Family Practice Vol. 21, No. 5 © Oxford University Press 2004, all rights reserved.
Setting priorities and identifying barriers for general practice research in Europe. Results from an EGPRW* meeting
ea Clinic of Social and Family Medicine, School of Medicine, University of Crete, Greece, b Departement of General Practice and Netherlands School of Primary Care Research (CaRe), Universiteit Maastricht, Maastricht, The Netherlands, c Department of General Practice, Georg August University, Göttingen, Germany, d Centre for Primary Health Care Studies, University of Warwick, UK, e Department of Family Medicine, University of Ljubljana, Slovenia and f Universiteit Maastricht, Maastricht, The Netherlands
Correspondence to Christos Lionis MD, PhD, P/A EGPRN Secretariat, Netherlands School of Primary Care Research (CaRe), Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands; E-mail: hanny.prick{at}hag.unimaas.nl
Received 29 October 2003; Accepted 17 May 2004.
Lionis C, Stoffers HEJHb, Hummers-Pradier E, Griffiths F, Rotar-Pavli D and Rethans JJ. Setting priorities and identifying barriers for general practice research in Europe. Results from an EGPRW meeting. Family Practice 2004; 21: 587–593.
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Abstract |
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Background. In spring 2002, WONCA Europe, the European Society of General Practice/Family Medicine and its Network organizations reached consensus on a ‘new’ European definition of general practice. Subsequently, the European General Practice Research Workshop (EGPRW) started working on a European General Practice Research Agenda. This topic was addressed during the 2002 EGPRW autumn meeting.
Objective. Our aim was to explore the views of European general practice researchers on needs and priorities as well as barriers for general practice research in Europe.
Methods. In seven discussion groups, 43 general practice researchers from 18 European countries had to answer the following questions. (i) What major topics should be included in a research agenda for general practice in your country? (ii) What are the barriers to adequate implementation of general practice research in your country? Group answers were listed and subsequently categorized by two authors.
Results. Research on ‘clinical issues’ (common diseases, chronic diseases, etc.), including diagnostic strategies, was considered to be the core content of general practice research, with primary care-based morbidity registration essential for surveillance of disease, clinical research and teaching in general practice. There was also consensus on the need for research on education and teaching. ‘Insufficient funding opportunities’ was perceived to be the major barrier to the development of general practice research.
Conclusions. These findings could be used as a basis for national checklists of ‘content of’ and ‘conditions for’ general practice research. European general practice research training programmes should be developed further.
Keywords. Barriers, Europe, general practice, priorities, research.
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Introduction |
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Research in European general practice
General practice is the cornerstone of many health care systems in Europe.1,2 In many countries, general practice has evolved as an academic discipline with its own curriculum, research base and peer-reviewed journals. However, across Europe, there is a variation in stage of development. In the UK, Scandinavia and The Netherlands, the position of general practice in the health care system is well established—although not undisputed—and there are many academic departments of general practice. These departments are involved in undergraduate education, vocational training, continuing medical education, research and research training. In southern and eastern European countries, academic general practice is still seeking recognition.3 Nevertheless, the importance of general practice for health care is recognized.
