Due to migration, an increasing number of the elderly in Sweden will be foreign-born, ‘old migrants’. Old migrants will need help from society with health care and social service. Migration may influence people's health and thus also their consumption of health care and social service. The aim of the present study was to discuss migration and health with the focus on old migrants by a review of literature, and to describe the pattern of health care and social service consumption among old migrants living in Sweden, studying whether there were any differences compared with old people born in Sweden. The results showed that there is a lack of data describing old migrants' health. Available data indicate poorer self-rated health, more chronic illness and impaired mobility capacity. There are some Swedish studies describing morbidity and mortality among migrants in Sweden. These are consistent: migrants have more health problems in general and migrants from the Nordic countries have a higher mortality rate. There are no public statistics about old migrants' consumption of health care and social service in Sweden. Some studies show that old migrants consume less than native Swedes. Other studies indicate the same or higher consumption of health care, but lower consumption of social service among migrants. In conclusion, few studies concern health and consumption of health care and social care among old migrants; the results are divergent and there could be several different explanations for dissimilarities, such as migrational background, cultural distance, time of residence, socioeconomic position and adaptation in the new society. Thus, further studies are needed.

Background: Teamwork and collaborative practice are acknowledged as key to strengthening primary health care. This study assessed Canadian family physicians/ general practitioners’ (FPs/GPs) interest and involvement in interdisciplinary collaborative practice. Methods: From nine focus groups conducted with 46 FPs/GPs in the Capital Health region (Edmonton, Alberta) concerning the quality and capacity of services in family practice, the discussions related to collaborative practice and practice teams were extracted and qualitatively analysed. Based on this analysis, one section of a mail survey assessed FPs/GPs levels of interest and current involvement with 11 other types of health professionals. Results: In focus groups, FPs/GPs identified seven categories of issues related to interdisciplinary collaborative practice: quality and capacity of care, quality of work life, affordability, availability/accessibility of other health professionals, team-building processes, responsibility/accountability, and system resources. Survey responses from 300 of 583 FPs/GPs in the region (51%) showed substantial interest in working with other health professionals, but strikingly less frequent current working relationships. Conclusions: The large gap between the interest and willingness of FPs/GPs to collaborate and their current involvement in teamwork must be addressed if collaborative practice is to increase in line with the goals of primary care reform in Canada.

This case study explores the patient self-presentational aspects of social interactions occurring during nurse practitioner consultations in primary health care. Previous consultation communication research has revealed that styles of patient self-presentation have an effect on the process and outcomes of consultations. However, it is noted that available consultation communication research is focused on doctor-patient interactions. Accordingly, this research aimed to redress the medically focused imbalance in consultation communication research by investigating and identifying the possible effects of patient self-presentation styles on the process and outcomes of nurse practitioner consultations. An observational case study was undertaken in a nurse-led primary care walk-in clinic, utilizing multiple methods of data collection including: direct observations of nurse practitioner consultations, postconsultation semi-structured interviews with nurse practitioners, and a field journal. Two sample groups were used: a purposive sample of 15 patients attending the walk-in clinic with upper respiratory tract infections (URTI), and a convenience sample of six nurse practitioners employed at the same clinic. Five different styles of patient self-presentation were identified, which all had variant effects on the process and outcomes of the nurse practitioner consultation. These styles included: Seekers (patients seeking treatment); Clinical Presenters (patients presenting clinical histories); Confirmers (patients checking the severity of their illnesses); Seekers to Confirmers (patients who initially seek treatment, but who change to a confirmatory style); Anticipators (patients who anticipate their need for treatment). The nurse practitioner participants were found to be flexibly responding to these styles of patient self-presentation, as an attempt to maximize patient satisfaction with their consultations. It is suggested that the observed nurse practitioners were able to flexibly modify their consultation communication strategies in response to different patient self-presentation styles, which helped resolve the tensions existing between the patients’ own reasons for consultation attendance and their actual clinically assessed needs for treatment.

