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Think Ethics - putting participants and ethics at the heart of health and social care research

We are working together to make ethics review more innovative, efficient and trusted:

  • clear and concise study information designed with and for patients and study participants
  • fast, proportionate review focused on key ethical issues in a consistent way
  • a rewarding experience for diverse, skilled and committed members
  • a streamlined and user-friendly service, attracting world-leading health research in the UK.

Research ethics review: why it matters

Think Ethics

Independent research ethics review ensures that the rights and wellbeing of people taking part are at the heart of all research. It reassures the public that health and social care research is designed and carried out in a way which responds to their needs, enables them to make informed choices about whether to take part and ensures they are treated fairly.

The review, carried out by Research Ethics Committee (RECs), applies to all types of research (with very few exceptions) which involve people, their tissue or their data, regardless of who is funding the research or which institution is leading it. Whilst the goal is to facilitate and enable high-quality research, it retains a crucial independence from the research team and sponsor. Research Ethics Committees (RECs) operate according to the principles set out in the Declaration of Helsinki, first published by the World Medical Association in 1964.

RECs and the service that supports them have evolved over the decades since the declaration was published. Today in the UK, research ethics review is carried out through a network of 84 RECs across the UK, coordinated by the Health Research Authority (HRA) and our devolved administration equivalents and underpinned by a single application portal and common standards and processes.

The people who sit on RECs bring a range of professional and lived experience to the review of research. They give their time for free and provide a vital service to research teams and the people who take part in studies.

Ethics review during COVID-19: speed and focus

Research has been the cornerstone of the UK’s response to the COVID-19 pandemic. The UK has been at the forefront of global efforts to develop vaccines in record time, determine whether existing drugs repurposed to treat COVID-19 are effective and understand the impact of the virus on our health and wellbeing.

Research ethics review has made a significant contribution to this effort. During the pandemic, the research ethics service reviewed pandemic research in a tenth of the time taken in normal times without comprising on ethical standards and provided expert advice to researchers on issues such as how to conduct ethical research when patients may not have capacity to consent or where infection control measures make normal consent processes impossible.

The HRA also took steps to support public involvement in COVID-19 research, which had been neglected in the early weeks of the pandemic. We set up a service to put research teams in touch with patients and the public who could review research at short notice and to short timelines. This meant that urgent research maintained high standards of involvement, making the studies more patient-centred and more likely to recruit and retain participants.

Learning from the current research ethics service and the pandemic

Virus cell

The pandemic saw us to have work in new ways - ways which are more flexible, creative and pragmatic – and we want to build on that experience. We also want to build on what we knew before the pandemic: that research ethics view has come a long way but could do more to support the needs of both researchers and research participants.

We have started a programme, Think Ethics, which aims to make ethics review more innovative, efficient and trusted:

  • clear and concise study information designed with and for participants
  • fast, proportionate review focused on key ethical issues in a consistent way
  • a rewarding experience for diverse, skilled and committed members
  • a streamlined and user-friendly service, attracting world-leading health research in the UK

This programme represents part of the HRA’s contribution to the Department of Health and Social Care’s Recovery, Resilience and Growth programme, as outlined in its recent publication, Saving and Improving Lives.

Since autumn 2020, we have been listening to the views and experiences of people involved in health and social care research and testing out a fast-track approach to ethics review for non-pandemic research. This research phase has helped us to identify what needs to change in the future and what we should focus on through the programme.

Listening to views about the current service

We have heard the views of REC members, patients, researchers and life sciences companies about what aspects of research ethics review work well and what could be improved. We have also analysed our service to understand where ethics review adds most value, to be more helpful to researchers and, ultimately, to enable patient-centred, ethical research to start as quickly as possible.

