The Research Agenda for General Practice/Family Medicine and Primary Healthcare in Europe: A solid basis for innovative research

Over the past half century, in many European countries general practice has steadily moved forward from making its first steps in shaping its specific professional and academic identity towards a quite strongly developed research-based medical discipline among other ones. After a period of defining and implementing key concepts such as direct accessibility, generalism, and continuous and personal care, and of establishing input in undergraduate education and designing a vocational training programme, research could develop. Important cumulative steps subsequently were: obtaining conceptual and methodological support from social sciences (in the 1960s); descriptive epidemiology of primary care morbidity patterns (1960s and 1970s); clinical (epidemiological) research in the primary care context (1980s); and quality of care research (1990s) (1).

Nowadays, academic recognition for general practice has been obtained in many countries, as was for example emphasized by the Royal Netherlands Academy of Sciences in 1994 (2). For general practice, and for primary care in general, it has now been widely recognized that its academic presence is not only important for appropriately achieving its own healthcare mission, but also as an essential basic value for healthcare and society as a whole (3,4). Of course, some assertiveness and alertness keep necessary in the academic medical and specialist domain, not so much because of active opposition but since in the academic arena the specific added value of any discipline must be scientifically shown and justified continuously (5,6).

In such a context, making the too often implicit and sometimes heterogenic general practice research agenda more explicit and comprehensive, is a very welcome step forward. The authors of ‘The Research Agenda for General Practice/Family Medicine and Primary Healthcare in Europe’, the first part of which is published in the previous issue (7), are therefore to be commended for achieving this important piece of work. They describe the Agenda’s objectives to provide guidance for further research and policy, and advocacy of general practice/family medicine (GP/FM).

The Research Agenda has a special commitment to the European context. This is a sensible choice, since European primary care has a rich tradition with vital European organizations (WONCA Europe, and the European General Practice Research Network (EGPRN)), and strong international and national journals. Moreover, there are many cultural similarities and health-related transnational problems such as infectious diseases and environmental exposures, and common challenges of ageing, unhealthy lifestyle, chronic illness, and migration. At the same time there is also much variety with relevant contrasts, in content, primary healthcare delivery, and healthcare system. For the years to come, with unavoidably increasing European integration, there is a lot to learn from one another’s ideas, experiences, quality of care approaches, system solutions, and policies (8). Furthermore, cross-border arrangements for healthcare delivery and insurance are to be increasingly expected. These issues will all be relevant topics for the European Research Agenda. However, acknowledging the importance of the European focus, also the worldwide perspective will become more important. In this context, international communication, the need of worldwide learning, sharing international responsibility and mutual supportive missions and between challenges and, also in facing huge global health challenges, and worldwide capacity building are key developments. This is also recognized by the Agenda’s authors.

In formulating the Agenda, a thorough methodology was applied. An analysis of healthcare-oriented research needs was related to already available and lacking evidence, combining literature reviews, expert consultations, and intense discussions in a European context. The Research Agenda is based on the six widely accepted core competences as defined by WONCA Europe (9). Since not all aspects could be covered and choices had to be made, this is an understandable choice. Accordingly, in specific research projects to follow, further elaboration will be needed. Personally, I would prefer a slightly differently presented and more compact set of core principles: direct accessibility, generalism, continuity of care, and family and community orientation, as these principles are the most specific for general practice, and all other aspects can be derived from these. Moreover, also for research this compact set represents an effective framework. However, in practice, we can be confident that the relevant research questions to be studied can be well covered by both approaches.

The Research Agenda rightly states that using a wide range of methodologies is essential for GP/FM research, which is in fact the case for all innovative research nowadays: new insights, often unexpected, emerge especially where new connections and bridges between methods and disciplines are being made. Indeed, multidisciplinarity is a basic requirement for fruitful research anno 2010. At the same time however, the Agenda’s authors say that ‘The focus of the Research Agenda is primary care delivered by GPs and multi-professional practice teams coordinated by them’. While this is fully understandable, two issues arise: is this approach not too much profession-centred rather than patient centred? Moreover, is team coordination always a task for the GP, and is healthcare not coordinated by them less relevant for the research agenda? Although I do not expect important research topics to be missed as a result of this focus, involving other primary care relevant disciplines, not only MDs, might provide extra opportunities in future updates of the Agenda.

There are other choices made by the authors that are understandable and acceptable, but which Agenda users must consider when making their conclusions. First, in achieving a primary care focus, the authors searched in Pubmed for RCTs labelled with the MeSH terms ‘family practice’ or ‘general practice’ and published since 2003. However, randomized controlled trials (RCTs) not performed in a formal GP context but that are, e.g. population-based such as most screening trials or community health interventions, may also be relevant for GPs. In addition, many good trials carried out before 2003 are still representing leading evidence. A second point is that in domains with a large volume of references, the authors’ reviews were limited to meta-analyses, systematic reviews, and RCTs, while editorials, unsystematic reviews or opinion papers were excluded. However, especially these excluded types of papers may open new insights and suggest innovative hypotheses for a future-oriented agenda. Systematic reviews and RCTs are typically focused on testing already generated hypotheses or quantifying effects, representing ‘review’ rather than ‘preview’. Therefore, given these limitations that are transparently stated and justified, for readers using the Research Agenda additional search may be needed before deciding on further steps.

Finally, on the occasion of the publication of a Research Agenda, it is appropriate to consider whether research outside the Agenda will also be useful and possible. While enthusiastically applauding the work for this Agenda, my answer would be: yes, as progress is also often in the unexpected. However, when checking the agenda before or after developing a new idea, a researcher can be either confident that the Research Agenda considers this a relevant issue based on an available, authoritative analysis, or should be challenged to make explicitly clear that the suggested topic is relevant in addition to ‘what is already on the Research Agenda.’ To serve these purposes, the Agenda is a solid basis and key reference for innovative research.