The study objective was to explore the way in which the expert patients programme (EPP) has been implemented by primary care trusts (PCTs) and to identify key barriers and facilitators to the implementation of this initiative in the National Health Service (NHS). The study forms the first part of a process evaluation to record the development of the EPP in the NHS and to identify the patterns of development which impact on NHS organizations and local community partnerships and networks. This preliminary survey consisted of telephone interviews with the key personnel working in primary care sites where EPP was initially piloted. Forty-six PCT leads (74% of those eligible) and 19 EPP trainers were interviewed (68% of those eligible). Secondary sources of data (such as PCT websites and literature promoting the EPP courses) were also examined. The PCTs’ ability to recruit to EPP courses was considered a key marker of early success which in turn related to wider issues concerning EPP’s position in the PCT’s priorities and the degree to which it was seen or made to link with other agendas and goals. A quarter of the sample had good rates of recruitment, the characteristics associated with these sites included: location in urban areas; early access to voluntary tutors; delegation of administrative responsibilities; networking and sharing resources with other PCTs; use of local newspapers to publicize courses; and active support from health professionals. Problems with recruitment were associated with a reliance on a paper-based strategy; poorly developed links to the broader community and health professionals. The evaluation shows that initial success of a lay-led self-care support programme in the NHS depends on commitment at the level of the PCT boards as well as those directly charged with organizing and delivering pilot training courses. Helping key health professionals understand and engage with the principles and benefits of training in self-care for people with long-term health conditions is likely to impact on the success and future of this programme within the NHS.

This paper focuses on one aspect of a research study exploring the cognitive processes of decision making by 11 nurse practitioners and 11 general practitioners from the south east of England, using six patient scenarios during 2000. It sets out to explain some of their decision-making processes. This paper is part of a larger study discussing the use of information processing theory as a framework for exploring decision-making. Schema theory is used to provide explanation of correct and incorrect responses to the six scenarios. The paper explores areas in which cognitive overlap occurs and uses the participants’ examples to illustrate schema functioning. The usefulness of information processing theory to explore decision-making by nurse practitioners is also addressed. The paper concludes by suggesting that information processing theory and ‘think aloud’ approaches were suitable for identifying errors in decision-making, and could therefore be used as a teaching tool. Change is required in the culture of primary care organizations if shifting emphasis towards developing collective responsibility and greater openness is to be achieved.

Personal Medical Services (PMS) contracts, introduced in 1997, provide a new financial model for providing general practice. The aim of this study was to measure the costs and consequences of the PMS first wave contracts for sites that aimed to increase the accessibility and the quality of care for vulnerable population groups; to describe the problems encountered in this measurement. A purposive sample of first wave PMS sites targeting vulnerable population groups were selected. A two-stage data collection procedure was used, to obtain micro-level data on the quantity and costs of capital and recurrent funds, and top-down data on costs and apportioning of monies received from central source to broad expenditure categories. The costs data focused on the largest cost components, such as staff and prescribing as well as alternative stakeholders’ contributions. The consequences data measured the accessibility and the quality of care for vulnerable population groups. Five case studies were considered. Sites that were formerly independent general medical practitioner (GP) contractors consolidated their staff with few changes in their staff-skill mix. In all sites the prescribing costs per patient were below the national average in 2000/01. Access was either consolidated or improved over the period and improved quality of care was in evidence through appropriate prescribing patterns. Though the evaluation found that the PMS sites were addressing their main objectives the data collection revealed difficulties in tracking the flows of PMS resources under the current budgetary system. We highlight the limitations of the PMS data monitoring procedures and discuss how these limitations can be overcome so that future National Health Services (NHS) reforms can be appropriately evaluated in the future.

The Government has identified school as a key setting for reducing health inequalities, but many schools fail to support pupils with medical needs, such as asthma. This paper describes a survey designed to elicit the views of asthmatic children in two contrasting general practitioner (GP) practice populations regarding their asthma care, including support at school. A questionnaire was sent to all asthmatic children aged 4–17 in two practices during August 2002. The population in Practice 1 (P1) was mainly white, suburban, with pockets of deprivation, and had a long-established asthma clinic. Practice 2 (P2) had an almost exclusively Asian population, was close to the town centre and did not have a regular asthma clinic. Children from P1 had a higher response rate, 69 of 124 (55%) (compared with 21 of 107, 21% in P2), they also reported lower symptom levels and less use of hospital services, particularly paediatric outpatient clinics. Nurses were perceived as the main source of information and support in P1 (68%), followed by doctors (43%). In P2 this was reversed, nurses being identified by 33%, doctors by 62%. If an asthma problem occurred at school, the vast majority said that they would ask a teacher for help, but they also said that school staff needed more information to help pupils with asthma. These results mirror what is already known from large survey data regarding inequality of access to asthma services. In view of the national shortage of GPs it would seem prudent for Primary Care Organizations to increase investment in delivery of comprehensive asthma management services by practice nurses, school health nurses and pharmacists. This should include support for teachers, who are being expected to cope with increasing numbers of children with medical needs in schools.

