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EDITORIALS: Chris Del Mar Is primary care research a lost cause? BMJ 2009; 339: b4810 [Full text]

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Neglected virgin areas in primary health care basic and applied research.

Rodolfo J. Stusser   (20 November 2009)

-not if it returns to its roots

john howie   (26 November 2009)

Pickles and Primary Care Research

Nicholas Summerton, HU15 1PN   (8 January 2010)

Not all those who wander are lost

Trisha Greenhalgh   (11 January 2010)

Or are we rising to the challenge?

Adam R Firth   (11 January 2010)

Some data to inform the discussion

Frank Sullivan, Frances Mair, Tony Kendrick, Chris Van Weel, Amanda Howe   (13 January 2010)

The second translational gap: The age of implementation research.

Emmanuel A Agogo   (14 January 2010)

Primary care research needs integration of disease and illness focused interventions

Chris C Butler, Jochen Cals, Rogier Hopstaken, Kerry Hood, Geert-Jan Dinant   (14 January 2010)

Possibly - but why?

Steven Ford   (17 January 2010)

The value of non-clinical research

Kath Checkland   (18 January 2010)

Is there hope for primary care research in Austria?

Florian L. Stigler, Helmut J. F. Salzer, and Adrian M. Moser   (20 January 2010)

From little acorns ...

John A A Nichols   (21 January 2010)

Is primary care research a lost cause? No - it isn’t lost and it was never a ‘cause’.

FD Richard Hobbs   (21 January 2010)

Preparing to blow our trumpet

Chris Del Mar   (1 February 2010)

Primary Care Research is still alive

Dr. Jonathan G. Hillman, Dr. Hamish K. MacNab   (15 February 2010)

