Kansliet
Medicinska fakulteten Lunds universitet Box 117
221 00 Lund
Telefon: 046-222 72 14
Region Skåne FoU-enheten 221 00 Lund
Telefon: 046 -15 36 00 www.skane.se/fou
Report into structure and organisation of Primary Health Care Research in the
Faculty of Medicine Lund University
and the Region of Skåne
ACKNOWLEDGEMENTS
We would like to acknowledge the help of: Sven-Olof Isacsson, Professor Emeritus for his article on history of Primary Health Care research in Lund and Eloy H. van de Lisdonk and David P. Weller, and publishers, Oxford University Press, for kind permission to reproduce the paper on research networks; Oxford Textbook of Primary Medical Care 2003, Eds. Jones R., Britten N., Culpepper L. et al.
Foreword
The assessment of research of relevance to primary care was initiated and commissioned jointly by the Region of Scania and the Faculty of Medicine, Lund University. The project arose from a need for research of relevance to primary care, ongoing changes in the public health service, and a need for evidence-based primary care and local medical services. Research of relevance to primary care has also been hampered by organizational fragmentation, both in the Region and the Faculty.
The external working group was to perform a multidisciplinary assessment of the research in question, its focus, its quality in an international perspective and its potential to contribute evidence-based knowledge of relevance to health care and medical services. The task was to include an analysis of the infrastructure and goals of the two organizations and the supply of researchers and research groups at different levels, with special attention to generational change. In particular, the external working group was asked to form an opinion on the relevance of the research to the problems and tasks typical to primary care and local medical services. Finally, the members of the working group were asked to propose objectives and an infrastructure which would serve the interests of both organizations and facilitate joint efforts to produce dynamic and internationally competitive research in close cooperation.
A local committee was formed to carry out the project, consisting of Ingalill Rahm Hallberg (chair), Carl-David Agardh, Rita Jedlert, Hannie Lundgren and Anne Messeter. An external review group was engaged, consisting of Professor Karen Luker, Manchester, Professor Roger Jones, London, Dr Ilmo Keskimäki, Helsinki, and Professor Gavin Screaton, London (advised by Professor John Bell, Oxford), with specialist support from Dr Mats Benner of the Lund University Research Policy Institute. The work was done in a series of steps. Basic documentation was collected, consisting of descriptions and self-assessment of the activities of the researchers during the last five years and plans for the future. The material was sent on to the external working group, who has also consulted independent examiners to assess the international standard of published work. The external working group has had regular meeting and contacts with the local committee and meetings with research groups and Region and Faculty management. Feedback has been given to research groups and management before the completion of this report.
The report, assessment and proposals of the external working group represent their picture of the research in question and its structure. The Faculty of Medicine and the Region of Scania will analyse and revise the proposals of the group, which should not, therefore, be regarded as final conclusions. The Faculty and the Region extend their warm thanks to the members of the external working party for their commitment and efforts.
Ingalill Rahm Hallberg Rita Jedlert
Professor, Deputy Dean Deputy Director, Health and Medical Care
Contents
Foreword
31. Executive summary and recommendations
71.1 Recommendations
71.2 Conclusion
82. Introduction
82.1 The review and review team
82.2 History and contemporary issues in Primary Health Care research
92.2.1 History 10 2.2.2 Development 10 2.2.3 The research agenda 10
2.2.4 Research themes 10 2.2.5 Contemporary issues in Primary Health Care research 11
2.2.6 Characteristics of successful departments of primary care 11
2.3 Research networks
123. Primary Health Care in Sweden and the Region of Skåne
123.1 Primary Health Care in Sweden
123.2 History of Primary Health Care research in the Region of Skåne
143.2.1 Financing of Primary Health Care 15 3.2.2 Primary Health Care research strategy within the Region of Skåne 15
3.3 History and organisation of Primary Health Care research at Lund University
153.3.1 Department of Community Medicine in Dalby 16
3.3.2 Malmö Department 16 3.3.3 Research and Development in Primary Health Care in Lund and Malmö 17
3.3.4 Summary 17
4. Research Funding and staffing
184.1 Funding
184.2 Staffing levels and demographics.
205. Quality assessment and research output
216. Creating a new structure to optimise output and collaboration between the
University and the Region of Skåne
247. Conclusions
26Appendices
1. Terms of reference for the review 2. Primary care research networks 3. List of people interviewed
4. List of researchers and research groups
5. Index of documents submitted to the committee 6. Schedule of meetings for the review team 7. Staff demographics
8. RAE 2001 criteria and results
1. Executive summary and recommendations
Professor Karen Luker, Professor of Community Nursing, University of Manchester, was asked to chair a group to review research activity in Primary Health Care at the Faculty of Medicine at Lund University and within the Region of Skåne. The group met three times during 2004 and made two visits to Lund. This report is based on an extensive review of documents and interviews with Faculty and the Region of Skåne management and a wide range of senior and junior faculty members, researchers and PhD students.
Primary Health Care (PHC) is an important area in terms of healthcare provision but in academic terms is a relatively new and under populated area. The review group was impressed by the contribution that Lund University had made to the education and training of doctoral students. The group were impressed by the high quality, dedication and enthusiasm of the doctoral and post-doctoral researchers and the commitment of supervisors to raising funding.
An assessment of the quality of research in PHC revealed that many of the faculty had internationally competitive programmes of research. Overall it was judged as a whole that the group, although not yet in the top flight, would receive an average or in some cases an above average score if compared with UK universities and in general the group as a whole would be considered comparable to good rather than excellent research groups.
1.1 Recommendations
1. The Committee recommends that the Region of Skåne and the University/Faculty set up a joint committee to examine their strategy and priorities in PHC research. The strategy for PHC research should be updated at regular intervals and besides scientific and research excellence it should serve research and development objectives of the health care system.
The Region of Skåne may wish to ring fence some of its funding to commission research of strategic interest from the University or Institute of PHC research described below.
2. The committee recommends that an institute of PHC research is established. The best site for this will need to be decided depending on whether existing infrastructure can be deployed in either Lund or Malmö. If funding was available a new build supported by the Region of Skåne may provide a prestigious base for PHC research and may aid in future recruitment.
3. Creation of this Institute will require wholesale reorganisation as it is envisaged that it will incorporate Primary Health Care and community based research. It is important that this Institute is located close to the University to allow collaboration or incorporation of other groups coming from the medical specialities, social sciences, epidemiology and health economics.