This paper provides a summary of an exploratory study based on an interpretive approach, aiming to elucidate how professional executive committee members of one primary care trust see their role and the training they need to fulfil their functions. The effective delivery of local and national health priorities in the newly created PCT depends on these members having the knowledge and skills needed to carry out their work. At the time of the study, no one had assessed whether or not the members had the requirements for their role. The study was conducted in 2002 during the first six months of the creation of the PCT. Using questionnaires and semi-structured interviews, the study examined the perceived training needs of the 26 participants. Data analyses were in two stages. Analyses of the questionnaires involved entering the responses into a statistical programme. These were categorized into four areas: intellectual, financial/commissioning, service issues and other issues. Matrices of the responses were developed for the group and for each executive participant. In addition, a further matrix was designed, with a weighting applied, to show the order of importance for each competency. The second stage of data analysis involved content analysis of the verbatim transcripts. Themes identified from the coded analysis include the participants’ views of the direction of the professional executive committee, and concerns about them. The paper shows that the training needs of the committee members are not so easily determined because of lack of clarity of their role, and the part they play in the development of managed clinical networks and in securing co-ordinated and seamless care for the PCT’s patient population. The paper concludes by suggesting that some of the difficulties faced by the executive committee members were not of its own making, but were due to the rapid nature of organizational change in the National Health Service. This project contributes to the knowledge base about executive committee members, group interaction and dynamics, as well as having practical implications for delivering both local and national health targets. Future research could address the extent to which the PEC’s role has been clarified and whether this has been helpful in contributing to the redesign of services.

This is a preliminary report on a quality improvement project for people with learning disabilities (PWLD) in one London Borough. The strategy document Valuing people required the implementation of a specific activity at two levels: both organizational development and individual health action plans. This activity was called health facilitation. It was left to local services to introduce health facilitation either by extension of existing roles or by creation of new specialist posts. Using neighbourhood renewal funding to improve access to health services, Barking and Dagenham chose to create new posts. This paper will focus on just one of these innovative posts, linked to improving transition planning for school leavers with learning disabilities. There was a pressing local need to improve continuity of care between child and adult services. Multiple methods were used to investigate this new Health Facilitator (HF) role. The HF carried out both service development and person-toperson work, with a wide variety of contacts. Developing ‘signposting’ and appropriate referral systems for young people led to improved access to adult services. In general, this developmental role was seen as making a positive contribution in addressing the gaps in current services for young PWLD. The findings of this evaluation have already led to changes within local services and shaped future workforce planning.

Attention-deficit hyperactivity disorder (ADHD) is a growing diagnosis in child mental health in the UK and is increasingly being treated with methylphenidate (Ritalin, Equasym, Concerta). There are, however, clinical and public controversies over the diagnosis and ‘labelling’ of ADHD as a disorder, the use of drug treatments, and a relative paucity of guidance on the initial diagnosis and referral of the disorder. General practitioners (GPs) are involved in the assessment, diagnosis and treatment of children with ADHD and in liasing with the other parties involved, such as parents, teachers and specialists. Therefore their understanding of ADHD and its treatment is important. This study explores Wandsworth (South West London) GPs‘ understanding of ADHD as a disorder and their views of its management in order to provide more precise detail about the issues concerning the management of ADHD in primary care by GPs.

Qualitative information was collected by semi-structured interviews (with 13 GPs) and quantitative information by means of questionnaires (93 completed by GPs) in Wandsworth.

Whilst GPs had differing views of the aetiology of ADHD, there was a consensus view about the division of responsibility in the treatment of those diagnosed with ADHD. GPs felt uncomfortable initiating the prescribing of methylphenidate and stressed the importance of ongoing specialist involvement in the management of ADHD. There was also a feeling of inadequacy in terms of the training that GPs had received.

It is suggested that guidance on the initial diagnosis of ADHD is drafted for GPs and that shared care protocols are agreed between primary care and secondary care so that the ongoing division of labour in the management of ADHD is made explicit, ensuring continuity of care.

As the numbers of cancer survivors grow, community-based primary care physicians are playing a larger role in their care. The goal of this pilot study was to begin to identify the problems and challenges faced by primary care physicians who treat patients with cancer histories. A mail survey was undertaken of 141 community-based primary care physicians in the Southeastern US that addressed physician characteristics, numbers and types of cancer patients treated, problems faced by these patients and challenges physicians face when caring for these patients. These physicians reported that on average 10% of their primary care patients had a history of cancer. The most frequent types of cancers seen by these physicians were skin, breast and prostate cancer, but there was a broad range of other cancers seen in their practices. They reported that patients and family members’ fears and emotional problems were frequently encountered problems. Side-effects of cancer and its treatments and limited access to supportive care services were also reported as frequent problems for the cancer patients they treated. The most challenging aspect of caring for patients with cancer histories they reported was promoting cancer-related risk reduction behaviours. Primary care physicians play a large and important role in the care of cancer survivors. They encounter a number of problems when providing this care, including patient fears and access to supportive care. These findings may be used to guide educational and policy initiatives aimed at improving the care of cancer survivors.