During our listening exercise, we’ve heard that:

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Researchers and research sponsors:

  • value research ethics review because it provides independent scrutiny of their work, building public confidence in research. They also value the space it provides to discuss the ethical issues and receive helpful feedback.
  • would welcome a continuation of virtual meetings used during the pandemic, to enable them to attend REC meetings
  • would like to see a reduction in the volume and complexity of information they need to submit for review. And they would like the review to be more focussed, highlighting essential improvements and doing so in a consistent way across committees.
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Patients and participants:

  • value research ethics for the independent assurance it provides. It can strengthen the relationship between researchers and participants and helps to ensure that study information is clear.
  • would like to see a greater focus on ensuring patient and public involvement in the design and management of research, improved participant information and a greater focus on including a wider range of people in research studies.
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REC members:

  • are rightly proud of the contribution they make to high-quality research.
  • would welcome a reduction in the volume of documentation they review.
  • would welcome review of the appropriate balance between protecting participants in research and enabling autonomy.

The feedback we have received so far has allowed us to identify key areas for change. But we want to gather more in-depth views about what that change should look like in detail and will be conducting further engagement and dialogue activities.

Testing new approaches to ethics review

We have been testing new ways of carrying out ethics review outside of the pandemic response service. In January 2021, the HRA and partners in Wales, Scotland and Northern Ireland opened a pilot to test a fast-track ethics review service for non-COVID Phase 1 and global clinical trials. The key features of the service are:

  • a dedicated fast-track Research Ethics Committee (REC)
  • a paid committee chair
  • committee members drawn from a panel of existing members, rather than a set committee membership
  • dedicated approvals staff
  • shortened timelines between submission and REC meeting and between REC meeting and outcome

The pilot service aimed to carry out research ethics review within 15 days of submission (not including time taken by applicants to respond to requests for further information), saving 50% on standard timelines for studies of this type.

During the pilot phase, which ran between January and March 2021, we evaluated review timelines, the experience of users, fast-track REC members and staff, the quality of decision-making in the committee and cost and demand. We found that:

  • there is demand for fast-track ethics review. Satisfaction with the service was high and some applicants would be willing to pay for an accelerated service. However, integration with the wider approvals service and the UK regulatory system is important.
  • the service benefits companies, making the UK more competitive and enabling quicker patient access to medicines.
  • a swift review is possible: the median review time (not including the time taken for applicants to respond to enquiries) was 14 days.
  • REC members were, in the main, very satisfied with being part of the fast-track service, despite the turnaround times being significantly shorter.

Research ethics review for the future

Researchers often talk about ‘getting ethics approval’, as part of the process they need to go through before their study can begin. Use of this shorthand in a complicated and sometimes lengthy process is understandable, but it suggests a view that researchers see ethics review as a hurdle to get over, rather than an opportunity to help make their research reflect the needs of participants and the wider patient population.

We know that researchers value ethics review, but although many will have good intent, they may not rigorously consider ethical issues from the very beginning of planning their research. We want to avoid research ethics as being seen as a check done by a committee, but instead as a way of thinking which can be used throughout the research, but which is enhanced by REC review.

One of the ways this can be done effectively is by involving patients, service users and the public in research studies. Public involvement in research means research that is done ‘with’ or ‘by’ the public, not 'to', 'about' or 'for' them. It means that patients or other people with relevant experience contribute to how research is designed, conducted and disseminated. Involving people with relevant lived experience in the design and development of research can improve its quality and relevance.

At its heart, our work to improve research ethics review is about embedding ethical thinking throughout research. That’s why we have called it ‘Think Ethics’. We aim to design a research ethics review service which enables thinking ethically – starting long before and finishing long after review by an ethics committee.