4. As part of the restructuring to ensure a closer alignment of research to the University, the Region of Skåne and National agendas, the Committee recommends that the Research and Development Centre in Lund should close and its activities subsumed into the Institute of PHC research.
5. Funds will have to be allocated for the recruitment of a top class individual, maybe from outside Sweden to lead this Institute. This recruitment should occur early so that the head can play a major role in the shaping of the Institute.
6. A strategy committee should be appointed to oversee activities within the Institute. It is essential that the Region of Skåne (possibly with involvement of the Municipalities) has both representation and some ability to influence strategy.
This can be achieved through this committee, the employment of some staff within the Institute and the commis- sioning/funding of specific research projects.
7. The committee recommends that the University and the Region of Skåne leads an effort to build a Primary Health Care research network based in the Region of Skåne. This will require considerable start up and recurrent expenditure which will be beyond the scope of the University. This will therefore involve substantial investment by the Region of Skåne. A key to the success of this initiative will be to identify a network leader or leaders who should have links either substantive or honorary to the University but will be firmly based in a practice environment.
8. The committee recommends that PHC researchers should be actively involved in clinical practice for at least an average of one day per week.
9. We recommend that the Region of Skåne and the Faculty examines whether the distribution of ALF support to PHC is equitable and justifiable. It also seems essential to ensure a voice for PHC in the committee disbursing ALF support and the Faculty Strategy Committee as a whole.
10. Faculty should consider developing transparent internal mechanisms/data bases, which make it easier to identify research income, research active staff and research output such as publications and commercially exploitable material.
11. An annual appraisal scheme for all staff should be established where performance as well as academic and profess- sional development and training is addressed.
12. Creation of a formal funded postdoctoral programme incorporating transferable skills in leadership and research management is strongly recommended. We suggest that the use of PhD students and in particular overseas PhD students carrying with them no financial support for their training is not an efficient way to manage research programmes.
1.2 Conclusion
We were encouraged by a number of interesting discussions with both junior and senior members of staff. There is a firm base to build on and we believe that with some refocusing of the research agenda toward issues relevant to PHC, and the necessary investment in personnel and management, that Lund University and the Region of Skåne should be able to secure a place as a major European player in the field of PHC research.
2. Introduction
2.1 The review and review team
In 2003 the Faculty of Medicine at Lund University was the subject of an in depth review by a committee led by Professor John Bell from Oxford University. This review was tasked with examining organisational and structural issues in the Faculty which pertained to the development and maintenance of research excellence at Lund University.
The main aim of the review was to create a more dynamic structure which could identify and respond to strategic research priorities and deficiencies. Several recommendation were made in this report which included: the
establishment of a faculty research strategy committee, opening up of ALF funding to non-clinical researchers pursuing translational clinically related projects, the rationalisation of departmental structures, contraction in PhD training, a reduction in the size of Faculty and the establishment of a post doctoral training programme.
This committee did not examine Primary Health Care and for this reason the Faculty at Lund University approached Professor Karen Luker, Professor of Community Nursing and Dean of the School of Nursing, Midwifery & Health Visiting, University of Manchester to lead this exercise. A review group comprising Professor Luker, Professor Roger Jones Professor of General Practice from Guys, Kings and St, Thomas’ School of Medicine, Kings College, London, Dr Ilmo Keskimäki, Director of the Division of Health and Social Services, National Research and Development Centre for Welfare and Health (STAKES), Helsinki, Finland, Professor Gavin Screaton, Professor of Medicine at Hammersmith Hospital Imperial College, London. In addition Dr Mats Benner from the Research Policy Institute, Lund University assisted the review team. The committee was also aided by Professor Ingalill Rahm Hallberg, Deputy Dean, Professor Carl-David Agardh, Chief of Staff, Specialist in Endocrinology, Lund University, and from the Region Skåne County Council: Rita Jedlert, Deputy Director, Health and Medical Care and Hannie Lundgren, Research and Development Manager. The review group was also provided with excellent support by Anne Messeter, the project manager at Lund University and a schedule of meetings and documentation available to the committee is provided in the appendices 5 and 6.
At the first meeting of the review group it became clear that there were a number of special issues which would need to be examined in detail, which were not a feature of the earlier Faculty wide review chaired by Professor Bell. Of Particular relevance was the relationship between the University and the Region of Skåne (the Skåne County Council) and we were particularly grateful for the help we received from Rita Jedlert and Hannie Lundgren from the Region of Skåne in providing us with much needed information.
The Committee visited Lund on two occasions and conducted a series of interviews with senior faculty, principal investigators, PhD students and representatives from the Region of Skåne. The committee was tasked exclusively with examining research and did not examine the considerable role played by these departments in service delivery or education, although we do not anticipate that our recommendations will have negative impacts in these areas.
One of the issues which challenged the review group was the definition of Primary Health Care and hence the scope of this review. The term Primary Health Care is not ideal and it would be easy to get bogged down in arguments as to where it begins and ends and hence what is in or out. For reasons of clarity we have chosen to include subject areas which have their origins in the history of PHC at Lund University and the University Hospitals or alternatively have a bearing on current issues in PHC internationally.
2.2 History and contemporary issues in Primary Health Care research
Primary Health Care is generally taken to signify first-contact care between patients and health care professionals. In the western European context this usually represents care provided in the setting of general practice and family medicine, although first-contact care also takes place in other settings, such as hospital emergency rooms, with community pharmacists and therapists (physiotherapy etc.) and also can be delivered in the community by specialists, such as those working in family planning and child health clinics. This variety of primary care providers is reflected in the multi-disciplinary nature of Primary Health Care research (PHCR).
2.2.1 History
The research tradition in primary care is relatively short and, with the exception of pioneers such as MacKenzie and Pickles, began in the 1960s when general practitioners working in health service (cf. university) practices began to critically examine issues such as workload, organisation of services and the natural history of common and chronic disorders. Trials and intervention studies were relatively rare until the last two decades, although clinical audit has been a feature of general practice for much longer.
