Leading Academic GP and Health Service Researcher
Inaugural RAND Chair of Health Services Research at the University of Cambridge where he founded and directed the Cambridge Centre for Health Services Research (CCHSR), a collaboration between the University of Cambridge and RAND Europe.(2009-2016)
Martin Roland trained in clinical medicine at the University of Oxford, where he obtained a first class honours degree and his doctorate. Following vocational training for general practice in Cambridge, he worked in London and Cambridge before moving to the Chair of General Practice in the University of Manchester in 1992. In 1994, he established and subsequently became Director of the National Primary Care Research and Development Centre.
Between 2006 and 2009, he was also Director of the NIHR School for Primary Care Research, a collaboration between the five leading departments of primary care in England. Clinically active throughout his career, his main research interests were in developing methods of measuring quality and evaluating interventions to improve care using both quantitative and qualitative methods. With over 350 publications, his h-index is 80. Professor Roland was appointed CBE for services to medicine in 2003.
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Hello, I’m Chris Salisbury and today I’m talking to Martin Roland, who is the Emeritus Professor of Health Services Research at the University of Cambridge. Martin has been one of the most influential academic general practitioners in the UK over the last 20 or 30 years, particularly in terms of the impact of his research on policy. Thank you very much for joining us. Let’s go back to the beginning. Have you always wanted to be a doctor?
Martin Roland: I wanted to be a train driver up till I was about seven years old. But after that, I wanted to be a doctor. And it was, I’m afraid, largely because my father was a doctor and my grandfather was also a doctor. So, it was without too much thinking, and I never really deviated from that throughout school, but I was very happy, and I’ve always been comfortable with the idea of being a doctor.
CS: And did you think you’d become a GP?
MR: I went to Oxford, and trained in Oxford, and one of my consultants was Director of Clinical Studies and was, in effect, in overall charge of the clinical school. I had an interview with him as I left, having been his houseman for six months, and I said at that point that I was undecided whether to do paediatrics or general practice. He strongly urged me not to do general practice because, in his words, he thought that would be a waste. I very recently had cause to chat to him about that again, he’s now well into his 90s, and he remembered saying that. And he said to me “Well, I suppose you made a decent shot of it.”
CS: So, what led you into academia?
MR: That was almost accidental. Towards the end of my vocational training, I got engaged to my then wife, who was a paediatrician and she was moving to a lecturer’s job in London. We were pretty sure we didn’t want to live in London long term because, in those days if you joined a practice, you joined for good. So, I was looking for some sort of job in London in general practice for a few years. And, having done minimal training in research I thought that maybe work in an academic department would fit. I looked around and found a couple of people who I thought would be interesting to work for. One of them was David Morrell. I wrote to him and asked if there was any chance you’ve got a job? He was about to advertise a lectureship in general practice, which I applied for and got, and then spent that four years in a really good research training environment at Saint Thomas’s.
CS: And is that when you did your PhD?
MR: Do you want to know the story of my doctorate?
CS: I was going to ask you about that because you did this work on back pain, which isn’t the most obvious topic considering the rest of your career.
MR: I had a number of false starts…Doctors mostly did an MD (rather than a PhD) in those days and I decided to look at the natural history of back pain presenting in general practice. And, it was supervised by David Morrell and Walter Holland, who was professor of epidemiology at Saint Thomas’s at the time.
I had a choice of submitting to University of London, where I was a lecturer, or to Oxford, which was my alma mater. I decided to go for Oxford because they had really smart DM gowns. I submitted to Oxford, which in those days was an unsupervised thesis. You simply submitted it, and they didn’t viva either unless you were borderline. And, after a few months, the result came back saying it was a straight fail, which was, I have to say, a major disappointment at the time. Slightly ironically, the papers that came out of that study are by far my most highly cited papers and are still being cited quite regularly. But, there was no appeal. I did a further study on back pain, cut the original thesis by half and added the extra study, talked to the Oxford Head of Department to try to ensure that it wasn’t examined by orthopaedic surgeons this time, which is what happened previously, and finally got my doctorate. But it did take nine years in the end, so it was a bit of a struggle. And, did I go and get it in person? I certainly did.
