SCHOOL OF PUBLIC HEALTH & COMMUNITY MEDICINE THE UNIVERSITY OF NEW SOUTH WALES SYDNEY AUSTRALIA

Primary Care Research Capacity Building: reflections on progress

in Australia and Britain

Nicholas Zwar

PHReNet is funded under a grant from the Australian Government Department of Health and Ageing

Primary Health Care Research Network

Why is Research Capacity Why is Research Capacity Building Needed?Building Needed? Lack of research activity in primary care when compared with

other sectors of health system Has implications for development of primary care as a discipline,

quality of care and transfer of research into practice In Britain Culyer Report (1994) pointed out lack of research

activity and recommended that all health sectors should have access to funding to support research

Mant Report (1997) was a strategic review of R&D in primary care.

As a result of Culyer and Mant reports funding came to support development of primary care research networks. Also access for primary care to NHS funds to support research

Establishment of networks in 1990s especially in England and a confederation of networks with > 40 members

What is meant by Research What is meant by Research Capacity Building? Capacity Building?

Development of structures to support expert researchers and provide access to primary care patients with aim of achieving greater success in competitive grant applications and more peer reviewed publications (“top down model”)

OR

Increase the capacity of primary health care practitioners who are primarily clinicians to participate in research relevant to their practice (“bottom up model”)

Research Capacity Building in Research Capacity Building in AustraliaAustralia

Federal Department of Health and Ageing have funded Primary Health Care Research Education and Development Strategy (PHC RED).$50 million over 5 years. Commenced 2001

Strategy has a number of elements:

– Australian Primary Health Care Research Institute. Based at Australian National University. Calling for applications for priority driven research projects.

– Research priority setting process– Research capacity funding for University Departments of General

Practice and Rural Health– Primary Health Care research program grants through NHMRC– NHMRC fellowship and scholarships program.

Research Capacity Funding Research Capacity Funding though Universities though Universities

Long list of objectives including:– Developing partnerships with primary care

organisations such as Divisions of General Practice– Increasing critical analysis skills of practitioners in

the field– Providing advice and support to applicants for PHC

RED training awards– Providing opportunities for practitioners to become

involved in research for example through research networks and participation in national initiatives

Research Capacity Funding at Research Capacity Funding at UNSW UNSW

Primary Health Care Research Network (PHReNet)

Network of general practices, divisions of general practice and other primary care providers interested in research and evaluation in general practice and primary health care.

PHReNet has nodes in South West Sydney, South East Sydney, Illawarra and Shoalhaven, Greater Murray regions (Wagga Wagga)

Research training activitiesResearch training activities

Introductory research training workshops

Formal and informal mentoring and research and evaluation support to Divisions, community health and individuals

Preparation of research materials

Research activitiesResearch activitiesCollaborate with local organizations to

conduct research and evaluation

Support organizations and practitioners interested in conducting research

A number of research projects are underway including:– Group projects – Asthma 3+, CVD risk assessment

– Individual projects

Future directions? Future directions?

PHC RED strategy due for review in 2005

Assuming that capacity building program is refunded what should be future directions for research networks?

Special studies project Special studies project Primary Care Research Networks: what can we learn

about the experience in Britain that could inform future directions in Australia?

Being done with input and support from Scottish School of Primary Care as well as University of Edinburgh

Qualitative project involving semi structured interviews with key informants from research networks in Scotland and selected centres in England and Wales. Field notes from interviews analysed for key themes

Semi-structured interviews Semi-structured interviews Key informants:

– Edinburgh – Dr Sally Wyke, Dr Lucy McLoughan (SSPC), Prof David Weller, Dr Brian McInstry (East Lothian), Vicki Hammersley (formerly with Trent Focus). Dr Alison Spaul (CSO)

– Dundee - Prof Frank Sullivan, Marie Pitkethly, Dr Peter Donnan, Dr Jan Clarkson (EastRen and Tayside)

– Cardiff – Professor Chris Butler (Capricorn)– Bristol – Prof Chris Salisbury, Dr Terry Kemple (Bristol & District PHC

R&D Consortium)– Birmingham – Prof Richard Hobbs, Dr Richard McManus (MidReC), Dr

Sue Wilson (Federation of Primary Care Research Networks)– Leeds – Dr Lisa Cotterill– Oxford – Prof David Mant– Cambridge – Prof Ann-Louise Kinmouth– Manchester – Prof Bonnie Sibbald– Aberdeen – Prof Chritine Bond, Prof Lewis Ritchie, Prof Phil Hannaford,

Dr Blair Smith

Interview Topics Interview Topics Role in relation to networks and research capacity building Views on aims and objectives of research networks Activities of network the person is involved with (where

applicable)– Views on role of networks as places for hosting research– Views on role of networks for developing research skills

of members – Views on role of networks in mentoring novice

researchers Outputs and sustainability Quality and evaluation Future directions

Role in relation to networks Role in relation to networks

Roles of people interviewed have been

– Co-ordinations and directors of networks or regional hubs

– Academics working with networks– Officials in funding agency

Overall aims of networksOverall aims of networks

Spectrum of views extending from:– Network’s role is to support production of

quality research and to act as portal for patients in primary care to be recruited for research projects

– Network’s role is to build research capacity by exposure of members to research, generate research interest and ideas from within the network and provide research training

Activities of networks Activities of networks Networks as places to host research

– View from funder and some academics that this is the major role. Research is a professional activity and best idea and projects come from professional researchers

– Focus should be on epidemiological research, clinical trials and selected health services research that require a consortia of practices

– Concern expressed by some network coordinators and directors that GPs will be treated as “research substrate”

– Relevance of projects and the interaction between researchers and clinicians essential for maintaining interest and engagement

Activities of networks - 2Activities of networks - 2 Networks as places to develop research skills of

members – View that this is a secondary activity and can only be

sustained if networks are achieving success in externally funded research. “This role is valuable but cannot justify funding for the long-term” GP academic.