Neglected virgin areas in primary health care basic and applied research. 20 November 2009
Rodolfo J. Stusser, Freelance PHC GFM Research Consultant (Retired from MINSAP), International Member of AAFP & NAPCRG. Primary Care e-Research Collaboration Center http://havanacenter.familydoctors.net Havana, Cuba. Send response to journal: Re: Neglected virgin areas in primary health care basic and applied research.	I agree with Del Mar's crucial and valiant editorial that primary health care (PHC) researchers need to know what to research in general family medicine (GFM),[1] when in the last 64 years all the classified diseases have progressively become handled and focused in depth by vertical hospital and lab specialists. Coming from cardiovascular and cancer research centers to PHC, I have been working, studying and reflecting in my last 20 years on a GFM own agenda,[2] and think that on the basis of an integration philosophy of science, I can suggest some more exclusive areas for the generalist researcher. The great influence of the specialist researcher's fragmentation philosophy on PHC GFM has meant that generalist researchers have lost focus on the possibility of research in at least three neglected virgin basic and applied areas, impossible to be approached by any specialists. These are as follows: 1) Founding a Science of Multi-System Connectedness. 2) Developing a Unified Primary Living and Health Care System. 3) Creating a Lifelong Health Maintenance Semiology-Nosology. Strangely, recently discussed very interesting and basic science information and models--at similar top levels to those of bio-molecular labs--argue that community-oriented PHC GFM is the only horizontal specialty capable of connecting the patient parts and the wholes, going in depth in the systems hierarchy (levels of organization) or holarchy of health care, through the pyramid of healing and transcendence, prioritized care, integrated care, and fundamental health care.[3] Hollnagel and Malterud discussed 9 years ago that Paul Backer in 1977 defined the 'health equation' as a formula weighing the balance between the patient's strains and resources. Reading the health equation, the generalist can understand why a person becomes sick when his strains are larger than his resources if he is not able to restore the balance by reducing the strains or increasing resources. According to this model, the generalist's task is to assist people in restoring the balance, not only by decreasing the negative points, but also to strengthen the positive ones.[4] Of course, the strains and resources should be both internally perceived by the patient and externally observed by the generalist. I think that great devotion from Graunt to Cullen's classification and nosology philosophies, has stagnated the classifications family up to ICD-10, ICPC 2, and ICF, as well as the health status assessment instruments supported by WHO, WONCA and NAPCRG.[5] Most of them, still are only negative-health dependent, static-discrete, independent of positive-health resources, outside Leavell and Clark's dynamic-continuous view for GFM health promotion and disease-disability preventive levels. Thank you. 1. Del Mar C. Is primary care research a lost cause? BMJ 2009;339:b4810. http://www.bmj.com/cgi/content/full/339/nov18_2/b4810 2. Stusser RJ. The creation of family medicine new research spaces. Havana: Plaza Community Polyclinic, 1996. http://rational.fortunecity.com/artfam2.html 3. Stange KC. A science of connectedness. Ann Fam Med 2009;7:387-395. http://www.annfammed.org/cgi/content/full/7/5/387 4. Hollnagel H, Malterud K. From risk factors to health resources in medical practice. Med Health Care Philos. 2000;3(3):257-64. http://www.springerlink.com/content/q4230jv133361x3p/ 5. Salomon JA, Mathers CD, Chatterji S, Sadana R, Ustun TB, Murray CJL. Quantifying individual levels of health: definitions, concepts and measurement issues. In: Murray & Evans. eds. Health systems performance assessment: debates, methods and empiricism. Geneva: World Health Organization 2003, 301-318. Competing interests: None declared
-not if it returns to its roots 26 November 2009
john howie, emeritus professor of general practicce university of edinburgh eh89dx Send response to journal: Re: -not if it returns to its roots	In his thoughtful editorial on the Report of the Academy of Medical Sciences into general practice research, del Mar asks if primary care research is a lost cause. Two institutional realities have contributed to the problem. First, universities and their medical schools have become imprisoned in the search for large sums of research money to survive, resulting in restructuring of research activity and the pursuit of high earning high technology activities, neither of which are helpful to the preferred agendas of academic general practice. Second, the re-ordering of community clinical services (at least in the UK) to promote incentivised public health interventions combined with the opportunity for general practitioners to opt out of out-of-hours care has seriously compromised the core values of continuity and the primacy of patient agendas at general practice consultations. Academic general practice has perhaps had no option but to go along with these realities, but in so doing it has risked losing its intellectual and research identities. In research terms, the effect has been an almost exclusive move into evidence-based research approaches to the exclusion of the work on the consultation, patient-centredness and holism which del Mar dates as belonging to a passing generation. Too many of the questions now being asked and of the papers being published lack either or both of interest or relevance to the individual patient in consultation with the individual doctor. del Mar kindly referred to my work on prescribing for respiratory illness in the 1970s(1). My first study(2) was a double-blind clinical trial which showed no benefit to antibiotic takers in a normally healthy working-age male population. I spent the next thirty plus years trying to explain why these findings had made so little change to standard clinical practice. In the end it was the work on the consultation and on patient- centredness that seemed to make most sense to the realities of the consulting room. I have recently had the opportunity to revisit one of my studies of the early 1970s, and to comment on its relevance to modern clinical practice(3). This has confirmed for me that if general practice research is to contribute to the future of medicine in the way patients most need to-day, it will only be through a combination of medical and social science approaches. del Mar says that 'primary care research is in the doldrums'. If that is indeed true, the way ahead must surely be for the original discipline of general practice (whether or not delivered solely by doctors) to re-assert its core values both in the medical school and in the consulting room. The discipline so many worked to develop in the second half of the 20th century was about much more important aspects of patient care than simply 'primary care' on its own. references 1. del Mar. Is primary care research a lost cause? BMJ 2009:339:b4810. 2. Howie J G R, Clark G A. Double-blind trial of early demethylchlortetracycline in minor illness in general practice. Lancet,1970;ii:1099-1102. 3.Howie J. Diagnosis in general practice and its implications for quality of care. J Health Serv Res Policy. doi:jhsrp.2009.009109. Competing interests: None declared
Pickles and Primary Care Research 8 January 2010
