Linking education, research, and service in general practice

British Medical Journal, Jan 31, 1998 by Paul Wallace, Stewart Drage, Neil Jackson

Over the past decade general practice has undergone major changes that have placed it theoretically in the forefront of a "primary care led NHS" and increasingly in the mainstream for providing undergraduate medical education.[1 2] Thus general practitioners have gained an increasing role in caring for patients who would formerly have been in hospital or other care facilities. Many general practitioners have also been engaged in purchasing care for their patients through fundholding schemes, and it is dear from the white paper that general practitioners will continue to have a major role in commissioning.[3] These and other changes in healthcare provision have led to a consensus that a much greater proportion of both undergraduate an postgraduate medical education should take place in general practice.[4] In addition, a clear commitment now exists for general practice and other primary care providers to begin to take a stronger role in research (see also editorial by Olesen on p 324).[5]

General practice might have been expected to be flourishing as a result of its expanding role, but this does not seem to be the case. Morale is claimed to be at an all time low, and recruitment to general practice is continuing to decline while increasing numbers of general practitioners are taking early retirement.[6 7] These problems are dearly worrying not only to the profession but also to those responsible for delivering a health service. In the face of these difficulties a consensus is beginning to emerge that giving general practitioners protected time for education, training, and research alongside their clinical commitments. may prove an important factor in countering these worrying trends.[8]

Recent changes in funding have begun to make it possible for general practitioners to emulate their hospital colleagues by benefiting from protected time for education and research. The service increment for teaching, which is designed to support undergraduate medical education, and the NHS research and development levy--both previously confined to hospital and community trusts--are now available to general practice. Thus general practitioners who undertake undergraduate teaching and research for the NHS can use this support to find additional clinical provision within their practices so that they can free their own time for academic activity. This situation has effectively been piloted in some parts of the capital through the London Initiative Zone educational incentives programme, and the initial findings are encouraging.[9] Over 70% of eligible general practitioners (a proportion that far exceeded expectations) have taken part in funded educational activities in London, many of which involved undergraduate teaching and academic fellowships.

With the experience of the London programme and national trends both to relocate teaching into general practice and to stimulate primary care research, a real potential now exists to develop general practice as a learning and research environment Medical schools are increasingly keen to establish university linked practices where substantial amounts of undergraduate teaching can be undertaken by practitioners with protected teaching time. Such practices could also naturally provide the focus for primary care research and a range of postgraduate training activities.

But several questions still need to be addressed. Can adequate numbers of practices be identified and developed to satisfactory levels of quality in service provision, teaching, and research? Will university linked practices be associated with better standards of patient care as well as greater general practitioner satisfaction? Can money and staff be found to support the development of such practices? Can the necessary contractual arrangements be made to enable practices to reconfigure their staffing and premises to accommodate this range of academic activity without impairing their ability to provide excellent patient services.

These and other questions will be addressed next month at a symposium organised by the Association of University Departments of General Practice, Thames Postgraduate Medical and Dental Education, and the Middlesex and London local medical committees. Those responsible for developing the links between education, research, and development in general practice need heed the answers as they emerge.

Paul Wallace Professor of primary health care

Royal Free and University College London Schools of Medicine, London NW3 2PF

Stewart Drage Medical secretary

Middlesex and London Local Medical Committees, London WC1H 9HX

Neil Jackson Dean of postgraduate general Practice education, North Thames (east) region

Thames Postgraduate Medical and Dental Education, London WC IN 3EJ

[1] Department of Health. Primary care delivering the future. London: HMSO, 1996.

[2] General Medical Council. Tomorrow's doctors. London: GMC, 1993.

[3] Secretary of State for Health. The new NHS. London: Stationery Office, 1997.

[4] General Medical Council. The new doctor. London: GMC, 1997.