Research Perspectives Applied to Primary Health Care

Preface

Chapter 6 Research Perspectives Applied to Primary Health Care

Dr Vasso Vydelingum, Professor Pam Smith and Pat Colliety

Smithet al. (2004) are cautious of the messianic ﬂ avour of the evidence-based health move- ment and invite other approaches to capture evidence, through narratives and participatory action research to both complement and offer alternatives to the ‘gold standard’ of systematic reviews, meta-analysis and randomised con- trolled trials (RCTs). Narrative and participatory action research, as we shall see later, have much to offer the community nurse practitioner.

Readers will be familiar with the changing discourse of health promotion and public health.

This discourse dates back at least to the 1976 policy document Prevention and Health: Everybody’s Business when responsibility for maintaining health and well-being was explicitly shifted from a collective responsibility at the level of government and ﬁ rmly placed on individual shoulders. A subsequent document, the Health of the Nation (DH 1992), was criticised for its nar- row focus on ﬁ ve prescribed areas: coronary heart disease and stroke; cancers; mental illness;

human immunodeﬁ ciency virus (HIV)/acquired immune deﬁ ciency syndrome (AIDS); and acci- dents. Research and development programmes were set up for each of these areas in order to document and reduce their incidence and inves- tigate treatment outcomes. The responsibility for these programmes was devolved to the regional health authorities, which, in 1996, were incorp- orated into the Department of Health.

Harris (1993) believed that changes during the early 1990s within the NHS offered oppor- tunities to redress the balance between ho spital- dominated research programmes of the past and population-based primary care and by inference, public health research of the future.

Historically, there has certainly been a dearth of research in the ﬁ eld of community nursing in favour of topics associated with the care of hos- pitalised adults. The White Paper Saving Lives:

Our Healthier Nation recognised that social and economic issues play a major role in the nation’s health (DH 1999a). Public health initiatives have been a key feature under the auspices of the health development agency and the continued interest in the development of strategies and toolkits to move the agenda forward.

As Wanless (2004) has so clearly highlighted, the emphasis for public health practice has to shift from a focus on individual needs to that of the whole population in order to recognise, understand and tackle inequality. Choosing Health (DH 2004c) refl ects this changing ideology of public health and identifi es ways in which individu- als and communities can be helped to optimise their health, and the importance of public health approaches is also refl ected in policy documents such as Every Child Matters (DH 2004a) and national service frameworks. Resources such as the public health electronic library (www.library.

nhs.uk/publichealth/), the NHS electronic libraries (www.library.nhs.uk) and the primary care electronic library (www.nelhpc.sghms.

ac.uk) ensure that information about these and other initiatives is widely disseminated.

A growing recognition of the impact of the increasing number of people with long-term conditions (LTCs) is another area that has been reﬂ ected in government policy and research, for example the DH document Supporting People with Long Term Conditions (DH 2005c). This document offers examples from social care, the NHS and international initiatives with the aim of helping local health communities improve services for people with long-term conditions. Complementing this is Raising the Proﬁ le of Long Term Conditions Care: A Compendium of Information which focused on the outcomes that people with LTCs said they want from services and describes how more effective management of LTCs in a number of areas is delivering high- quality, personalised care (DH 2005b).

As part of implementing the government’s framework to put patients and frontline staff

‘at the heart of the NHS’, the government pub- lishedThe NHS Improvement Plan: Putting People At The Heart Of Public Services (DH 2004d) which set the priorities for 2004–8. Key points were the identiﬁ cation of primary care trusts (PCTs) as taking a lead role in the changes because of their ‘unique position across community, hospital and primary care’ and at the interface of the NHS and local authority. The need to develop both existing staff and new roles to support innovative services such as Hospital

at Home and Hospital at Night while taking account of the reduction in junior doctors’ hours were also identiﬁ ed. Within the NHS there is a move away from working with traditional roles towards looking at what needs to be done and who is the most appropriate person to do it, all of which must be underpinned by a sound evidence base. Subsequent policy documents such as Our Health, Our Care, Our Say andCare Outside Hospital reﬂ ect this approach too (DH 2006a,c).