Nicholas Summerton, General Practitioner 7 Hall Walk, Welton, Brough, HU15 1PN Send response to journal: Re: Pickles and Primary Care Research	Successful primary care research depends on a partnership between those who develop the successful grant proposals and those willing to participate in collecting the data. In his editorial Chris Del Mar highlights the key role of William Pickles working in Wensleydale back in the 1930s (1). However, in recent years, there has been relatively little primary care research activity across Yorkshire. Two years ago I assembled and secured funding for a group of six practices and two practice groupings with the aim of facilitating recruitment of patients into studies on the UK Clinical Research Network portfolio (2). The eight `Pickles Practices` were selected based on considerations of size (at least 15,000 patients) and NHS performance ratings (i.e. consistently high rankings in relation to the NHS Quality & Outcomes Framework). Furthermore, although they were required to have an interest in research, only one quarter had published any research themselves. A supplementary list of research criteria was also developed in conjunction with the `Pickles Practices` to select out those studies of greatest relevance to day-to-day primary care practice i.e. • Is the answer from the study worth getting? • Is it seen as relevant to primary care in terms of the likely impact on current clinical care either by virtue of participating in the research or in relation to the likely outputs from the research? • Is the study feasible in a specific practice setting? • What is the current policy/local context that might encourage participation? This list was then used by the `Pickles Practices` to guide their interactions with researchers, industry, secondary care and, subsequently, in providing advice and support to other practices across Yorkshire. In a report presented to the North & East Yorkshire and North Lincolnshire Comprehensive Research Network Board last summer (3) the research accruals for the year ending 31st March 2009 were as follows: Number (%) of patient accruals into UKCRN portfolio studies Primary Care 4980 (69%) Secondary Care 2239 (31%) Cost per patient accrued into UKCRN portfolio studies Primary Care £61.96 Secondary Care £923.95 Food for thought by those allocating funding! References: 1. Del Mar C. Is primary care research a lost cause? BMJ 2010; 339: 61- 62. 2. http://public.ukcrn.org.uk/search/ 3. North & East Yorkshire & North Lincolnshire Comprehensive Local Research Network. NIHR Portfolio Registration. Report to CLRN Board, 2nd June, 2009. Dr Nick Summerton, General Practitioner and Co-Director CLRN 7 Hall Walk, Welton, Brough. East Yorkshire. HU15 1PN n.summerton@hull.ac.uk Competing interests: None declared
Not all those who wander are lost 11 January 2010
Trisha Greenhalgh, Professor of Primary Health Care University College London Send response to journal: Re: Not all those who wander are lost	Chris Del Mar claims that primary care researchers once studied bread -and-butter clinical problems and produced findings directly relevant to front-line practitioners – but have latterly drifted off course into the study of ‘processes’ (1). This analysis is superficial and suggests a certain naïveté about who controls the agenda. The direction and underpinning values of primary care research in the UK over the past 40 years have been systematically studied by critical discourse analysis of key policy documents (2). In short, the leading edge of primary care research now marches almost exclusively on roads laid by politicians, civil servants and a handful of senior decision-makers within the profession. Research policy is currently powerfully shaped and constrained by talk of the knowledge-based economy and the contribution of high-technology innovation to UK plc. This discourse has re-positioned the core business of primary care research as running a ‘population laboratory’ for large-scale epidemiological studies, preferably with a pharmacogenomic component. Such studies are important but they are not the whole story. The golden days when general practice researchers explored clinical curiosities and local disease patterns using a combination of meticulous observation and kitchen-table epidemiology are long gone. But this is not because we are no longer turning out researchers of comparable calibre to Pickles, Tudor Hart and Howie. It is because (a) the study of single diseases in small, stable and ethnically homogeneous communities by singlehanded practitioners unburdened by the creeping institutionalisation and regulation of research belongs to a bygone era; (b) epidemiology’s unanswered questions demand large-scale collaborative studies which can only be undertaken by those linked into a complex research infrastructure; and (c) non-epidemiological questions relevant to primary care (e.g. on the humanistic and social dimensions of illness and healing or why promising new technologies fail to get adopted) are currently defined as a lesser form of science for which only B-list funding streams and publication outlets are available (3). If you don’t water a plant, it will wither. Let’s stop blaming the plant. Reference List (1) Mar CD. Is primary care research a lost cause? BMJ 2009; 339(nov18_2):b4810. (2) Shaw SE, Greenhalgh T. Best research - For what? Best health - For whom? A critical exploration of primary care research using discourse analysis. Soc Sci Med 2008; 66(12):2506-2519. (3) Greenhalgh T. Thirty years on from Alma-Ata: Where have we come from? Where are we going? Br J Gen Pract 2008; 58(556):798-804. Competing interests: None declared
Or are we rising to the challenge? 11 January 2010
Adam R Firth, ST2 NIHR ACF in General Practice Bowland Medical Practice, Wythenshawe, Manchester, M23 1JX Send response to journal: Re: Or are we rising to the challenge?	Professor Del Mar's editorial has highlighted some of the issues faced in primary care research and alluded to the process of deeper reflection that has taken place within the specialty following the publication of the Academy of Medical Sciences report.[1] As an academic trainee in General Practice, the outcome of my own reflection is a greater sense of potential and opportunity, coupled with a responsibility, to rise to the challenge of helping ensure primary care continues to deliver 'clinically relevant disease orientated research' as exemplified by the 2009 BMJ Research Paper of the Year.[2] Steps have been taken to facilitate primary care research such as the establishment of the NIHR Primary Care Research Networks, the RCGP Research Ready Program and the creation of NIHR funded academic training posts but more has to be done to engage GP's at the clinical coalface.[3- 5] Opportunities to incorporate research training and meaningful research experience afforded by the proposed extension to GP training in the UK is one example in many of how this may be achieved. Despite the overriding sense of opportunity felt, I fully endorse the final sentences of the editorial. It is a telling fact that of the 260 Academic Clinical Fellowships (ACFs) on offer through the NIHR in 2009 only 8 were in General Practice.[5] There is a need for greater research funding and support and we do have a lot of catching up to do but as I prepare for the annual meeting of GP ACFs taking place in Bristol this week I am confident that we will answer Richard Horton's provocative question with a resounding no. 1. Del Mar C. Is primary care research a lost cause? BMJ 2009;339:b4810. http://www.bmj.com/cgi/content/full/339/nov18_2/b4810 2. Sullivan FM, Swan IRC, Donnan PT, Morrison JM, Smith BH, McKinstry B, et al. Early treatment with prednisolone or acyclovir in Bell's Palsy. N Engl J Med 2007;357:1598-607 3. http://www.crncc.nihr.ac.uk/index/networks/primarycare.html [Accessed 10/01/10] 4. http://www.rcgp.org.uk/clinical_and_research/circ/research/primary_care_research_team_ass/research_ready.aspx [Accessed 10/01/10] 5. http://www.nihrtcc.nhs.uk/intetacatrain/ [Accessed 10/01/10] Competing interests: AF is a NIHR Academic Clinical Fellow in General Practice.
Some data to inform the discussion 13 January 2010
