Best research – For what? Best health – For whom? A critical exploration of primary care research using discourse analysis

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Abstract

Health research is fundamental to the development of improved health and healthcare. Despite its importance, and the role of policy in guiding the kind of research that gets addressed, there are very few empirical studies of health research policy. This paper redresses this, exploring the means by which one area of health research policy is shaped, enabled and constrained. We ask: what are the historical, social and political origins of research policy in primary care in England? What are the key discourses that have dominated debate; and what are the tensions between discourses and the implications this raises for practitioners and policymakers? To answer these questions we employed a Foucauldian approach to discourse analysis to explicitly recognise the historical, social and ideological origins of policy texts; and the role of power and knowledge in policy development. We adapted Parker's framework for distinguishing discourses as a means of selecting and analysing 29 key policy documents; 16 narrative interviews with historical and contemporary policy stakeholders; and additional contextual documents. Our analysis involved detailed deconstruction and linking across texts to reveal prevailing storylines, ideologies, power relations, and tensions. Findings show how powerful policy discourses shaped by historical and social forces influence the type of research undertaken, by whom and how. For instance, recent policy has been shaped by discourse associated with the knowledge-based economy that emphasises microscopic ‘discovery’, exploitation of information and the contribution of highly technological activities to ‘UK plc’ and has re-positioned primary care research as a strategic resource and ‘population laboratory’ for clinical research. Such insights challenge apolitical accounts of health research and reveal how health research serves particular interests.

Introduction

Policy can be broadly conceived as the translation of political values into changes in society, with the policymaking process involving dialogue, argument and influence (Bacchi, 2000, Fischer, 2003, Majone, 1989, Russell et al., 2008). Writers such as Fischer (2003) and Sanderson (2006) argue for greater attention to the emergent nature of policy and fundamentally moral nature of the choices involved; in other words, recognising that what might be regarded as the ‘best’ course of action also involves some kind of value judgement. We align with this view, arguing that policy is a complex intervention – as opposed to, for instance, a simple clinical intervention such as a drug therapy – and must be analysed in its social, political and historical context.

In this light, health research policy must be considered in relation to social, technical and political developments. For instance, it is important to consider how, as countries have become defined less in terms of geographical borders and more as ‘corporate states’ in competition with one another, health research (as part of the science base) has been reoriented as a national strategic resource to secure competitive advantage (Stein, 2002, Stoneman, 1999).

To understand how health, research and policy interact, our paper explores the means by which one area of health research policy is constructed: that of primary care research. We ask three questions: What are the historical, social and political origins of research policy in primary care in England? What are the key discourses that have dominated debate about primary care research policy; and which have been suppressed or excluded? And what are the tensions between discourses and the implications this raises for practitioners and policymakers? To answer these questions we frame ‘primary care research’ in the wider context of health, research and science policy in England.

We begin by describing the context in which primary care research has developed. We then describe our approach to studying policy; before presenting our findings and considering implications in subsequent discussion.

The field of primary care ranges from first point of contact to everything outside of hospital, encompassing a range of disciplines and professional groups. In this sense, it provides a valuable exemplar to explore how and why health research is shaped and moulded. However, there is also much that makes primary care research distinctive. In particular, the complex, applied and context-bound nature of primary care research generally requires highly diverse, interdisciplinary research teams and addresses fundamentally different types of research questions from those relevant to (say) hospital medicine. Hence it is important to appreciate the context in which primary care research has developed.

However, there is a distinct lack of empirical work on which to draw: although considerable energy goes into developing health research policy, very little is written that is capable of describing (through empirical observation) the forces shaping policy with studies only recently emerging on the development of national health research programmes (May, 2006, May et al., 2003, Williams et al., 2003). This is surprising given the increasing attention paid to health research by governments that view health research as integral to their national ‘system of innovation’ (Elzinga & Jamison, 1995), offering the potential to deliver scientific and technological advances and economic growth through the exploitation of ideas (Stein, 2002) and link this with practical concerns to improve health.

Take the recent publication of a revised NHS R&D Strategy (DH, 2006), re-badged as a Government (as opposed to what was formerly a government department) health research strategy. This re-badging suggests a substantial ideological shift in delivering NHS support for wider government commitments, enhanced political intimacy between science and government, and allocation of an explicit role to health research in the government's strategy for building a knowledge-based economy. However, limited empirical work has been undertaken exploring such shifts. Unravelling the trail of policy-related documents reveals that the revised strategy emerged out of high-profile recommendations at ministerial level on the future of UK health research (DH, 2004), Government consultation on future investment in science and innovation (HM Treasury, 2004), substantial increases to NHS R&D funding, and the creation of a UK Clinical Research Collaboration (UKCRC) with a vision of establishing the UK as a world leader in clinical research and developing close partnership between government, the voluntary sector, patients and industry (Department of Health, 2004, Department of Health, 2006). The dominant view presented in such documents is of policy as value-free (Shaw, 2006, Shaw, 2007).