Our Health, Our Care, Our Say: A New Direction for Community Services (DH 2006a) has recom- mended a substantial transfer of NHS functions to the community, proposing that upto 15 mil- lion outpatient attendances should be delivered in community settings. While PCTs develop the necessary infrastructures to shift specialist care, it is suggested that most of the control of local health resources be granted to general practices via practice-based commissioning, to avoid fragmentation of services. PCTs will be given the incentives for managing the change through the mechanism of payment by results and such plans require considerable investment in infrastructure and training and would result in fundamental changes in working practices for many health care professionals. The recent announcement (BBC News 1 April 2008) about health screening for the over 40s, may be part of the new initiatives for a greater focus on primary care prevention. Everyone aged 40–74 in England will be offered health checks for heart disease, stroke, diabetes and kidney disease under new government plans, with a full roll out in 2009.

Partnerships with communities and individ- uals working together with health authorities, local authorities and the voluntary sector are seen as key to improving health and promot- ing equity. Schools, workplaces and neigh- bourhoods are identiﬁ ed as the key settings for action. Professionals from different agencies are expected to work together to achieve this. The imperative for partnership working has been given further impetus in the wake of such tragedies as Victoria Climbié, whose cruel treatment and subsequent death at the hands

of her great-aunt went undetected because of a lack of integrated working between the police, health and social services. Although at the time of writing (December 2008) the ofﬁ cial inquiry into the death of Baby P in the same borough has not yet taken place, newspaper reports sug- gest that similar failings in communication and integrated working occurred. A report (Guardian 2 December 2008) commissioned at the conclu- sion of the Old Bailey trial of the toddler’s death highlighted the following failings:

● Failure to identify children and young people at immediate risk of harm and to act on the evidence

● Agencies working in isolation from another and without effective coordination

● Poor gathering, recording and sharing of information

● Inconsistent quality of frontline procedures and insufﬁ cient evidence of supervision by senior management

● Insufﬁ cient challenge by the local safeguard- ing children’s board to council members and frontline staff

● Poor child protection plans

● Failures to ensure all requirements of the inquiry into Victoria Climbié’s murder were met

Readers would be well advised to read the report of the ofﬁ cial inquiry into the death of Baby P when it is published and consider what the similarities are to Victoria Climbié’s case and what recommendations follow.

Joint assessments between community nurses and social care staff to ensure that patients’

health and social needs are considered and the creation of children’s trusts to promote effect ive communication and coordination between all those working with children as highlighted by the Laming report (DH 2003) are examples of how working partnerships can be developed.

The emergence of new roles for NHS staff and the new mechanism for funding primary care discussed above, further enhance the partnership process. The development of children’s trusts, encompassing health, education and social services as well as the voluntary sector,

has also been supported by policy (DH 2004a), as have the development of Sure Start and Extended Schools initiatives.

The NHS Reform and Health Care Professions Act 2002, as well as deﬁ ning the distribution of functions between strategic health authorities and PCTs, also extended the role of the Commission for Health Improvement, and reformed the struc- tures for patient and public involvement in the NHS. Additionally, it provided for joint working between NHS bodies and the prison service and reformed the regulation of the health care professions, including the establishment and functions of the Council for the Regulation of Health Care Professionals; further evidence of the government’s agenda for patient and public involvement and partnership working.

Sir Liam Donaldson (2006) argued that partnerships between health care providers and recipients were key to developing effective health care as:

‘patients, and the citizens from whom they are drawn, are the paymasters and commission- ers of all that we collectively do. As the thrust of governmental policy seeks to devolve decision-making back to communities and indi- viduals, the centrality of the patient becomes ever clearer. I am encouraged by what I see as a paradigm shift in the world around us: the old-fashioned professionalism, often critiqued as paternalistic and distant – a closed shop, has genuinely given way to a new, inclusive and patient-centred concept of professionalism’.

A further factor to consider in relation to the changing milieu of health care provision is the emergence of Social Enterprise organisations, which are not-for-profi t organisations which supply services to the NHS through the commissioning process (Social Enterprise Coalition 2008). The drive towards a plurality of providers is refl ected in a number of government policies, for example Our Health, Our Care, Our Say (DH 2006a), which specifi cally discusses encouraging innovation and allowing different providers to supply services.