Frank Sullivan, Professor and Head of Division, University of Dundee School of Medicine, and Director SSPC Makenzie Building, Kirsty Semple Way, Dundee DD2 4BF, Frances Mair, Tony Kendrick, Chris Van Weel, Amanda Howe Send response to journal: Re: Some data to inform the discussion	We were surprised by the somewhat negative tone of the editorial by Chris Del Mar [1] and of the Editor’s comments [2] because the BMJ has actually recognised and published a significant number of high quality primary care research papers in recent years, including both clinical and organisational research. For example, the journal awarded one of us its prize for the best research paper published in 2008 which reported original research on the important clinical topic of Bell’s Palsy [3]. This may highlight the fact that primary care is the setting of high quality research on the diagnosis and treatment of important diseases in the population – just to add the example of gout [4,5] – and indeed, three out of the five original research papers published in the same edition of the journal as Del Mar’s editorial were clinical research papers with primary care authors [6-8]. In our view, the editorial [1], which bemoans a perceived lack of clinical research and implicitly criticises research that examines organisational aspects of care, promotes a false separation of the two aspects of care and is rather at odds with other primary care papers published recently by the BMJ. One on the policy aspects of the management of chronic disease emphasised the importance of a generalist approach to the growing challenge of multiple morbidity and the need for better co- ordination of care, and research taking a holistic rather than disease specific view [9]. The second highlighted the importance of the organisational context in relation to the clinical management of depression [10]. Primary care research is certainly alive and continuing to develop in the UK. One of us (CvW) was the international observer on the Primary Care unit of assessment (UoA) for the 2008 UK Research Assessment Exercise and can confirm the internationally excellent quality of the majority of research submitted to that panel. Furthermore, a postal survey carried out among heads of UK departments of academic primary care by three of us (FS, FM and TK) in 2009 showed that, in addition to the 151 full time equivalent (fte) researchers submitted to the Primary Care UoA, a further 97 were submitted across 11 other units of assessment, with Health Services Research (48.4), Epidemiology and Public Health (10.8) and Social Policy (10.4) comprising the other largest submissions. The results demonstrate a continuing increase in the amount and quality of primary care research in the UK over the four RAE cycles undertaken so far [11]. Despite this however, Del Mar is right to highlight the need for more investment in primary care research [1]. In an international comparison to other specialty domains, primary care is lagging in its research production [12]. Even in the UK, which is doing relatively well in comparison to most other countries, the total of 248 fte active researchers is small when compared to disciplines such as Health Services Research (505 submitted in RAE 2008), Epidemiology and Public Health (544 submitted), Cardiovascular Medicine (359) and Cancer Studies (678), given the importance of primary care as the place where more than 90% of patient contacts are made with the NHS, and where most chronic disease management now takes place. We call for more investment from universities and other funders (alongside the very welcome recent investment from the Chief Scientist Office in Scotland and the National Institute for Health Research in England) to enable primary care research to develop and maintain sufficient critical mass to sustain high quality research programmes in the longer term, for the good of patients and of health care systems across the world. Frank Sullivan Professor and Head of Division, University of Dundee School of Medicine, and Director of the Scottish School of Primary Care. Frances Mair Professor of Primary Care Research/Head of Section, University of Glasgow School of Medicine. Tony Kendrick Professor of Primary Medical Care/Associate Dean for Clinical Research, University of Southampton School of Medicine. Chris van Weel Professor of General Practice, Department of Primary and Community Care, Radboud University Nijmegen, The Netherlands, and President, World Organisation of General Practitioners Wonca . Amanda Howe Professor of Primary Care & MB/BS Course Director, School of Medicine, Health Policy & Practice, University of East Anglia, and Honorary Secretary, Royal College of General Practitioners. 1. Del Mar C. Is primary care research a lost cause? BMJ 2009;339:b4810. 2. Godlee F. Questions for research. BMJ 2010;340:c94. 3. Sullivan FM, Swan IRC, Donnan PT, Morrison JM, Smith BH, McKinstry B, et al. Early treatment with prednisolone or acyclovir in Bell's Palsy. N Engl J Med 2007;357:1598-607. 4. Janssens HJ, Janssen M, Lisdonk EH van de, Riel PL van, Weel C van. Use of oral prednisolone or naproxen for the treatment of gout arthritis: a double-blind, randomised equivalence trial. Lancet 2008; 371:1854-1860. 5. Janssens HJEM, Fransen J, van de Lisdonk EH, van Riel PLCM, van Weel C, Janssen M. A diagnostic rule for acute gout arthritis in primary care without joint fluid analysis. Archives of Internal Medicine. Accepted for publication. 6. Williamson I, Benge S, Barton S, Petrou S, Letley L, Fasey N, Haggard M, Little P. Topical intranasal corticosteroids in 4-11 year old children with persistent bilateral otitis media with effusion in primary care: double blind randomised placebo controlled trial. BMJ 2009;339: b4984. 7. Paddison CAM, Eborall HC, Sutton S, French DP, Vasconcelos J, Prevost AT, Kinmonth AL, Griffin SJ. Are people with negative diabetes screening tests falsely reassured? Parallel group cohort study embedded in the ADDITION (Cambridge) randomised controlled trial. BMJ 2009;339:b4535. 8. Collerton J, Davies K, Jagger C, Kingston A, Bond J, Eccles MP, Robinson LA, Martin-Ruiz C, von Zglinicki T, James OFW, Kirkwood TBL. Health and disease in 85 year olds: baseline findings from the Newcastle 85+ cohort study BMJ 2009;339:b4904 9. May C, Montori VM, Mair FS. We need minimally disruptive medicine. BMJ 2009;339: b2803. 10. Dowrick C, Leydon GM, McBride A, Howe A, Burgess H, Clarke P, Maisey S, Kendrick T. Patients’ and doctors’ views on depression severity questionnaires incentivised in UK quality and outcomes framework: qualitative study. BMJ 2009;338:b663. 11. Howe A. UK General practice is ‘the best in the world’. RCGP News 2009;1:1. http://www.rcgp.org.uk/PDF/RCGPNews%20Feb09.pdf 12. Mendis K, Solangarachchi I. PubMed perspective of family medicine research: where does it stand? Fam Pract 2005;22:471-473. Competing interests: None declared
The second translational gap: The age of implementation research. 14 January 2010
Emmanuel A Agogo, General practitioner/ Instructor, Physician Assistants Programme School of Health and population Sciences, University of Birmingham Send response to journal: Re: The second translational gap: The age of implementation research.	