Background
Academic primary care encompasses the activity of practitioners, researchers and teachers from multiple backgrounds (see Table 1), who are committed to the development, improvement and delivery of high-quality primary healthcare. It ‘shines a light’ on the daily work of primary care, offering a critical and creative voice to help shape it and engender a vision of primary healthcare. Although a young and relatively small discipline, APC has considerable impact internationally (Glanville et al., Reference Glanville, Kendrick, McNally and Campbell2011; Watt, Reference Watt2011): a sign it has ‘come of age’. Continued success depends on maintaining the multidisciplinary workforce necessary to deal with the complex primary care environment.
Background disciplines of the UK Academic Primary Care Workforce (From a UK-wide SAPC survey, 2013)
SAPC = Society for Academic Primary Care.
Findings from the MacKenzie Report (SAPC, 2003), a comprehensive review by SAPC Heads of Departments (HoDs), were that the APC workforce was much smaller and lacking in critical mass compared with branches of secondary care medicine. It was also comparatively less well supported by both universities and the National Health Service (NHS), most noticeably among senior primary care academics, but there was also a deficit in middle grades, both of which threatened to undermine APC's long-term viability. Unsurprisingly, career progression was noted to be problematic, both for clinical and non-clinical academics. The report called for clear career pathways and reliable funding to allow career progression.
Since then, HoDs’ surveys (SAPC, 2004, 2007) have shown rising numbers of professors and senior academics, but a steady fall in lecturers, suggesting lack of refreshment of the pool of junior academics joining. More recent findings, since the ‘bedding in’ of the Walport Report (UKCRC, 2005), aimed at modernising medical career pathways by creating closer linkage between clinical practice and medical education, are more encouraging. They show a small but steady increase in clinical academics in general practice: higher than increases in most other areas of medicine (Fitzpatrick, Reference Fitzpatrick2010). Parallel career pathway modernisation has been implemented for other NHS scientists (www.nhscareers.nhs.uk). We expected these modernisation programmes to have improved APC career sustainability.
However, during the last decade several universities have restructured APC, resulting in the loss of distinct departments. This is mainly due to preparation for the Research Excellence Framework, creating larger research groupings. Additionally, in some universities, primary care academics with a teaching role have been moved into generic medical education departments. This means that academics with a primary care clinical background and those who research primary care provision are often no longer affiliated to a primary care organisational unit, which can both support their professional identity and discipline needs, and provide a visible APC face to the outside world. Simultaneously, the advent of the National School for Primary Care Research has focussed APC resources within eight highly rated English universities, with implications for supporting universal development, delivery and evaluation of a person-centred primary healthcare vision through critical scholarly activity.
The changes imposed on the NHS by the NHS Health and Social Care Act (2012) compounds the effect of these processes. General practitioners (GPs) have unprecedented organisational and commissioning power, but those in APC are facing uncertainty about NHS funding for research and posts, and how best to engage with new NHS structures. This may entice GPs to develop their leadership role within clinical practice rather than academia, which could result in a split between scholarship in and of primary care.
In light of all this, SAPC is re-examining career sustainability and what it means to be a primary care academic. The overall question examined was:
• Are APC careers sustainable in the current academic and NHS climate?
With sub-questions:
1. What career pathways do primary care academics follow?
2. What factors enable and sustain APC careers?
3. What difficulties do primary care academics encounter in building a career pathway and in career progression?
4. What has changed over time?
5. What needs to be done to support future APC career pathways?
Methods
Phase 1 of the research involved semi-structured interviews carried out by executive members with a purposive sample of 15 primary care academics from a cross-section of disciplinary backgrounds and career stages, across the range of UK universities engaged in APC. A qualitative approach was most suitable for applying the concepts of normalisation process theory: sense making, engagement, action and monitoring (May, Reference May2006), which were used to understand participants’ career pathway narratives.
Consequently, interviews explored facilitating factors and barriers affecting key transition points (eg, job changes, promotions), including UK-wide APC changes; and also participants’ academic identity and what APC means to them. Interviewees included both SAPC members and non-members.
Findings
Two broad themes relevant to sense making and engagement emerged: ‘organisational factors’ and ‘identity and values’. As in the MacKenzie report (SAPC, 2003), lack of clarity and flexibility in career pathways was reported to constrain APC career progression. This affects all disciplines, causing most distress in mid-career (ie, middle-grade research fellows and lecturers). One mid-career primary health care scientist (PHCS, ie, a researcher without a medical background) commented:
11 years ago, I was promoted to Senior Research Associate but I haven't had any promotion since because there is nowhere to go ……apart from moving into a tenured post which is not becoming available.
Similarly, a mid-career academic with a medical background said:
You can move up and you can be, you know, a head of year….but I don't think that's even a move up as such…..you don't get paid any more, you just have more responsibility ……if there is any kind of next step up, I don't actually know ….what the pathway is.