2.2.2 Development
The development of substantive PHCR activity began in earnest with the establishment of university departments of general practice, often with initial responsibilities secondary to the need to provide undergraduate (and in some countries postgraduate) education in general practice and primary care. By the mid to late 1980s many north-western European universities had well-established academic departments of general practice, with professorial chairs, and were engaged in a range of research activities supported by peer-reviewed funding. The publication targets for this research were journals such as the British Journal of Family Practice (previously the Journal of the Royal College of General Practitioners), Family Practice, the Scandinavian Journal of Primary Health Care and, particularly in the Netherlands, native-language journals. More recently, and increasingly, high-quality research publications have appeared in the high- impact generalist journals, such as the British Medical Journal and the Lancet, and also in journals with a focus on health services research and on social science, such as Social Science and Medicine and The Sociology of Health and Illness. It has proven notoriously difficult for general practice research to find a publication niche in North American journals. General practice has often played a leadership role in developing innovative approaches to education, and also in leading the incorporation of topics such as medical ethics in undergraduate curricula, reflected in publications in Medical Education and other cognate journals. A number of university departments have developed particular clinical interests which have involved research collaborations with specialist medicine, notably in the areas of respiratory disease, gastrointestinal disease, mental health and cancer, with this activity sometimes reflected in contributions to papers appearing in a range of specialist journals.
2.2.3 The research agenda
The spectrum of PHCR is broad, reflecting the generalist nature of the disciplines involved. This can be regarded as representing both a strength and a weakness for PHCR. Academic departments of general practice have frequently been able to offer support to otherwise isolated general practitioners with an interest in pursuing their own research interests, and have contributed greatly to the expansion of research capacity in primary care. On the other hand, university research assessment mechanisms have tended to demand more tightly-focused programmes of research, and it has to be said that the acquisition of programme grant funding, a real challenge for many primary care departments, is likely to depend on the recognition of a particular department’s expertise in a small number of research themes.
2.2.4 Research themes
The move from descriptions of the structure and processes of primary care to engagement with research into the outcomes of care has meant that research methodologies have shifted from descriptive, survey approaches to the increasing use of experimental and quasi-experimental methods, particularly in relation to trials of complex interventions, where multi-method approaches, involving qualitative as well as quantitative research have been required. Indeed, the combination of high-quality qualitative research methods with sophisticated quantitative techniques has been the hallmark of much successful research in PHC in recent years.
2.2.5 Contemporary issues in Primary Health Care research
Much research undertaken in Primary Health Care has been stimulated by the recognition that evidence from work conducted in other settings, such as hospital outpatient and inpatient units, has yielded information of limited value to primary care practitioners. Indeed, the unique case-mix seen in general practice, which includes early, diffuse presentations of potentially serious illness, as well as the frequent presentation of minor, often self-limiting disease, makes it essential for primary research to be conducted in general practice. The management of many common disorders is undertaken almost exclusively in this setting, so that the evidence for effective practice needs to be obtained from research carried out there. This is proving particularly important in areas such as respiratory disease, cardiovascular and gastrointestinal disorders and mental health. Primary care-based research is also important because of the increasing need to conform to practice guidelines, which need to be based on evidence collected in primary care.
The current issues of particular importance to primary care research can be broadly described under the twin headings of clinical and health services research, as follows:
Clinical research involves research into the epidemiology, natural history and management of the common – major and minor – conditions encountered in primary care, particularly those mentioned above, and including the major chronic diseases, asthma, diabetes, hypertension, ischemic heart disease and chronic respiratory disease. There are many gaps in the evidence about the most appropriate approaches to diagnosis and management and the best models for long-term care.
Health services research comprises a broad group of research activities, ranging from detailed studies of practitioner/patient interactions in the consultation (often focused on the communication of risk and the transfer of information, often in relation to prescribing and disease management), through issues of quality, equity and access to primary care services and to the evaluation of new roles and methods of providing primary care e.g. nurse /doctor substitution, and also involving policy analysis and development. Much recent high-quality work has been conducted in the areas of meta-analysis, systematic review, guideline development and implementation, and clinical decision support, including the use of information technology.
The prosecution of research in most of these areas necessarily involves a multi-method, multi-disciplinary approach, with contributions from a range of professions, including clinical and non-clinical scientists, colleagues in nursing and the therapies, health psychology, medical sociology, epidemiology, biostatistics and health economics.
2.2.6 Characteristics of successful departments of primary care
Successful and highly rated departments of general practice and primary care generally possess the following characteristics:
• Critical mass
• Focused programmes of research
• Productive collaboration with other academic units, nationally and internationally and with research networks (see below) and with the health service
• High-quality training environment
• Effective, multidisciplinary research, bringing together the range of professionals mentioned earlier
It is important for successful departments to be able to rise to the challenges facing primary care, including:
• A continued funding emphasis on molecular and genetic medicine, sometimes at the expense of clinical and applied research.
• The need to attract long-term, programme funding, rather than relying on opportunistic, project support
• Bibliometric comparability – most of the primary care journals mentioned previously have relatively low impact factors, although successful departments, often through collaboration with specialists and by the conduct of translational research are successful in publishing in high-impact journals.
• The need to please two masters – the universities and the health service.
• Integration of research agendas is becoming increasingly important
• Invariable tensions between teaching and research. Much of the expansion of primary care departments over the years has occurred because of their greatly increased contributions to undergraduate medical curricula, and it is often difficult to balance the need to pursue research with the need to deliver often complex and extensive undergraduate teaching programmes.
• A widespread recruitment and retention problem facing much of clinical academic medicine in the UK and in other western countries.
• Effective leaders of successful departments need to have strategies in place to deal with these challenges
2.3 Research networks
Much of the success of primary care research in recent years has derived from the availability of networks of practices, generally linked to an academic centre, frequently to a university department, which are capable of capturing high- quality data in the conduct of research studies. In this respect primary care research networks represent the community equivalent of the ‘well-found laboratory’ and the concept of the ‘community datalab’ is an important one in thinking about ways of conducting multi-centre large-scale trials of therapeutic and other interventions. Networks often have other functions, including the development of research capacity, research training and the dissemination of evidence- based practice.
The research functions of these networks is very important. The challenge for general practitioners engaged in setting up research projects has often been the need to re-construct a sampling frame for every new study. The establishment of good links with a number of committed practices, which have to be properly resourced, and which are supported by high-quality, mutually-compatible IT systems greatly facilitates recruitment of patients (and practices) to research studies. Many of the most highly-rated general practice departments in the UK have access to primary care research networks of this kind. As well as providing data for research studies, there is recognition that, through engagement of practitioners and their teams in evidence-based practice, participation in network activities contributes to the quality of care provided by participating practices.
Further details about PHC research networks are provided in Appendix 2 (taken with permission from the Oxford Textbook of Primary Medical Care (2003), Eds. Jones R., Britten N., Culpepper L. et al.), in which structure and organisation, key functions and some of the benefits are discussed in more detail. In particular organisational and quality control issues, and the kind of information collected in PHC data bases.