Professor Del Mar in his review of the Academy of Medical Sciences report has revived the debate on the state of research in primary care and ended with a challenge that ‘primary care researchers need to know what to research’. He suggests that primary care researchers should outgrow the lack of confidence that has changed research focus from diseases to models of care and health services research and embark on a new paradigm of collaborative research that is disease focused but multifaceted enough to impact on patient outcomes(1). Most frontline clinicians and primary care researchers will disagree with the opinion that the research priorities are unclear and primary care research is in the doldrums. The second translational ‘gap’ that the 2006 Cooksey report(2)identified, refers to this disconnect between the development and the implementation of new interventions in clinical practice. This report went further to suggest the promotion and funding of incentives aimed at implementing new ideas and technologies in practice in contrast to incentives aimed at spreading best practice and ensuring that costs and benefits of change impact equally on the implementers and funders. They also proposed the role of ‘research disseminators’ who would simplify research evidence and facilitate its uptake into policy and clinical decision making. It is important to realise that many forward thinking Primary Care Trusts and primary researchers have identified this gap and begun to develop partnerships to improve uptake of proven interventions. There are initiatives in several departments of Academic General Practice to develop implementation research(3).Implementation research is aimed at achieving application of research in ‘real world’ settings. This involves an understanding of the factors underlying clinical practice in order to understand what sort of processes should be used in implementing interventions as well as understanding how the interventions themselves work. Implementation research is the scientific study of methods to promote the uptake of research findings, and hence to reduce inappropriate care. It includes the study of influences on healthcare professionals' behaviour and interventions to enable them to use research findings more effectively(4). Until research is undertaken to understand the determinants which sustain this disjoint, there will be a perpetual lag between synthesis of evidence and implementation by individual practitioners. The adoption of evidence based intervention can be advanced by evidence based policy making. This underlines the need for joined up thinking between researchers, policy makers and clinicians. The Academy of Medical Sciences report advocates a long-term commitment to implementation research. It recommends the establishment of a national programme of implementation research, including a combination of project and programmatic funding and training programmes(5). This editorial outlined the evolution of the areas of primary care research. The next phase in this process is likely to be the ascendancy of Quality improvement and implementation research. This means that Quality Improvement and Implementation research will have to become more rigorous and the evidence base for researching interventions has to become more robust. It is important to achieve clearer consensus in order to homogenize research methodology, research protocols and reporting standards(6). The Government and other funders of research ought to commission work which is focused at resolving the difficulties and barriers to implementation of evidence based interventions that exist at the individual and organisational levels as well as develop interventions that can achieve effective translation of evidence into practice. It is simplistic to define a genre of research as the final solution; however, the importance for research that is relevant, which will produce impact, is imperative. Primary care researchers really do have a lot of catching up to do. References Del Mar C. Is primary care research a lost cause? BMJ 2009; 339:b4810 Walker A, Grimshaw JM, Johnston M, Pitts N, Steen N, Eccles MP: PRocess modelling in ImpleMEntation research: selecting a theoretical basis for interventions to change clinical practice. BMC Health Services Research 2003, 3:22-22. Personal communication with Prof R Foy, AUPC, University of Leeds. Sir David Cooksey. A review of UK health research funding. HM Treasury report 2006. The Academy of Medical Sciences. Research in general practice: bringing innovation into patient care Workshop report. October 2009 Shojania KG , Grimshaw JM Evidence-Based Quality Improvement: The State Of The Science Health Affairs, 24, no. 1 (2005): 138-150 Competing interests: Prospective researcher in Quality improvement and Implementation. This rapid response was kindly reviewed by Prof R Foy.
Primary care research needs integration of disease and illness focused interventions 14 January 2010
Chris C Butler, Professor of primary care medicine Cardiff University, Jochen Cals, Rogier Hopstaken, Kerry Hood, Geert-Jan Dinant Send response to journal: Re: Primary care research needs integration of disease and illness focused interventions	Dear Editor Del Mar inappropriately dichotomises primary care research into that which examines the impact of consultation processes (which he considers somewhat pointless and lacking in evidence for effect) and disease- focussed research (which he promotes as the future for primary care research).(1) Our recent cluster randomised trial of physician communication skills training and CRP point of care testing in the management of lower respiratory tract infection in primary care integrated the evaluation of both enhanced communication process and a disease focussed intervention and found both approaches effective.(2) Interestingly, our process evaluation found that clinicians who were not exposed to the enhanced communication skills intervention prioritised the disease focussed intervention. However, clinicians who had been exposed to both approaches prioritised the communication skills intervention as this was applicable to a range of diseases and management challenges in primary care.(3) Clinicians exposed to both the communication skills training and who also used the point of care CRP test achieved the greatest effect in our trial. For primary care to maximise its impact, we surely need the integration of both disease- and illness-focussed interventions, supported by a robust evidence base. 1. Del Mar C. Is primary care research a lost cause? Bmj. 2009;339:b4810. 2. Cals JW, Butler CC, Hopstaken RM, Hood K, Dinant GJ. Effect of point of care testing for C reactive protein and training in communication skills on antibiotic use in lower respiratory tract infections: cluster randomised trial. Bmj. 2009;338:b1374. 3. Cals JW, Butler CC, Dinant GJ. 'Experience talks': physician prioritisation of contrasting interventions to optimise management of acute cough in general practice. Implement Sci. 2009;4:57. Competing interests: None declared
Possibly - but why? 17 January 2010
Steven Ford, Retired GP Haydon Bridge. NE47 6HJ Send response to journal: Re: Possibly - but why?	Editor Del Mar's editorial and the responses to it are illuminating. Having been around long enough to observe the completion of more than one full rotation of the professional sentiment roundabout I am confident that there will be a resurgence of primary care research, along the lines suggested by other respondents, when the new wave of researchers rediscovers the central role that primary care has in any nations healthcare. It may well be that the days of the lone practitioner scratching at his parchment with a battered quill in the guttering light of a candle at the kitchen table are past but there is a great and intimidating gulf between that and the massive projects that are undertaken at regional, national or international level. The approvals and funding barriers are all but insuperable let alone the difficulties of the work itself. Perhaps we should be looking at locality based research, where practitioners can work on manageable populations and in close association with each other and the support of local academic institutions. This would facilitate a range of projects across the nation and relevance to distinctive groups. Lastly, Del Mar's assertion that processes such as consultation have been discarded is questionable. Further on around the current gyration of professional sentiment we will find that the 'new black' is indeed interpersonal processes. Papers will be written, lectures given and gongs awarded for this spectacular new insight. Reputations and careers will be founded on what was known long before but forgotten momentarily. The same cyclical forgetting and rediscovery is what underlies the recent banking crisis. Politicians and bankers forgot why Glass-Stiegel was passed originally. The cycle time is approximately equal to the active professional lifetime of the participants. Though I am not optimistic about the outcome, I propose that we research methods of permanently engraving on the professional group consciousness the primacy of the consultation in all healthcare interactions. It is what happens between the patient and the healthcare professional that underpins everything. Atomising the patient's presentation, by not viewing the whole physical/psychological/social context - which comes from patient and practitioner being unfamiliar with each other, will also be re-researched one day too. Nothing new will be discovered because people don't change, only fashions wax and wane. Not all history is bunk... Yours sincerely Steven Ford Competing interests: None declared
