Academic Primary Care - Now More Than Ever
Tackling today’s Primary Care problems: unlocking the potential of Academic Primary Care
Primary care is not just care that is provided outside of hospitals. It is a distinct model of health care which underpin how we design, deliver and monitor care.
We know a lot about what makes good primary care. The best primary care is designed to meet the needs of people, rather than to treat individual diseases. It does this by providing continuous, comprehensive, accessible, coordinated, person-centred care.
But many things challenge today’s primary care: from the growing and changing needs of the patients and populations it serves, to the changing priorities and structures of the systems which manage it.
The continuing success of primary care therefore depends on the continuing work of the academic community that underpins it. Academic Primary Care…
- Provides the critical voice necessary to achieve the clarity of strategic vision recognised by Kringos as vital to maximise the potential of the primary care approach
- Trains the primary care medical workforce
- is the main source of new evidence for cost effective primary care, guiding health policy and updating clinical practice.
- Provides key leadership across the primary care community
Academic primary care has innovative solutions to key problems facing today’s primary care community: in addressing the workforce crisis, in developing new models of care that address today's needs, and support the re-design of tomorrow's primary care.
Academic Primary Care has evolved rapidly in the last 45 years, growing in breadth, stature, and impact. APC has much more to offer. But to unlock the potential of both Primary Care and Academic Primary Care, we now need to address gaps related to clarity of vision, creativity and capacity.
SAPC has therefore made four recommendations needed to achieve quality improvement of primary care through education and research:
We need to prioritise sustained and sustainable support and investment in primary care and academic primary care
We need to establish a Primary Care Strategic Body, with academic primary care at the core
We need a Primary Care Observatory to survey the impact of policy and practice changes on the core components of the primary care model
We need to Seed Innovation through a strategic shift in the funding and focus of research.
Dr Joanne Reeve, Prof John Campbell, Dr Joe Rosenthal, Dr Sandra Nicholson, Prof Bob McKinley, Prof Paul Wallace, Dr Phil Evans, Prof Richard Hobbs, Dr Imran Radi, on behalf of SAPC
Strong primary care is necessary for effective, efficient and equitable health care systems. The NHS needs primary care Now more than ever
Thirty five years ago, the World Health Organisation first put forward a vision of achieving Health For All through primary health care. International evidence now supports that view that primary health care matters. Starfield first highlighted the link between primary care based health systems achieving better outcomes, at lower cost, and with greater equity. Kringos’s more recent comparative analysis of European primary care demonstrates a link between strong primary care and
The success of our primary care systems depends on the academic primary care community that underpins it
Academic Primary Care is vital to the delivery of the medical workforce. We deliver all undergraduate teaching on primary care and are the only academic generalists in the NHS. 15% of the undergraduate medical curriculum is delivered in General Practice. Primary care academics carry a significant load in medical curriculum development, quality assurance, and delivering emerging models of integrated delivery of training. General Practice is the primary discipline involved in the training of generalist doctors (a priority recognised by the Shape of Training review ). It is the only context in which future doctors are exposed to the complexities of managing undifferentiated symptoms, longitudinal patient contact and responsibility for care, undertaken in a whole person context. Academic General Practice champions the core skills of medical generalism, balancing population and personal health care needs, and understanding the modern health service, to all medical students; whilst also promoting a career in general practice.
Academic primary care is the main source of new evidence for cost effective primary care, guiding health policy and updating clinical practice. Primary care academics are research leaders, developing and overseeing high quality studies which provide the evidence base for national and international comprehensive primary care delivery and development. UK primary care research guides and improves care and governance related to key NHS priorities including appropriate antibiotic use, screening, prevention and self-management of diabetes, cardiovascular risk assessment and addressing musculoskeletal related disability. Our work improves coordination, continuity and equity of access, for example, to high quality primary mental health care.
Academic primary care supports the postgraduate training of primary care practitioners including GP through providing short course and Masters level training for professional practice including for GPs with Special Interests and other advanced primary care practitioners; and Masters and PhD training for future leaders of primary care including academic GPs.
Primary care academics support engagement of all clinicians with governance and quality improvement. Firstly improving care by providing opportunities for staff (as well as patients) to be involved in research through their leadership of the primary care component of the NIHR Clinical Research Network (previously the PCRN) . 50% of English General Practices having contributed to at least one NIHR PCRN study in the last 5 years, and over 500,000 patients having been recruited to major, nationally recognised and approved studies through primary care. And secondly through driving practice engagement with workforce development. 46.7% of English general practices are engaged with undergraduate education or post postgraduate training (Rees, unpublished data)
Academic GPs personally make a significant contribution to primary care service delivery, and fulfil key leadership and management roles in primary care organisations including medical schools, the National Institute for Health and Clinical Excellence, and the National Institute for Health Research.