“It was successful in a number of ways. It was successful in providing career development for a substantial number of people who went on to ‘chairs’ elsewhere. I haven’t counted but, I think it is probably between 12 and 15.”
CS: You’re the third person I’ve interviewed and one theme that comes out of all interviews is that things happen that may seem to be a disaster at the time, and that very few of us have a straight line to success. Things happen along the way.
MR: Exactly. Bad things happen, and they aren’t always terminal.
CS: I first met you when you were in Cambridge, and you then went to be professor in Manchester and established the National Primary Care Research and Development Centre, which was very influential. Tell us about that.
MR: It was a very fortunate time to move because, very shortly afterwards, the Government advertised a contract for the National Primary Care Research and Development Centre with 15 million pounds, which was a huge amount of money in the early 90s, on a ten-year contract, both of which were unheard of before. We applied from Manchester, jointly with York and Salford Universities, and were exceptionally fortunate to have got that. That long term funding, and to be able to think long term about the sorts of projects that you could do, and to be able to give your staff reasonable security of tenure, made a huge difference to what one could achieve. We had a steering committee from the Department of Health who came and reviewed us after one year. Some of the civil servants were minded to close us down because we hadn’t really made a difference to anything within a year but, fortunately, there were other guys on the committee who said that, actually, things take a little bit longer than a year. It was successful in a number of ways. It was successful in providing career development for a substantial number of people who went on to ‘chairs’ elsewhere. I haven’t counted but, I think it is probably between 12 and 15. So, it proved to be a really good training ground for academic staff from a range of disciplines. It was very multidisciplinary, as my work has always been. Clinical doctors were often at the heart of things but we had economists, we had sociologists, we had statisticians, psychologists, and my ethos has always been that, if you want to do a particular piece of work, first think about the expertise that you need and then make sure that you’ve got really good experts in those areas.
CS: Not that long after that was the introduction of the NIHR School of Primary Care Research, and you became the first Director. Do you think that’s been a success?
MR: It is a very different model because the funding is spread across a number of different schools and it has certainly enabled a number of things to happen, including career training and development, because there are some really tricky gaps in people’s careers if they want to become academics. Doctors, especially specialists, face a big reduction in income if they don’t become NHS consultants with a private practice. There is a big gap between finishing your PhD and being able to get some sort of tenured or semi tenured post. One of the things that I was pleased to be able to do, when I sat on the ‘Walport’ committee in the mid 2000’s, at a time when academic medicine was under real threat partly because of the RAE (Research Assessment Exercise) rules, was in establishing some sort of career pathway and academic clinical fellowships that General Practice has benefited from significantly, and there’s no doubt that it’s provided very good funding for some excellent work. To what extent have there been collaborations between the universities, or has it just strengthened the individual members? I’m not sure, which doesn’t mean it hasn’t happened.
“Governments have been obsessed with access to general practice and have consistently failed to understand the importance of continuity of care and that there is a trade-off between those two things.”
CS: Then, in 2009, you moved back to Cambridge as Rand Professor in Health Services Research. I mentioned that your research has had a huge impact on policy and I’ve got three things in mind. First I’d like to ask you about your research on patient experience because I remember you developing the General Practice Assessment Survey, and there was the financial incentives for practices to do surveys, and then you were very instrumental in developing the National GP Patient Survey. How much do you think they’ve really fulfilled the aim of improving quality, what have they achieved?
