The ULEARN-GP network profile
Table 2 describes ULEARN-GP member practices and compares them to the national profile as described by data from other published research networks. Thirty-five per cent were rural, 18% were urban and just under half the practices were mixed. All of the practices were computerised, with 89% using Socrates or Health- One. The median number of GPs working in each practice was two and 15% were single-handed. Over half of the practices had three or more GPs, while 32% had three or more full time equivalent GPs. One practice did not have a practice nurse and nearly half the practices had more than one nurse. One practice did not have administrative staff with 80% having more than one administrator and 16% employing a practice manager. All of the practices operated a form of shared out of hours system, with 94% of practices involved in an out of hours co-operative and six per cent opting for a privately funded locum system. Three quarters of GPs were coding chronic disease, with 17% coding individual consultations. International Classification of Primary Care (ICPC) was used slightly more than International Statistical Classification of Diseases and Related Health Problems (ICD-10). Sixty-two per cent were involved in research in the preceding three years.
Table 2 Comparison of National, West of Ireland Research and Education Network (WestREN) and ULEARN-GP profiles
|
National
1992 (34)
|
National
2005 (34)
|
WestREN
2009 (33)
|
National 2015 (34)
|
ULEARN-GP
2018
|
No. of practices
Response rate
|
428
68%
|
545
87%
|
71
73%
|
462
72%
|
134
100%
|
Practice Type
GMS() + Private
Private practice only
|
91%
9%
|
96%
4%
|
100%
0%
|
89%
11%
|
100%
0%
|
GMS List Size
<500
500-1900
>2000
|
25%
72%
3%
|
27%
71%
2%
|
4%
82%
14%
|
18%
75%
7%
|
10%
58%
32%
|
Practice Location
Rural location
Urban location
Mixed location
|
33%
47%
20%
|
21%
43%
36%
|
50%
25%
25%
|
21%
42%
37%
|
34%
18%
48%
|
Premises
Purpose built premises
Adapted premises
Attached to residence
|
27%
46%
27%
|
43%
46%
11%
|
54%
40%
5.7%
|
54%
43%
3%
|
37%
53%
1%
|
Practice Organisation
Computerisation
|
27%
|
89%
|
100%
|
94%
|
100%
|
Out of Hours
Internal rota
External rota
Co-operative
|
25%
60%
0%
|
5%
15%
42%
|
4%
19%
61%
|
1%
6%
93%
|
0%
6%
94%
|
Practice staff
Single handed GP
Practice nurse
|
57%
17%
|
35%
75%
|
25%
92%
|
18%
82%
|
15%
99%
|
Education
Involved in postgraduate training
|
8%
|
18%
|
42%
|
22%
|
63%
|
Qualitative evaluation of research priorities, barriers and levers.
Twenty-two GP participants were invited to participate and all agreed to be interviewed.
Four major themes summarised below in table 3 emerged from the qualitative data and these were: catalysts; coherence; systems failure; and aspirations for a better future. Major themes were divided into a series of subthemes described below which were often inter-related.
Table 3. Summary of qualitative data in major themes and subthemes.
Major theme
|
Subtheme
|
Catalysts
|
Evidence-based practice and practice-based evidence
|
Organisational catalysts
|
Students as catalysts
|
Coherence
|
Coherence in policy and academia
|
Novice mentality
|
Normalisation
|
Systems failure
|
Boundaries
|
Research culture
|
Scaffolding and support
|
Aspirations for a better future
|
Partnership and equity
|
GPs fulfilling potential
|
Foundations for a research network
|
I) Catalysts
‘Catalysts’ describes an overarching theme of concepts and factors that GPs perceived to be important to promote participation in research. It contains the following subthemes: evidence-based practice; practice-based evidence; organisational catalysts; and student interaction. These subthemes describe the key motivational context and interactions within the working environment that have the potential to stimulate research activity.
Evidence-based practice and practice-based evidence
GPs universally appreciated the importance of basing their clinical practice on sound principles grounded in evidence. When GPs recognised the relevance of research to how they practise medicine and to their patients, they see a value in it. A very strong patient-centred theme was present throughout the interviews. The role of general practice and the research conducted within it should be to produce better health services and outcomes for patients.