Senior and junior academics reported concern about lack of flexibility in career pathways: there are fewer entry points and fewer opportunities to move in and out of APC compared with previously. One senior academic with a medical background remembered:
there was no sensible career path but on the other hand, for the right person with the right skills….however difficult, you could go outside a structure and do things that look non-standard and still….get to where you thought you might be going…
Factors undermining sustainable careers were, not surprisingly, largely related to funding difficulties and job insecurity, including: loss of funding through shifting government and funding body priorities, or lack of fellowship opportunities at key stages (getting started in APC or mid-career). National Institute of Health Research fellowships were much valued and appreciated, but are not universally accessible. On-going uncertainty and high job insecurity undermined the sustainability of APC careers in a vicious circle. A typical comment from a mid-career PHCS was:
that…feels paradoxical….When you are establishing yourself and you are getting more and more esteem, also externally outside of the University and getting in a situation where your funding situation is becoming worse rather than getting any better or keeping the same….That psychologically for me has had quite an impact.
Also having a negative impact on career sustainability were organisational cultures characterised by division between different APC constituencies: clinical and academic GPs, people with medical backgrounds and PHCSs, researchers from different methodological traditions, and sometimes between male and female colleagues – giving rise to strain and perceived disparity in opportunities and access to resources.
Many of these issues related to wider questions about the organisation and management of academia. However, participants also offered evidence of ways to overcome problems. They said the sustainability of APC careers is enhanced by good mentorship including, for example, encouragement and help with applying for fellowships and offering career advice. An early career PHCS explained:
It's just having …somebody encourage you to do the right things… And I've been very much encouraged to do things, so I'm on a committee at the [X] society because it was encouraged… And I'm on the editorial board for the journal because it was encouraged.
Likewise, a senior medical academic recalled:
the good transitions have nearly always been under the guidance of a respected mentor…certainly that's when I've made the good transitions.
Other ‘sustainers’ were organisational cultures embracing: scholarship, academic freedom and creativity; valuing the expertise and unique contributions to APC of different disciplines; commitment to the development, inclusion and retention of good staff; flexible work hours for those who need them; a ‘rounded’ and not a functional approach to working (ie, where people are involved in all aspects of projects and not just skill-specific components); creative ways of using funds to support individuals; and where there was a strong shared vision of why their work is worthwhile. Emphasis on valuing horizontal, multidisciplinary team structures appeared to mitigate divisive structural problems.
Despite the many challenges described, suggesting little has changed over time (Lester et al., Reference Lester, Carter, Dassu and Hobbs1998; SAPC, 2003), most people were committed to an APC career. The key explanation appeared to be that the identity APC confers can also mitigate structural problems. APC provides opportunities to apply discipline-specific knowledge and skills to the ‘real world’ work of improving primary care practice; and, simultaneously, scope to work within a context offering congruence between people's personal values and interests. A mid-career PHCS explained:
I was interested in….primary care, I mean I am very much in end of life care and the focus is that I have done quite a few things which were fun and interesting but sometimes a little bit self indulgent and so I was quite keen to engage with the issues in end of life care and palliative care ……some of which were to do with personal interest and what I did feel were a little bit more important…
People were keen to continue in APC, despite the difficulties, if their work is congruent with their personal values. Achieving this relied on people being proactive and developing resilience in what can feel like a hostile employment environment. Mechanisms involved people finding meaning in their work, gaining feedback that their efforts are worthwhile and securing opportunities to promote themselves and their work. One mid-career PHCS emphasised the importance of:
communicating what you are doing and….also being proactive in attracting funding…. you know that will need to be signed off by the Head of Unit and I think that's a good way to increase your visibility too to show that you have got ambition and you want to move on, and are committed to staying.
There was, however, uncertainty about the discipline of APC. Some participants had difficulty articulating what it is or being able to distinguish it from, for example, health services research. Lack of a clear and positive vision for APC is a difficult background against which to plan to sustain APC career pathways, or integrate the needs of different workforce constituencies. It also prevents promotion of the discipline to others. Primary healthcare scientists told us that career opportunities within APC, while very attractive, are not well known about outside it: most arrived in APC unplanned.
APC's external image is also a problem. An early career PHCS explained:
…people doing fantastic things in surgery or in hardcore clinical research or lab stuff… it just seems probably more exciting what they are doing, than…‘plodding old primary care’ because, but then I think that is not necessarily a valid way of looking at primary care, because a lot of the work that does go on in the primary care field is exciting and it is innovative and it can change things, but maybe the perception of it, is often that it's a little bit old fashioned and old hat.
Conclusions
Despite career modernisation, many previously identified difficulties in sustaining an APC career remain (Lester et al., Reference Lester, Carter, Dassu and Hobbs1998; SAPC, 2003; SAPC, 2004; 2007; Wilson et al., Reference Wilson, O'Donnell and Bateman2004), which constrains our ability to deliver improvements in primary healthcare for patients. Findings highlighted clear challenges and opportunities for our discipline – the need for leadership supporting a vision of APC, and for primary care academics to be able to articulate a working definition of the discipline. The next step for the SAPC executive is gaining fuller understanding of sustainability across the United Kingdom, including what motivates primary care academics. A UK-wide survey, a five-year planning initiative and a mentorship scheme are among activities already underway to address career sustainability (see Table 2). Visit the SAPC website www.sapc.ac.uk to find out more.
SAPC's potential solutions for overcoming constraints on the sustainability of APC careers
SAPC = Society for Academic Primary Care; APC = academic primary care.
Acknowledgements
This research was funded by the UK Society for Academic Primary Care and ethical approval was given by the University of Warwick Biomedical Research Ethics Committee. The authors wish to thank all the primary care academics who generously gave their time to take part in the research.
