Amanda Howe is Professor of Primary Care at the University of East Anglia in Norwich - one of the newer medical schools in the U.K. She is also a GP, Vice Chair of Council at the RCGP, and President-Elect of the World Organization of Family Doctors. She writes here in a personal capacity.
When I starting out as a junior researcher, the big fight was to get primary care research into the universities and the big national and charitable funding streams. The first professor of general practice took up post in 1962, and by 1992 when I became a lecturer, most medical schools had a department of general practice (‘family medicine’ in other countries). But all my seniors still talked as if they were fighting an uphill battle – treated as a minority group, outsiders, less powerful, less well funded, and with a tide to turn against the biomedical ‘lab to bedside’ paradigm.
20+ years on, I am not sure whether that victim voice still needs to be heard. There are some amazing big research units now in U.K. – the School of Primary Care’s member departments all punching above their weight, far more applied funding going into primary care and epidemiological work via the National Institute for Health Research, and medical schools being complemented by nursing and allied health units with excellent track records of their own research.
But some medical schools have put their GP teachers into medical education departments, and made their GP researchers a small part of a ‘big’ health services research unit. And others try to establish a research profile and national/international impact with fewer than 2 full-time academic GPs (my own unit). My ‘Primary Care Group’ also contains brilliant bright colleagues from public health, health economics, sociology and ethics – and the university sees this as a good mixture for applied methods research - but it is not much capacity for clinical work, research, teaching, and academic leadership.
I see tensions from the clinical side – the new genomics needs 'blue-skies' funding, but genomics also now has daily impacts on patients in primary care who come in for genetic testing because family members have been found to have genetic abnormalities that may impact on their own health and that of their children. I see impatience in government – a plea for new types of research focusing on service innovation evaluation rather than randomised controlled trials – “I can’t wait 5 years to know if this works!” And I still see the shadow of Big Pharma, even if the days of overt inducements to GPs for post-marketing use of new drugs has been constrained by the use of local NHS formularies and the joys of generic substitution on computerised prescribing.
So what is the state of primary care research in the U.K.? We have a major academic conference each year run by the Society for academic primary care, which explicitly invites pre-publication work from the relevant university departments and our national academic community (as well as welcoming other work of course!) The Royal College of GPs has a thriving conference for members each year, where the work has got better and better – more scientific, robust, and of real interest to practising GPs. And we have excellent journals in the BMJ, BJGP, and Family Practice, where good work gets published and shared.
But I think there is still no cause for complacency. New deans come in - and suddenly the game is prostate cancer not domestic violence research. Your lovable colleagues in the local NHS need help with evaluations – but this won’t make the international publications strategy. GP training is under-subscribed as young doctors worry about the shape of the new NHS and the future of GPs – so candidates for academic training also are reducing in some parts of the country, and the succession planning with more units but fewer candidates becomes more and more difficult. The pay gap between the academic sector and clinical practice is widening, and the job market in universities is highly unstable compared to the NHS. I spend my time advocating for family medicine, and its value to teaching and research, while feeling that, like Sisyphus, I am pushing a boulder up a hill that I had not expected to be there in my own country – because every gain seems threatened by someone else’s agenda.
So would I do it again?
Yes! Because research adds knowledge and intellectual excitement and a scope to a career, that patients and students, however rewarding, cannot. And because, if we love our discipline, we must want to make the evidence base about it, and coming out of it, better and better. But, as researchers, we need to be smart about power and resources and direction. Competing among ourselves needs to be balanced with bringing on new and smaller units for the greater good. Every medical school needs GP researchers. Let’s make that a global goal.
This blog is part of a series on global primary care research that CMAJBlogs is publishing in the lead-up to the NAPCRG Annual Meeting 2014