The value of non-clinical research 18 January 2010
Kath Checkland, GP and Clinical lecturer in general practice Eyam Surgery, S32 5QH and University of Manchester, M13 9PL Send response to journal: Re: The value of non-clinical research	As a long-serving GP and a GP academic, I could not disagree more with Chris Del Mar. Notwithstanding the truth of the claims made by my fellow authors of rapid responses about the lack of funding for primary care research and the extremely constrained environment within which such research takes place, it simply is not good enough to say that non- clinical research is 'not relevant' to GPs. In the past three years I have been engaged in studies of pay for performance (QOF)(1,2), practice-based commissioning (3,4) and PCT commissioning and am about to take part in a study of the impact of new forms of primary care practice in the UK, including those run by private companies. All of these are issues that are of vital importance to GPs, having a fundamental impact on our ability to provide a good service to our patients. What is the use of knowing in detail how best to manage diabetes in primary care, if the organisational and structural constraints imposed by the environment in which we work prevent us from delivering that service? Both clinical AND organisational/service research are required. If my fellow GPs are not interested in the work that I do, or perceive it not to be relevant to them, then that is an indictment both of my failure to communicate properly with them and of journal editors' failure to publish the research in journals that GPs might read. Rather than refocusing primary care research on clinical issues, we should engage more directly with GPs, and present them more effectively with the evidence that we have gathered, so that they can, in turn, engage with their PCTs, LMCs and the Department of Health from a position of power, fully informed as to what the evidence tells us about the impact of current health policy. Kath Checkland 1. Checkland K, Coleman A, Harrison S, Hiroeh U. 'We can't get anything done because...': making sense of barriers to Practice Based Commissioning. Journal of Health Services Research & Policy. 2009;14(1):20-26 2. Checkland K, Harrison S, McDonald R, Grant S, Campbell S, Guthrie B. Biomedicine, holism and general medical practice: responses to the 2004 General Practitioner contract. Sociology of Health & Illness. 2008;30(5):788-803. 3. Checkland K, McDonald R, Harrison S. Ticking boxes and changing the social world: Data collection and the new UK general practice contract Social Policy and Administration. 2007;41(7):693-710. 4. Coleman A, Checkland K, Harrison S, Dowswell G. Practice-based Commissioning: Theory, implementation and outcome. Final report. University of Manchester: National Primary Care Research and Development Centre; 2009. Competing interests: the author is a primary care researcher, engaged in non-clinical research
Is there hope for primary care research in Austria? 20 January 2010
Florian L. Stigler, IFMSA Liaison Officer on Public Health 8042 Graz, Austria, Helmut J. F. Salzer, and Adrian M. Moser Send response to journal: Re: Is there hope for primary care research in Austria?	The question of how to shift the focus of primary care research towards more relevant objectives might be appropriate for Australia, but not for Austria. The big challenge we are facing is the question, how to get research in the field of primary health care even started. Research in primary care as well as research in public health is still a very novel and curious phenomenon in Austria. Research activities are traditionally conducted at a university and hospital setting. This kind of research is generally based on a very high biomedical level and can produce some remarkable achievements, contrary to the neglected primary care research, which is not just caused by the shortage of expertise and relevant training, but also by its insufficient structure and funding. (1) The last decade brought a paradigm change which resulted in the foundation of the first two academic positions for primary health care in Austria. This might not be enough to launch a primary care research which is broad enough to actually gain access to the daily work of general practitioners, but it is a starting point with the potential for a positive and sustainable long-term process. Further steps are needed like the implementation of research training programmes, institutional research of general practice and sufficient funding opportunities. This postulation to strengthen primary care research in Austria is similar to the postulation of Denis Pereira Gray (2) to strengthen research primary care in the United Kingdom. The only difference -- this postulation was published in 1991, almost 20 years ago. Even if the position of the United Kingdom might have been preferable compared with the one of Austria nowadays, it doesn't prevent us from anticipating a positive future -- the developments during the last few years have been promising. (1) Sprenger M. Allgemeinmedizinische Forschung. Graz, 2007. (2) Gray DP. The Future of General Practice. Research in general practice: law of inverse opportunity. BMJ 1991; 302:1380-1382. Competing interests: None declared
From little acorns ... 21 January 2010
John A A Nichols, semi-retired GP 60 Manor Way, Onslow Village, Guildford, Surrey GU2 7RR Send response to journal: Re: From little acorns ...	The recommended pathway for the young GP interested in research is well described by Del Mar (1) and your other correspondents. You become an academic GP, join a university department of primary care and help to organise large trials or to research the dynamics of primary care. Ordinary GPs may be called upon to help recruit for such research but are not expected to have any ideas of their own. However, there is another path. A GP can work with scientists in other academic departments such as nutrition, psychology and genetics. These academics will often welcome a GP who has developed a research question of his own. They will advise whether this is a research question that can be tested and probably help to improve and develop the GP's research idea. This has been my experience and it led me into doing a masters degree in Nutritional Medicine and more research (I have eight publications to my name). Sometimes these small projects will help to develop the GP's perspective but are not suitable for publication. That is not a failure or a waste of time. This was the approach to research of Koch who was a GP when he started small scale research. The idea that this approach is outdated and unproductive is dominating GP academia and government policy and yet out of such small acorns great oaks may sometimes grow. (1) Del Mar C. Is primary care a lost cause. BMJ;340:61-62 Competing interests: None declared
Is primary care research a lost cause? No - it isn’t lost and it was never a ‘cause’. 21 January 2010