MR: All those things you said are correct. I’ve been very influential and very involved in all of those things, and I think they’ve made hardly any difference to policy. If I give you an example. Governments have been obsessed with access to general practice and have consistently failed to understand the importance of continuity of care and that there is a trade-off between those two things. In the very first iteration of the national GP Patient Survey I and one or two others fought pretty hard to try and get something in relating to continuity of care, and we weren’t going to get much. In the end, we were only allowed two questions which relate to continuity. These were – is there a particular GP you prefer to see? And, if there is, how often do you get to see that doctor? And partly because politicians weren’t very interested, that question has survived over 15 years and we’ve been able to track longitudinal continuity over that whole period of time and watch it decline and decline and decline. Governments have occasionally said that they might try and do something about it. In this Government’s manifesto, they’ve said they’ll do something about it. Whether they actually will, we shall wait and see. This is an aspect of performance that has been demonstrably declining very substantially in the last 10 or 15 years, but has been ignored by policymakers.
So, no, I don’t think patient surveys had much influence on policymakers and, frankly, I doubt very much that they’ve made an awful difference to what practices do. They’ve been tremendously useful for research!
Patients valued seeing a doctor who knew them well over rapid access. Cheraghi-Sohi S, Hole A, Mead N, McDonald R, Whalley D, Bower P, Roland M. What do patients want from a primary care consultation? A discrete choice experiment to identify patient priorities. Annals of Family Medicine 2008; 6: 107-115Access the paper here
“… financial incentives improve quality but not very much, and usually nothing like as much as the payers think they’re going to. And secondly, that for quality improvement generally, there’s no magic bullet, there’s no single thing that improves quality of care.”
Final report of the programme grant: Burt J, Campbell J, Abel G, Aboulghate A, Ahmed F et al. Improving patient experience in primary care: a multimethod programme of research on the measurement and improvement of patient experience. Southampton (UK). NIHR Journals Library April 2017.
CS: There been a whole raft of papers coming out, not only for you, but for lots of other people and it’s one of the great things that so many people have done studies based on the data. Your interest in surveys is linked to your overarching interest in how we measure and improve quality. And again, I think of you as one of the main architects of the Quality and Outcomes Framework (QOF) in England, introduced in 2004, which again generated lots of papers that had a big impact. Looking back, what do you think about its pros and cons? Or rather, not looking back because it still exists.
MR: One of the things that people don’t always realize is why ‘QOF’ was introduced in the first place. It came at the time when the Blair government had decided to give a major boost to NHS funding and committed to increasing to mid European levels in terms of GDP. As soon as that happened the hospital doctors, of course, thought of all sorts of ways of spending the money because they are really good at that. The GPs were a bit stuck for what they were going to do. And right at the end of the 1990s, there was a real recruitment crisis in general practice and general practice pay had fallen substantially behind that of hospital doctors. There was a tacit agreement between the Department of Health and the BMA that GP’s needed a big pay rise but the problem was that the Treasury was not going to give them money for nothing. And so the deal was that GP’s would offer quality and in return they would get a decent pay rise. What happened was that GP’s got something like a 25% increase in income over that first year or two, and there was a big improvement in GP recruitment. So for that unstated aim, it was entirely successful. If you look at financial incentives to improve quality of care in the UK through QOF or frankly, anywhere else in the world where they’ve been evaluated, we were probably ahead of most countries and many countries have followed in one form or another and continue to do so. I think there are a number of universal truths. The first is that financial incentives improve quality but not very much, and usually nothing like as much as the payers think they’re going to. And secondly, that for quality improvement generally, there’s no magic bullet, there’s no single thing that improves quality of care. And QOF came on the back of a whole raft of things going on in the late 90s and early 2000’s, under Liam Donaldson’s general umbrella of clinical governance: the development of national clinical guidelines, development of compulsory audit in general practice, initially private release of information on quality of care and then public release of information on quality of care. There were a whole raft of things including compulsory audits that trainees had to do, which was a new thing to quite a lot of trainers. So there were a whole raft of things that QOF came on the back of, and there was clear and documented improvement in quality of care in a number of areas before QOF came in and QOF made a little bit of difference, improved things a bit more. Since then we’ve had another natural experiment with Scotland removing the financial incentives for quality but being able to continue to track quality of care. That’s been quite interesting because the things that are simply tick boxes dropped like a stone as soon as you take the incentives away. But other things that are more objective measures of quality, such as actual measurements of cholesterol in people with heart disease, have been shown to get less good when the incentives were removed. So, we’ve got evidence of some improvement but not as much as a lot of people would like and some reduction in quality if you take the incentives away. But they’re not the big stick or carrot that people imagine they might be.