Since its election in 1997 and its continued ofﬁ ce until the current time the New Labour

Government has introduced a number of corner- stone documents that continue to conﬁ rm the prominence of evidence-based practice, research, quality and audit as components of clinical governance (DH 2008b). These are regularly updated and can be accessed via the Department of Health website (www.dh.gov.uk/en/

Publichealth/Patientsafety/Clinicalgovernance).

In 1997 The NHS Modern, Dependable stated:

‘The NHS Research and Development strategy aims to create a knowledge-based health service in which clinical, managerial and policy decisions are underpinned by sound information about research ﬁ ndings and scientiﬁ c developments.’

(DH 1997) The NHS Research and Development strategy has subsequently shifted its emphasis to support these initiatives (DH 2006e,f, 2008a,b). Active research programmes are encouraged, based on locally deﬁ ned priorities and alliances in order to develop specialist research which ‘reﬂ ect con- sultation with NHS users and staff’. The need for a capacity building strategy to take the pro- posed research forward is also acknowledged.

The increased prominence of public health policy, the development of new roles and new funding models all lead to a renewed emphasis on a broad sweep research agenda to incorp- orate the associated ﬁ elds of primary care, health promotion and public health to ensure the rhetoric matches the reality.

The importance of research skills to community nurses and public health practitioners is highlighted by a study undertaken by the three authors of this chapter (Vydelingum et al. 2004).

They were commissioned by the local strategic health authority to create a vision for public health and undertake an audit of public health skills among the local community nursing staff.

This included school nurses, practice nurses, health visitors and district nurses who all identiﬁ ed a range of research, epidemiological and change management skills as being essen- tial for taking the new public health agenda forward.

Changes to local working arrangements such as meeting targets for ﬁ rst contact, public health and chronic disease management, as outlined in the report Liberating the Talents (DH 2002), and subsequent documents such as The NHS Improvement Plan (DH 2004d), Liberating the Talents for Nurses Who Care for People with Long Term Conditions (DH 2005d) also highlight the need for new skills as part of the development of new community nursing roles.

For example, the impact of the new roles on nursing practice and perception are captured in the following quotation featured in a paper by Franks and Smith (2002). A nurse consultant working in the care of older people describes the scope of her new role that allows her to work collaboratively with other professions thus:

‘central to this job is trying to forge links between health and social care. I work with entire ward teams of nurses, domestic staff as well as strategically with the PCT (Primary Care Trust). I have told people about my role – the community team, other professionals, trust boards, voluntary organisations… and I’m still doing it two years later.’

From a reading of government policy therefore, there is clearly a need to identify an appropriate knowledge base and ﬂ exible and innovative research methodologies and methods for investigating a range of issues associated with health service reform in general and public health and primary care in particular. The next section examines the knowledge, methodologies and methods required to fulﬁ l the research requirements of the current primary health care and public health agendas.

The knowledge base for public health and primary health care practitioners

Primary health care practitioners constantly have to respond to complexities of clinical situations, political changes, societal demands and economic challenges such as increased migra- tion, refugees and asylum seekers. Consequently they need to draw on knowledge from a range of

disciplines including medicine, epidemiology, psychology, sociology and anthropology. The ﬁ eld is complex and as such needs a multidisci- plinary approach to its practice, education and research.

Epidemiology, often described as the corner- stone science of public health (Mulhall 1996) is concerned with the occurrence, distribution and determinants of states of health and disease in human groups and populations (Abramson &

Abramson 1999). Scientiﬁ c knowledge, which predominates in medicine and epidemiology, is associated with facts and theories. On closer scrutiny these are not necessarily set in tablets of stone, as the risk factor literature illustrates. For example, stress, which prevailed as a risk factor in the development of peptic ulcers for decades, was overturned during the 1990s in favour of a bacterial model of disease causation. Researchers demonstrated that there was a strong association between the organism Helicobacter pylori and the occurrence of the condition (Moore 1995).

