Primary Care Research Capacity Building: reflections on progress in Australia and Britain

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• 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

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Why is Research Capacity 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 RD
  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 gt 40
  members

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What is meant by Research 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)

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Research Capacity Building in Australia

• 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.

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Research Capacity Funding 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

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Research Capacity Funding at 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)

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Research 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

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Research activities

• Collaborate 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

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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?

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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

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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 RD 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

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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

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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

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Overall aims of networks

• Spectrum of views extending from
• Networks role is to support production of
  quality research and to act as portal for
  patients in primary care to be recruited for
  research projects
• Networks 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

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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

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Activities 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

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Activities of networks - 3

• Mentoring role of networks developing members
  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.

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Outputs

• 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.

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Sustainability

• 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.

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Quality 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.

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Future 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

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Future 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.

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Universities
MRC
DOH
UKCRC
Academic Units
PCRN Coordinating Centres
GPRF Coordinating Centre National Management
UK CRN Coordinating Centre
Local
Management
Primary Care


Secondary Care
Cancer
N
G
T
National Topic specific coordinating centres
Mental Health
E
O
E
Diabetes
T
P
N
Meds for Children
W
I
E
Stroke
K
C
R
Alzheimers
S

I
Mental Health


C
Fig1 Interaction between UKCRN, GPFR Academic
Units prior to establishing UKPCRN
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Implications for future directions in 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

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Implications for Research Networks - 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

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Implications for Research 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

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