 3
    submissions
  • Further revisions x3 and contract signing 1/11/09
  • Difficulties around NHS budget holding
    sponsorship for academic partners

109
Overall Impressions of Application Process
  • Two stage process pointless where HEI involved,
    and causes delay
  • Review process thorough and professional
  • (- overly so?)
  • CCF staff superb
  • Rules a disincentive to career academics
  • Online forms not optimal

110
Pointers for Applicants
  • Referees showed strong focus on TEAM and
    ENVIRONMENT
  • Strong track record with relevant pilot data
    essential
  • Patience and flexibility required

111
Setting Up
  • Agreeing Contract after award can take time
  • Ethics vastly improved in last 5 years
  • Permissions to enter hospitals challenging!!

112
Achieving permission
  • Issues
  • Difficulty in determining what is needed HC,
    OC, RP ?
  • Multiple steps required
  • time and money
  • Multiplies chance of delay
  • Justification for several steps unclear
  • CRB
  • Medical Director sign-off
  • Occ Health at each Trust
  • Clearance for Letter of Access
  • Delays
  • (n 24)
  • Mean 7.8 weeks
  • Median 8 weeks
  • Range 3 18 weeks

113
Budgetary control
  • Subcontracting awkward NHS, University and NIHR
    accounting systems
  • Generally flexible and sensible in day to day
    running
  • Good interaction with CCF staff availability
    and ability
  • Interpretation of rules for funding NHS support
    costs seems difficult and narrow.

114
Reporting
  • Requirements light and not onerous
  • Requirement for permission to publish irritating
  • No real feedback on reports

115
Dealing with NHS RD Offices at Trust Level
  • Urgent and serious problem which is damaging
    research
  • Access
  • Ethics Amendments
  • Protocols
  • Sponsorship
  • Perverse incentives
  • Staff justify existence by activity not results
  • No targets or deadlines (? Look at Ethics model)

116
Patient Public Involvement
  • Principle not easy to implement
  • PALS
  • Patients Association
  • Special interest groups
  • More support needed?

117
SummaryThe Good
  • Generous support, vitally needed and unique
  • Very thorough and fair reviewing process
  • Superb staff interface at CCF - very helpful
    prompt and professional advice
  • Financial and Reporting structures effective and
    not onerous

118
SummaryThe not so good
  • Two stage application process
  • Iterations in contract negotiation
  • NHS RD Offices at Trust level a serious problem
  • Dissemination and PPI obligations could do with
    more help
  • Lack of rigorous mid-stage evaluation

119
Conclusions
  • Vital and important funding for clinically
    relevant research
  • Innovative on a world scale
  • Slow and bureaucratic selection and contracting
  • NHS budget holding a problem
  • Major problems with Trust research governance
  • Effective and helpful day to day management
  • Need to put more into PPI and reporting

120
Thank You NIHR!
  • Peter McCulloch
  • Ken Catchpole
  • Lauren Morgan
  • Eleanor Robertson
  • Julia Matthews
  • Beth Bosiak
  • Sarah Wills
  • Sharon Pickering
  • Mohammed Hadi
  • Damien Griffin
  • Steve New
  • Trevor Dale
  • Alastair Gray
  • Oliver Rivera
  • Doug Altman
  • Gary Collins
  • Crispin Jenkinson
  • Renee Lyons
  • Alison Kitson

121
Thank you
122
(No Transcript)
123
NIHR Workshop on Surgery Research
9 February 2012
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