The analysis and feedback received so far have led us to focus on the following areas for change:

  • differentiated, proportionate review methods
  • better participant information
  • the right committee format for the future
  • a better experience for REC members
  • more consistent REC review

We think this approach will derive more benefits:

  • public, patients, participants and applicants feel protected and reassured
  • participants are better informed about the studies they join and have a better experience in taking part in research studies
  • researchers applying for ethics review have a clear route of review for different types of research and each research study is reviewed in a way that suits the ethical issues it raises
  • research ethics review is more focused, consistent and makes good use of the skills and experience of REC members
  • the involvement of patients and the public in the design, conduct and dissemination of research is ‘business as usual’, not an optional extra
  • international companies choose the UK as their preferred place to do research

Differentiated, proportionate review methods

The health and social care research reviewed by ethics committees across the UK is enormously varied; using a range of research methods, involving different types of participants and testing many different interventions across numerous disease areas. Some raise minimal ethical issues, whilst others require careful review to ensure the dignity, rights and autonomy of participants are protected.

To reflect this, we offer three types of review:

  • Full REC Review – providing committee review of studies with a median timeline of 26 days
  • Proportionate Review – providing a light-touch review of studies outside of a committee which raise no material ethical issues with a median timeline of 19 days
  • Fast-Track Review – an expedited review carried out by a special REC with a paid chair with a median timeline of 15 days. This service is currently available only to clinical trials of medicines (CTIMPs).

We know that prioritisation works and that not all research studies raise the same type of ethical issues. The current approach to differentiated review methods is welcomed. However, we could improve them and go further.

Through the Think Ethics programme, we will review the different review methods including review at a REC meeting, light-touch review and, building on feedback from researchers, the possibility of self-assessment by researchers and sponsors. The aim is to ensure that REC members’ time is focussed where it adds most value, reducing the work pressure on them and reducing bureaucracy for studies with few or no ethical issues.

Better participant information

Participants

People who are invited to take part in a research study need clear, accessible information about the study so that they can decide whether or not to join. Whilst many study teams produce excellent participant information developed in partnership with people and communities, Research Ethics Committees still see participant information that is lengthy, complex and inaccessible to many people.

Most studies are not given a favourable opinion at first review and around 40% of those are the result of problems in the information and consent documentation. This is often because the participant information is not good enough, but there is also some inconsistency in the changes that RECs ask research teams to make. This creates additional work for applicants, RECs and staff and extends the timeline to the final outcome.

Through the Think Ethics programme, we will work with research participants, researchers and REC members to improve participant information and ensure that review of this information by a REC is consistent and proportionate. Good public involvement in the development of participant information is central to this.

The right committee meeting format for a diverse membership

The use of virtual committee meetings during the pandemic has enabled greater attendance by applicants, made co-opting committee members more straight forward, and has opened up the possibility of becoming a REC member to a wider group of people for whom attendance at a face-to-face meeting would be difficult. However, we know that REC members value the sense of community that their committee provides and benefit from the times that they are able to meet and work together in person.

Through the Think Ethics programme, we plan to design a committee format which takes advantage of virtual working but retains the sense of community within and between RECs which is so important. This will be aided by different forms of learning and opportunities for REC members to come together outside of a formal REC meeting.

Streamlined documentation for REC review

REC members often observe that the information provided in response to IRAS questions and in study documentation takes many hours to review and the information can be repetitive. They report that it is hard to know what is most important to focus on and what can be checked by staff.

Through the Think Ethics programme, we will clarify research ethics questions for applicants and ensure REC members review only the information required for ethics review.

More consistent REC review

Whilst RECs use the same approach to considering ethical issues and work within standard operating procedures, there will always be some natural variation in how they make decisions. In some areas, however, this variation is too wide, leading to a frustrating experience for applicants, inconsistency in the focus of ethics review and, potentially, different rates for provisional and favourable opinions at first review.

Through the Think Ethics programme, we will work with REC members to determine what level of variation is appropriate and agree steps to address this. This will include learning from the examples of good practice in individual RECs and the experience of the fast-track REC and consider how good practice can be spread across the service.

How we will take this work forward

Working with others to agree the improvements

Research ethics review affects many people: participants in research projects; patients and the public who have an interest in research and its findings; Research Ethics Committee members and the staff who support them; researchers and research sponsors and funding bodies. To design changes which meet the needs and expectations of these stakeholders, we will work in an open and consultative way, listening to their perspectives and experiences, whether though standing groups, workshops or more in-depth research.

