Who are we and where are we going? Primary care academics in non-clinical posts

Abstract

The development of a high-quality primary healthcare system requires multidisciplinary perspectives and collaborations between clinicians and non-clinicians. Academic primary care departments across the United Kingdom and Ireland employ academics from a range of disciplines. However, questions remain about the parity of opportunity for career progression with a consistent trend to focus more on clinicians than non-clinicians. In this paper, we analyse the employment and careers of non-clinical primary care academics working in Ireland and Scotland. We draw on survey data from the island of Ireland and conference workshop discussions among Irish- and Scottish-based academics. We highlight problems with career progression and identify some strategic actions. We argue for a renewed attempt to ensure that all academics who are contributing to the discipline of primary care are appropriately acknowledged and supported to continue their endeavours to develop high-quality primary care health systems.

Introduction

Primary care research and development requires a combination of clinical and non-clinical knowledge and a multidisciplinary approach (Health Research Board, 2006). There is general recognition that a large proportion of the research and teaching in academic primary care departments in the United Kingdom and Ireland is delivered by individuals without a clinical background (Bond and Eldridge, 2011). However, the majority of senior-level posts are held by individuals with medical backgrounds (Society for Academic Primary Care, 2002). This raises questions about the parity of opportunity for career progression in academic primary care.

In 2008, there was an expansion of academic primary care in Ireland because of increased funding for health services research. This led to a series of appointments for individuals with and without clinical backgrounds. The first author is the ‘non-medical representative’ on the Executive of the Association of University Departments in General Practice in Ireland and wanted to ensure that she was connected with the growing community of academics working in non-clinical posts. Specifically, she wanted to develop a profile of the backgrounds, employment status and career issues of this community so that she could better represent them at the Executive's meetings. Therefore, the first author initiated a survey of the profile of academics working in non-clinical posts in Ireland. The focus on ‘academics in non-clinical posts’ reflected existing knowledge about the group's profile; there are primary care clinicians in Ireland employed in non-clinical research positions who, therefore, cannot accurately be described as ‘non-clinicians’.¹

The second author has also had a long-standing interest in the career trajectories and opportunities available to non-clinical and early career clinical researchers in academic primary care and has written on this subject previously (Wilson et al., 2005). Subsequent discussions between the first and second author about the survey clarified that the issues under investigation were also of relevance in the Scottish context. A joint meeting of the Scottish Departments of General Practice/Primary Care (ADEGS)/Association of University Departments of General Practice in Ireland (ADUGPI) scientific meeting in Dublin in January 2011 provided an ideal opportunity to present findings of the survey conducted in Ireland to a Scottish audience, to compare and contrast contexts and experiences and to consider strategic action for the future that would benefit academics in non-clinical posts in Ireland and abroad.

The purpose of this paper is to report on the findings of the survey and the workshop and to identify strategic action for the future. No ethical approval was required for these activities as they were among a professional network and participation was completely voluntary.

Methods

Survey of academics working in non-clinical posts in Departments of General Practice on the island of Ireland

This survey was led by the first author. As above, the aim was to generate a detailed profile of academics in non-clinical posts in the Departments of General Practice on the island of Ireland so that she could better represent her colleagues at the meetings of the Executive of the AUDGPI. The objectives of the survey were to establish:

• • Current and projected qualifications

• • Employment status

• • Contributions to academic general practice and primary care

• • Employment issues.

The sample comprised 20 individuals in non-academic posts who were already in contact with the first author because they had self-selected to be part of an e-mail list that she used to communicate with the group. The group had grown organically over time based on formal and informal collegial interactions at primary care meetings and conferences in Ireland.

On the basis of the objectives stated above, survey items were designed by the first author and shared by e-mail with the respondent group for feedback and input. The survey comprised questions seeking factual information about demographics, background and employment status (Qs 1–7) and questions that encouraged a free text response about career issues (Qs 8–10; see Appendix I). The final survey was administered using Survey Monkey in August 2009. This was considered an efficient way to administer a short survey to an existing e-mail group.

Responses to questions 1–7 were analysed using frequency analysis or by collating the reported information in other appropriate ways. Responses to questions 8–10 were analysed according to the principles of thematic analysis with a focus on identifying discrete statements, which could be coded to reflect an overarching theme, such as ‘multidisciplinary working’ or ‘research impact’. Each discrete statement was numbered for the purposes of analysis and reporting (eg, S1, S9). The first author shared the results with respondents by e-mail for comment and verification.