Academic Primary Care is a distinct discipline dedicated to advancing primary care through education and research.
We are a multidisciplinary professional group combining distinct expertise and understanding of the primary care context with specialist skills in education and research methodology to advance practice and policy. The discipline has its origins in the medical school (university) setting1 but is now also strongly embedded in clinical service and practice, including within partner Clinical Commissioning Groups, Postgraduate educational contexts (Health Education England), Clinical Research Networks, Collaborations for Leadership in Applied Health Research and Care, and Academic Health Science Networks.The discipline works to identify, explore and address problems facing primary care populations and health care systems. It develops, tests and disseminates primary care solutions to complex problems through planning, undertaking, and reporting on the findings of both basic and applied research. This includes its essential role in the design, delivery and evaluation of appropriate undergraduate and postgraduate curricula for tomorrow’s doctors training to work in an ever evolving NHS.
1Howie J, Whitfield M (eds). 2011. History of Academic General Practice in UJ Medical Schools 1948-2000. Edinburgh University Press, Edinburgh.
The strength of primary care links to seven core dimensions: three structural (governance, economic, and workforce development) and four process (access, continuity, coordination and comprehensiveness). Support for primary care needs to address all components in order to deliver desired outcomes related to quality, efficiency and equity of health care. As highlighted above, Academic Primary Care underpins the development, delivery and evaluation of each of the described dimensions of primary care.
UK primary care is internationally recognised for its quality. Much of this reputation relies on the strong Academic Primary Care (APC) community driving constant quality improvement through education and research. The discipline of APC has developed rapidly1 in response to the needs of the primary care community. Markers of quality show it to be performing at the highest levels on an international stage. This needs protecting – to maintain APC as an integral part of a vital primary care service. But to meet the emerging challenges, it also needs to evolve further – to unlock its full potential. APC is an integral part of continuing to deliver future quality primary care, and so unlocking the potential described in the World Health Organisation primary health care vision.
Academic Primary Care has innovative solutions to the emerging problems of today’s health care systems
The needs and demands of primary care are changing . Doing more of the same will not be enough to meet new and growing problems such as multimorbidity, treatment burden, overdiagnosis, problematic polypharmacy, and indeed inequity and underdiagnosis. For primary care to continue to evolve and adapt to changing demands, we need innovation and strong leadership in three areas – developing people, delivery of care, and strategy. Here we provide some illustrative case studies of the work that academic primary care is already doing to shape the future of the clinical discipline.
Developing People, Developing Innovators
DEVELOPING CAREER PATHS
We have an urgent need to recruit and retain clinicians in primary care. Survey evidence demonstrates an association between having a portfolio career and reduced intention to retire early. Perceived lack of intellectual stimulation in General Practice is known to deter some people from considering GP training, but other medical students and early career GPs report being attracted to General Practice by opportunities for career diversity. Developing new general practice career paths (including both university-based academic GP roles, as well as extended scholarship roles for NHS employed GPs) offers scope to enhance recruitment and retention in the primary care workforce. Innovative researcher-in-residence (RIR) roles have been developed , and now extended to offer additional opportunities for clinicians (e.g. a clinical RIR role in the Oxford Collaboration for Leadership in Applied Health Research and Care (CLAHRC) involved in evaluation and development of the EMU model).
Similar initiatives in the field of education are attracting and retaining GPs. In one English medical school, a small GP team (one Professor and four lecturers) created two year development posts for eight local GPs. Three now have permanent university teaching contracts (two UK and one in Australia), one has won a NIHR career development fellowship and one has joined a practice and led it to full teaching practice status .Three past members of the team have been appointed to senior leadership roles in the school.This small team has made a substantial contribution to securing the future educational leadership through developing, delivering and sustaining innovative posts.
Innovative solutions to new problems often emerge from practice. The RCGP Sowerby Innovation Fellowship initiative sought to capture the potential of new ideas developed by front line GPs. Over seventy applications were received for these fellowships. SAPC worked with RCGP and partners from Wellcome to review the applications. We observed many good ideas emerging from front line practitioners but with clear difficulties in translating ideas in to practical innovations. We recognised the potential for primary care academics to provide important training and mentoring for front line clinicians to support the translation of ideas into actions. SAPC and RCGP are now working on ideas for generating career development resources to support these activities.