“I believe research in general practice should be very much focused on the pragmatic stuff, on the delivery of care, on how we can best deliver care to our patients. And where there is an evidence base as well… It is about improving care for the patients. That is what it is about.” GP 6
The data clearly described the evolution of the clinical role of the GP from treating acute and often minor illnesses to managing chronic illnesses, preventative medicine and an overall increase in complexity. This development was viewed as an impetus for research in general practice so that the management of patients with these conditions would be informed by up-to-date evidence which would emerge from primary care settings. There was interest among GPs in directing research that would answer clinical questions to inform guidelines and provide an evidence-base from-community-based research. In addition, many participants articulated the need for GPs to contribute to formulating research agendas and setting research questions.
Organisational catalysts
Health services research, specifically examining the processes of care and how health care is delivered, emerged as a strong area of interest from the data. GPs were aware of the impact of their work on the patients and community they serve and, specifically, how their work fits in the context of the wider health service. They recognised that the computerised data collected through their daily clinical practice has the potential to contribute important data to research of health care delivery. The wider political context of health service restructuring, ongoing GP industrial relations issues and the decline of rural general practice emerged as significant sources of concern for GPs. Participants voiced a degree of curiosity about their own performance and the hidden value of the work that they do.
“the patchwork quilt type of quality of what happens between doctor and patient… I would love to see more of the technicolour aspect of what actually goes on in the consultation.” GP 19
Students as catalysts for research
For many GPs, interaction with medical students on placement, who had research and audit requirements of their own, was an important introduction to having research conducted in their practices. Perceived benefits of a student in the practice included stimulating reflection on their practice, the role of the student in collecting data and students presenting findings back to the GPs and staff in the practice. In this context, the student was perceived as a bridge between practices and the medical school and, in some instances, were seen as an educational source for GPs on research methods. Some participants discussed examples of projects, designed by faculty, whereby students could opt in and receive training on data extraction using practice software to answer a specific research question. In such instances, the stages of getting ethical approval, developing a coding sheet and piloting of the study were carried out by faculty. The GP tutor would then collaborate with the student on placement and many found it useful as a way of understanding the research process and learning how to use the practice software for data collection purposes.
“Certainly, student projects have helped me re-examine my own practice. I can look at it and say ‘why do I do it that way’ or ‘I didn’t realise that was going on” GP 3
II) Coherence
Coherence refers to the multi-faceted journey for GPs in making sense of the relevance of research to them. Coherence in this context includes the following subthemes: coherence in policy and academia, novice mentality relating to research among GPs and normalisation of research as part of general practice.
Coherence in policy and academia
GPs perceived a lack of consistency of priorities among the principle health service bodies, as well as a perceived disconnect between medicine and research in the hospital and medicine and research in the community. A clear perception emerged from the data that academic bodies have not respected them, have not valued their input into research and that their data is used but they are not approached for intellectual input, they are not acknowledged or rewarded for their contribution.
“It is again just about the whole remove of academia, and the idea that they talk about research in general practice. You know, it is like apples and oranges. They think in a different reality.” GP 12
Novice mentality
GPs perceived that they do not have the expertise or experience to formulate research questions or to get started on a research study. Many were working in isolation and lack the encouragement and support that is needed to undertake a research study. There was awareness of the steps involved in conducting studies. However, lack of confidence in their ability as researchers was a recurring theme in the data. It seemed that GPs viewed that research as an activity for other professionals.
“people think research is [what] people with white coats do a lot and it’s very remote and irrelevant and a lot of the stuff that you actually see in the so called high powered peer reviewed journals, a lot of it is of little relevance to guys…in the trenches.” GP 19
Normalisation – research as part of the GP role
This theme refers to research becoming a normal part of practice. Notwithstanding the lack of consistency in policy around research and the poor self-image of GPs as researchers, most participants expressed a vision of how research could become embedded in practice. GPs realised the importance of the data that they had collected in practice computers and were aware of the need for other research team members such as statisticians and qualitative experts. In several interviews, although the participants initially spoke about their lack of time and interest in research, later they would express a vision of how research could happen in general practice, the support that would be needed and how they themselves might contribute. They saw their role not as static but having the potential to change.
