Moving the research agenda to where it mattersBMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7204.206 (Published 24 July 1999) Cite this as: BMJ 1999;319:206
It's time to rattle the academic cage in primary care
- David Kernick, General practitioner,
- Jonathan Stead, General practitioner,
- Michael Dixon, General practitioner
- St Thomas Health Centre, Exeter EX4 1HJ
- Wyndham House, Silverton, Devon EX5 4HZ
- College Surgery, Cullompton, Devon EX15 1TJ
Ninety per cent of healthcare contacts take place in primary care, and the importance of undertaking research in this setting is well recognised.1 2 Primary care research is not new but has evolved around university departments of general practice. Here, academics work within a fixed hierarchical structure—which may inhibit flexibility and innovation. Funding spirals, assessment exercises, and internal politics often divorce research practitioners from their service commitments and there remains a dissonance between the view of the world of those who guide decision making in health care and those who commission and provide it.
General practitioners are reluctant to follow evidence based guidelines3; health economists continue to develop technical solutions that are inaccessible and unacceptable to end users4; university academics remain trapped in a paradigm of hypothesis generation, experimental design, and interpretation of data as they seek to make reality fit their disciplinary matrices. Although research general practices and research practice networks have evolved to foster research that is oriented towards service,5 they remain within academic frameworks. The research industry continues to provide answers to questions that are often irrelevant to every day practice and to produce solutions that general practitioners seem reluctant to adopt. Why is this?
Healthcare issues are mainly complex, multidimensional, and grounded in individual experience.6 Research in the discipline of complexity theory is beginning to offer alternative perspectives on how the predominately non-linear systems in which health care is delivered work.7 8 The behaviour of general practitioners reflects this environment, showing pragmatic and adaptive characteristics as they accommodate and implement small changes with the aim of evolving and improving on current treatment.9 In an area characterised by the often conflicting dictates of evidence, economics, equity, and empowerment, the focus needs to be changed from academic research based paradigms to pragmatic health management approaches which reflect the context in which interventions are delivered.
This approach requires investigative frameworks where the practical realities of patient management are not seen as confounding variables in an otherwise perfect study design. The need is to align the three key elements of research, commissioning of care, and service delivery around the day to day health and social problems of patients. The formation of primary care groups in England (and some of their equivalents elsewhere in the United Kingdom) provides such an opportunity.
Primary care groups are developing as the major force in the planning of English health services and could provide the ideal vehicle for commissioning, producing, and using research that is relevant and acceptable to users. Within a collective and accountable framework of governance, primary care professionals and patients could make mature decisions about the sort of evidence they require, which could then be commissioned or undertaken locally. This would be bottom up research relevant to the context rather than top down, well intentioned, research that may not change anything. For example, quality improvement projects and integrated care projects will be soon under way in primary care groups as part of the new health improvement programmes. Where several primary care groups are linked to a single secondary care provider this would provide an opportunity to undertake comparative studies to evaluate the effectiveness of these interventions.
National structures would need to be developed to support and facilitate this new approach, in which commissioner, producer, and user are all one—an approach that would reflect a shift towards a wider methodological base and an acceptance of the social construction of so many events Increasingly, patients would be partners in every part of the research process, emphasising a move towards user led and controlled research.10
The closer that decision makers are to the production of purchasing appraisals, the greater is the likelihood that they will be influenced by their findings.11 The evolving primary care groups would provide an ideal focus for health service research, offering a more realistic perspective for the NHS research agenda than remote regional funding centres Research practices and networks are in a unique position to align their research perspectives to service provision and the commissioning of care and could work closely with their primary care group boards and clinical governance leads to strengthen a service based research culture. This integration could be promoted through the research practice accreditation scheme currently being developed by the Royal College of General Practitioners.
Funtowicz has described how, in some complex systems where one viewpoint predominates, there can be a vulnerability to sudden collapse or oscillation at lower levels as the system “shakes itself to bits.”12 It could be time for the providers of primary care to start rattling the academic cage and seize this unique opportunity.
JS has received funding from North and East Devon Health Authority to study the links between research practice and primary care groups; MDD is chair of the NHS Primary Group Alliance; DK receives funds from the NHS R&D executive for general practice research practice.