So how and why have such changes occurred? The field of science studies has much to reveal about the social and political context of changes in science and technology. The financial crisis of the 1970s is described as an important starting point for considering recent transformations. This is because the broad policy response facilitated economic liberalisation and the orchestration of contemporary science policy (Elzinga and Jamison, 1995, Stein, 2002), as well as linking of science and technology to industrial innovation and academic research to commercialisation (Barben, 2007, Demeritt, 2000). Whilst primary care research received little government attention during this time, from the late 1980s successive governments' strategies for a primary care-led NHS, combined with the perceived need to ‘procure evidence’, meant that it became more visible as part of the policy agenda (Shaw, 2006). Political impetus (including a national report on the state of primary care research (Mant, 1997)) helped to secure increased funding from 1997 for a period of 5 years.

Health research was subsequently reoriented around a series of managed research networks focused on pre-defined clinical areas and providing NHS infrastructure to deliver high quality clinical trials (DH, 2004). Whilst primary care was initially omitted, a new National School for Primary Care Research and a Primary Care Research Network for England have since been established.

Section snippets

The analysis of policy in its social context

Traditionally, policy analysis has adopted rationalistic approaches, been strongly influenced by conventional scientific method, and placed importance on the search for generalisable findings devoid of the social context from which they have been drawn (Fischer, 2003, Sanderson, 2006). The tendency has been to consider social problems as somehow existing ‘out there’, waiting to be ‘discovered’ and ‘solved’. This led to a focus on delivery of pre-defined programme goals, with assumptions

Results

Our findings indicate that health research policy shapes, and is shaped by, a ‘knowledge-based economy’ discourse. We first describe this discourse, how and why it has emerged and the meanings allied to it, before exploring the means by which it has transformed primary care research.

Discussion

Health research and associated policy are fundamental to the development of improved health and healthcare. However, there are very few empirical studies in the field. Our paper goes some way to addressing this gap. Our findings show that contemporary health research policy has its roots in the development of a knowledge-based economy that situates research as an object that governments can use to manipulate knowledge production, predominantly in support of economic growth and global

Acknowledgements

Our thanks go to all those who participated in interviews and to anonymous reviewers whose comments have helped to shape this paper. This work formed the basis of a PhD supported by the Department of Health National Coordinating Centre for Research Capacity Development and continues via an interdisciplinary postdoctoral fellowship funded jointly by the Economic and Social Research Council and the Medical Research Council.

References (36)

  • C. May et al.

    Health technology assessment in its local contexts: studies of telehealthcare

    Social Science & Medicine

    (2003)
  • T. Williams et al.

    Normative models of health technology assessment and the social production of evidence about telehealth care

    Health Policy

    (2003)
  • Academy of Medical Sciences

    Strengthening clinical research

    (2003)
  • C.L. Bacchi

    Women, policy and politics

    (1999)
  • C.L. Bacchi

    Policy as discourse: what does it mean? Where does it get us?

    Discourse: Studies in the Cultural Politics of Education

    (2000)
  • D. Barben

    Changing regimes of science and politics: comparative and transnational perspectives for a world in transition

    Science and Public Policy

    (2007)
  • E. Burman et al.

    Discourse analytic research: Repertoires and readings of texts

    (1993)
  • D. Cooksey

    A review of UK health research funding

    (2006)
  • D. Demeritt

    The new social contract for science: accountability, relevance, and value in US and UK science and research policy

    Antipode

    (2000)
  • Department of Health

    Research for health. A research and development strategy for the NHS

    (1991)
  • Department of Health

    Research and development for a first class service: R&D funding in the new NHS

    (2000)
  • Department of Health

    Science and innovation strategy

    (2001)
  • Department of Health

    Shifting the balance of power within the NHS. Securing delivery

    (2001)
  • Department of Health

    Research for patient benefit working party: Final report

    (2004)
  • Department of Health

    Best research for best health: A new national health research strategy. The NHS contribution to health research in England

    (2006)
  • Department of Trade and Industry

    Bioscience 2015. Improving national health, increasing national wealth

    (2003)
  • M. Edelman

    Constructing the political spectacle

    (1988)
  • A. Elzinga et al.

    Changing policy agendas in science and technology

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