” …whatever you do, you rely hugely on the professionalism of doctors. And if you lose that, then you’re in serious trouble.”
All methods of payment have potential unintended consequences. Roland M. BMJ
MR: Well, there’s no question that, however you pay doctors, there are risks and benefits to all methods. If you just pay them with a salary, there’s a risk that they’ll take the money and not do anything, if you pay them fee for service they’ll do loads of things whether or not it helps the patients. And many countries do that. If you pay them on quality, then they might do just those things and nothing else, and we might come on to some of the things they don’t do through QOF. If you pay by capitation, then the incentive is to have as many people as possible but not necessarily provide care that’s any good. There are two things as a consequence of that. One is that most countries aim for some sort of balanced payment system that includes both benefits and tries to minimize the dis-benefits of each of those payment systems because they all have dis-benefits.
But, the other thing is that, whatever you do, you rely hugely on the professionalism of doctors. And if you lose that, then you’re in serious trouble. So one of the things that’s terribly obvious with things like QOF is that some things are much easier to measure than others. I don’t know how many indicators there were on diabetes in the first iteration- perhaps 12, maybe 15 or something. And how many on mental health care? And, thats simply because mental health care is difficult to measure. So you prioritize in people’s minds things that are easy to measure, and potentially at the expense of things that aren’t. And it’s very hard to know how much of a problem that is. I think there is possibly a difference between QOF in its very early days and as it’s subsequently iterated. In the early days, the government thought that they wouldn’t have to spend too much on QOF in the first year or two. The BMA were pretty sure the GP’s would get all their money more or less straight away, because they were pretty sure that the quality was pretty good and they were right, it was, and GP’s got almost all of their money almost straight away. Those early indicators were pretty much low hanging fruit, they were mostly things that people thought they should be doing anyway and were quite pleased to be paid for doing, and mostly they were doing them.
Since then, QOF has become more of a burden as people’s lives have become generally much more pressed, and demand has increased. There have been some really bad ideas introducing into QOF – things that basically had a managerial focus. And if you’ve got professional financial incentives that cut against professional values, then you’re in serious trouble. Ideally, if you’re going to have financial incentives at all, they should be fully in line with professional values.
“We still have fewer full time GP’s than we had then and the reason for that is not that they’re not training more. They’re training more than ever were trained before, but can’t stop people leaving.”
CS: We could talk about QOF for ages but I’d like to talk about one more thing, the changes in the primary care workforce because, in 2015 you chaired the Commission on the Future of Primary Care and recommended expansion of lots of roles like physicians associates, pharmacists, and physiotherapists in primary care. And that’s now happened, but its proved to be very controversial. Have you got any reflections on that? Has it turned out as you planned?
MR: In parts, yes. Our first recommendation was that we needed 5000 more GP’s and the government committed to producing 5000 more GP’s by 2021. We still have fewer full time GP’s than we had then and the reason for that is not that they’re not training more. They’re training more than ever were trained before, but can’t stop people leaving.
We were spot on in saying that more GP’s were needed, and that government needed to provide them. I think that some roles in general practice have been really useful. I think that direct access to physiotherapy is useful but I want to say a little bit more about that. Pharmacists in practice have been really useful and we have employed pharmacists in our practice in Manchester going well back into the 1990s, and it made things like repeat prescriptions miles easier. Physician Associates are a huge problem because we’ve ended giving a task that actually needs some of the highest levels of GP skills in dealing with undifferentiated illness to people who have some of the lowest levels of skills.