3. Primary Health Care in Sweden and the Region of Skåne
3.1 Primary Health Care in Sweden
The provision of health services in Sweden is primarily the responsibility of the county councils which are relatively independent regional level administrative organisations with elected council representatives and a right to levy income tax. On average, 89% of the budget of the county councils is spent on health care. The county councils cover health care spending mainly through raising taxes which cover over 70% of the total operational costs of the county councils. In addition, central government supports the county councils by non-specific block grants and grants ear-marked for health services. Patient fees cover about 4% of the budget of the county councils. In 2001, 19% of the total public health care expenditure was used for primary care, 58% for short-term care, 10% for psychiatric care, 3% for dental care, and the remaining 10% for other activities.
Primary Health Care services are mainly provided by health centres run by the county councils. The total number of the health centres in Sweden is about 1200 and they serve areas with populations of 10000-50000 inhabitants. The health centres provide a wide variety of Primary Health Care services comprising consultations by general practitioners and district (community) nurses, maternity and child clinics, ambulatory care rehabilitation, and physiotherapy and community dental services.
Since 1995, all physicians working in Primary Health Care in Sweden have been required to be specialists in general practice which requires five years of clinical training practitioners working in the public sector are employed by the county councils and they receive a monthly salary based on their qualifications and work schedule. Due to the requirement of specialist qualification, general practitioners have often a longer training in Sweden compared to other European countries. Since Primary Health Care is mainly provided by public health centres, most general practitioners in Sweden are working at group practices and their practices usually provide a high level of equipment for diagnostics, functional testing and laboratory tests.
Besides general practitioners, the district nurses have an important role in Swedish Primary Health Care, since they often offer the patients' first contact with the health care system. The district nurses are employed either by county councils or municipalities. They administer medical treatment, advice and support at their own offices but also make home visits. District nurses have a basic nursing education of three years followed by specialisation training of 1.5 years in community nursing. Like doctors, district nurses, as well as other personnel at public health centres, are employed by the county councils and receive a monthly salary.
In most health centres, general practitioners and district nurses work in teams providing services for a population of 2000-2500. The primary care team usually also contains a practical nurse and is assisted by other staff, such as medical secretaries and laboratory assistants.
Maternity and child clinics provide services for expectant mothers and children under school age, which are free of charge. Their services include mainly preventive activities, such as regular maternity and child development check ups and vaccinations. While health centres also employ gynaecologists and midwives for maternity clinics, the general practitioners' involvement in maternity care has generally been low in Sweden.
Some services usually regarded as part of Primary Health Care are provided by municipalities. In about a half of the 290 municipalities, home care is provided by the municipality, while the county council health centres are responsible for home care in the remainder. The municipalities also provide some preventive services, such as school health care, and care for elderly and disabled people and for persons with chronic disabling psychiatric conditions.
In addition to public provision, care services are also provided by private providers. Of all outpatient visits in Sweden, about 25% take place at the private practitioners' surgeries. Private health centres and practitioners are relatively common in major cities and urban areas. However, most private providers have contracts with the county council and are thus reimbursed by the county council for attending patients.
In Sweden, the general practitioners are not gate keepers for specialist care. The patients have a right to choose their attending doctor among those working for or having a private care provision contract with their resident county council.
They may also directly contact specialists working in county council hospitals. However, the patients referred by their
general practitioners may expect to have a somewhat shorter waiting time for the specialist's appointment than those without a referral. The patients may also consult doctors not practising in their county council, but a referral may be required.
According to an agreement between central government and county councils, the patients are guaranteed to receive medical attention on the same day they contact their local health centre. In practice, this means a visit to a nurse practitioner. If a general practitioner's consultation is required, an appointment should be given to the patient within eight days. If the patient is further referred to a specialist, an appointment should be offered within three months or within one month when the diagnosis is uncertain.
In Swedish health care, the role of the hospitals has remained strong and hospitals receive a high proportion of the medical resources despite emphasis given to the development of Primary Health Care in health policy since the 1980s.
The relatively poorly developed Primary Health Care sector is reflected by a low number of general practitioners in relation to the total number of doctors working in health care (less than 20%) and by the low number of visits per person to Primary Health Care doctors in Sweden (about 1.4 per year in 2002). For comparison, the proportion of general practitioners to all doctors is 25% for Denmark and 32% for Finland. Correspondingly, the number of general practice visits per person is 3.3 and 2.3 per year in Denmark and Finland.
Patient fees are relatively low in Sweden. For a hospital stay, the fee is SEK 80 per day. Due to the independence of the county councils patient fees vary from SEK 100 to SEK150 for a visit to a primary care doctor, up to SEK 300 for consulting a specialist between county councils. However, there is a uniform cost ceiling for patient fees meaning that after paying a total of SEK 900 for health services the patient is entitled to free medical care for the rest of the twelve month period. Moreover, medical treatment for the patients under 20 is free of charge. For pharmaceutical expenditure, there is also a cost ceiling for patients' personal spending. The health insurance reimbursement rate gradually increase so that the patients pay at maximum SEK 1800 in any twelve month period.
3.2 History of Primary Health Care research in the Region of Skåne
Role of the County Council, the Region of SkåneThe Region of Skåne (the Skåne County Council) was established in 1999 and has overall responsibility for health care within the region. The health care system is managed by a political assembly consisting of 149 representatives. The Assembly decides on the direction of the health care system, overall principles and policies and establishes the financial framework. The Health and Medical Service Committee is one of the Committees working under the Assembly. The committee’s task is to decide on the overall direction for the whole of Skåne, as well as deciding on important principles for the development of health care. The system is divided into five geographic districts, each with its own politically elected committee. The local committees are in charge of the health care within their geographical area; i.e. the hospitals, Primary Health Care and private care.
Primary Health Care is provided to the inhabitants in the region, mainly at local primary care centres. A new organization of PHC (Skåne Primary Care) was implemented in 2000. Five Primary Health Care districts were founded.
Each district contains several local health care centres. The main purpose of Skåne Primary Care is to focus on the well- being and health of the population in Skåne, not primarily diseases and disorders. Skåne Primary Care also allocates financial support for development, education and research within Primary Health Care. Continuous professional training, research cooperation and quality assessment are identified as important issues and are being supported.
Primary Health Care in the region also includes support for the Research and Development Centre located in Lund and for the Primary Health Care unit linked to the Department of Community Medicine in Malmö.