Workshop at ADEGS/AUDGPI joint meeting

This workshop was convened by the authors in January 2011. It was open to academics working in clinical and non-clinical posts because we recognised that career progression was an issue of concern across the academic primary care community in general and that it was not favourable or collegial to create an exclusive event for academics only in non-clinical posts. We presented an overview of career progression issues in Ireland and Scotland. This included information about the survey that had been completed in the Irish context. The rationale for the survey was outlined and methods and results were described. Participants were then invited to work in small groups and to consider three predetermined questions: First, to discuss the findings of the survey in Ireland; second, to compare and contrast career development issues in both settings; and, finally, to identify relevant strategic actions for improving career professional for academics working in non-clinical posts. Each group was asked to identify a note-taker to provide feedback on the small group discussion to the wider group. Feedback from small groups was recorded by the authors on a flipchart and discussed by all to clarify content, understanding and the key points of consensus. The flipchart material was then analysed further by the authors by synthesising the emerging themes under the three areas of discussion.

Results

Irish survey

There were 18/20 respondents to the survey. Twelve were female, three were male and three did not respond to this question. All respondents provided information about their age. Over half of the respondents were between the ages of 25 and 34 years (55%) and just over another quarter were between the ages of 35 and 44 years. The remainder were either <25 years (6%) or between 45 and 54 years (11%). This indicates that the majority were early/mid-career academics.

All respondents provided information about their qualifications and expertise. The disciplines represented include psychology, sociology, anthropology, speech and language therapy, pharmacy, engineering, technology, epidemiology and health promotion. Results indicate that this is a highly qualified group with 11 completed PhDs and three in progress (see Figure 1). Over half of the sample reported quantitative and qualitative expertise (56%), one-third reported quantitative expertise only (33%) and a smaller group reported qualitative expertise only (11%).

Figure 1 Number of Qualifications

The majority of respondents provided information about their current position (14/18) and contractual arrangements (16/18). The majority of respondents (80%) were in temporary ‘researcher’ posts with only four in formal lectureships (see Figure 2). Fifteen out of 18 respondents described their current work duties in their posts indicating contributions to research (grant applications, empirical projects, dissemination), teaching (at undergraduate and postgraduate level) and general departmental duties (eg, webmaster).

Figure 2 Current contractual situation (n = 16)

Respondents were asked an open-ended question about positive aspects of their current employment and 16/18 responded. Forty-five discrete statements (S) were recorded and over half of these referred to a positive work environment with an emphasis on positive experiences of team working, multidisciplinary approaches to research (S34), enjoying work (S22, S15) and gaining satisfaction from seeing research impact on policy and practice (S16, S23).

Respondents were asked an open-ended question about improving current employment and 13/18 responded. Twenty-five discrete statements were recorded. One respondent said that no improvements were necessary (S11). However, just over half of the recorded statements related to career progression issues with reference to the need for career pathways (S17), career prospects (S7), longer-term contracts (eg, S1, S5) and the opportunity for progression to senior-level posts (S12). Two statements referred explicitly to the need for better salaries (S18, S19).

Irish and Scottish workshop

There were ∼25 participants at the workshop, with representation from academics in clinical and non-clinical posts from both countries, including senior, mid-stage and early-stage academics. Reports from the small group discussions indicated that the findings of the Irish survey resonated with the Scottish context in the sense that there were academics with equivalent profiles in Scottish academic departments of primary care, making similar contributions and with similar concerns about career progression. For example, participants spoke about concerns about the lack of career pathways for Irish- and Scottish-based academics working in non-clinical posts. Most were in short-term positions, with no clear progression routes and very poor job security. There was, however, general acknowledgement of similar career pathway problems for primary care academics with medical backgrounds, especially for early-career academic clinicians. Importantly though, it was noted that although colleagues with backgrounds in clinical practice (eg, medicine, pharmacy, speech and language therapy) have the option to leave academia and return to full-time clinical work, this is not true for academics with backgrounds in non-clinical disciplines.

In terms of comparing and contrasting the situation in Ireland and Scotland, the career situation is marginally better in Scotland than in Ireland. The Career Scientist Awards, which are open to clinicians and non-clinicians, have protected money for non-clinicians but there is no equivalent in Ireland. In addition, there are positive examples of permanent posts for non-clinicians and important role models in senior-level appointments in Scotland since 2000. To date, there has been only one permanent full-time lectureship for non-medics in Ireland (established at NUI Galway 2007), and the first professorial appointment in primary care, which was open to applicants from medical and non-medical backgrounds, was filled by a non-medic at the Graduate Entry Medical School at the University of Limerick in 2011. Another important recent development in Ireland is that the Health Research Board has announced a new scheme to establish research leaders in Population Health and Health Services Research in Ireland. This scheme is open to applicants from clinical and non-clinical backgrounds, providing important parity for career progression. See http://www.hrb.ie/research-strategy-funding/grants-and-fellowships/hrb-grants-and-fellowships/grant/88/.

