In total 62 interviews were completed (tables 1 and 2). Around two thirds of practice staff participants were female, ages ranged between 22-56 years of age, 40% worked fulltime at the practice and the majority reported high levels of job satisfaction.
Mechanisms linking research activity and general practice performance
We extracted the themes relating to mechanisms, which we divided into ‘direct’ mechanisms (where there was a clear link between the mechanism and general practice performance) and ‘indirect’ mechanisms (where the link was mediated through broader changes). The core themes are presented in Figure 1 and then further expanded in the text.
[Figure 1]
Direct effects on care - additional resources
One of the main benefits of research activity was the access to extra resources, including extra income that could be reinvested into the practice:
And then secondly we also try to use research as a way to boost our revenue a little bit, so we do try to have a nice mix between commercial studies and ones that benefit the patients, obviously the ones that can help generate some revenue for us is always good, particularly ones where we can afford to fund more staff to get involved with the research projects. Because we want to keep growing and I think the way we see doing that is by creating a big enough revenue stream that we can almost have a research team embedded in the practice” (M03S04- Practice Manager)
Some studies were seen as beneficial because they provided access to equipment such as scanners, centrifuges, freezers or home monitoring devices. Not all of the benefits described were clinical. Staff and stakeholders described the value of time for patients, with increased appointment times for recruitment and access to staff (such as research nurses) giving patients someone else with time to attend to them, again relieving pressure on practices.
“a lot of our patients, they enjoy…we don’t have the time restraints that you would have with general practice. So, we can see a patient for up to an hour, whereas in general practice, maybe you are limited to a sort of seven-minute time slot, or a ten-minute time slot. And they also get, almost like a backdoor into the surgery.” (CS407- Clinical Trials Manager)
Direct effects on care - Improved knowledge and skills
Taking part in research was seen by some practitioners as a way of keeping up to date with innovations in health and care, including awareness of new treatments. Trials were seen as a way of potentially ‘upskilling’ the practice team by providing extra learning about new procedures. For those that were involved in the set-up of studies, reading study protocols could provide an update on current evidence for particular conditions.
“So one is the training. So because the training we do for the studies, our knowledge has improved, we have a heightened awareness. And then because we discuss those in our clinical meetings, our colleagues then have heightened awareness of it." (CS203- Advanced Clinical Practitioner)
Direct effects on care - Improved systems
General practice staff are often involved in the identification of potentially eligible research participants. Respondents noted that the processes of running searches and identifying eligible patients gave them the opportunity to maximise accuracy and consistency of coding, helping to improve care through maintenance of systems for identification and follow-up of patients. This had the further potential for improving assessment of practice performance in the Quality and Outcomes pay for performance scheme, and the external ratings of practices by the independent regulator the Care Quality Commission:
“And sometimes it can be, from our point of view, being able to flag up and pick up patients a lot better after sometimes the research team have done searches on the practice numbers and recognise that actually there are these patients that haven’t been coded, for example.” (MSH05- GP partner and Research Lead for PCN)
Direct effects on care - Better care for patients
Some practitioners thought that taking part in research could give them access to more modern and evidenced-based services, such as increased access to specialist services (e.g. mental health) or ‘extra’ tests for their patients, facilitating access for patients and helping relieve burden on practice resources.