3.2.1 Financing of Primary Health Care
Health care is financed through taxes, and the amount of tax payable is decided by the Assembly. The Region of Skåne finances the greater part of the health care, with some additional state funding for special purposes. In 2002 the budget for Primary Health Care amounted to 1.857.8 million SEK (approx 2.095 thousand SEK per inhabitant of the Region of Skåne). State educational programmes for doctors’ training and work experience for physiotherapists also come within the Primary Health Care remit. Compensation for this is received in the form of ALF funds. In 2003 the revenue was 5,700 thousand SEK for doctor’s training, 178 thousand SEK for physiotherapists and, in addition 1,600 thousand SEK was provided from the University for nurses practical training. Primary Health Care also receives compensation from the Region of Skåne for acting as the host for education and research activities which amounts to 10,300 thousand SEK.
3.2.2 Primary Health Care research strategy within the Region of Skåne
The Region of Skåne has a research policy and vision for research and development work: “to be perceived by its co- operative partners as a leading dynamic organisation and player in research and development – regionally, nationally and internationally – with good European co-operation. This is to create the requisite conditions for positive develop- ment in society to benefit the population.” The vision is to be attained by applying a comprehensive approach to identify, initiate and propel research and development activities.
The main research strategy for the PHC is to focus on research cooperation within Skåne Primary Care and the universities. Grants for projects is one way of strengthening the research within this field. Support and guidance for clinical patient related research projects is also of importance.
The Research and Development Centre in Lund is part of Skåne Primary Care. The aims of the Centre are to support and stimulate research and development activities and to promote increased competence among staff members in the field of research and development. Major assignments are; to arrange high quality education for all professional groups and to promote evidence based medicine in all fields and to coordinate internship and residence in family medicine. The budget for the Primary Care and Development Centre in 2003 (SEK) was as follows:
Central office 4 600 000
Coordinators (14) 4 000 000
CME activities for all professional groups 3 600 000 Supervisors/tutors for internship and residency and secretary 3 300 000
Research funding1 200 000
Special projects (Easy Access) 300 000
Total 17 000 000
3.3 History and organisation of Primary Health Care research at Lund University
The foundation of Primary Heath Care research in Skåne was laid in 1964 when the Swedish government and Malmö County Council agreed to build and operate a medical centre in Dalby (later, similar medical centres opened in Uppsala and Umeå). The Government agreed to guarantee funds for research and education and the County Council was responsible for healthcare services. Research began in February 1968 under the leadership of Senior Lecturer Åke
Nordén from the Department of Internal Medicine at the hospital in Lund. Dr. Nordén became professor of ambulatory Medicine in 1972, but remained at the Department of Internal Medicine at Lund University, from which he ran the research operation in Dalby together with District Medical Officer Gustaf Haglund, who was in charge of medical services. In connection with the 1974 municipal reform a social welfare office was added to the medical centre, after which research encompassed the social sciences as well.
The mandate of the division thus became research and education in Primary Health Care and related areas within the social services. In 1981 family medicine was added as a medical specialty in Sweden and the following year, when Professor Nordén retired, internist Bengt Scherstén was appointed professor of family medicine at Lund University and became Sweden's first professor in the subject. Haglund was succeeded by District Medical Officer Per-Olof Bitzén.
They contributed to the development of family practice as an academic discipline and medical specialty. Educational activities and research have been the cornerstones of this development. Many doctors and nurses from all over the country have completed primary care programmes and/or participated in the annual continuing education programme at Dalby, when new research results were also presented.
3.3.1 Department of Community Medicine in Dalby
In 1981, at the same time that Dr. Scherstén was appointed professor, the University created the Department of Community Medicine in Dalby. This department in Dalby encompassed family medicine (one professor), geriatrics (one lecturer) and social medicine (one lecturer) and the division for research in Primary Health Care and related social services was also based there with one administrator (Bengt Scherstén) for both operations, which in reality functioned as a single division.
The number of dissertations (45) between 1969 and 1999 reflects the research within Primary Health Care and related social services and more recently, in community medicine as well, when organizational changes were implemented. The expertise in medicine and social sciences as well as a well-equipped chemistry laboratory helped to guarantee both depth and breadth in these PhD thesis projects. These thesis projects were in fields such as diabetes, hypertension, infectious diseases, ophthalmic diseases, aging and care for elderly people, paediatrics, healthcare research, maternal health services, joint diseases, immigrants' health, occupational therapy and physiotherapy. Another important accomplishment was the database of ambulatory care visits that the Dalby department established.
In 1993 the research operation (except the chemistry laboratory) moved to the Södertull health care centre in Lund and the following year the operation was reorganized. The Department of Community Medicine was established in Malmö with divisions in family medicine, geriatrics, forensic medicine, and the history of medicine. The unit for research in Primary Health Care and related social services was incorporated into the organization of this department. On December 31, 1998, the department in Dalby/Lund closed and most of what was left (excluding forensic medicine and the history of medicine) was integrated into the Malmö department.
3.3.2 Malmö Department
The Department of Community Medicine in Malmö was established in 1981, at the same time as its counterpart in Dalby. Two positions for professors were opened at the Malmö department; one in social medicine (Sven-Olof Isacsson) and one in geriatrics (Bertil Steen). A position for a senior lecturer in family medicine was also created.
However, despite participation in the primary care segment of the medical school during the early years, research related to primary care did not get off the ground. In contrast, research at the other community medicine units expanded.
Attempts to establish a professorship in family practice at the Malmö department were not supported by the Faculty and the Dalby department was too dominant in the field of Primary Health Care research for Malmö to hold its own. In 1987 Lennart Råstam was appointed to the position of senior lecturer in family medicine in Malmö. Until about 1980 public primary care did not exist in Malmö, but by 1987 the specialty had grown considerably, with several new health care centres and an increasing number of district medical officers.
In 1992 the first dissertation in family practice was defended before the department in Malmö. At the same time the Malmö department expanded and received more external appropriations and services than Dalby/Lund. Since 1987 (when the first dissertation was defended at the Division of Geriatrics) the department has produced 53 dissertations, some 30 of which were completely or partially focused on Primary Health Care and 20 on family medicine. A number of dissertations in health economics were also defended at another faculty at Lund University. Gradually more and more district medical officers interested in research in both Malmö and Southern Sweden came to the Malmö department, where 50 doctoral students are currently enrolled, including 10 in family medicine and another 10 in public health or fields related to primary care.
