How Does Research Activity Develop in General Practices? A Series of Organisational Case Studies.

This thesis examines how research activity develops in general practice in the UK. It is based on the concepts and theories of organisational development, and seeks to enhance understanding of the triggers and barriers that moderate and mediate the adoption and embedding of general practice research as an organisational process. The theoretical framework is based on Van de Ven’s model of organisational triggers and shocks and on findings from Greenhalgh’s study on the diffusion, spread and sustainability of complex innovations in the service sector. Research in general practice is conceptualised as a complex innovation, and as such can be examined in terms of the seven components of the model (the nature of the innovation, the characteristics of potential adopters, interpersonal and inter-organisational influences, the internal (organisational) context, the outer (environmental) context, and the implementation process. This study has four main stages. Stage 1 was an exploration, using semi-structured open-ended interviews, of why GPs become involved in research and what organisational aspects helped to promote research activity and identify some key issues which hindered its development. Stage 2 was the development of an organisational perspective using an emergent in-depth case study approach to look at research development and research governance in general practice; and Van de Ven's framework for organisational development forms the theoretical basis for this work. Stage 3 comprised a series of case studies of general practices looking at the adoption of research activity as an organisational innovation. This stage was based on interviews with staff and executives from three research PCTs and a re-analysis of the data gathered in Stage 2 using the Diffusion of Innovations Framework developed by Greenhalgh et al. A brief fourth stage looked at why research fails to get started at all in some practices. GPs become involved in research because it provided stimulation and a way of answering clinical questions that would help to improve their service delivery. Research activity was seen as a way of raising the profile of the practice among colleagues, patients and the wider community. The major disadvantage of research was seen to be the time commitment and its inability to compete with service delivery activities in making financial contributions to the practice. Research practices may go through a series of phases when developing their research capabilities. These phases are based around a number of key events and processes. There appears to be a five-phase model of practice development in relation to research activity (creative energy, concrete planning, transformation/ differentiation, consolidation and collaboration). Movement between these phases is not linear or continuous, but showed emergent and adaptive properties in which specific triggers and set-backs were often critical. The Diffusion of Innovation Framework describes the uptake of research activity in general practice and the implementation and development of research activity depends on a range of issues including the practice’s needs, the inner and outer contexts of the practice environment and the support available for the practice. Some GPs choose not to undertake research because for many time, money and bureaucracy all mitigate against involvement, many GPs prefer the short time frame for feedback that being an educator or service deliverer provide. The long time frame for results in research is not something that motivates GPs. Again, the findings are interpreted using the model from the diffusion of organisational innovations. The conclusion from this research is that some practices and GPs will never get started in research, despite the encouragement of policy makers and research networks. These GPs will prefer to concentrate on service delivery or may get involved in education delivery to medical students, registrars or colleagues. The practices which do get involved in research activity will always wrestle with the difficulty of justifying from a patient and financial basis. Policy makers and managers can do much to facilitate the spread of this activity and, using Van de Ven’s approach, introduce more triggers and reduce the setbacks to this developing. Research activity should be treated as an innovation and that if policy makers, local managers and GPs which to promote its adoption many aspects should be considered. These aspects include ensuring that it has a relative advantage over alternative activities such as teaching, that it addresses local needs and that the inner and outer contexts are appropriately configured