The discovery of this new information was not welcomed by the drug companies at ﬁ rst and indeed ﬁ nancial reasons may have played a part in delaying the uptake of the bacterial rather than the stress theory of causation.

Practitioners need to ‘accept that the information and research we talk about today is based on yesterday’s understanding’. It is also necessary

‘to understand the limitations of our present knowledge’ and acquire ‘skills to evaluate new information and research fi ndings and to apply this to tomorrow’s situations’ (Rees 1992). As clients and patients are becoming well informed through the media and the internet, primary health care practitioners are no longer the only holders of evidence or information about dis- eases and treatments. They need to become more familiar therefore with critical appraisal of the literature, research methodologies, methods and fi ndings and evaluate them in the light of practice. Rogers (2005) suggests that nurses have been sharing knowledge and experience with others through ‘on the job’ learning and this form of knowledge has been critical in the development of nursing. Ways of doing this are through refl ective practice and increasing

research mindedness. The practitioner who combines reﬂ ection and research mindedness is in a good position to apply research to practice and undertake research to generate knowledge to advance practice.

Reﬂ ective practice and research mindedness

Refl ective practice described by Benner (1984) and Schön (1987) assists practitioners to work in a refl ective and analytic way to recognise their fi eld knowledge, evaluate research fi ndings and guide future practice. Researchers work in similar ways, moving between the fi eld, the literature and their data to make interpretations to generate fi ndings and guide future research.

Research mindedness is deﬁ ned by the Royal College of Nursing’s research group as ‘a critical and questioning approach to one’s work, the desire and ability to ﬁ nd out about the latest research in the area and apply it as appropriate’

(Royal College of Nursing [RCN] 1982). Such a view is also shared by Parahoo (2006), suggesting that research mindedness involves an attitude and an ability to ask questions of one’s practice but not necessarily all having to carry out research.

Practitioners need to be involved in practice-based inquiry; however, Freshwater & Bishop (2003) contend that practitioners may be involved at different levels. This may range from knowing what good evidence is and using such evidence to guide practice, how and where to ﬁ nd it and how to evaluate it, to undertaking research to produce evidence that will inform practice. To achieve this, practitioners require a good understanding on the most suitable research method- ology and methods.

For the primary health care practitioner who shares many similar work experiences to social workers the elements of research mindedness identiﬁ ed in a textbook for social work practitioners seem particularly relevant (see Box 6.1).

Although Everitt and colleagues published their textbook in 1992 their original insights on refl ective practice and critical thinking are still as pertinent today. This defi nition of research mindedness refl ects an integrated approach to research-based practice. The emphasis for the

authors is clearly not simply on doing research but on using its theoretical perspectives and methods to think analytically about and inform practice. Research mindedness also allows practitioners to identify their own knowledge and expertise that would otherwise go unrecognised and undetected. Being research minded therefore encourages reﬂ ective practice and critical thinking, challenges the status quo and con- structs arguments to defend resources and assist decision-making (Smith 1997).

Box 6.1 The characteristics of the

research-minded practitioner (Everitt et al.

1992)

● Constantly deﬁ ning and making explicit their objectives and hypotheses

● Treat their explanations of the social world as hypotheses – that is, as tentative and open to be tested against evidence

● Aware of their expertise and knowledge and that of others

● Bring to the fore theories that help make sense of social need, resources and assist in decision-making with regard to strategies

● Thoughtful, reﬂ ecting on data and theory and contributing to their development and reﬁ nement

● Scrutinise and analyse available data and information

● Mindful of the pervasiveness of ideology and values in the way we see and understand the world

Everitt et al. Applied Research for Better Practice, 1992, Macmillan. Reproduced with permission of Palgrave Macmillan.

Evidence-based approaches to primary health care practice have been formalised in the rise in nurse prescribing powers through the introduc- tion of extended nurse and supplementary prescribing to provide patients with quicker and more efﬁ cient access to medication (DH 2003).

The contribution community nurses make to the monitoring and evaluation of health care has long been demonstrated, as evidenced in a series of papers compiled by the Health

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