In 1995 Dr. Råstam became Professor of Public Health Science, associated with a position as senior physician in family practice. Anders Håkansson succeeded him as senior lecturer and in 2003 Dr. Håkansson was promoted to Professor in that field. For the past few years the department has also had three senior lecturers in family medicine. For some time the Department of Community Medicine in Malmö has also had another position for a professor of family practice, held by Birgitta Hovelius. Professor Hovelius is currently active at the Department of Internal Medicine at Lund University.
In recent years the Malmö department has worked with other parts of the country, particularly Skaraborg county.
Dissertations in family medicine have focused on subjects such as maternal and child health, hypertension and diabetes, clinical general medicine and migration medicine. Other research is underway in the fields of pharmaceutical epidemiology and learning within medicine. The department is involved in teaching medical students as well as in postgraduate education in Malmö, Skåne, the Southern Healthcare region and in Denmark.
3.3.3 Research and Development in Primary Health Care in Lund and Malmö
In 1997 a separate unit for research and development in Primary Health Care was established under the same roof as the Department of Community Medicine, managed by the healthcare administration at Malmö University Hospital (UMAS). After restructuring in 2000 the unit was placed under the administration for primary care in the Region of Skåne. After 2003 the organizational responsibility for the unit was moved to the Research and Development Centre in Lund.
3.3.4 Summary
Research and education operations began in Dalby in 1968 under the sponsorship of the Swedish government. The operation acquired great significance regionally and for the entire country. The operation was at its peak during the 1970s and 1980s, after which activity declined. At the same time the Department of Community Medicine in Malmö expanded, attracting large external research grants in a competitive situation. On December 31, 1998, the Dalby/Lund department was closed and the remaining resources were transferred to Malmö. Historically, research in family practice and primary care has a strong, solid position in the Faculty of Medicine's research and education operations.
4. Research Funding and staffing
4.1 Funding
The majority of funding of research with relevance to Primary Health Care in Sweden comes from three sources: the research councils, municipalities and county councils, and the Vårdal foundation.
Public health research is primarily funded by the Swedish Council for Working Life and Social Research (FAS), which allocates over 90 million SEK annually to this field (including funding of family medicine), about a third of its total budget. Of the 90 million SEK, about 50% is distributed to medical faculties. The median grant from FAS is about 700.000 SEK per year, roughly three times the size of the median grant from the Medical Committee of the Swedish Research Council. FAS also supports larger research programmes, for instance for research on elderly people, epidemiology and drug and substance abuse. Such programme grants are typically in the range of 1-2 million SEK annually. FAS also supports a number of large research centres, such as SORAD (Centre for Social Research on Alcohol and Drugs) and CHESS (Centre for Health Equity Studies). No such centre is located in Skåne.
Public health research has traditionally been a highly prioritized area in Swedish research policy, and despite indications that the support of public health research has been reduced during the last few years, the area is relatively well supported with resources in comparison with other biomedical fields. This also shows in the strong position of Swedish public health research in international comparisons using qualitative (peer review) and quantitative measures (bibliometrics).
The public health research landscape in Sweden is heavily dominated by the Karolinska Institute. It is by far the largest receiver of project and programme grants in the public health area, both in terms of funding received and in the number of research projects. Lund University is the second largest public health research institution in Sweden, both in terms of grant size and the number of projects funded. Lund University has its relative strength in the area of social medicine, epidemiology and alcohol research; on the other hand, there are very few grants in the area of family medicine, at least in the years 2002 and 2003.
Allocation of resources to public health research in medical faculties, 2002 and 2003:
University/year 2002 (Million SEK) 2003 (Million SEK)
Karolinska 18.4 23.4
Lund 4.3 7.4
Uppsala 6.0 4.8
Gothenburg 4.8 4.8
Umeå 2.5 3.6
Linköping 2.0 1.0 Source: FAS project register retrieved at www.fas.forskning.se
Another large source of funding for public health research comes from municipalities and county councils. They often allocate resources directly to groups and departments with relevance to the health care system, based on a wide variety of selection and allocation mechanisms. According to estimates from the Region of Skåne, it allocated in total (excluding the Research and Development Centre in Lund) about 18 million SEK in 2003 to the Department of Community Medicine. Of the 18 million SEK, 8.6 million is unconditional support, based on an old commitment from the former Malmö City Health Care Authority. 4.9 million SEK is ALF-funding. Hence, a large share of this support
(not including the ALF-grants) is distributed primarily on the basis of historical trajectories rather than rigorous evaluations and strategic considerations.
Funding of research in nursing (and to some extent also of family medicine and health services research) is dominated by the Vårdal foundation for Health Care Sciences and Allergy Research. The foundation was established in 1994 by the state to support research with relevance to nursing and to allergy treatment, each receiving half of the support. It should be noted that the Vårdal Foundation – which is a foundation with its capital invested in stocks and bonds – reduced its spending dramatically in 2003, following the sharp dip on the stock market in Sweden, and did not support any new projects in 2004.
The size of grants from the Foundation is small, and the median grant is at about 200.000 SEK annually, which covers about 50% of the salary for a PhD student or one third of the salary for a post-doc.
University/year 2002 (Million SEK) 2003 (Million SEK)
Karolinska 6.0 2.1
Lund 2.7 2.1
Uppsala 3.6 1.2
Gothenburg 1.5 1.5
Umeå 1.9 1.1
Linköping 1.5 0.8 Source: FAS project register retrieved at www.fas.forskning.se
The Vårdal Foundation from early on concentrated on research in the area of health care sciences, with many smaller projects and difficulties in integrating research activities into the education-dominated environments. As a result, a working group was appointed which suggested the establishment of a centre for health care sciences, the Vårdal Institute (The Swedish Institute for Health Sciences). After a review process and negotiations between the Foundation and Lund and Gothenburg universities, the Institute was set up in Lund and in Gothenburg, co-funded by the Foundation, the health care authorities and the universities.
The Institute has an open recruitment process, i.e. not only those affiliated with the universities in Lund or Gothenburg can apply. Lund and Gothenburg are, nevertheless, dominant, with about two thirds of the PhD students. Research is organized into three platforms: older people and their health care; psychiatric long-term diseases or functional disability; and physical long-term disease and/or disability. The platforms together employ 35 PhD students and more than 40 post-docs. The research involves several disciplines, including disciplines from the social sciences, human sciences and medical sciences e.g. ethnology, theology, law, medicine, nursing, physiotherapy, health economics, philosophy and psychology. It is noteworthy that a relatively large share of the research staff come from the humanities and social sciences, roughly one quarter of the post-docs and the PhD students. The Vårdal Institute represents a major investment in creating a new structure for health care sciences, not least by connecting research activities in nursing with the social sciences and humanities. The recruitment of PhD students with a medical degree has, however, been less successful.