FD Richard Hobbs, Head of School Primary Care Clinical Sciences Building, University of Birmingham, B13 9PH Send response to journal: Re: Is primary care research a lost cause? No - it isn’t lost and it was never a ‘cause’.	When Richard Horton posed his provocative editorial title in 2003,(1)he was commenting on a WONCA conference about research in general practice he had attended which he found defensive and excuse focussed on why primary care research was misunderstood and under-valued – too much reflection and too little presented evidence he concluded. This seeming collective reticence to promote our best science seemingly persists in academic primary care, which probably explains Chris Del Mar’s repeating the title in the BMJ,(2) again in response to a meeting on the status of primary care research, this time hosted by the Academy of Medical Sciences. The AMS meeting appears to have been much more positive in terms of the importance of primary care work and (rightly) lauded the much enhanced capacity in the UK in terms of routine clinical databases, research networks, and funding. However, the report is peculiarly lacking in citing recent primary care research that had altered scientific thinking and changed our clinical practice, listing only historical figures or retired research leaders. Ironically, the AMS report also commented upon the importance of primary care research to the ‘second translational (read implementation) gap’ but we appear to have our own translational gap – our big impact science, delivered from within our midst, is either not conspicuous or we fail to acknowledge it. If primary care was a ‘cause’ and hadn’t delivered science that has changed practice for the better, despite significant investment in some health systems, then perhaps Chris could be forgiven for thinking we focused too much on health process research (patient centredness, models of care) and too little on clinical science. However this view is wrong on both counts. Firstly, ours is not a ‘cause’ for this carries connotations of a ‘special case’ which we simply don’t need – investment in primary care research is essential for the particular relevance and significance of the science we can deliver, not because it is from an emerging discipline per se. Secondly, it is wrong on the failings - primary care led, primary care based research has repeatedly changed our thinking in important areas to healthcare, and increasingly during the recent past. There is much new evidence from the UK alone in the management of important diseases, such as that steroids improve prognosis but acyclovir doesn’t in Bell’s Palsy (3; that in the elderly with atrial fibrillation warfarin is as safe as aspirin but three times more effective in )preventing stroke (4); that self-monitoring in those that agree to do it does not improve glycaemic control in patients with diabetes (5), but does improve blood pressure control in hypertensives (6), and in those needing to monitor INR (7). Similarly, in diagnosing major disease, primary care has shown the disutility of traditional signs in diagnosing meningitis (8); validated a plethora of new risk scores or decision rules, including for CVD (9) or heart failure (10); and tested novel diagnostic tools, whether they be symptoms in cancer (11), new assays in left ventricular systolic dysfunction (12), or test and treat strategies (13). These few examples, that have immediately influenced my clinical practice, barely scratch the surface of how the evidence base has changed latterly because of primary care driven science. I could have easily extended to exemplary work in mental health, musculo-skeletal disorders, infection, GI disorders – its a long list of primary care clinical research from the UK alone. However, we are an academic discipline of greater variety in opportunity and ability to deliver internationally, indeed some of Chris Del Mar’s challenges to academic primary care are real and present issues for many countries, but they are avowedly not in the UK, Netherlands, North America, Australia and Scandinavia. These countries, which have all invested in primary care research to some degree, have shown that you can transform the environment that supports the research. The National Institute for Health Research (NIHR) in the UK probably leads the way in scale of investment, with £2.4 million per year in support for GP research networks (infrastructure to support primary and secondary care research), plus £15 million per year in service support funding; £31 million since 2007 on 5 year NIHR Programme Grants in primary care, plus £52 million over the next 10 years on the primary care elements that represent 60% of the CLARCs; £25 million since 2005 on HTA and RfPB awards in primary care; £13 million over 5 years for the National Primary Care R&D Centre; and approaching £5 million per year on the NIHR National School for Primary Care Research (personal communication). This investment has delivered some of the ‘big science’ cited here and should encourage health systems that dismiss the importance of primary care to get real. So why does the impression that we ‘under-perform’ arise, even in the UK? It is probably more an issue of under-acknowledgement or low visibility. Doing more clinical research in primary care carries the obvious consequence that the researchers become more specialised in a particular area of practice and this can unsettle generalists. This is unnecessary concern – good research is difficult, encouraging focus in narrow context and clear boundaries in expertise. This can be achieved without sacrificing the generalists’ overview – indeed it enriches the science of the speciality area by answering questions that might not have otherwise been considered but are critical to the majority of those with illness outside the secondary sector. Specialists increasingly acknowledge and laud such primary care research - so should we in primary care. Some clinical research will articulate a wider role for sub-specialisation in primary care, which is a GP fear, but most will have direct relevance to the practice of generalist GPs caring for the majority of the population. Perhaps another reason for the relatively low visibility of our clinical research is the low impact factor of our few primary care journals. Furthermore, much high quality primary care clinical research appears in specialist journals, where the origins may be less apparent, with the notable exception of the generalist journal flagships like the BMJ and Annals of Internal Medicine. So the evidence suggests that with the right investment primary care science does deliver. Two challenges then remain. The human capacity is still a big issue. Even in the UK, with its strong investment in research training schemes, the overall numbers of primary care researchers has been static for a decade – the massive infrastructure could yet become rudderless. The second challenge is within primary care to value more and talk up our clinical science, alongside valuing our process research. If primary care was a ‘cause’ it would be a cause célèbre. 1 Anonymous, Is primary-care research a lost cause, Lancet 2003: 361; 977. 2. Del Mar C. Is primary care research a lost cause? BMJ 2009; 339: :b4810. http://www.bmj.com/cgi/content/full/339/nov18_2/b4810 3. FM Sullivan, ICR Swam and PT Donnan et al., Early treatment with prednisolone or acyclovir in Bell's palsy, N Engl J Med 357 (2007), pp. 1598–1607 4. Mant J, Hobbs FD, Fletcher K, Roalfe A, Fitzmaurice D, Lip GY, Murray E; BAFTA investigators, Midland Research Practices Network (MidReC). Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial. Lancet 2007; 370 (9586): 493-503. 5. Farmer A, Wade A, Goyder E, Yudkin P, French D, Craven A, et al. Impact of self monitoring of blood glucose in the management of patients with non-insulin treated diabetes: open parallel group randomised trial. BMJ 2007;1136/bmj.39247.447431. 6. McManus RJ, Glasziou P, Hayen A, Mant J, Padfield P, Potter J, Bray EP, Mant D. Blood pressure self monitoring: questions and answers from a national conference. BMJ 2008; 337: 7. Fitzmaurice DA, Murray ET, McCahon D, Holder R, Raftery JP, Hussain S, Sandhar H, Hobbs FDR. Self management of oral anticoagulation: randomised trial. BMJ 2005; 331: 1057 8. Thompson MJ, Ninis N, Perera R, Mayon-White R, Phillips C, Bailey L, Harnden A, Mant D, Levin M. Clinical recognition of meningococcal disease in children and adolescents. Lancet 2006; 367 (9508): 397-403. 