Primary care

Networks for research in primary health care

Paul Thomas, director of West London Research Network ^a, Frances Griffiths, clinical senior lecturer ^b, Joe Kai, clinical senior lecturer ^c, Aislinn O'Dwyer, programme manager ^d. 

^a Department of Primary Health Care and General Practice, Imperial College School of Medicine, Charing Cross Campus, Reynold's Building, London W6 8RP, ^b Centre for Primary Health Care Studies, University of Warwick, Coventry CV4 7AL, ^c Department of Primary Care and General Practice, University of Birmingham, Birmingham B15 2TT, ^d North West Primary Care Research and Development Programme, NHS Executive North-West, Millennium Park, Birchwood, Warrington WA3 7QN

Correspondence to: P Thomas p.r.thomas{at}ic.ac.uk

The evolution of the academic discipline of primary care throughout the world is resulting in more primary care practitioners taking part in research. Primary care has a generalist nature,¹ and several research approaches are therefore required to understand the complex interplay between medical and psychosocial factors in the discipline.² Collaboration is needed between primary care professionals (general practitioners, nurses, health visitors, etc) and a variety of academics with a breadth of expertise.³ In this article we give an overview of primary care research networks. These networks were established as a way to enable diverse practitioners to engage in research. We start by outlining what these networks are and what they do, using examples from the United Kingdom and elsewhere. We then go on to discuss the lessons learnt from UK experience and suggest how these lessons can be built on through better integration with emerging primary care structures.

	Origins of primary care research networks in the United Kingdom

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Primary care research networks began to develop in the United Kingdom in the 1960s (box), but until recently there has been little political recognition of their importance. Primary care research was specifically included in the NHS research and development strategy for England and Wales for the first time in 1997. Before then there was no acknowledgement in government of the need to address the low research capacity of primary care. In 1997, the research and development in primary care national working group recommended an investment in care research networks to "achieve an evidence based culture in primary care."⁴

The research activity of the networks has included collection of morbidity data, clinical research, practice based research, large multicentre trials, and research training. Building on this experience, the NHS Executive funded primary care research networks in England and Wales from 1998 in order to increase the capacity for research in primary care.⁸ Networks were thought to be a good method of engaging and training practitioners in research. The UK Federation of Primary Care Research Networks was formed in 1998 to support these new entities, and it currently has over 30 member networks.

Recently published research arising from UK networks shows the breadth of research issues being undertakenfor example, clinical research,⁹ social research,¹⁰ and research into complex interventions. ^{11 12} A survey of general practitioners in southern England showed that nearly all considered research to be important and over half were interested in doing research themselves. Most practitioners were interested in research into disease processes, but nearly half considered that organisational and behavioural research were emerging priorities for primary care research.¹³ This grass roots view might reflect the increasing organisational complexity of primary care.

The need for organisational research has been noted elsewhere. The Medical Research Council topic review identifies "the theoretical basis of innovation in complex systems" as a priority for research,¹⁴ and the NHS strategic review identifies research gaps in understanding how to make research relevant to local contexts.¹⁵ Views on research priorities are changing rapidly. Research networks may be able to engage their members in ongoing dialogue about what they perceive the research priorities to be. This iterative approach has been successful at identifying the research needs of Australian farmers, encouraging them to become researchers and finding creative new ways forward with research findings.¹⁶

	International developments

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Research network activity in primary care has developed around the world. In the United States several small and large networks have emerged since 1980. For example, the Ambulatory Sentinel Practice Network has successfully recruited large numbers of patients to studies in the United States and Canada.¹⁷ The Dutch Sentinel Stations in the Netherlands have been gathering data since 1970. Health sector reforms in eastern Europe have prompted international collaboration through networks. For example, the European General Practice Research Workshop is facilitating collaboration between several eastern European countries, and Scandinavian general practice researchers network with primary care workers in the Baltic states. Further examples of different styles of general practice networks in Israel, France, and the United Kingdom are available on the BMJ's website. Each of the three networks described has been able to operate large scale collaborative projects and small scale personally developed projects at the same time.