“So usually one of the first things we look at is benefit for the patients, so we look at opportunities that patients might not have access to elsewhere. We’re from quite a deprived area and there’s obviously quite a lot of disparity in healthcare of quite poor outcomes, so we tend to look for studies that have good outcomes for patients first of all (M03S04- Practice Manager)
Another raised impact on patient care was that screening patients for study participation might lead to reviews of specific patient groups and picking up on clinical issues that may have otherwise been investigated or detected later. Whilst this potentially could lead to increased workload for practitioners, practices perceived this as a potential benefit for patients. For example, studies around Chronic Kidney Disease (CKD) where patients were told that they have CKD following a search of practice records, reportedly generated additional work in terms of patient queries and appointments to explain the diagnosis to patients who were not aware they had it. However, this ‘extra’ work was recognised as being in line with best practice:
“I think although in that case it was a little bit more work, actually it highlighted something that we should have been doing anyway. He should have known that he had kidney disease and someone should have had that conversation. I expect there will be a few more bits like that that will probably bring us in to line with best practice as well. So it might be a little bit more work but I think it is all in the right direction. It has not deviated from what we are doing in terms of patient care on a day to day basis and it fits in with managing his CKD.” (M04S07- GP, salaried)
Direct effects on care - Improved relationships with patients
In research-active practices, some staff reported that patients may view staff as more knowledgeable, taking more notice of advice they give. Some practitioners reported that engaging a patient in research gave them the opportunity to build their relationship and increase trust. Other members of practice staff also saw these benefits, reporting more positive feedback from patients involved in research:
“I think like a lot of other practices, we struggle with some negative feedback at times with how hard it is to meet demand and everyone wanting appointments and everything the same day or exactly when they want, so you can sometimes get in a bit of a negative environment with that, but this as a separate arm, the patients have all been fantastic when they’ve been on these studies. So I think those ones that have been involved so far have seen a massive positive benefit and we’ve noticed the positive feedback which is something we don’t always get.” (M03S04- Practice Manager)
Indirect effects on performance – Improved practice image
Although respondents reported that improved relationships with patients could result from their active participation in research, others spoke of the wider impact where being known for taking part in research had a positive effect on the practice reputation, with these practices being thought of as more ‘progressive’ and ‘innovative’ compared to others. Stakeholders involved in research outside the specific practices also suggested that research activity was indicative of a well-run practice that must be doing the everyday clinical work effectively to be able to take on additional tasks.
Indirect effects on performance – Job satisfaction
One of the most significant benefits reported by staff active in research was the positive impact on their job satisfaction. In a system under pressure, the variety offered by research to their daily routine was seen as essential in helping maintain a good working environment. Particularly, GPs reported that research activity complemented their clinical roles, offered variety, revitalised them during their clinics and therefore potentially reduced burnout.
“Other reasons, so from a selfish point of view, it just varies the week for me. I think when you do slightly different things it keeps you fresh mentally, does keep you going. And if you do…I think if…if you do the same thing again, and again, especially in GP, you can burn out quite quickly.” (M03S05- GP partner)
Other factors raised included improved self-esteem, taking pride in research work and making a contribution to national and global health. A further theme from some of the practice staff interviews was improved team working due to delivering research, in particular across practices when research involved activity across a wider primary care network:
I think so, and I think the other thing about general practice often in this job is, you work in silo, so when you’re doing research studies it actually…it’s an opportunity to work in very small groups with other people and deliver something where you’re all working on the same project as others. So, it’s nice having these little mini projects to work on, gives a focus for the group, and actually helps engagement within teams as well. (L01S01- GP partner)
Indirect effects on performance – Staff recruitment
Research activity of general practices was not always explicit to all of those respondents in the practice, and indeed not always visible outside of the practice. However, some interviewees did report that it could influence recruitment and that they thought this would increasingly become a ‘selling point’ in the future.
“Yes, I think it’s something that’s advertised, you know, when we’re recruiting for staff. It’s something that interested me in coming back to the practice so I’ve spoken to other people who have been thinking about applying for jobs here and it is something that people are interested in, so yes. …I don’t know about the wider staff in general. For me, it makes me more inclined to stay here because, you know, it’s something that not a lot of GP practices do. But yes, I don’t know about everybody else.” (CS311- GP, salaried)
There were also comments on the positive effects being a research active practice might have on the type of staff attracted to posts. For example, people identified as ‘forward thinking staff’ and those who are progressive or keen to learn by offering expanded roles or portfolio careers.