However, with regard to research, general practice has to fight for recognition and approval of its research domain. The need for both clinical and health care research is not yet acknowledged by funding organizations on a European level. From a European perspective, general practice as a discipline has failed to attract a sufficient share of European medical research funds. The new European definition of General Practice/Family Medicine was published to inform policy makers, funding organizations and others outside the field about "the essential role of family medicine within health systems at both national and pan-European levels".4 The definition describes essential characteristics of the discipline irrespective of the health care system in which it is applied. These have been translated into six core competencies that the GP should master: (i) primary care management (first contact, unlimited access, all health problems; co-ordinating care, managing the interface between generalist and specialist care); (ii) person-centred care (individual, family, longitudinal continuity); (iii) specific problem-solving skills (wide spectrum of diseases, specific incidence and prevalence, all stages, acute and chronic, co-and multi-morbidity); (iv) a comprehensive approach (health promotion, prevention, early intervention, cure, care, palliation); (v) a community orientation; and (vi) a holistic approach (biomedical as well as psychological, social, cultural and existential dimensions).4 The new European definition should guide European agendas for general practice research, education, teaching and quality assurance.4,5
ESGP/FM interest in a European research agenda
The opinion that general practice as a discipline lacks enough power to attract local, national or European funding and the awareness that it would not be efficient to let each national college of general practice and each university department or research institute invent the wheel for themselves called for a European initiative to set a European research agenda for General Practice. At the WONCA Europe ‘Invitational Conference on Core Content and Core Competence’ (Noordwijk, The Netherlands, March 2002), consensus was reached on the ‘new’ European definition of general practice. During this meeting, the European Society of General Practice/Family Medicine (ESGP/FM) asked its associated Network on research, the European General Practice Research Workshop (EGPRW), to start working on a General Practice Research Agenda. EGPRW took up this task and chose a ‘bottom-up’ approach. As a first step in this process, EGPRW organized a brainstorming session during its 2002 autumn meeting with the aim of exploring the views of active European general practice researchers on needs and priorities as well as barriers for GP research in Europe. This paper reports on the findings of that EGPRW workshop.
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Methods |
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In October 2002, EGPRW held its autumn meeting in Bled (Slovenia). There were 76 participants from 25 European countries. There was an open invitation to a short workshop on ‘the European Research Agenda’. To facilitate exchange of views, the intention was to distribute participants over small discussion groups of countries of the same geographical or linguistic region.
The participants were asked to discuss the following questions. (i) What major topics do you think should be included in a research agenda for general practice in your country? (‘content’) (ii) What are the barriers to adequate implementation of general practice research in your country? (‘barriers’)
The groups listed the topics and issues and prioritized them. The results were discussed in a plenary session. The lists were transcribed and CL and HEJHS summarized and categorized them. ‘Content’ was categorized into seven groups according to research domain (health services research, public health, clinical issues, specific research questions, specific research methods, quality improvement and educational research). ‘Barriers’ were categorized into five groups, according to organizational level, using a format similar to the one used at the WONCA Europe invitational conference in Noordwijk (health care system/politics, academic infrastructure, GPs and practices, postgraduate research training and research networks). Items from the lists were categorized into both tables where appropriate.
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Results |
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The workshop was attended by 43 persons (19 female) from 18 European countries. The participants were GPs (35), other physicians (four), social scientists (three) and one medical student. Thirty-one participants were academic staff members or were otherwise affiliated to a university department; six of them were professors of general practice. Sixteen participants were the national representatives of their country in the EGPRW. The composition of the groups appeared to be diverse with regard to size, health care system and geographical region, and was as follows: (i) UK (n = 7); (ii) Austria (n = 1), Belgium (n = 4) Germany (n = 4) and The Netherlands (n = 3); (iii) Italy (n = 3), France (n = 2) and Portugal (n = 1); (iv) Greece (n = 1), Malta (n = 1) and Turkey (n = 1); (v) Slovenia (n = 5); (vi) Bulgaria (n = 5) and Romania (n = 1); and (vii) Denmark (n = 1), Finland (n = 1), Ireland (n = 1) and Israel (n = 1).
In Box 1, the results of the discussion on ‘content’ of a European research agenda are summarized. ‘Research on clinical issues and diagnostic tools’ was mentioned most often (in six discussion groups). There was almost general consensus on the need for research on education and teaching (mentioned in six groups). Three groups mentioned morbidity registration as a research base for surveillance (in general and in special groups), research, education and medical decision making.
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Obstacles to effective general practice research are summarized in Box 2, ‘barriers’. ‘Insufficient financial resources’ was mentioned in all groups and is represented at GP level as well as at the political level. The need for a proper electronic medical record (EMR) was expressed in three groups and is represented in both boxes as a potential aid in practice management as well as a tool to facilitate research.
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Discussion |
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In a recent editorial in The Lancet, the rhetorical question was raised of whether primary care research was a lost cause.6 The answer was ‘no’ and we agree. In this paper, we attempt to identify a preliminary set of priorities for European general practice research and to give a first impression of what European general practice researchers regard to be barriers for effective research in their country.