INNOVATORS INSPIRING OTHERS
Innovative posts also create new mentors and inspirational figures to attract medical students and early career doctors in to General Practice training. SAPC continues to work closely with the Royal College of General Practitioners, National Institute for Health Research (NIHR), and the NIHR School for Primary Care Research to develop innovative extended portfolio roles for primary care clinicians.
Developing Innovative Solutions for Delivery
REVITALISING EXPERT GENERALIST CARE
Future health care needs more generalists . There has been an international call for more generalist health care to address emerging problems associated with overly specialist focused care. Problems which include treatment burden, overdiagnosis, underdiagnosis, and problematic polypharmacy. UK academics are leading work to develop a new science and practice of generalism. Primary care academics have led work to teach , deliver (also) and evaluate generalist health care. Work which supports development of new models of future delivery of primary health care, especially for chronic conditions.
INNOVATIVE WORKING ACROSS THE PRIMARY-SECONDARY CARE INTERFACE
Primary care academics have led innovative work to develop new models of care across the interface between primary and secondary care.
Associate Clinical Professor Dan Lasserson, an academic GP, brought a primary care perspective to the redesign of Accident & Emergency services in Oxford, the new service being awarded a Guardian Innovation prize . He now leads work with the local Collaboration for Leadership in Applied Health Research and Care (CLAHRC) to combine academic, clinical and leadership expertise to describe how the model can be developed and rolled out to support wider change.
Professor Jeremy Dale, working with Health Education West Midlands, led innovative work to evaluate the impact of a post-Certificate of Completion of Training fellowship for GPs that involved co-training Accident & Emergency, General Practice and ambulance staff. The findings are informing future design of new models of service delivery for acute care, and the fellowship is now being rolled out in other regions.
Developing innovative approaches to driving quality improvement through research
Primary care academics lead innovative work to support evidence based practice through the development of the science of implementation . The National Institute for Health Research (NIHR) has awarded Knowledge Mobilisation Research Fellowships and the National Institute for Health and Clinical Excellence (NICE) has awarded Fellowships to primary care academics in recognition of the important role they play in researching and leading implementation. The NIHR funded MOSAICS study, for example, focuses on translating previous research findings (interventions that could improve care for people with osteoarthritis) in to practice. Findings suggest that the use of tools supporting the implementation of evidence into routine clinical care was associated with improved adherence quality indicators of care. This led to collaborations between academic primary care and South Shropshire CCG to secure Regional Innovation Funding to develop updates for GPs and training for practice nurses (JIGSAW). The RCGP and Education for Health have developed on-line multidisciplinary training with Arthritis Research UK for national adoption and spread. JIGSAW is now on an international repository of implementation programmes for osteoarthritis and a proposal for sharing the tools with academic primary care in the Netherlands, Norway, Denmark and Portugal, led by WMAHSN, has been developed and submitted for funding (JIGSAW-E).
Co-production is a recognised model in public service decision making, which involves pooling patients’ and professionals’ expertise to develop and deliver new ways of working . For example, the People Powered Health project in Wales worked to develop true partnership in commissioning of local services. UK based research within the CLAHRC setting has demonstrated these ideas being extended in to the co-production of new knowledge from research supporting service development.
Primary care academics now lead work to bring research expertise in to the process of co-production of knowledge . One example was the Bounceback project - an NIHR funded Innovation project to drive quality improvement in access to primary mental health care through the development, implementation and evaluation of practice based evidence . It used academic expertise in the construction of trustworthy knowledge, working with clinical expertise in the development and delivery of innovative care models, to produce a scientific account of an innovative practice mode and its integration.
In 2009, representatives of the North American Primary Care Research Group called for this shift from a pipeline vision of translating research into practice to optimising health and health care through research and quality improvement . UK academic primary care is already engaged with this work and so has a potential important international leading role in driving innovation and improvement in primary care through scholarship.
Unlocking the potential of Academic Primary Care
UK Academic Primary Care has undergone a rapid advancement in recent decades, delivering the highest standards of education and research, and establishing itself as integral to the delivery of quality primary care. It is now poised to deliver on its ambitions to respond to the changing demands facing modern western health systems: to lead innovation in primary care, and so to ensure the continued delivery of efficient, effective, and equitable health care. But to unlock this potential, we need to recognise and address three key barriers, namely the challenges of clarity of vision, creativity and capacity.
CLARITY OF VISION
In 2008, the World Health Organisation highlighted concerns that the vision of whole-person centred primary care driving efficient, effective, equitable health care was being lost . Health systems are becomingly increasingly focused on a command and control approach to disease management. Internationally, health systems lack a clear vision of primary health care.