The treatment of mental health problems is now a national priority in the UK. With a prevalence rate of 23% in the general population and 75% of the population visiting a GP each year, the role of primary care in the detection, management and treatment of mental health problems is pivotal. However, around 20% of mental health problems remain unidentified by GPs. Many reasons may contribute to this. One reason is cited as being the training received by GPs, although research into this has yielded inconclusive results. This study aimed to investigate qualitatively the attitudes of GP registrars, firstly towards dealing with mental health problems in primary care and secondly in relation to the training and support received. Sixteen semistructured interviews were conducted and analysed thematically. Results indicated that GP registrars in this study understood the psychosocial nature of mental health problems and felt confident in detecting these issues in their patients. However, they were less secure about the management of mental health problems due to a number of constraints such as inadequate time, lack of knowledge of referral pathways and local resources, and a limited understanding of the psychology of mental health problems. They appreciated the support provided by their trainers, the training practices and the vocational training scheme (VTS). They would benefit from additional input concerning assessment and management of psychological problems, and discussions around their new role as a GP, acknowledging its potentials and limitations.

Partnerships and participation are important principles of primary health care and increasingly are advocated in poverty-related health research. These concepts were central to our study of low-income Canadians’ use of health-related services and supports. We created partnerships by including community members on the research team, establishing a community advisory committee, involving community agencies in recruitment and interviews, and obtaining stakeholder perspectives on the research findings. We fostered participation of low-income people by including their perspectives during the design and implementation of the study, reducing barriers for participation, and using peer interviewers. Despite the successes of these strategies for promoting partnerships and participation, challenges emerged in relation to maintaining involvement of stakeholders and ensuring adequate opportunities for research capacity building. Stakeholders and lowincome people identified policy and service delivery changes that would enhance accessibility to health-related services as well as potential barriers that influence change efforts. Participants emphasized the need to view poverty as ‘everyone’s business’, which necessitates participation and partnerships with people living in poverty, with service providers, and with policy influencers. Our findings suggest, however, that people living in poverty encounter barriers to participation, and that further efforts are needed to obtain their input in the development of programmes, services, and policies. We recommend that primary health care research include community partners on the research team, community advisory committees and perspectives of policy makers and service providers. Researchers require adequate funding to develop and maintain partnerships with stakeholders, to train and support vulnerable people in developing skills and confidence as active research participants and to communicate the research to relevant stakeholders. We also recommend that evaluation of the participatory process be built into the research design.

An evaluation of the views of primary health care team members participating in an intervention programme of a Resource for Education, Audit and Teamworking (CREATE) is presented. The pilot CREATE programme comprised of a series of nine educational and team building workshops delivered in protected time to all clinical and administrative staff in seven general practices in one Health Board locality, within a 12-month period. The content of the programme was developed in response to an educational needs assessment undertaken by the CREATE steering group. The purpose of the evaluation study was to identify if the CREATE programme altered participants’ views of teamwork, education and audit, and to ascertain the suitability of the CREATE programme for more extensive implementation in Scotland.

The evaluation study utilized a combination of quantitative and qualitative survey methods. Quantitative questionnaires devised specifically as evaluation tools for the project were manually distributed and collected at the first and last CREATE workshops to all participants present on each occasion. Following the first and last CREATE workshop, key informants from each practice subsequently participated in qualitative, indepth interviews.

The combined results of the quantitative and qualitative analyses reveal that the CREATE project is highly valued by the majority of primary health care team members who participated in the programme, particularly clinical staff but to lesser extent administrative staff. The findings indicate that a relatively simple but inclusive programme delivering appropriate education to primary care teams within protected time is able to overcome barriers to teamwork and has led to staff developing improved quality of health care services. Areas where teamwork and quality improvement were perceived as developing most significantly included: developing objectives, meeting as a practice and communication so people were more involved in discussions and decision-making. As a result of the findings from the pilot, the key elements of CREATE are being replicated elsewhere in Scotland.

