WHY ‘AT A TIPPING POINT’?
Academic primary care in the UK has come of age. In terms of research, in 2008, the costly national Research Assessment Exercise (RAE) ranked the top research outputs from the premier UK centres of academic primary care (APC) as mainly ‘world leading’ or ‘world influencing’. For undergraduate teaching, all UK universities are critically dependent on APC staff for community-based teaching, and often communication training, behavioural science teaching, and much else. The role of traditional APC is less involved with postgraduate training in the UK, but a key academic training role has emerged.
So why the question in the title — because tipping implies risk of slipping back as much as forward — if APC teaching is so embedded in medical schools and the research so influential in changing clinical guidelines on better disease management,1,2 and, promoting innovation in self-management,3–5 risk assessment,6,7 and diagnosis? 8–10 The tipping point is now one of capacity, whereas for most of the past 30 years it has been on quality.
INVESTMENT IN ACADEMIC PRIMARY CARE
Within the UK there has been significant investment in APC since the mid-1990s, from the NHS via Service Increment for Teaching (SIFT) and ‘Tasked’ academic post funding, from significant national research funding won by increasingly competitive primary care researchers, and from more academic fellowship funding. This investment has transformed the APC landscape and directly led to the rapid increase in the academic capacity of primary care to not only deliver the substantial amount of community-based teaching now required by the General Medical Council, but also develop large scale, high-quality research programmes. A key change in the past decade has been junior training posts enabling dedicated time and processes for formal research training and certification (such as methodological courses and more formal Masters and Doctoral level training), which should deliver a future APC senior workforce earlier and better equipped for the challenges than their predecessors.11 There has, in parallel, been some investment in established APC posts in many UK universities, especially at the most senior levels.
However, despite this impressive growth, it was from such a negligible base that the current capacity of academic primary care remains perilously low. There has been a large shift in the profile of academic primary care, with many more senior academics, but overall numbers have been relatively static for approaching a decade. Furthermore, the success with competitive research funding and the expansion of community-based teaching means that clinical primary care researchers are over-committed in many universities; not dissimilar to the excessive workload that UK general practice as a whole is currently struggling to bear.
ACADEMIC PRIMARY CARE RESEARCH
When benchmarked, high volume UK primary care researchers compare very well internationally.12 However, the ‘best’ primary care researchers returned in the 2008 RAE numbered 151 full-time equivalents (FTE) returned to the Primary Care Unit of Assessment (UoA) and 97 to 11 other UoAs (including 48 to the health services research, 11 to epidemiology and public health, and 10 to social policy).13 Although this total of 248 FTE senior primary care researchers returned to RAE 2008 may seem impressive, it is small in comparison with other academic disciplines such as the 505 submitted under health services research, 544 under epidemiology and public health, 359 under cardiovascular medicine, and 678 under cancer studies.
It is surprisingly difficult to obtain accurate figures on the overall current capacity in APC, hence the RAE comparisons above. This is partly as a consequence of its multidisciplinarity and, by definition, its generalist focus. There are many people that research primary care — after all, it’s where over 90% of NHS activity occurs — but what distinguishes academic primary care is that it is the main environment for academic GPs; the clinicians who provide care within primary care as well as research it. Their research expertise is as contextually critical to primary care research as an academic oncologist is to cancer research, over and above any methodological expertise. The clinical academic base in primary care is therefore tiny since only a minority of the 248 FTEs returned in RAE 2008 will have been academic GPs; we as a professional group remain in ‘species extinction’ territory.
WHY IS ACADEMIC PRIMARY CARE RESEARCH IMPORTANT?
But does it matter if academic general practice, as separate from academic primary care, withers? Well, the research successes listed in the references were all led by academic GPs (and these are but a small set of exemplars): these types of research questions need such clinical expertise and context experience. We also must not forget the critical role of academic GPs in undergraduate teaching. At a time when the Department of Health talks of mandating that medical schools graduate at least 50% of doctors choosing a career in general practice (around 20% at graduation presently), we need to consider what influences these early career choices. Exposure to charismatic role models and observing academic opportunities during rotations are repeatedly cited as important influences on career choice.14–16 Therefore, in addition to well organised, well-trained GP attachments as an undergraduate, the NHS needs good role models in academic general practice to be visible to medical students. Effective support and mentoring is also required to ensure the best and brightest academic general practice trainees are encouraged to continue in a clinical academic career path and ensure senior posts continue to be filled in the future.11 In addition, and perhaps most crucially, academic general practice needs to develop a better profile among service practitioners: this is a vital symbiotic relationship which may not currently be perceived as important by many GPs. This visibility is hampered by the fact that well under 1% of GPs are academics currently, compared to around 7% of consultants holding academic appointments.17
At a national level, the only structures that prioritise the development of academic general practice-led primary care research are the Society for Academic Primary Care, the NIHR School for Primary Care Research (for its eight current members), and to a limited extent historically the Royal College of General Practitioners. Given the present woeful under-capacity of academic general practice, maintaining this focus is critical.
Notes
Provenance
Commissioned; not externally peer reviewed.
- © British Journal of General Practice 2014