To sum up, Lund University has a relatively strong position in the national competition for funding in both public health and nursing; second after the Karolinska Institute, which tends to overshadow the other medical faculties in Sweden in almost all areas. It should, however, be noted that its baseline funding from the state is about three times the size of Lund. Lund University, like other medical faculties in Sweden, has a rather impenetrable mixture of resource flows
from the health care system to PHC research, with a wide variety of selection mechanisms and post evaluation criteria.
It seems likely that these resources can be managed in a more transparent and efficient manner if a more stringent and uniform allocation model is adopted.
Currently, PHC research at Lund University is strongly dependent on external funding – apart from the professorships, which in most cases are funded jointly by the University and the Region of Skåne, practically all post-doctoral research positions are based on external support, often in combination with other sources of income (undergraduate teaching, health care service, etc.).
4.2 Staffing levels and demographics.
Family medicine employs three full-time equivalent staff, of which 0,25 of one position is externally funded.
Occupational therapy has two full-time research positions funded by the Swedish Research Council and three positions funded by external sources (the Vårdal Institute, the Swedish Road Administration). Epidemiology has two full-time and two part-time research positions, of which one full-time (professorship) is internally funded by Lund University together with the Region of Skåne. External support comes mainly from FAS but also a large programme grant from the Region of Skåne. Preventive medicine reports 3,25 research positions, 2,25 of which are externally funded and one jointly funded by the university and the Region of Skåne. Physiotherapy in total employs four researchers, three of whom have external support (mainly from the Vårdal Institute). Nursing reports five researchers at a post-doc level, of which all are externally funded, including the professorship (four from the Vårdal Institute). Geriatrics has three researchers employed, of which two and a half are externally funded, primarily from FAS. Social medicine has one full- time position funded by Lund University and the Region of Skåne and three positions funded by external sources. FAS is the most important external funder.
There are also a small number (5-10) of individual researchers in the area of PHC research, many of whom have limited or no funding from the university or from external sources – the main exception is the professorship in family medicine in the Department of Medicine at Lund University.
The age structure of researchers in PHC, like other departments in the Faculty, is rather skewed towards individuals in the last ten years of their career. It can be assumed that at least 15 individuals and perhaps considerably more will retire in this period (appendix 5.). Succession planning will be an important area to address in the future although there are also clear opportunities to be able to capitalize on this headroom to make strategic appointments in order to shape the department of the future. We have chosen not to make specific recommendations on the nature of future recruitment as these decisions will be best be made by the new head of the Institute for Primary Health Care research and the strategy body created to shape its future. It is our impression that the relatively large number of retirements anticipated in the next few years should be viewed more as an opportunity than a liability. The challenge will be to attract high quality individuals to Lund University. It is therefore essential to develop a distinctive research profile which makes a strong national and international contribution to both the academic disciplines of primary care and to the quality of service provision, a combination of excellence with relevance, which will ensure sustained financial support from the Region of Skåne.
5. Quality assessment and research output
One of the central tasks set for the committee was to assess the quality of PHC research at Lund University. One obvious question which occurred early relates to the definition we have used to circumscribe the field of Primary Health Care. In this review we have chosen to use the Starfield definition: First contact, continuous, comprehensive and coordinated care provided to individuals and populations undifferentiated by age, gender, disease or organ system.
(Starfield B 1992, Primary Care: concept, evaluation and policy. Oxford University Press). This definition in the UK clearly singles out general practice as the focus of primary care. In Sweden it is possible for patients to self refer to hospital based practitioners. In the UK these referrals can only be made from general practice. This fundamental difference in referral patterns rather blurs the definition of primary care as self referral can take place directly to a hospital based specialist which will then be the first point of contact that patients have with the medical system.
The research provided for review was very broad ranging. Although an attempt was made to break it into groupings adults, elderly, health economics, children and women the range of research occurring in these groups was diverse.
Another problem relates to Nursing, Physiotherapy and Occupational Therapy. These are developing disciplines which have not yet fully matured and it is difficult to judge these against the more established areas. As demonstrated in the two tables below Lund University has made considerable progress in building these academic departments over the last 10 years which can clearly be seen in the increase in outputs relative to the Swedish and international comparators. It was our feeling that the individuals working in these areas should be congratulated for their efforts in developing these academic departments.
Original publications in international scientific journals with a referee system
Year 90–94 Lund 95–99 Lund 00–03 Lund
Nursing
Number 249 529 1 002
Range (0–65) 5 (0–145) 31 (6–122) 106
Physiotherapy
Number 119 239 388
Range (0–50) 50 (0–70) 70 (5–155) 155
Occupational therapy
Number 21 58 153
Range (0–10) 0 (0–20) 15 (4–40) 38
Publications from 1991–2002 (Pub Med)
Sweden Finland USA Great Britain
Nursing
91–93 374 155 8 257 2 668
94–96 244 79 8 120 2 888
97–99 298 171 8 957 3 860
00–02 357 146 8 386 4 836
Occupational therapy
91–93 98 47 1 690 252
94–96 95 49 1 661 362
97–99 135 74 1 952 390
00–02 99 62 1 740 475
Physiotherapy
91–93 169 72 2 313 522
94–96 192 96 2 547 639
97–99 258 115 2 848 601
00–02 361 115 2 973 875
Terms used Nursing: Nurses; nursing care; nursing. Occupational therapy: Occupational therapy; occupational therapists; activities of daily living; functional ability; disabled persons; disabled. Physiotherapy: Physical therapy;
physical therapy techniques; physical therapists; physiotherapy; rehabilitation; habitation. All searches were combined with Sweden, Finland, United States, United Kingdom or England or Great Britain.
In order to assess research quality we were provided with a brief resume of research and the last five years publications from individuals and groups within the Faculty and the Region of Skåne. Because of the very broad range of subject areas submitted the review group decided to send this submission out for peer review by an expert group of 8 individuals from a top ranking 5∗ Departmentof Primary Care and General Practice. These were examined in a fashion consistent with the UK Research Assessment Exercise (RAE). In this process the output (4 submitted publications over 5 years) of each individual are assessed and rated as either internationally, nationally or sub-nationally competitive.