I think that has been a misapprehension by government, and probably completely predictable, that these things would reduce GP workload. We’ve evaluated, for example, the impact of direct access to physiotherapists in general practice and the bottom line is that in ‘NICE’ terms, cost per QALY, physiotherapists are fantastically cost effective. They come out really well in terms of cost per QALY but make not a jot of difference to GP workload, and are very popular with patients. They are a good extra resource but is it the answer to GP workload? No, it doesn’t seem to be. Of course if you gave them prescribing and sickness benefit writing rights, you might change that a bit. That’s an example of an unintended consequence, or a consequence not realized. There have been quite a few NHS developments which have been really popular with patients but have not had the effect of dramatically reducing GP workload, or A&E attendance, which is what they were intended to do.
“Before I retired, somebody asked me what I wanted my legacy to be. I thought about that a little bit. One of the things that your legacy is unquestionably not is the many papers that people like you and I may have published over the years”
The world’s largest collection of contemporary art by women artists. Home | The Women’s Art Collection Website : The Women’s Art Collection
CS: I remember you telling me one of the great things about being retired is that you can still work, but just do the things you feel like doing. And you’ve become an ambassador for the women’s art collection at your college in Cambridge. I hope you won’t mind me saying but you don’t seem the most obvious person to be the ambassador for a women’s art collection
MR: Mary Edwards College is one of two Cambridge colleges that admits just women students. All the others admit both men and women. As well as educating smart young women, we think we have a role in society in promoting the place of women more generally, including collecting art by contemporary women artists. And apart from one museum in the States, we’ve got the world’s largest collection of contemporary art by women artists. Home | The Women’s Art Collection Website : The Women’s Art Collection
And, for Fellows of Cambridge colleges there are all sorts of committees; there are gardens committees, admissions committees, and an art committee. And I ended up chairing the art committee for quite a number of years. My personal interest in art goes back to my family background. That’s been a great part of retirement as well as the some of the academic bits that people still ask me to do. And I enjoy both.
Before I retired, somebody asked me what I wanted my legacy to be. I thought about that a little bit. One of the things that your legacy is unquestionably not is the many papers that people like you and I may have published over the years, because in a few years’ time very few of them will still be quoted. I think our only real legacy is the people we train, and the people we influence, because they’re the people who carry on the values and the skills that we’ve given them. So, to see quite a few people who worked with me going on to do other good things has been very rewarding indeed.
CS: A great way to end. Thank you. You’ve had an incredible career and you’ve managed to do research that’s really relevant to issues of the day. And, in fact, you quite often set the agenda on some of the issues of the day. We’ve talked about your influence on policy, but I know that you’ve had an influence on lots of people’s careers as well. And a lot of people have learned from you. So, thank you so much for talking to us today.
Key papers on financial incentives and quality of care:
Campbell S, Reeves D, Kontopantelis E, Sibbald B, Roland M. Quality of primary care in England with the introduction of pay for performance. New England Journal of Medicine 2007; 357:181-190
Campbell SM, Reeves D, Kontopantelis E, Sibbald B, Roland M. Effects of pay-for-performance on the quality of primary care in England. New England Journal of Medicine 2009; 361: 368-78.
Sutton M, Nikolova S, Boaden R, Lester H, McDonald R, Roland M. Reduced mortality with hospital pay for performance in England. New England Journal of Medicine 2012; 367: 1821-28.
Roland M, Campbell S. Successes and Failures of the United Kingdom’s Pay for Performance Program. New England Journal of Medicine 2014; 370:1944-1949
Minchin M, Roland M, Richardson J, Rowark S, Guthrie B. Quality of care in the United Kingdom after removal of financial incentives. New England Journal of Medicine 2018; 379: 948-57