To help steer the Think Ethics programme, we are working closely with organisations in Wales, Northern Ireland and Scotland who support Research Ethics Committees and have established an Advisory Group, chaired by  Professor Andrew George, a Non-Executive Director on the HRA Board.

Our Ethics Review Advisory Group is giving us advice based on their lived and professional experience.

The group includes academics, commercial sponsor organisations, Research Ethics Committee (REC) members and Public Involvement Network members. 

Read the minutes of the meetings and see the terms of reference for the group.

Partners in the Devolved Administrations

Health and Care Research Wales / Welsh Government
Health and Social Care Research and Development, Northern Ireland
NHS Research Scotland / Chief Scientist Office

Meet the members of our Ethics Review Advisory Group

Professor Andrew George

'In addition to being a NED at the HRA, I have a strong interest in education and am on the board of Health Education England and chair of two Colleges. I am Chair of Imperial College Health Partners, who are responsible for fostering health innovation in North West London, and am on the board of Surrey Borders Partnership NHS Foundation Trust. I am an executive coach. My academic background is in immunology. I chaired the Hammersmith Hospital Research Ethics Committee for a decade and was Chair of the National Research Ethics Advisors’ Panel.

Professor Andrew George (Chair), Non Executive Director at the HRA
Head and shoulders image of Sue Harrison

'I have been a lay plus REC member since 2011 so I must enjoy it! Recent events such as the EU exit and the COVID-19 pandemic have really highlighted the value of the first class research being carried out in the UK. I welcomed the opportunity to join the advisory group to help improve the efficacy and efficiency of our reviews and meetings, but also ensure that it is a rewarding experience for everyone involved. This will help to ensure that the UK maintains and improves its competitiveness in life sciences.'

Sue Harrison MBE, REC Vice Chair, acting Chair Berkshire B, lay plus member
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‘I have a PhD in neurochemistry followed by three postdoctoral fellowships in Trinity College, Dublin, Southampton University and Cambridge University where I also taught undergraduates and postgraduate courses in biochemistry and pharmacology. Subsequently I was a commissioning editor of medical publications for Elsevier in the Netherlands. I was appointed manager of academic medical journals for WB Saunders in London. These jobs both involved international travel to visit research groups engaged in emerging fields of medical research. In 2000 I started by own virtual company publishing academic medical journals online. This company now supports other companies. Apart from REC activities, I worked as a data manager in Bart’s Health Emergency Department (ED). The role was part of Emergency Department (ED) Youth Crime data sharing initiative, funded by the Department of Health (TKAP). The initiative aimed to map crime and engage with local community safety partners using data gathered from emergency departments.’

Marie Bardsley, REC lay member
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‘I have sat on the East Midlands - Nottingham 1 REC for almost four and a half years now. I have previously worked in clinical trials and have also worked in research and healthcare more broadly and studied as part of my degrees. I have taken part in clinical research as a patient/participant before. I’m currently undertaking Mitra studies (Buddhism) of which ethics is one of the 'Theefold Path'.’

Oliver Matias, MPhil/PhD student at City, University of London and REC member

‘I have seven years’ experience as lay plus member of a regular REC and recently of the fast track REC. I’m also a member of the local Health Watch and, until recently, spent 12 years as a Citizens Advice volunteer.’

Dan Mace, lay plus REC member
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‘I have over 25 years of experience in NHS research, previously as a researcher in primary care and public engagements and then as Director of Research and Development in an acute trust. I am now responsible for ensuring efficient, effective and high-quality research support and delivery across NHS Wales.’

Dr Nicola Williams, Director of Support and Delivery, Health and Care Research Wales
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‘I have been a REC member for almost four years and I additionally was a research scientist for many years running human intervention studies. In my role as governance manager, I act both as a sponsors’ contact and additionally support researchers in their applications through NHS REC and HRA review.’

