Universities needs help, if it is not to remain a minority activity, providing challenging and satisfying careers for individuals, but isolated in academic centres and lacking the critical mass to influence and work more effectively with service colleagues.
Although much research in general practice and primary care is carried out by colleagues in other disciplines, this is not a satisfactory alternative to a substantial and vibrant research presence within general practice itself, responding to its own problems and producing its own evidence to inform policy and practice.
Evidence to inform decisions
In the absence of evidence, much decision-making in primary care (including policy making) is based largely on experience, pragmatism and good conscience. This approach, which pre-dates scientific medicine, has served the NHS well, in terms of patient satisfaction with the GP service and the relative efficiency of the NHS compared with health systems without a general practitioner system, but it is insufficient.
There is a plethora of evidence-based guidelines, of course, to inform some types of clinical decision, but there are many other types of decision in general practice and primary care for which there is little or no evidence, such as the integrated management of patients with several problems (co-morbidity), decisions made by the rest of the health care team and by patients, and organisational decisions (when patients are not present) concerned with the management of the complicated micro-economy of a practice, LHCC or Trust. Many studies show large, unexplained variations and inefficiencies in practice.
In the absence of a suitably large and effective academic sector, a culture has evolved in general practice and primary care, which does not look for academic support. In some situations, academic contributions may even be seen as threatening to existing policy and medico-political positions.
The new GP contract illustrates both the strengths and weaknesses of research in general practice and primary care in the UK.
On the one hand, all of the quality indicators are evidence-based. On the other, many important clinical areas, including hallmarks of the generalist clinical function (comprehensiveness, continuity, co-ordination), lack a usable evidence base.
Numbers
On 1st April 2003, there were 17.95 WTE senior academic general practitioners in the four university departments in Scotland, including 10.0 professors and 7.95 senior lecturers.
These numbers comprise about 5% of the total senior clinical academic establishment in Scotland, and represent about one senior academic general practitioner for every 200 service general practitioners (varying from about 1/120 in the East to about 1/400 in the West of the country).
In most hospital specialities in Scotland, clinical academic posts comprise about 10% or more of the establishment. It is usual for consultants in training to pass through academic environments and to be required to engage in academic activities (e.g. a higher degree) for career advancement.
Higher research degrees have their limitations, but they do indicate a substantial research training experience, an original contribution to knowledge, the ability to write clearly in an evidence-based paradigm and tests of intellectual commitment and stamina.
In the 28 years between 1974 and 2002, only 33 general practitioners currently working in Scotland obtained a higher degree by research. Of these, only 5 were obtained by service general practitioners without an academic appointment.
Career structure
In the absence of a career structure it is left to individuals to put together a sequence of posts allowing research experience, while continuing to acquire clinical and practice experience. The informal career structure has four stages.
First, the NES higher professional fellowship scheme provides “first rung” experience of academic activities, usually for recently qualified GP registrars, who spend 2 years based in university departments and clinical practice. About 50% go on to some further clinical academic activity. On 1st April 2003, there were 10.60 WTE fellows in post, amounting to 28% of all clinical academic posts in Scotland.
The second stage usually involves more dedicated research experience, leading to a higher degree (PhD or MD), which is necessary both for academic advancement and substantial research training (although there are a few notable principal investigators in general practice and primary care research in Scotland without a higher research degree, this is unusual). On 1st April, 2.45 WTE (n=4) general practitioners were engaged in such training via established national research training fellowship schemes. A further 2.8 WTE (n=10) general practitioners were engaged in less formal research training arrangements via employment in fixed term research contracts (usually designed and led by more senior clinical academic staff). Some departments provide “second rung” experience via part-time clinical lectureships, using GP ACT or other non-University funds On 1st April, 2.8 WTE (n=5) general practitioners were employed in such posts.
The third stage occurs when a higher degree by research has been achieved but the individual still lacks the experience and research output (e.g. publications from their degree project) which are necessary to obtain a senior post. This “post-doctoral gap” has been filled via the development of career scientist posts, funded by such bodies as the Wellcome Trust, MRC and Chief Scientist Office. On 1st April there were 1.8 WTE such posts in Scotland.
The fourth and final stage involves a whole-time or part-time senior academic position. While the 10.0 WTE clinical professor posts involve 11 individuals, the 7.95 other senior clinical academic posts involve 21 individuals. The difference reflects the fact that senior lecturers are more likely than professors to have split university and practice posts, usually with separate contracts and responsibilities.
Most current senior academic general practitioners have followed this type of career route in one way or another. The “system” can work for individuals with the motivation and ability to pursue an academic career, but is insufficient as a basis for increasing academic capacity. There are three main problems.
First, academic careers are fraught with uncertainty as individuals compete for short term posts to allow them to put together a credible sequence of training experiences. It is not unusual for experienced, post-doctoral GP researchers to survive on locum work between periods of academic funding.
Second, at every stage of the process, service incomes are considerably more attractive than the salaries available via fellowship and lecturer posts. Anecdotes abound of young, and relatively inexperienced, service GPs earning as much as senior clinical academics. These disincentives are set to increase substantially as a result of the new GP contract.
Third, it is difficult to combine academic training experience with relevant, substantial experience as a clinician and service general practitioner. These two tracks should be followed together, but are often put together in haphazard sequences.
The clinical academic career structure in general practice comprises an obstacle course, sufficient to deter all but the most committed individuals. These circumstances explain why academic general practice is a minority and marginal activity within the speciality, providing challenging and rewarding careers for individuals but lacking the critical mass to interact effectively with service general practice.
The example of current senior clinical academic staff, in which administrative, research and teaching responsibilities curtail clinical experience, is not necessarily a model for the future. Additional university-based posts are needed to distribute academic leadership and to relieve existing senior staff. In the longer term, however, the greater need is to establish a larger number of posts allowing general practitioners to combine practice and university careers.
Although each of the above career stages could be addressed separately, the real challenge is to address the problems of career continuity, including substantial and continuing commitments to clinical and practice work. Only when clinical academic careers provide a reasonably secure and financially competitive alternative to service general practice will a larger proportion of the most able general practitioners add academic skills to their repertoire and apply these skills in clinical practice and service development.
It is a fact that on 1st April 2003, in a clinical discipline comprising almost 4000 general practitioners in Scotland, only 8 WTE were engaged in “second rung” activities, representing a substantial commitment to starting a career in academic general practice. What does this say about general practice as a clinical speciality, what does it tell colleagues in other specialities and what would the public say, if they knew?
The author wishes to thank his fellow heads of department for providing census data. The paper expresses a personal view.
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