Each of the submissions provided were reviewed by four different blinded reviewers (a total of 8 senior academics were involved) and the composite scoring was then assessed to produce a consensus overall grade per research group. Where all four independent scores produced the same grading, then this assessment was automatically applied. However, where there was lack of unanimity across reviewers, then the research submissions were re-reviewed in depth by a fifth senior academic (clinical scientist) who was constant to this process.
Each of the reviewers were asked to moderate the research submissions by scoring each individual paper as sub- national, national or international status. These individual paper scores were then considered by each independent reviewer to determine an overall submission score, based on the same categorisation. In reaching these decisions, the reviewers were using information such as paper title indicating original research, observational work, review, or book chapter. A judgement was also reached upon the journal of publication and its impact factor. Finally, where overall submissions were at the borderline between quality grading, the reviewer determined the final score after considering additional factors, such as whether the paper was returned also by other members of the same research team and what order within the author list the submitting researcher was placed.
Publishing in highly ranked international journals will clearly be classified as international if publications are made in journals which are largely nationally based or which have low impact scores then the individual will be ranked national and if the individual is failing to publish in refereed journal then they will be ranked sub-national. Clearly, in some areas of research it is easier to publish in high impact journals than it is in others such as PHC. To compensate for this account is taken of where an individual is publishing in comparison to others in the same field.
The top score, 5∗,is given to institutions where over half of the material is internationally competitive and other parameters such as research environment and peer esteem factors support this judgement, a 5 is given where less than half is internationally competitive but most of the rest is nationally competitive and a 4 is given where most of the material is nationally competitive and there is evidence of some internationally competitive material. We have included the results from the last UK RAE for comparison (See Appendix 8 for further details).
The process of assessment of the submissions was complicated by some incomplete submissions, the diversity of the research and the inclusion of Physiotherapy, Occupational Therapy and Nursing which were difficult to score alongside the medical specialities. Overall 40% of submissions were rated international, 40% national and 20% sub-national. This would therefore give the submission a 4-5 rating. It is admissible for an institution to not submit a small proportion of academics who are primarily involved in teaching or administration which may have slightly affected the scoring. A score of 4-5 in the RAE would be regarded by some of the top Universities in the UK as under achieving because it would have a severe negative impact upon the Government grant awarded to the Universities. However, to put this in perspective PHC and community based subjects traditionally do not do as well as laboratory or hospital based medicine in this assessment and a score of 4-5 was the average for community based clinical subjects in the UK 2001 RAE and would have been above average in the unit of assessment “other studies and professions allied to medicine, or Nursing”
which would subsume caring sciences (Appendix 8).
Although the research was judged to be competitive with a number of UK universities much of the material submitted would not be judged as satisfying our definition of PHC. Particularly as mentioned elsewhere in this report there was a deficiency of research based in general practice and for this reason we have recommended the creation of GP networks and an institute of PHC research.
As well as a relative paucity of general practice based research we also noticed relatively little work on primary mental health care and palliative/supportive care. In addition, although there was quite a lot of activity in health economics much of this research related to macroeconomic issues and less relating to the delivery of Primary Health Care.
Similarly we saw very little work relating to organisational and workforce issues related to care delivery. Because of funding constraints it is clearly not possible to compete in all areas and it is also perhaps not appropriate for us to dictate which areas of research are appropriate for Lund University and the Region of Skåne to invest in. However, in our recommendations later on in this report, we suggest the need for the creation of a strategic committee to map the research agenda and also to ensure that there is some match between academic research conducted in the university and the needs of one of its major sponsors the county council.
Because of the huge differential in remuneration for UK universities the RAE has had a very major impact upon research strategy, organization and staffing. It is no longer permissible to carry failing academics and the new culture aims to reward and maintain success and excellence. The need to achieve at the RAE has also forced universities to develop mechanisms to monitor research output and income and to institute internal audit and appraisal as well as concentrating on staff development and training. As part of this process individuals have become more aware of the quality of their publication records so that attention is given to publication in high impact factor journals rather than purely on the volume of published work. Currently there is no RAE in Sweden, but some of the activities mentioned above may still have relevance in driving research in PHC at Lund University up to a 5* performance standard.
6. Creating a new structure to optimise output and collaboration between the University and the Region of Skåne
Primary Health Care in academic terms is a relatively under populated area. However, the review group was impressed by the high quality and dedication of the doctoral and post-doctoral researchers they met.
During the course of this review it has become clear that there have been a number of changes in organisation and structure in PHC, which although they have occurred in an evolutionary fashion have not necessarily led to the selection of an organisation fit to face the current academic and health care challenges. The committee was impressed by the esteem and affection with which the Dalby Unit in Lund was held. Since its closure in 1995 it would seem that PHC research has lacked a focal point, and most importantly a clear strategy, mission and drive. Attempts to rebuild a hub for such activities namely the research and development centre at Lund have not been successful and activities have become fragmented between Lund and Malmö and connection with General Practice has also not been ideal.
Closure of the Dalby Unit has particularly hit practice based research and although some family medicine has been incorporated into the Department of Community Medicine in Malmö the aim of promoting an integrated link between University, practitioners and Health Service management has not developed. This is in part due to a lack of institutional priority given to these activities in Malmö and also a lack of enthusiastic leadership. There also seems to be a distancing of academics from clinical practice.
The committee recommends that PHC researchers should be actively involved in clinical practice related activities for at least an average of one day per week.
To pursue research in a practice setting will require the recruitment of an enthusiastic group of practitioners to get involved in data acquisition and analysis. The best way to achieve this will be the establishment of a research network in the Region of Skåne. Setting up research networks is a considerable undertaking which will involve addressing a number of thematic, organisational, financial and management issues. The most important factor will of course be the human resource. It is essential that the activity be seen to have benefits to practitioners as a critical mass of enthusiastic and motivated individuals will be the key to the development and maintenance of the networks.
Time spent on this research will have to compete for time in the busy workloads of many practitioners so it is essential that the participants feel a sense of ownership over their activities and that their work is valued by both the Universities and health services. A clear management structure will need to be created to define the goals of the network, help recruit new members, form and maintain links with University and the Region of Skåne and define strategies to create and maintain a stable financial platform for these activities. Leadership in this area particularly in the early stages will be the key.
The committee recommends that the University and the Region of Skåne leads an effort to build a Primary Care research network based in the Region of Skåne. This will require considerable start up and recurrent expenditure which will be beyond the scope of the University. This will therefore require substantial investment by the Region of Skåne. A key to the success of this initiative will be to identify a programme leader or leaders who should have links to the University but will be firmly based in a practice environment.