“It is not everybody’s cup of tea and you can’t expect it to be...and you will have people who will be very happy to be data collectors but who don’t want to be involved in the nitty gritty writing up of the (project).” GP 14
III) Systems failure
The third overarching theme described how participants felt that the current health system is destined to fail with regard to the production of general practice-based research. Subthemes described the problems with the system that prevent GP engagement such as a lack of boundaries around the role of the GP; lack of research culture and lack of scaffolding and supports.
Boundaries
The ever-increasing workload for GPs, coupled with lack of time for pursuing activities other than service provision were identified at an early stage in the data analysis as major and recurring barriers to research activity. On further analysis, lack of clear boundaries around the role of the GP emerged as the most important contributing factor. The way the system is designed currently means that GPs are being tasked with increasing responsibilities and associated administration and are not in a position to refuse any of the demands being placed on them. Poor health service planning, with no clear vision of the potential of general practice and how it can be supported is a significant part of the problem.
“Whenever there is some hassle out there in the health services, someone up in the offices says "sure look, the GPs will take care of that, sure they always roll up their sleeves and get stuck into that". That is kind of a general thing out there "your doctor will always take care of it". But, you see, we don't have protected time to do anything else other than keep our head down to the grindstone practising medicine.” GP 9
Research culture
Relating to the lack of boundaries in the system, a culture appears to have developed whereby GPs, their peers and the wider health system do not value the potential contribution of GPs to research. When research is not prioritised and an attitude of passivity or disinterest develops, research is seen as a burden rather than a natural component of the role that could enhance the working life of a GP. There was a sense of despair with the current working environment coupled with a suspicion of research proposals.
“I think people are frightened and I think that general practice sees it as a bit of a burden. Like don’t ask us to do anything else. You know, it is their only way of showing that they are suffering ‘don’t ask me to do anything more. I am fed up and I am tired and I don’t want to know about it’. They see it as the business for men in suits” GP 14
Scaffolding and supports
Participants discussed the lack of infrastructure or readily available expertise from their own peers and from academic bodies with which they could discuss and develop ideas. Similarly, the paucity of readily available frameworks and training in research mean that research is unlikely to grow in general practice in the current climate.
“You could spend hours yourself trying to look at ways of doing it but, if they could send someone that could take a couple of minutes to look at it and answer the questions for you, that would be very helpful.” GP 21
IV) Aspirations for a better future
The first three themes all contribute to a system that seems to be poorly set up and under resourced. Despite these negative factors, many participants had very clear ideas on how things could improve. This fourth and final major theme describes the GPs aspirations for a better future in terms of research engagement, and that they saw a place for the network in improving research engagement and ultimately the care of patients. The subthemes here, included partnership and equity; fulfilling potential; and foundations for a research network.
Partnership and Equity
The medical school must work to develop relationships with GPs, to build trust and mutual respect and take measures to include GPs in the academic environment. Some of those interviews described previous negative experiences when they had collaborated by academic bodies by facilitating data collection from their software and were never properly acknowledged for their input.
“If GPs felt more included and associated more with the medical school’s events, they might feel more of an urge to meet other GPs and collaborate on various research projects.” GP 12
GPs fulfilling potential
The health services and other bodies in the health system can support increased GP involvement by organising and financing protected time for the GPs, and by providing resources such as computers and trained staff such as research assistants. Furthermore, for GPs with a serious academic interest, there could be the possibility of resourcing them to take time out and go into the universities for training and meetings.
“Facilitate his involvement by buying the time out of his practice that would cost money and provide research assistants that would add to the practice for access to his data. By giving something back to the practice, by giving him suggestions on care for patients with certain conditions and suggestions for improving care and if he does that then his name goes on papers and being part of a research group.” GP 8
Foundations for a research network
From the data a new spectrum of possible relationships between academia and GPs can be seen. This ranges from one-to-one to an active forum of peers; to establishing a full research network of GPs. This is the new infrastructure that could be built on the principles outlined. In order establish and sustain this, leadership is required.
“I have this concept of the unseen university… it is almost like a hedge school, you don’t have to have a big building to have a university. It can be all scattered throughout the country. And this is a kind of a network of practices... It is like what in Natural History we used to call “field research”. Instead of having all the animals inside in a lab running around you actually go out there with your Land Rover and camera and see what they are actually doing.” GP 4