Outside mainstream general practice, networks of researchers throughout the world have been active in primary care since at least the 1970s. There are many examples from India, Bangladesh, Australia, and Africa.¹⁸ These projects have largely been supported by non-governmental organisations and revolve around local communities rather than healthcare professionals. They have tended to emphasise participatory and action oriented approaches to research because such approaches help empower local people to cause much needed change.¹⁹

	Features of primary care research networks

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A network provides a set of pathways for people and ideas to come together. Networks can help coordinate diverse activities and disseminate information quickly, membership can be closed or open, and the direction can be rigidly defined or self organised. Closed, rigidly defined networksfor example, road systemstend to have outcomes that are more predictable. Open, self organising networksfor example, the internettend to have more uncertain but perhaps more creative outcomes.

Research networks may be able to produce multidisciplinary coalitions of researchers, provide widespread ownership of research activity, and motivate members to disseminate research findings quickly. They do not have to focus only on research. Indeed, there may be value in researchers sharing network infrastructure, which is slow to build and expensive to maintain, with those concerned with education and service development. This could contain the costs and enhance opportunities for collaboration. ^{20 21}

	Lessons learnt from UK experience

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Networks need organisational coherence
A network is a virtual organisation and requires organisational coherence. Its constitution must define membership criteria, accountability, and authority. Its organisational strategy must address issues of governance and describe the systems to be used to meet its objectives. It must evaluate its activities and provide an annual appraisal of its activities in the form of a report. Insufficient evidence is available about how networks can best achieve their competing aims of producing high quality research, transforming cultures, and engaging all practitioners in reflective inquiring practice.

Members need to be motivated and effort sustained
People are motivated to take part in research through networks when they freely see it to be in their own interest and when they can easily see that they can afford the time. If effort is to be sustained participants also need to be supported through problems. A research network is unlikely to be successful in the long term without ongoing attention to these factors. The main method of support may reflect the organisational structure of the network. Methods include peer support, academic support, and support from people with similar interests. However, most networks will have a complex interplay of support mechanisms, and new networks may benefit from planning multifaceted support.

Develop synergy with other local services
Researchers in networks can share the goal of sustainable reflective practice with professionals concerned with education in primary care, service development, and quality assurance. Practitioners working in these different areas may benefit from collaboration. The benefits include cross pollination of ideas, sharing of effort, and ultimately sharing of organisational structures.

	Looking forward

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The future development of networks in England needs to be understood in the context of another important development in primary careprimary care groups. These are clusters of 20-30 general practices that are allied with other local health service providers to serve geographical areas of about 100 000 people. They have responsibilities for addressing health inequalities, commissioning health services, and developing local health services. The groups are intended soon to become independent primary care trusts with financial control of the local health services. This could provide the structural opportunity for "health communities," where research and development become relevant to and integrated with each other. ^{23 24}

Primary care groups and trusts potentially offer research networks an opportunity to enhance motivation, sustainability, and synergy with local services. Informal and formal contact between local practitioners with different interests could make research partnerships easier. Primary care trusts also potentially provide a political mechanism whereby different resources can be brought together locally to maintain a network for several related purposes. They offer common grounda shared geographical areafor quantitative and qualitative research methods to be simultaneously applied to develop local services. Thus, the historical conflict of values between public health practitioners, general practitioners, and service developers²⁵ could be reconciled as each experiences the value of the others.

There are many cultural and practical obstacles in the way of implementing this idea. Primary care research networks are well placed to explore these obstacles and help facilitate "joined up" support for quality in primary care. The result could be improved community and patient experience of primary health care as well as high quality research that is increasingly relevant to primary care.

	Acknowledgments

We thank Jeffrey Borkan and Dominique Huas for information about research networks in France and Israel given on the BMJ's website.

	Footnotes

Funding: All authors hold academic posts and are funded by the NHS in England.

Competing interests: All authors are engaged in work related to the development of primary care research networks in the NHS in England.

	References

Top Origins of primary care... International developments Features of primary care... Lessons learnt from UK... Looking forward References

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(Accepted 21 December 2000)