Dr Joanne Doleman, Senior Research Governance manager at Wellcome Sanger Institute and REC lay member
Juliet Tizzard

‘I joined the HRA in January 2018. My role is to lead the policy and partnerships function, ensuring the UK Policy Framework for Health and Social Care Research reflects current legislation and best practice and is translated into practical advice and guidance which is communicated effectively to researchers. I lead on strategic engagement, pursuing HRA’s ambition to become an influential voice in the UK health research environment. Before joining the HRA, I was Director of Strategy at the Human Fertilisation and Embryology Authority, leading on a number of initiatives to improve patient access both to fertility research and safe and effective treatment services.’

Juliet Tizzard, Director of Policy and Partnerships at the HRA
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‘I have significant experience of research ethics and delivery of the NHS research ethics service having served previously as Chair of the university REC, Vice-Chair of an NHS REC, National Research Ethics Advisor, and as a Non-Executive Director of the HRA. In my university role, I am the executive lead for research governance (including sponsor responsibilities), ethics and integrity.’

Professor Nalin Thakkar, Vice President, Professor of Molecular Pathology, Consultant Histopathologist, The University of Manchester
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'I am a clinical trialist with expertise in placebo-controlled trials of interventional procedures. I am co-lead of the cardiovascular theme of the Imperial NIHR BRC, NIHR CRN cardiovascular speciality lead for North West London and a public and patient involvement/engagement theme champion at the National Heart and Lung Institute.'

Rasha Al-Lamee, Clinical Senior Lecturer and Consultant Cardiologist, Imperial College London and Imperial College Healthcare NHS Trust
A head and shoulders photo Lynn Laidlaw with short curly hair and brown glasses and wearing a polo neck jumper smiling and looking at the camera

'I live with a rare disease and multiple long-term conditions. I am an experienced public contributor and have recently been funded, as part of a team, to do a piece of patient led research.'

Lynn Laidlaw, Public Contributor/Research participant/Patient researcher
A head and shoulders image of Dr Susan Kohlhaas, with shoulder length blonde, hair, wearing black glasses and a blue jumper and smiling

'I am the Director of Research at Alzheimer’s Research UK which is a major funder of dementia research in the UK. I have worked for over a decade in the charity sector working closely with the academic community and industry to support research from concept to completion. It’s great to be part of this group that aims to streamline the HRA processes and support more research that can ultimately benefit patients.'

Susan Kohlhaas, Director of Research, Alzheimer’s Research UK
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'I am a public engagement specialist, combining experience of policy, clinical research and media representation to emphasise that meaningful patient engagement is the key to sustainable innovation in healthcare. I am a member of the European Health Parliament and a European Patients’ Academy on Therapeutic Innovation (EUPAT) Fellow, and an internationally-recognised consultant operating with patient organisations all over Europe.'

Thomas Smith, Life Sciences Public Engagement Specialist, ProPatient
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'I am a philosopher by training and have worked on issues in research ethics and governance for about 20 years. This has involved research in ethics and delivering training to researchers and REC members about research ethics. I have been a National Research Ethics Advisor since 2012.'

Dr Mark Sheehan, Oxford Biomedical Research Centre Ethics Fellow, Ethox Centre, University of Oxford
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I am an expert member and Alternate Vice Chair of Oxford C REC. I have a medical background with particular experience of health protection and microbiology.

Linda Cartwright, expert REC member and alternate Vice Chair
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'I lead IBM’s Life Sciences consulting team in the UK, which brings world-leading business, technology and digital capabilities to innovative pharma and growing SMEs. IBM deploys deep expertise enabling digital reinvention, bringing leading capabilities across digital strategy, analytics, cognitive technologies and cloud technology solutions. As Director of the Office for Life Sciences, I have shaped the UK ecosystem and health data environment and led for UK government on the development of the Life Sciences Industrial Strategy and first Sector deal, focusing on the creation of new UK industries in the UK such as Genomics, Digital Health and early diagnosis. Before IBM, I worked at Deloitte and AT Kearney, providing strategy consulting across Health and Life Sciences from Big Pharma and Med Tech to SMEs and national policy. I am a Non Executive Director of the Wellcome Sanger Centre and the Health Research Authority and hold a DPhil, MSc and MA from the University of Oxford.'

