Research in general practice

British Medical Journal, Jan 31, 1998 by Frede Olesen

In the borderland between health, illness, and disease, general practice assumes a principal role in securing the smooth working of a complex health care system and satisfying the needs of patients, purchasers, and providers alike.[1 2] Hence, research needs to draw on theories from humanities (psychology, philosophy, ethics), social sciences (sociology, anthropology), and the organisational sciences as well as medical science. Two recent British reports on research and development in general practice both recognise this need.[3 4] A report from the Medical Research Council addresses the important research questions in general practice and covers the developments in infrastructure necessary to support the research A report from an NHS working group complements this by suggesting strategic principles and specific objectives.

Both reports give comprehensive and well argued proposals for future research. These include biomedical research, such as clinical trials, morbidity surveys, and cohort studies, but both also state that biomedical research is not enough, recognising that multidisciplinary research must use qualitative and quantitative methods and designs and be organised to reap maximum benefit from this dual approach.[5]

This wide range of research skills will be necessary to address the variety of research problems that both reports identify. Both reports want to see more research, and not only within prevention, health promotion, and clinical research on acute and chronic conditions in primary care. They also demand more research on help seeking behaviour, doctor-patient interaction, and clinical decision making[5 6]; organisational research on coordination of care, shared care, and the process of quality development; implementation of new skills and technology; cost effective audit; and continuing medical education.[7-9] Part of this research should be aimed at developing methodologically sound outcome measures covering all aspects of care.[10]

The organisational implications of these proposals are both strategic and specific. The intensification of research in primary care demands well planned, parallel developments in universities, funding bodies, and the NHS, including adequate staffing of academic primary care departments. More specifically, it demands the support of clinicians and purchasers, education of researchers, appropriate career opportunities, and sufficient funding sources. The time has come to realise that a situation where most doctors in small academic departments spend half their time on clinical work, sharing the rest between teaching, administration, and research, will foster nothing but minimal, research, poor university status, and little political clout. University departments of general practice must be sufficiently staffed with near full time senior researchers and they need to be bigger, to ensure a critical mass. New strategic programmes, such as the National Primary Care Research and Development Centre in Manchester, have realised this.

Both reports emphasise the need for basic and advanced methodological training of researchers. Efforts to do this may, however, be thwarted by the lack of an explicit, comprehensive theory of what constitutes "family medicine." Indirectly, the reports recognise this problem by drawing the research agenda very broadly. Researchers should be trained in key theoretical and practical concepts--for example, communication theories, health beliefs, coping, stress, somatisation, empowerment, social networks, health technology assessment, quality development, health economy, and priority setting[2 6 9 12]--without getting embroiled in definitions of core general practice. We need researchers to devote time to developing the core content of general practice, not defining it.

The evaluative culture in the NHS and primary care also needs to be buttressed. This will challenge political decision makers and systems of vocational and continuing education--which often seem detached from research traditions.[11] It will be interesting to see how stakeholders in the NHS and the Royal College of General Practitioners and continuing medical education tutors will cope with this demand.

The commitment of, and funding by, the government, the NHS, the royal college, and universities will be crucial to implementing these ambitious ideas for developing research and development in primary care. Nationally, the challenge lies in creating a framework for a broad research agenda, and individual institutions face the challenge of selecting particular areas to obtain the quality that springs from focused commitment Hopefully, these two reports will influence research and development in family medicine outside Britain as well as within. Successful implementation of these plans in the British NHS will offer a welcome opportunity for continental Europe to embark on a competitive match in innovation--a match we will enjoy not least for the partnership it offers.

Frede Olesen Professor