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Domhnall McAuley: A defining moment in UK primary care research

18 Dec, 08 | by BMJ

Domhnall Macauley Ever wondered what it is like to be present at an event that changes history? The Academy of Medical Sciences organised a meeting entitled “Research in General practice; bringing innovation into patient care” on Dec 12, a meeting that will, I suspect, be looked upon in future as a defining moment in UK primary care research. Orchestrated by Yvonne Carter (University of Warwick), who sadly was unable to be present, it brought invited representatives of the major funding bodies and research institutions and like many events, the unstructured and informal components were as important as the official programme.

Roger Jones (Kings College London) gave an elegant summary of the achievements of UK primary care research, using an original model of the doctor patient consultation. This laid, both literally and metaphorically, the foundations for subsequent discussion. Sally Davies (director of R&D, Dept of Health) outlined the funding opportunities – one can only congratulate her on how she has created such a rich and diverse funding stream open to innovative and exciting community based research. She made the interesting observation that in a market oriented research environment, she was funding market failures. Frede Olesen (Aarhus University, Denmark), gave an international perspective, which for me, carried the most important message. He was very polite and gentle in his approach, and praised past achievements, but behind this charming presentation was a criticism and a warning about the future position of UK primary care research. The audience dialogue and panel discussion seemed, initially, to miss this message, focusing on UK domestic housekeeping issues. But, given the opportunity to explore this a little further, his message was clear and, for me, raised three very difficult questions: He implied we should reflect on why health care appears better in France, Switzerland and Germany. He wondered aloud about why primary and secondary care appear to be going in opposite directions and the hazards of this enmity. And, striking to the heart of what Primary Care holds as a core value, he asked if continuity of care has side effects- questioning if familiarity impairs diagnosis, and a close relationship with patients encourages us to normalise symptoms rather than investigate.

Of the four workshops in the afternoon, I attended the session addressing the second translational gap, lead by Martin Roland (National Primary Care R&D centre) and Ann-Louse Kinmonth (University of Cambridge). This is exactly where the BMJ stands; trying to publish research that bridges this gap – bringing scientific advances into clinical practice. It was attended by representatives of the major funding agencies, who are clearly interested in supporting this work. They will fund it and we will publish it- the challenge is in finding the researchers to make the link.

Sir John Bell, President of the Academy of Medical Sciences, chaired the final discussion which was, perhaps, the highlight of the meeting. He has a clear vision of the challenges facing primary care, and values the importance of the patient journey from the first consultation. During the vibrant discussion, various speakers highlighted problems with recruitment, retention and resources. This highlighted the challenge for large university departments to create dedicated and focused research units at one level yet still encourage and integrate clinician scientists who can generate new ideas based on patient experience. It was in informal discussion afterwards that Sir John made the most telling comments. He felt that Primary Care should be more proactive in carving out its position in the research funding marketplace. And, that when primary care academics are appraising their colleagues’ research ideas they are should be more generous in their praise than critical in their assessment.

So, what were the main messages? Our international colleagues, who recognise that UK general practice research has always been the world leader, sense that this position is no longer secure and we need to think beyond our current vision. Our UK research colleagues, through the Academy of Medical Sciences, have given us encouragement and direction, and the NHS R&D will provide the resources. The days of primary care research as a cottage industry are gone but, while we now have structure and funding, there is still a need for new blood and new ideas.

Research in General Practice: bringing innovation into patient care. A meeting of the Academy of Medical Sciences on Friday 12 December, London

Domhnall McAuley is primary care editor, BMJ

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  • http://www.semeioticabiofisica.it Sergio Stagnaro MD

    What a pithy! I did not know such as meeting. In fact, here in Italy a physician have discovered – starting from November 2007 – Quantum Biophysical Semeiotics, performing an interesting clinical experiment, Lory’s Experiment, now in Nature.com (http://blogs.nature.com/news/thegreatbeyond/2008/06/weekly_round_up_39.html#comments), utilizing a simple stethoscope.
    To much information kills information!

  • http://www.wishfulthinkinginmedicaleducation.com Anne Marie Cunningham

    Thank you very much for your account. I am sure this is what blogs are best at!

    I think it would be useful to hear more about your thoughts on Frede Olesen’s comments. I feel that at time passes we have less to worry about any ill effects of continuity. The multiple options that patients have for accessing primary care now, and the complicated journeys they can have within it, mean they are much more likely to have the opinion of more than one health professional during the course of an ilness.

    Thanks again.

  • Parker Magin

    It is unquestionably so that the days of primary care research as a cottage industry are gone.
    But we should consider the discussion point that Domhnall reports of the tension inherent in departments building dedicated and focused research units still needing to encourage and integrate clinician scientists who can generate new ideas based on patient experience. Not to do so runs the risk of promoting adequately-powered, methodologically impeccable, studies that provide answers to questions that don’t particularly concern clinicians or their patients.
    Also, it can be argued that engaging clinicians in research and increasing their research literacy has flow-on effects in terms of appreciating evidence and appropriately practicing evidence-based medicine (in them and their clinical colleagues).
    Our anecdotal experience in Newcastle, Australia, of having (research-naive) GP and primary care clinicians engage with, and be upskilled in, research is that they may be more comfortable in bringing their practice-derived research questions into a cottage-style environment rather than the “industrial” production of research demanded by dedicated and focussed research units.

  • George Freeman

    Dear Domhnall,
    So sorry not to have responded earlier!
    Naturally Frede’s mischievous comments on the ‘totemic’ status of relationship continuity caught my eye.
    My answer to Frede is ‘yes of course!’ to each of the three questions posed (side effects? imparing diagnosis? normalising symptoms?).
    It has become apparent to most of us studying continuity over the years that always seeing the same doctor is not an unmitigated good. Asssociation with patient and staff satisfaction is usually strong. Association with favourable clinical outcomes is much less consistent. Frede’s questions suggest some of the directions we should look to explain this apparent paradox.
    What we need to know now is more about how the dr-patient relationship affects care received and future behaviour; and how and when it is most important to encourage a good and consistent relationship.
    Anne Marie Cunningham makes a good point that actually such relationship continuity is vanishing fast. I have never advocated forcing continuity on patients – but the current evidence is that patients want more than they can get these days.
    But we need to know when we should make efforts to allow or enable relationship continuity to happen.

  • http://www.adelaide.edu.au/directory/oliver.frank Oliver Frank

    My unpublished analyses of which GPs in a practice each patient sees have found a notably consistent pattern that each patient sees the same GP for about 4 out of 5 visits, with the remaining 20% of visits distributed between one or more of the other GPs in the practice, presumably when the patient’s usual GP is unavailable when the patient needs or wants to to be seen.

    No GP is available 100% of the time. This means that most patients are likely to receive the benefit of having at least one other GP consider their situation, presenting at least the possibility that a problem missed by the usual GP as a result of familiarity may be noticed. With 85% of the Australian public having an average of six consultations per year, the mythical average patient is likely to see a GP other than his or her usual one at least once annually.

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