Dr Nicole Mather, Non Executive Director of the HRA and Wellcome Sanger Centre
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'I’ve worked in clinical research for almost 20 years, starting off filing one page application forms in an R&D office and then seeing the gradual, though exponential increase in hoops and obstacles to deliver studies in the NHS in roles with the Clinical Research Network, NHS set up and delivery teams, R&D management, and latterly within the HRA and pharma. My main goal in that time has been to support people that want to do effective, high quality, safe research deliver their studies, and to work to start the decrease in those hoops and obstacles.'

Chris Cannaby, Senior Clinical Operations Manager, MSD UK
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'I have worked for the HRA since 2013, initially to develop and implement HRA Approval and subsequently leading all the HRA’s operational activities and their supporting functions. I work collaboratively with a wide range of partner organisations to fulfil the HRA’s aims to make it easier to do good quality ethical research in the UK. I have a PhD in biochemistry from University of Cambridge, followed by many years’ experience of clinical research in the pharmaceutical industry. I subsequently moved into research management in the NHS and the NIHR Clinical Research Network, and have been involved in a wide range of national initiatives and large-scale change programmes.'

Jonathan Fennelly-Barnwell, Deputy Director of Approvals Service at the HRA
A head and shoulders image of Mary Dixon-Woods who has shoulder length brown hair and wears dark glasses, smiling at the camera

‘This initiative to align systems, processes and values relating to research ethics with what the system is seeking to achieve will be hugely valuable. I am particularly impressed with the emphasis on respect for participants is the guiding principle and with the drive for clarity, consistency and smooth processes.’

Professor Mary Dixon-Woods, Director of THIS Institute, University of Cambridge
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'I have a degree in Pharmacology and a PhD in Neuropathology, and over 25 years’ experience in the pharmaceutical industry. This covered development and launch of new medicines in a variety of therapy areas including infectious diseases, diabetes, respiratory and oncology, and a wide range of countries and regions. I joined the the ABPI (Association Of The British Pharmaceutical Industry) in May 2018, covering all aspects of New Medicines discovery, development and manufacturing including a focus on AMR, vaccines, advanced therapies, and harnessing health data. I’d like to see as many patients as possible have the opportunity to take part in clinical research, that research is relevant to improving patient outcomes and the patient experience and that the results of research are available, accessible and understandable.'

Bryan R Deane MA, PhD, dipM Director, New Medicines & Data Policy ABPI (Association Of The British Pharmaceutical Industry)

Other Ethics Review Advisory Group members

Helen Lewis-White North Bristol NHS Trust
Jo Rycroft-Malone National Institute for Healthcare Research (NIHR)
To be confirmed Chief Scientist Office (CSO)

A roadmap for change

The key activities for 2021-22 are:

Summer 2021 Autumn Winter Spring 2022 Summer
Establish Advisory Group to steer Think Ethics work Public launch of Think Ethics Right review: consulting on options for light touch
ethics review of some research studies
Right review: a new framework for light-touch
review of low ethical risk studies
Keeping what works: introducing fast-track ethics
review for clinical trials of medicines
Testing options for change: interviews and
workshops with research participants, researchers and ethics committee
members
Reducing paperwork: cutting down the document
workload for ethics committee members
New format for ethics committees: virtual review,
face-to-face learning and discussion
Reducing paperwork: Redesigning application
questions to promote ethical thinking and reduce burden
Informed consent: exploring the options for better
participant information
Informed consent: agreeing new ways to enable great
participant information, produced with patients
Public engagement: what do research participants
expect of studies and of ethics review?
Committee culture: Testing new approaches to
decision making around public involvement
Committee culture: Working with stakeholders to
make ethics review more consistent
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