Our results express the collective view on GP research of 43, predominantly academic, researchers from all over Europe. They do not represent the view of a random sample of European GPs nor the opinion of European patients. Another limitation of our exercise is that although a draft version of the paper was discussed during the subsequent EGPRW spring meeting in Ankara (May 2003), a formal ‘triangulation’ of the findings has not been performed. However, the workshop participants can be considered as a group of experts on the theme concerned: they represented a broad spectrum of general practice researchers from 18 European countries, practising GPs (35 out of 43) as well as social scientists, and many of them are well aware what is going on in their country (16 national representatives, six professors). Given the diverse composition of our groups, we decided not to analyse on ‘region’, and our results will stress similarities between countries rather then differences; ‘needs’ or ‘barriers’ specific for some countries or regions are less obvious.
We believe that our results are sufficiently valid to be used as a starting point for further enquiry and development. Our approach has some similarities to the process that was followed by the NHS in the UK.7 In that study, ‘research on clinical issues’ and ‘teaching research methods’ were found to have high priority with regard to the content of a research strategy requested for Europe. Furthermore, our list of barriers for effective research in general practice in Europe shows several similarities to the list reported by Haines and Donald.8 Finally, during the discussion of our draft paper at EGPRW's spring meeting 2003, the audience approved our results and thought they correlated well with the core elements of general practice as described in the ‘new European definition’ of general practice. The opinion was that the essential part of the ‘new definition’ was the focus on the ‘specific problem-solving skills’ of the primary care physician and that this element was well represented in our results (‘clinical issues’).
What can we learn from these results?
Box 1 gives an overview of what is regarded to be the ‘content’ of general practice and primary care research. All ‘core competencies’ are represented.
- The topics mentioned under ‘health services research’ represent ‘primary care management’.
- The topics mentioned under ‘public health’ correspond to the ‘community orientation’ of general practice.
- The topics mentioned under ‘clinical issues’ reflect the ‘specific problem-solving skills’ and ‘the comprehensive approach’ of the GP.
- The topics mentioned under ‘specific research questions’ represent all competencies, in particular ‘person-centred care’ and ‘holistic approach’.
Three topics were regarded as most important:
- The core content of general practice research is research on ‘clinical issues’ (common diseases, chronic diseases, risk groups, etc.) including diagnostic strategies: results of this kind of research provide the evidence base for clinical guidelines and support medical problem solving in primary health care (six out of seven groups).
- In order to have a research base for clinical research and teaching in general practice, as well as for surveillance of disease, primary care-based morbidity registration is regarded to be essential (three out of seven groups). Electronic record keeping is crucial to accomplish this task (three out of seven groups).
- There appeared to be a general consensus on the need for research on education and teaching (six out of seven groups).
The ‘barriers’ mentioned in Box 2 vary between European countries. However, even in countries with a well-developed funding infrastructure, the nature of research in general practice is not always recognized. For example, diagnostic research in primary health care rarely involves the evaluation of high-tech instruments, but the evaluation of diagnostic strategies such as medical history, physical examination and simple diagnostic tests. However, this kind of research often requires relatively large studies, involving many doctors, over a number of years. Another example is research on patient preferences, health promotion and risk communication. This requires labour-intensive qualitative design. However, this type of methodology is less well known among biomedically oriented reviewers.
The identified ‘barriers’ can be influenced by the discipline itself. This table can read positively, as a list of conditions that the discipline should try to achieve and maintain. The common denominator behind many of the topics in Box 2 is ‘research training’. This is a key activity to focus on: without proper research training, we will not develop research-minded GPs, productive research networks, GPs with research degrees or a high quality academic research infrastructure.
What can we do with the results of this expert brainstorming session?
