Well-supported general practice research is essential to the delivery of quality primary care.
The treatments and techniques used in modern Australian general practice are the result of a long and continuing history of peer-reviewed research backed by a high level of evidence. Recommendations and guidelines evolve and improve as a result of this research.
‘We know research in general is important for any industry, field or endeavour,’ Prof Mark Harris, Professor of General Practice and Executive Director of the Centre for Primary Health Care and Equity at the University of New South Wales, told Good Practice.
‘It helps to keep us learning and renewing, doing things better and differently.
‘Any industry that doesn’t invest in research is destined to stagnate.’
According to Prof Tania Winzenberg, Professor of Chronic Disease Management at the Menzies Institute for Medical Research in Hobart, operating in any field without the guidance provided by research is analogous to travelling without a map.
‘If you don’t know where you’re starting from, how do you know how you’re going to get where you want to go? And how do you know when you’ve arrived?’ she told Good Practice.
Prof Winzenberg believes that general practice research is vital to the work of all GPs, regardless of whether they are researchers themselves.
‘Quality research helps us to understand what is the best care for general practice patients across the full spectrum of conditions and problems that GPs deal with, and how to deliver that care most effectively, efficiently and in a patient-centred way,’ she said.
‘Research underpins the entirety of our clinical practice.’
A unique perspective
According to Prof Winzenberg, general practice is still comparatively young as a research field.
‘It wasn’t until the 1990s that the General Practice Strategy Review identified that research capacity in general practice was necessary,’ she said.
Such a relatively short life has perhaps led to a certain lack of understanding, in some quarters, of the purpose and importance of general practice research.
‘When I was first appointed as an Associate Professor back in 1990, a professor of another medical specialty came up to me and asked, “What does a professor of general practice do? Surely general practice is just about all of the easy bits of the specialties,”’ Prof Harris said.
While this comment was exasperating for Prof Harris, he also found it useful in that it made him reflect on what is unique about general practice: accessibility, continuity over time, coordination of care, and comprehensive care.
‘Those four characteristics mean that general practice has a central role in the health system,’ he said. ‘It has the ability to reach a large proportion of the population and, therefore, do something about population health.’
Prof Winzenberg agrees that this type of scope is one of the most important aspects of general practice.
‘We know the figures: 85% of the Australian population attended a general practice at least once in the last year. We deliver approximately 137 million GP consultations a year,’1 she said. ‘Multiple studies have shown that a strong primary healthcare system is associated with greater efficiencies, lower rates of hospitalisation, better health equity and better health outcomes.’
The broad application and accessibility of general practice means it can provide researchers with the perfect window into the health needs of the population via large-scale projects. Conversely, the versatility of general practice research means it can also go in the opposite direction and allow a focus on more precise aspects of the profession.
‘There’s an incredible range of [general practice research topics], including fairly specific clinical problems,’ Prof Harris said. ‘For example, I’ve got a GP looking at a particular skin condition that’s related to treatment, and a registrar who is using fitness trackers to help older people improve their physical activity to prevent weight regain once they lose weight in a management program.
‘Some of the best research is looking at these specific areas that relate to the way in which GPs, practice nurses and other people in general practice work, and how care is delivered.’
The unique nature of general practice can also impact the way research is conducted. Prof Winzenberg believes this can occasionally be somewhat difficult for researchers from other specialties to grasp.
‘The peers who are assessing my research are frequently laboratory-based researchers, or endocrinologists, or cardiologists,’ she said. ‘They don’t have an understanding of what it’s like to be in general practice, so it’s hard to communicate why you’ve done your study in a certain way.
‘It might not look scientifically perfect, but it has to integrate with the general practice environment.’
Prof Winzenberg cited an example of a research project under consideration for funding that focused on the use of orthotics in footwear.
‘A criticism was made that the research design didn’t require all of the participants to wear the same type of footwear constantly for 12 months, and that the variation in the footwear would mean that we couldn’t get a good result,’ Prof Winzenberg explained.
