Networks for research in primary health care

Rambam: Israeli Family Practice Research Network

Rambam is a national family practice research network with members throughout Israel, including members of the five university departments of family medicine, general practitioners, and health policy researchers. The network office is located at Ben-Gurion University of the Negev in Beer Sheva. It started in 1992 with funding from several sources for network infrastructure and for pilot studies.

Family medicine became established in Israel in the 1960s but research capability has lagged behind. A research network briefly existed in the mid-1980s, as part of an international effort to collect primary care data on otitis media, but it requested only data collection from its members and quickly disintegrated after the initial project ended. In 1991, representatives of the university departments of family medicine and the newly formed Israeli National Health Policy Center of the Negev held discussions on how to advance primary care research. A network was thought to be the optimal mechanism.

The network was established with the following aims: to encourage, educate, and nurture family practice researchers and to increase the number, quality, and complexity of research projects in primary care and health policy. It worked to raise the level of awareness and priority of research in family medicine and to create a voice for research in family practice.

Until 1998, members met at periodic meetings and biannual conferences, during which all participants attended research skill workshops as well as meetings around individual research projects. These meetings provided "real-life" experience with research from beginning to end. The network has had 10 research articles published in peer reviewed journals (and more are in preparation) and made 23 presentations at international conferences and over 20 presentations at national conferences. It has groomed about 10 new independent family practice research investigators and inspired and encouraged the development of an ambulatory paediatric network.

The development and success of the network has been enabled by:

· The growing recognition of the importance of primary care research in Israel and internationally

· Advanced training of family practitioners in research skills, both locally and in Europe and the United States

· The emphasis on peer leadership and involvement at all levels

· The dedication of a few individuals

· Steady and consistent infrastructure support from the Israeli Health Policy Center

In 1998 the network began to disintegrate, partly as a result of its success. As more independent researchers were trained and able to do research the need for a national network diminished. In 1999, the network began moving to more regional, rather than national, coordination and conferences.

College National des Generalistes Enseignants (National College of Teachers in General Practice)

The National College of Teachers in General Practice is a federation of regional colleges undertaking the training of general practitioners, linked to the medical universities. It was founded in 1983 and includes 37 colleges from across France. The research network was started in 1989 with infrastructure support from the resources of national college, but each research project seeks its own funding.

In France, general practice became accepted as a medical speciality and an academic discipline in 1992. It was recognised that in order to teach general practice, research was needed. General practitioners and both public and private organisations that fund research were aware that research from the other specialities is often inappropriate to general practice. Acceptance of this has enabled the development of research specifically related to general practice. This was recently formalised when INSERM, the French national institute for research in medicine, created a structure specially dedicated to research in general practice.

The aims of the research network are to carry out and promote research in general practice in France, to participate in European projects, to train general practitioners in research, and to help them to present their studies in France and abroad. As part of the academic structure, the network also aims to ensure future general practitioners are taught about research during their postgraduate training.

To achieve these aims, the network is seeking to develop a structure and capacity for research in every medical faculty through the regional colleges. It works to raise the profile and priority for research in general practice throughout the French medical world. In its "teaching the teachers" courses, there are sessions held twice a year to train general practitioners in research development and participation. The network encourages the presentation of French general practice research at national and European research meetings and through publication, and provides training in presentation skills and writing for research.

The network has carried out studies on alcohol problems, chronic pain, and influenza. It has participated in European studies on the prevention of cancer in women, on general practice interventions related to alcohol and tobacco use, and on home visits. The research feeds into medical teaching and has informed the writing of the French textbook of general practice. However, there are still only a small number of general practitioners with experience of research as the introduction of research training is so new, and there is a shortage of academic support and research funding for those interested in pursuing research.

West London Research Network

The West London Research Network operates in a geographical area of west London containing 2 million people and served by 500 general practices in four health authorities. Since it started in 1997, one fifth of all practices have become members of the network and most have already collaborated in research projects. About 70 researchers in different disciplines now operate 30 research projects that involve a range of approaches including literature reviews, action research, qualitative research, and randomised controlled trials.

Methods that facilitate dialogue and encourage consensus between members are used to allow research priorities to be agreed. For each year, one priority research theme is identified for each of the four health authorities involved. Participants at the annual conference use nominal grouping methods and small group discussion to reach consensus about these. After the conference multidisciplinary practitioners, both experienced and novice, who wish to develop a collaborative research project, participate in a year of connected educational events (a theme group). Here they reflect on their own and each others’ contexts and together develop a research project relevant to the research theme. They learn theory—for example, literature searching, research methods, writing skills—when the stage of their project requires these. Experts become attached to groups when needed and constructive criticism is encouraged in peer support groups.

This sequence of events allows research projects to be directed by the interests of the participants but also broadly supported by the network as a whole. Consensus and creative diversity coexist. For example, one health authority theme for the year was mental health. Members of the group to move the theme forward included health visitors, who were particularly interested in the health of children. After looking at various options the group decided to research the effects on children of depression in mothers.

In the first 30 months over 300 individuals have been involved in research generating activity of various types. 55 individuals have taken part in three cycles of the theme group; 36% of these have been general practitioners, 18% have been community nurses, and 49% have been "key allies"—academics and a wide variety of interested people from health authorities, community groups, hospitals, and related development projects. There are presently 70 active researchers involved in 29 different research projects.

The cycle is the backbone of the network operation. Other mechanisms exist to help more experienced researchers undertake projects that they have devised alone and also to gain collaborators for externally funded research and development projects. The network is currently working to develop alliances with a variety of agencies that support research, development, quality, and learning throughout local primary care. This may make it easier to move the culture of primary care towards reflective inquiring practice.