9. Hippisley-Cox J, Coupland C, Vinogradova Y, Robson J, Minhas R, Sheikh A, Brindle P. Predicting cardiovascular risk in England and Wales: prospective derivation and validation of QRISK2. BMJ 2008; 336 (7659):1475 -82 10. Mant J, Doust J, Roalfe A, Barton P, Cowie MR, Glasziou P, Mant D, McManus RJ, Holder R, Deeks J, Fletcher K, Qume M, Sohanpal S, Sanders S, Hobbs FDR. Systematic review and individual patient data meta-analysis of diagnosis of heart failure, with modelling of implications of different diagnostic strategies in primary care. Health Technol Assess 2009; 13 (32): 1-207 11. Hamilton W, Peters TJ, Bankhead C, Sharp D. Risk of ovarian cancer in women with symptoms in primary care: population based case-control study. BMJ 2009; 339: 2998 12. Hobbs FDR, Davis RC, Roalfe AK, Hare R, Davies MK. Reliability of N- terminal proBNP assay in diagnosis of left ventricular systolic dysfunction within representative and high risk populations. Heart 2004; 90 (8): 866-70. 13. Delaney BC, Qume M, Moayyedi P, Logan RF, Ford AC, Elliott C, McNulty C, Wilson S, Hobbs FDR. Helicobacter pylori test and treat versus proton pump inhibitor in initial management of dyspepsia in primary care: multicentre randomised controlled trial (MRC-CUBE trial). B Richard Hobbs Head of School, Health and Population Sciences, University of Birmingham Director, NIHR National School for Primary Care Research Competing interests: primary care academic
Preparing to blow our trumpet 1 February 2010
Chris Del Mar, Professor of Primary Care Research Bond University, Gold Coast Qld 4229, Australia Send response to journal: Re: Preparing to blow our trumpet	Primary Care research is obviously a sensitive topic for primary care researchers. Out of 13 rapid responses to the editorial[1], there was an additional discussion among 24 academic general practitioners from the UK, USA, the Netherlands, Canada, Slovenia, Denmark, Cuba, Hong Kong, Australia and New Zealand, on the Primary Care List Server run by BMJ editor Prof Domhnall Macauley. Notably, no non-research clinicians responded, nor anyone from another speciality. The discussion can be classified into three main areas. Research productivity was the most contested. Assertions of increased productively were supported by some (as yet unpublished) data for three countries (USA – a problem because of what is there classified as 'primary care' is different to elsewhere – and UK, and Netherlands). Our global increased productivity is almost certainly patchy at best, especially were it to be compared to many other medical fields of endeavour. Primary care academia is grossly under-represented in trials (and sometimes our input is only 'advisory') on conditions (such as diabetes) usually the responsibility of primary care, but, worse, the trials themselves are sometimes inappropriately not even undertaken in primary care. But it is true that there are many good examples of research published in high impact journals, and well-translated into clinical practice. Few argued that primary care research on clinical matters was enough, and some worried about relevance to most primary care clinicians. But many are proud of their collaborative research across varied disciplines, arguing that the special approach of primary care – which looks at the whole patient, including the healthcare setting, and translational effort – could be easily lost in an overly 'illness' focus. With respect to increased investment in primary care research, this was all agreed on. We urgently need more. There are excellent increases in research personnel in the UK, but even there, we remain way behind our specialist colleagues. Data about research productivity are more difficult to collect (the problem is in the definition of 'primary care'). What to do next? Calls to arms need to avoid being too defensive or voicing special pleading. Our responsibility seems to be to 1) make sure that our efficient productivity is adequately aired; and, 2) show society the benefits that can come out of primary care research, which is of course caught up in the benefits of primary care, itself. Now the next question is: how? And: who? 1. Del Mar C. Is primary care research a lost cause? BMJ 2009;339:b4810 Chris Del Mar cdelmar@bond.edu.au Professor of Primary Care Research Bond University, Australia Competing interests: None declared
Primary Care Research is still alive 15 February 2010
Dr. Jonathan G. Hillman, General Practitioner Practice One,The Medical Centre,Station Avenue,Bridlington,East Yorkshire,YO16 4LZ, Dr. Hamish K. MacNab Send response to journal: Re: Primary Care Research is still alive	IS PRIMARY CARE RESEARCH A LOST CAUSE? Primary Care research is still alive. A Glaucoma Screening programme was instituted by a family doctor in a four partner general practice between 1991 and 1994 in a seaside town in East Yorkshire using basic equipment (Snellen’s chart with and without a pinhole, ophthalmoscopy, intraocular pressure with a Perkins’s tonometer and visual fields using an oculokinetic perimetry chart). It more than doubled the confirmed diagnoses of Primary Open Angle Glaucoma in that stable population, and the results weer reported in the BMJ1. It was hoped that this methodology might be used in the Third World where the disease is more prevalent and batteries may be the only energy supply available. The results of this study aroused the interest of Consultant Ophthamologists and 2 of the family doctors in that practice set up a community eye screening programme for the whole town, specifically for residents aged 65 and over – The Bridlington Eye Assessment Project (BEAP). The screening was carried out by local optometrists, given extra training, and took place in the local hospital. In addition to traditional methods of detection (Slit lamp using a Goldman tonometer , visual fields using a Henson Pro Field Analyser), patients were scanned using a Heidelberg Retinal Tomography, digital retinal photography and ultrasound pachymetry. Optometrists were able to refer directly to consultant ophthalmologists. Over 3500 patients were seen and the results are still being analysed. Initial papers published have already shown that there is an anatomical difference between the female and male eye (larger neuroretinal rims)2 and that central corneal thickness is greater in diabetics3 It has become the largest community-based eye project ever undertaken in the UK. Money was raised not only by drug company involvement but also by many local charities and individual patients. Pipe bands marched down the main street to collect donations! BEAP became a registered charity until after the last patient was seen. The idea and the initial research came wholly out of primary care and it is an example of what further achievements can be made when primary and secondary care co-operate. The project has been overseen and results analysed by Professor S A Vernon at the Queen's Medical Centre, Nottingham Research will continue to be carried out in Primary Care by doctors who retain their curiosity and wish ‘to make a difference’. Dr. J.G.Hillman - general practitioner, The Medical Centre, Bridlington Dr. H.K. MacNab - general practitioner, The Medical Centre,Bridlington 1Hillman, J.G. Abolish Charges for elderly people -Letter BMJ 1994;309:1371-2 (19 November) 2 Steven A. Vernon, Matthew J. Harker, Gerard Ainsworth, Jonathan G. Hillman, Hamish K. MacNab, Harminder S. Dua. Laser Scanning of the Optic Nerve in a Normal Elderly Population : The Bridlington Eye Assessment Project Investigative Ophthamology and Visual Science 2005;46:2823-2828 3 Hawker,M.J., Edmunds M.R., Vernon S.A., Hillman J.G.,MacNab H.K.: Eye (2009):23;56-62 Competing interests: Supported by an unrestricted grant from Pfizer to the Bridlington Eye Assessment Project and by Pharmacia, Yorkshire Wolds and Coast Primary Care Trust, Lord Feoffes of Bridlington, Bridlington Hospital League of Friends, The Hull and East Riding Charitable Trust, The National Eye Research Centre (Yorkshire),The Rotary Club of Bridlington,The Alexander Pigott Wernher Memorial Trust, Bridlington Lions Club, The Inner Wheel Club of Bridlington, Soroptomist International of Bridlington and the Patricia and Donald Shepherd Charitable Trust