– View that this is a key role of networks “Networks have a role in nurturing research. Traditionally there has been a lack of research in primary care especially compared with hospital based research.” Network co-ordinator

Activities of networks - 3Activities of networks - 3 Mentoring role of networks – developing member’s research

ideas.– General view that this was time consuming and hard work.

Outputs are limited in terms of success in competitive grants and peer reviewed publications

– Value seen in interaction with primary care clinicians “We must be responsive and have an open door policy. But that does not (necessarily) mean that we will help them do it” GP academic

– View that research ideas come from professionals not novices– View that all researchers need to start somewhere but that most

will develop an interest early in their career and need to be supported to get formal research training

– Need for a grants program that is prepared to offer funding to junior researchers.

OutputsOutputs Spectrum of views on outputs

– Outputs need to be research grants and peer reviewed publications

– Other outputs were seen as important by some interviewees – a learning culture, increased research literacy, critical appraisal skills, burn out prevention strategy. “A learning culture is an important output, not just papers. This means asking questions, awareness of events outside the consulting room, diffusion of change, being prepared to change practice” GP leader of research network.

SustainabilitySustainability Sustainability was considered in terms of resources and interest

and engagement of members– The key to resource sustainability was seen as showing outputs in

terms of external grants and publications. – Payment to practices was seen as essential for sustaining

involvement by nearly all those interviewed. Preference for paying for work done not just for being a member. One GP academic disagreed arguing research networks create an expectation of payment when there is not enough money in primary care research and what there is needs to be kept within academic institutions

– Sustaining interest and engagement involves taking on projects of interest which often means clinical research projects, providing feedback such as early results.

– To some interviewees sustaining interest also requires having the resource to provide training and mentoring.

Quality and evaluationQuality and evaluation Quality

– Professional academic input needed in developing ideas into research questions and then into protocols that can be funded and conducted.

– Ideas of members will infrequently translate into original research questions. Do not feel obliged to put work into ideas that are of dubious value “Be strict about what to support. Be wary of people who do not want to listen or want to prove prejudices” Director of research network

Evaluation– Outputs of grants and publications will inevitably be the major

measures of achievement– Other process measures should be kept eg numbers o people

involved, numbers receiving training, measures of evidence culture in practice such as use of guidelines.

Future directions - 1Future directions - 1 If starting again what would you have done

differently– Separate functions of skills development and

hosting research. Both important but different roles

– Provide more methodological support and training

– Do more pre-pilot work and protocol development

Future directions - 2Future directions - 2

Future of networks in Britain– Changing role and nature of networks– Primary care research networks becoming linked to other

structures– More emphasis on role in hosting research including large clinical

trials and epidemiological research– Disease specific networks with national coordination centres– Role of UK Clinical Research Collaboration. MRC GPRF,

Universities and Department of Health– Networks should be linked to academic centres and there should

be fewer in number.

Universities MRCDOH UKCRC

AcademicUnits

PCRNCoordinating Centres

Local Management

GPRFCoordinating

Centre

National Management

UK CRNCoordinating

Centre

Cancer

Mental Health

Diabetes

Meds for Children

Stroke

Alzheimer’s

Mental Health

N G T

E O E

T P N

W IE

K C R

S I

C

Secondary Care

Primary Care

National T

opic specific coordinating centres

Fig1: Interaction between UKCRN, GPFR & Academic Units prior to establishing UKPCRN

Implications for future directions Implications for future directions in Australiain Australia

National level– Begin dialogue on role of research within a health

system with aim of getting gaining acceptance that research activity by practitioners is a core activity and needs to be funded.

– Push for acknowledgement and funding of research skills development as a worthy activity without the expectation of competitive grants and peer reviewed publications as an outcome

– Push for expansions of junior researcher support programs such a fellowships, scholarships and bursaries

– Push for a grant program that will fund investigator led research from relatively junior researchers

Implications for Research Implications for Research Networks - 1Networks - 1

Develop role of networks as a means of interacting about research ideas and projects to be developed or being developed by professional researchers – i.e. a discourse about ideas, their relevance and salience. Also about the practicality of projects.

Use networks to help develop or host research projects developed and being conducted by academics. Need to consider the issues of input into ideas and projects, communication/feedback and payment

Consider development of networks or linkages of existing networks to create structures that could support larger scale studies

Consider topic based networks linked to secondary care

Implications for Research Implications for Research Networks -2 Networks -2

Research support/mentoring for network members wanting to develop ideas– Need to have a more explicit and critical process of

assessing which projects can be provided support

– restrict support to proposed projects that are within the field of academics associated with the network and refer others elsewhere

– require that beyond a certain level of support people need to be prepared to do a course in research methods

Primary Health Care Research Network