In her seminal work analysing the strength of primary care in Europe, Kringos also noted concerns about a lack of coherence in healthcare planning with relation to primary care. Her work highlighted that the individual components of a primary care system alone, without a coherent and cohesive strategic vision, do not guarantee strong primary care. Her findings are echoed in the Commonwealth Foundation analysis of strength of primary care around the world.
The academic primary care community has great potential to address this barrier and so support development of a coherent vision of the potential for primary care within healthcare systems by virtue of its leadership and activity in both basic science and applied research in primary care. As well as through its international partnerships with, for example, Australia (Ellen McIntyre, Primary Health Care Research Information Service in Australia) and the US (North American Primary Care Research Group).
UK APC has an established track record of delivering world class academic research suitable for translation into clinical service. This so-called pipeline model of evidence based practice has successfully delivered improvements in disease management, for example in contributing to the significant reduction in cardiovascular mortality in recent years. As chronic disease prevalence rises, so does the need for this type of work.
But emerging health problems, characterised by complexity, variability, and uncertainty, have also highlighted the limitations of the pipeline model as a mechanism for driving quality improvement through research. International colleagues have recognised a need to shift from a vision of translating research into practice to optimising health and health care through research and quality improvement . Using research expertise creatively to support innovation, and the rigorous production of practice-based evidence needed for the work to be scaled up, sustained and so have impact. These new roles will need review of the support mechanisms for academic practice (including governance, funding, and performance targets) in order to support new ways of working.
And crucially, APC, with its 205 full time equivalent senior academic GPs against a workforce of 32, 628 full time equivalent GPs , does not currently have the capacity to deliver our ambitious vision of an academic primary care co-led primary care. Indeed the capacity to continue to deliver current levels of impact are threatened by static recruitment in to the discipline, an aging senior workforce, overregulation of research, and changing priorities in the service context (with academic work still too often viewed as an added extra rather than an integral part of quality care).
Both the Royal College of General Practitioners vision of GP in 2022 and the recent workforce review recognise a need for clinical roles to change. Including developing an enhanced role for clinicians in scholarship and research driving quality improvement. Creating innovative portfolio career options linked to academic work would be one possibility.
Expansion of the Academic Primary Care community would be essential. Both to sustain and expand capacity for training of the clinical workforce, but also to continue and extend the provision of academic expertise in education and research driving quality improvement. In addition, there is a need to develop and support innovative academic career pathway in order to unlock the potential of the discipline to support innovation and quality through the research process .
Academic primary care is well placed to drive and deliver innovation and improvement in primary care through its leadership and practice in education and research. A future model of academic primary care would need to retain its place within the university context (including medical education and research), but also take on new roles to support innovation and co-production across the clinical context. Doing more of the same is not enough . Future models of primary care and academic primary care need to support innovation as well as service delivery. To achieve this ambitious plan needs urgent attention to four key issues:
Recommendation 1: Prioritise sustained and sustainable support and investment in primary care as described in the evidence submitted by Royal College of General Practitioners and in academic primary care as described here. Both elements are essential. Without strong clinical primary care, it is not possible to capitalise on the full potential of this important academic discipline. In particular, we highlight the urgent need to expedite the review of national funding arrangements (SIFT funding) to increase capacity for undergraduate placements in primary care. We welcome the investment in academic primary care research in recent years, and recognise the growth in professorial appointments. However, we highlight the particular concerns about the risk posed by a lack of middle grade academic posts in undermining the sustainability of the discipline.
Recommendation 2: Establish a Primary Care Strategic body with Academic Primary Care as co-leads to deliver the clarity of strategic vision (coherence) called for by Kringos and so maximise the potential of the primary care approach. There is international work and interest in this area (including from the Canadian College of Family Physicians, the Primary Health Care Research Information Service in Australia, the North American Primary Care Research Group, and from amongst members of the Oxford Primary Care Research Leadership Training cohort – an international group who are the next generation of senior primary care academics). This initiative would therefore also place UK as a leader on the international stage.
Recommendation 3: Establish a Primary Care Observatory to support the continued surveillance and development of primary care in the UK. The goal would be to monitor the impact of changes in service, policy and context on the core concepts of primary care (workforce, access, coordination, continuity etc.) and so the strength of primary care. Academic primary care is integral to this work. Again, there is international interest from North American colleagues in working with us on this.
Recommendation 4: Seed innovation by supporting a strategic shift in the funding, prioritisation, dissemination of primary care academic work from a focus only on translating research in to practice to coproduction (optimising health and health care through research and quality improvement).