University-linked localities

Abstract

In this article, we propose that reframing the old concept of ‘academic general practices’ as ‘university-linked localities’ will help to integrate the work of those leading commissioning, education, research and public health. It will provide a ‘playground’ for different disciplines to creatively interact for the benefit of all.

History of academic and practitioner partnerships in London

General practice has a long tradition of academic excellence, within university departments, academic general practices and in establishing higher qualifications. However, as with public health, the partnership between the worlds of ‘those who think and those who do’ – between theory and practice – has always been problematic. Clinical commissioning makes it more important than ever to bridge these worlds. We need leaders who are skilled at theory and practice.

Divisive structures are to blame. There are just too few opportunities to learn from and with each other. Instead, those who are concerned with undergraduate teaching, postgraduate training, research and clinical practice operate largely in isolation from each other. In London, the five university primary care departments do cooperate with one another and with bodies in their neighbourhoods, but contacts with postgraduate training are informal and sparse. The system relies on a small number of individuals who span these worlds. A better system would build a network of relationships, which would allow everyone to dip in and out of each others lives and learn through osmosis. Whether this requires formal associations across the silos, as was suggested in the 1990s but never implemented, is an open question.

Between 1995 and 1998, the London Initiative Zone Educational Incentive (LIZEI) programme provided resources for primary care practitioners to step back from their practical work, reflect on it and learn. This was intended to overcome the problems of recruitment, retention and refreshment of London general practitioners (GPs). In 1998, over 100 participants contributed to a King's Fund symposium to highlight the lessons of LIZEI. The book that followed from the symposium describes these lessons¹ and makes interesting reading because it emphasises our present need to develop local leaders who are both practical and informed. Here are some extracts:

If properly coordinated, the system of national education levies (SIFT, MADEL and NMET) together with R&D funds provides the wherewithal to develop primary care. The different funding streams have yet to be devoted to maximum effect. (Gillam, Easmon and Leech, p. 28)

… a partnership is needed between practitioners, health authorities, academic departments, colleagues in the primary care team as well as people with a broader understanding of adult learning. (Bowler, Petchey and Murphy, p. 41)

University departments and postgraduate establishments, including the RCGP, need to work closely with Primary Care Groups (the ‘local health authority’ of the time) to ensure that involvement of primary health care teams in undergraduate education, postgraduate learning and research can develop synergistically… One such model is the University Linked Practice (ULP)… (Wallace and Heath, p. 115)

The idea of a ‘university-linked practice’ has been flirted with ever since. The idea that a hub of practices could give access to the field for various academics is attractive to universities. It could streamline administration and cross-pollinate ideas. But it became clear that asking one practice to engage comprehensively in all academic activities was not feasible, and the idea was left on the shelf.

Instead, the next attempt to facilitate academic/practitioner partnerships came from networks. In 1997, the UK NHS Research and Development Strategy recommended an investment in primary care research networks (PCRNs) to ‘achieve an evidence-based culture in primary care’.² PCRNs and other networks for quality in primary care quickly proved their worth in recruiting into academic-led research projects. East and West London became the first and second fastest recruiting centres in the world for the famous ASCOT study on hypertension.

PCRNs aimed for much more than recruiting patients into academic-led research. They intended to increase the capacity of primary care to inquire into, and collaborate to improve healthcare. Between 1998 and 2002, data were gathered about the ability of four networks (West London Research Network – WeLReN, North Central Thames Primary Care Research Network – NocTeN, East London and Essex Network of Researchers – ELENoR, and Hertfordshire Primary Care Research Network Consortium – HertNet) to do this.³ This revealed that different types of network processes are associated with different outcome profiles. A ‘top down’ network is good at attracting funds and political support. A ‘bottom up’ network is good at highlighting practical primary care experience. A ‘whole system’ network is good at facilitating ongoing multidisciplinary collaborations. Network leaders thought that a hybrid network is possible, that would provide ‘top down’ support for ‘bottom up’ engagement in collaborative inquiries and ongoing service improvements.

But the main approach to academic/practitioner partnerships has remained ‘top down’; needed by academics and obliged by academic-inclined practitioners. Now, clinical commissioning groups provide a new driver that might change this. They are obliged to harness ‘bottom up’ insights and energies to integrate whole systems of care. Theories of networks, organisational learning and community development, previously of little interest to practitioners, now offer answers to the practical question posed by commissioners: ‘how do we integrate care?’

Each of the four PCRNs studied between 1998 and 2002 used shared projects and learning spaces to help practitioners and academics to share their insights and try out new ideas. Commissioning groups need to provide these, and link them together to stimulate broad engagement in ongoing collaborative inquiries and coordinated improvements.

University-linked localities

University-linked localities offer a mechanism to support local collaborative inquiries and coordinated service improvements. Universities can help practices that undertake undergraduate teaching, postgraduate training and research recruitment to cluster together in geographic localities, in which at least one practice regularly engages in each activity. Resources will flow to those practices as before. Sequential research teams would enjoy security of access to the field. The practices and the area would benefit from a steady stream of students and other resources. Public health and local authorities could join in, leading health promotion campaigns, undertaking health needs assessment, and informing the evidence base for health improvement. Together they could become a ‘community of practice’ skilled at devising and evaluating locally-relevant service improvements.

The community of practice is of course, a loaded term, coined by Wenger as a descriptor of situated learning taking place in a group of common workers.⁴ Only in the last 20 or 30 years has UK primary care started to function in this way. We envisage that the need to commission integrated care will stimulate evolution to geographic clustering of practices, and they will find the community of practice approach very useful. University-linked localities could become a main way to nourish such communities, to the benefit of all.