‘My response was, as a GP, how could I possibly restrict any patient to wearing lace-up black shoes for 12 months to test an orthotic?
‘The first thing an intervention has to be is acceptable to the patient before it has a chance of working in the real world.
‘You might have to sacrifice, sometimes, the scientific narrowness of a laboratory-based approach in order to get something that works in the real world.’
Looking to the future
Recent funding cuts to bastions of general practice research, including the Bettering the Evaluation and Care of Health (BEACH) program and the Australian Primary Healthcare Research Institute, have proven discouraging for people working in the field.
‘It’s going to be very hard to monitor how changes being made to the Health Care Home, to Medicare rebates and so on, are going to impact in the future without something like BEACH,’ Prof Harris said.
There are also concerns about effects these funding cuts may have on the viability of a career in research.
‘We risk losing our existing general practice researchers who can provide the leadership that’s necessary to build our profession,’ Prof Winzenberg said. ‘We risk making people think twice about even starting a research career.’
Prof Helena Britt, Professor of Primary Care Research at the Sydney School of Public Health, who was also the Director and Chief Investigator of the now-defunct BEACH program, is also concerned about the future availability of independent data that GPs can use to advocate for their profession.
‘Where is the individual research, the individual reliable data that general practice or any other group in primary care can use to argue with patients or government about what they do?’ she told Good Practice.
All three researchers agree that because general practice is so essential in the provision of primary care for the Australian population, research in this area needs to be prioritised.
‘[We need] a recognition of the incredibly necessary role of general practice,’ Prof Britt said. ‘It’s not just necessary, but good quality. It decreases the expensive side of the costs of health.’
But, even though the situation may seem somewhat dire, Prof Winzenberg believes there is cause for optimism.
‘There are things on the horizon that do offer hope,’ she said.
‘The Medical Research Futures Fund and its emphasis on research that is of practical importance will possibly favour a field such as general practice. Because, when it comes to delivering healthcare well, general practice is where it has to happen.
‘It will be interesting to see what replacement for the PHCRED [Primary Health Care Research, Evaluation and Development] Strategy actually comes to the fore.
‘And I’m watching this space with a great deal of interest to see, hopefully, some other structural support come through.’
In addition, smaller research grants from bodies such as the RACGP Foundation remain available. While such institutions are intended for the support of specific, relatively small-scale projects, they can still be incredibly helpful to general practice researchers.
‘RACGP Foundation support has been absolutely critical to me throughout my career,’ Prof Winzenberg said. ‘They provided me with my first piece of funding to do my first-ever project as part of my master’s project.
‘Also, RACGP Foundation funding has sometimes sustained my research program when other sources have dried up.
‘Without the capacity to keep going with projects and have some research success through that funding, I really doubt I would have been able to achieve research positions at several critical times in my career when things have been particularly tight.’
Prof Mark Harris is also pleased that these smaller grants are available, but remains concerned for the future of large-scale products.
‘I think the exploratory research, particularly with the RACGP Foundation and so on, will hopefully continue. But answering some of the really basic questions about how to deliver care or, indeed, the most effective way to manage care, will be difficult to do at scale,’ he said.
Prof Harris is keen to see some solid planning and investment in the future of the specialty.
‘I’d like to see it as part of a vision for how general practice and primary care is going to be renewed and informed into the future,’ he said.
‘I’d like to see investment in people. If we look at the history of general practice research, we have seen some astonishing leaders.
‘There are still lots of people who have done and are doing research, and there’s some new people coming forward.
‘But if they’re going to adopt a serious role in research, then they need support.’
- Britt H, Miller GC, Henderson J, Bayram C, et al. General practice activity in Australia 2014–15. General practice series no. 38. Sydney: Sydney University Press, 2015. Available at http://purl.library.usyd.edu.au/sup/9781743324523 [Accessed 26 October 2016].