Public health restructuring in Ontario, Canada occurred in the midst of the rhetoric of ‘primary health care (PHC) reform’. The purpose of this descriptive mailed survey of nurses working in public health nursing in Ontario, Canada was to describe the nature and scope of public health nursing practice, establish a baseline against which to monitor future change, examine nurses’ reports of changes in practice that had occurred in the previous five years, and determine current public health nursing staffing levels. Findings were examined to ascertain whether the changes had moved Ontario closer to PHC. Two sets of questionnaires were mailed in 1999: one to a public health nurse (PHN) in a senior manager position in each of Ontario’s 37 official public health units and one to all PHNs in Ontario.

Response rate was 87% for the managers’ surveys (n = 32) and 77% for PHNs (n = 2242). Reported staffing levels represent an 11% reduction in public health nursing full-time equivalents (FTEs) from 1988 data. Furthermore, between 1993 and 1998, the population:nurse ratio rose 32% from 3710:1 to 4910:1. Many traditional public health nursing services, such as those to individuals, families, and schools, had been reduced or eliminated. Significant regional disparities were revealed. Nurses used a wide variety of individual, community, and population-focused health promotion strategies consistent with principles of PHC in their practice but evidence suggested the continuance of biomedical domination of public health and public health nursing, rather than the shift to a multidisciplinary model that would be more consistent with PHC.

Findings suggest that changes in public health nursing over the last 20 years are incongruent with several tenets of PHC, such as equity, accessibility, social justice, and community participation.

The changing demands on primary health care have focused attention on workforce diversification. Although skill mix has been researched for some time, exploration of delegation decision-making is an underresearched topic. This limits the sharing, teaching and monitoring of the inherent skills. Utilizing focus groups, this exploratory research was therefore designed to map delegation perceptions, experiences and decision-making processes of health visitors and districts nurses in a primary care trust in the north of England. The focus group discussions revealed a diversity of delegation practices. Decisions were driven by both pragmatic and needs assessment factors. Issues around the delegatee, the delegator, patient need and structural factors were strongly influential. Delegation of aspects of ‘established’ care was at times in conflict with the philosophy of holistic care. The research suggests that it is important to recognize the community context of practice increases the complexity of delegation decision-making.

The aim of the present study was to review the district nurses’ documentation of patients suffering from chronic pain conditions and to investigate whether the documentation changed after the introduction of specifically educated, district nurses (‘pain advisers’) at the primary health care centres (PHCC). A study area with five PHCCs and a control area with seven PHCCs were selected. One ‘pain adviser’ was introduced at each PHCC in the study area. The district nurses in the study area and the control area were asked to register all the patients older than 16 years with chronic pain conditions with whom they were in contact. The records of all the registered patients were collected in two periods (before and after the introduction of the pain advisers) and a review of different aspects of the nursing documentation related to chronic pain was performed. The nurses’ documentation regarding the patients’ chronic pain conditions was found to be incomplete and minimal. After the introduction of ‘pain advisers’ into the study area, some improvements were found in both areas. Our results indicate that the introduction of ‘pain advisers’ to some extent improved the documentation in the study area, but that further interventions are needed in order to improve it further.

The implementation of single assessment for vulnerable older people by 2004 was introduced in the National Health Services (NHS) Plan and the National Service Framework for Older People. The evaluation reported and discussed here is of a single assessment and integrated care process (SAP, ICP) piloted and subsequently introduced into a NorthWest of England Primary Care Trust. The initiative introduced enabled district nurses to undertake social assessments and fulfil the role of care manager for people already on their caseloads whose social needs increased.

The objectives of the evaluation were to explore the impact of the initiative on service users and on district nurses and social workers professional roles compared to the previous system of separate assessments and to examine any barriers to the implementation of single assessment and integrated care.

The perceptions of health and social care professionals and service users were collected via telephone and face-to-face semi-structured interviews (n = 21).

All professionals could identify both actual and potential benefits and disadvantages to service users of single assessment and integrated care planning. The areas important to respondents included a SAP that is, more efficient, without duplication; familiarity with assessor; timeliness of assessment; increased co-ordination and the quality of assessments. Many of these are also discussed in terms of a change in professional roles, mainly that of district nurses. The introduction of the ICP was not as successful as had been anticipated; a number of reasons for this were identified. The requirement to assess clients’ financial circumstances was the main conflict reported for district nurses compared to their traditional role. Issues relating to their lack of knowledge and familiarity of the social care sector were also highlighted. The discussion focuses on how these issues could be addressed namely through education and training, and facilitating integrated working.