In many countries, general practice research networks have already been established as a way to enable individual practitioners to engage in research. This provides a base for achievement and spreading of an evidence-based culture in European primary care. The implementation of comprehensive general practice research programmes that add value to a health care system has been recognized as a real challenge.6 A next step could be to identify for each country the needs with regard to general practice research and the expertise available. In this respect, our findings could be used as a starting point for national checklists of ‘content’ and ‘conditions’ of general practice research (Box 3). EGPRW is planning to make an inventory of the scientific expertise, orientation, research strategies and agendas of departments and institutes of general practice (family medicine, primary health care) across Europe.
| BOX 3 ‘What have we learned?’ The results of the EGPRW brainstorming session on the ‘content’ of general practice research (Box 1) confirm and specify the domains described by the ESGP/FM ‘new definition’ of General Practice/Family Medicine Research on ‘health services’ and ‘public health issues’ should provide the evidence base for health care reform in Europe The core content of general practice research is research on ‘clinical issues’ (common diseases, chronic diseases, risk groups, etc.) including diagnostic strategies; it provides the evidence base for medical problem solving in primary health care Primary care-based morbidity registration is essential for the development of a research base for clinical research and teaching in general practice and for surveillance of disease Electronic medical record keeping facilitates morbidity registration and clinical research; exchangeable software should become available There is a need for research on education and teaching in primary health care The specific nature of general practice research is not always recognized by biomedically oriented reviewers General practice research training is a key activity to focus on Box 2 on ‘barriers’, can read positively, as a list of conditions that the discipline should try to achieve and maintain
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A variety of activities could be developed for research training. Countries in which primary health care and research are relatively well developed could support countries in which general practice is developing. EGPRW and other (international) organizations involved in research, as well as university departments, should take the initiative to create more ways of exchanging knowledge and expertise: organize workshops, scientific meetings and research courses at a price that is affordable by anyone. Other options are creating individual exchange programmes and opportunities for gaining research degrees. Some examples of existing international co-operation in this field are the EGPRW Research Methods Course, the collaboration between UK and Hungary in the ‘Forum’ programme, the Dutch GP training programme in Romania (‘MATRA’ programme), the Mediterranean Family Medicine Group and the Brisbane International Initiative on advanced education for primary care research (UK, The Netherlands, Australia and the USA).3,9 EGPRW—the organization as well as its individual members—participates in several of these activities and is prepared to intensify its collaboration with other groups. Initiatives like these should be developed further and deserve financial support.
Finally, in order to organize the European research network and influence national and European political organizations, EGPRW and other research organizations could co-operate with national colleges under the umbrella of ESGP/FM and WONCA.
In the meantime, EGPRW has changed its name to European General Practice Research Network (EGPRN), to express its ambition for the coming years: not only to continue organizing interactive scientific meetings, but also to participate in building a European primary care research training network and to contribute to the scientific debate on general practice, family medicine and primary health care.
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Declaration |
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Funding: None.
Ethical Approval: The Council of Board Members at the EGPRN Spring meeting in Ankara (May 2003).
Conflicts of interest: None.
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Acknowledgments |
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EGPRW would like to thank all participants in this brainstorming session for their creative contributions to the discussion, and Hanny Prick for making the transcripts of the session.
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Notes |
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* During its scientific meeting in Ankara, May 2003, EGPRW decided to change its name to European General Practice Research Network (EGPRN).
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References |
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2 Starfield B. Is primary care essential? Lancet 1994; 344: 1129–1132.[CrossRef][Web of Science][Medline]
3 Soler JK, Lionis C, Kaloeidas M et al. Developing a Mediterranean Family Medicine Group: the Malta consensus. Eur J Gen Pract 2002; 8: 69–70.
4 Allen J, Gay B, Crebolder H, Heyrman J, Svab I, Ram P. The European definitions of the key features of the discipline of general practice: the role of the GP and core competencies. Br J Gen Pract 2002; 52: 526–527.[Medline]
5 Olesen F. Do we need a definition of general practice/family medicine? [editorial]. Eur J Gen Pract 2002; 8: 138–139.
6 Anonymous. Is primary-care research a lost cause? [editorial]. Lancet 2003; 361: 977.[CrossRef][Web of Science][Medline]
7 Jones R, Lamon Tt, Haines A. Setting priorities for research and development in the NHS: a case study on the interface between primary and secondary care. Br Med J 1995; 311: 1076–1080.
8 Haines A, Donald A. Making better use of research findings. Br Med J 1998; 317: 72–75.
9 Van Es, JC. Dutch–Romanian cooperation in the area of general practice. Ned Tijdschr Geneeskd 2001; 145: 2089–2092.[Medline]
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