There were three interrelated key suggestions for strategic action to address this situation. First, it is important to develop explicit long-term career pathways for primary care academics in non-clinical posts so that there is opportunity for tenured posts for those on a research and/or teaching track, irrespective of disciplinary background. This would require inter-agency working between universities, professional bodies (such as the AUDGPI, the Irish College of General Practitioners and the Society for Academic Primary Care), funding councils (such as the Health Research Board in Ireland and the Medical Research Council in the United Kingdom) and in Scotland, the Chief Scientist Office, to develop appropriate structures and resources. Second, it would be valuable to explore alternative models to permanent full-time posts for career structure and development. In the University of Aberdeen and in some other parts of Europe, there is a system whereby universities will fund half-time research/teaching posts and security for researchers who can then seek external funding for the remainder of their time. Finally, it was suggested that it is important to raise awareness of the skill base of primary care academics in non-clinical posts among senior university members so that the contributions they are making to teaching and research are fully understood and recognised. This should enhance university participation in any relevant inter-agency collaboration in this area.

There were also interesting suggestions for primary care academics in non-clinical posts to exert action in their own right and at an individual level in order to improve their chances of career progression – for example, developing strategic collaborative research with international colleagues so that teaching and research is of international standing and relevance, and identifying mentors to guide career decisions. Taken together, it was suggested that these actions would improve the quality of individual CVs and enhance success at interviews for any available posts.

Discussion

A survey of academics in non-clinical posts in Irish Departments of General Practice shows that this is a young, predominately female, highly qualified group of academics who are positive about, and interested in, academic primary care and its impact on health and social gain. They value multidisciplinary team working but have concerns about security and career progression. To have 11/18 PhDs in this specific academic population on the island of Ireland is quite remarkable, showing high performance in academic primary care according to national targets for higher education and the knowledge economy (Department of Education and Skills, 2011). These post-doctoral scholars and their colleagues are contributing to the generation of grant income, the completion and publication of research and the education of future medical doctors. Their contributions to the discipline of primary care should be duly acknowledged and rewarded.

The workshop at the joint ADEGS/AUDGPI meeting was well attended by a highly participative group of clinicians and non-clinicians, which confirms the level of interest in this topic. Participants agreed that job security and career progression are major issues that require attention. The workshop discussions were valuable because variation between universities and countries was highlighted, which means that there is scope for learning and sharing models of best practice across institutions and settings. It was positive to see suggestions for individual-level strategic action, but it is imperative that there is inter-agency-level action as well, because high-quality CVs will not lead to much if there are no posts to apply for.

Clearly, there are obvious and significant barriers to the implementation of the identified strategic actions because of the current global economic crisis, which is arguably particularly bleak in the Irish context. However, in Ireland, there is a national and strategic emphasis on building a knowledge economy in general (Department of Education and Skills, 2011) and in the healthcare sector specifically (Health Research Board, 2006; Department of Health and Children, 2009). Therefore, there is a rationale for inter-agency action and collaboration to invest in the education and career development of academics in this field. Otherwise the investments that are being made in primary care postgraduate education and the expertise of early/mid-career academics will be lost to other disciplines and/or other jurisdictions because of dissatisfaction or emigration, among other things.

In terms of planning career pathways, it is important that structures are congruent with promotion criteria in universities so that posts provide both employment and scope for career progression. For example, the development of dedicated research or teaching posts may provide employment, but may mean that an individual is not eligible for promotion within their institution if there is a requirement to excel in performance across both research and teaching.

To summarise, in this paper we have focused on career progression for academics in non-clinical posts. We have highlighted problems with career progression for this group, identified some strategic actions and argued that all academics who are contributing to the discipline of primary care should be appropriately supported in their career pathways.

The limitations of the reported survey are that it is a small survey with a self-selected group. The findings may not be representative of all academics in non-clinical posts in the Irish context and have limited generalisability. The limitations of the reported workshop discussions are, again, that this was a small group of self-selected academics and the emergent discussions have been synthesised rather than analysed systematically. However, the survey findings provide important facts about an important community of the academic primary care community in Ireland, where none previously existed and the workshop confirmed our view that the issues of career progression are problematic on contexts beyond Ireland, and that discussions across contexts can stimulate critical thinking about strategic actions to address this problem. Taken together, these constitute valuable pilot data, which can be used to inform further large-scale research on this important topic. An important next step would be to encourage a collective effort on behalf of primary medical care departments throughout the United Kingdom and Ireland to draw together information about the issues that have been reported here.

Finally, in writing this paper we have discussed individuals from ‘non-medical backgrounds’, ‘non-clinicians’ and ‘academics in non-clinical posts’. It is never positive to be labelled in terms of what one is not. Our suggestion is for all to be described as ‘academics in primary care’ with individuals providing supplementary details about their background in social science/general practice/pharmacy/etc. as appropriate. We believe this would serve an important purpose of providing us with a shared name while also being able to acknowledge diverse disciplinary backgrounds. Importantly, the detail of a medical background should be secondary to the broader name of primary care academic and it should not hold that status as a normative discipline against which others are positioned. This kind of name change would be important symbolically and practically, as it would acknowledge that we are a diverse group in terms of background, but all worthy of equal acknowledgement for our endeavours to develop high-quality primary care health systems for health and social gain in our communities.