Background: Research in general practice is expanding rapidly but studies are frequently challenged with recruitment difficulties resulting in inadequate sample size, recruitment bias, delayed completion and additional costs. Aim: This study was designed to explore how practice teams make decisions to participate in research, to identify the key influences on the decision making process and to generate for researchers some ways of enhancing recruitment. Method: Semi-structured interviews were conducted with a representative from each of the 11 participating general practices. A thematic analysis of the verbatim transcripts was conducted using the method described by Burnard. Findings: Whilst not having a formal process for considering research requests the criteria used in discussion appeared to be very similar between practices and included the clinical relevance of the research question, clarity of practice responsibilities, realistic expectations and support available. Attention to presentation (style, length, clarity) is also important for engaging attention. Some of the measures to improve recruitment appear to be common sense but the experiences of practices suggested that such measures are not being incorporated routinely by researchers. The need for good project management and cognisance of marketing strategies is also highlighted.

In recent years government emphasis on improving access times in general practice has centred on a target of 48-hour access to a doctor. Attempts to achieve this by changing appointment systems may threaten relationship continuity of care, another valued feature of general practice. Now the recent primary care White Paper proposes financial incentives for both these aspects of care. We studied two contrasting booking systems in three large inner London group practices using a one page questionnaire distributed to consecutive patients in the waiting rooms. While most patients in the so-called ‘advanced access’ practice were seen very quickly, fewer patients, especially those with chronic conditions, were able to see their chosen doctor than in two practices offering more scope for booking appointments ahead. This preliminary study in an inner-city area supports other work, as well as anecdotal reports, suggesting that unbalanced emphasis on rapid access may impair patients’ scope to see their practitioner of choice.

This study used Knowles's adult learning theory as a framework, to explore the meanings of the lived supervision experience of healthcare support workers in primary care. In this study, seven healthcare support workers participated in tape-recorded interviews, in which they described their supervision experience, yielding transcripts that were subjected to qualitative analysis. Four themes reflective of their supervision experience emerged from the data. These were the beginning; creating the space; the supervisory relationship and outcomes of supervision. The results of the study provided a clearer understanding of the meaning of supervision from healthcare support workers' perspective and additionally, support for Knowles's adult learning theory as a framework for adult learning. At the end, the findings were presented and recommendations were made in terms of primary health care practice and research.

We have developed the Female Urinary Symptom Score (FUSS), a symptom questionnaire for the evaluation of urinary incontinence and lower urinary tract symptoms in women and their effect on quality of life. The FUSS is a modified version of the International Prostate Symptom Score adapted for use in women. It consists of a simple questionnaire of only eight questions, which patients can answer quickly on a numerical scale. We performed a validation study of the FUSS by comparing it with the King’s Health Questionnaire (KHQ), a well-validated but longer symptom questionnaire. We sent both questionnaires to 220 women between the ages of 45 and 65 years randomly selected from two general practices in the United Kingdom. Urinary symptom status was unknown; 149 (94%) of the FUSS questionnaires and 115 (73%) of the KHQs were completed correctly. Correlation was conducted on the scores of the 115 matched pairs and was high (r = 0.83). We sent another copy of the FUSS questionnaire to the same group of women after four weeks, and found that the test and re-test scores for FUSS were highly correlated (r = 0.88). We conclude that the FUSS is a simple, reliable and reproducible tool for the diagnosis of urinary symptoms in women. As it is brief, we believe that it will be useful in the primary care setting, enabling women to receive appropriate treatment and care as early as possible.

Aims: To assess the feasibility of keeping a log of diabetes-related communication in a community pharmacy and to explore the potential of the logs to reflect diabetes-related communications within pharmacies. Design: A reflective log-keeping exercise (the log designed by the researchers and provided in a booklet form) in community pharmacies of any diabetes-related communication taking place between pharmacy staff and their service users, and any signposting made to and from other relevant health professionals. The study ran for four weeks. Subjects and setting: Nine community pharmacy branches of the Independent Pharmacy Care Centres PLC based in Hull, East Yorkshire and North & North East Lincolnshire. Outcome measures: A description of the form and nature of diabetes-related communication, taking place within the community pharmacy. The research team also sought feedback on the experience of keeping the log. Results: Twenty-two communications were logged; twenty-one involved direct face-to-face contact and one log involved a telephone conversation. Two-thirds of the communications involved conversations with patients with diabetes, a third were with a partner/family member. The conversations captured fell into five categories: sugar free medicines, blood glucose-testing metre, prescription medicines, diabetes specific education/ information and an unclassified category, respectively. The logs demonstrated that communications can involve all members of the staff team, working independently or jointly across their roles in the pharmacy. Conclusion: Community pharmacies in the pilot study were actively involved in providing diabetes health-related information/education and support. Communications involved directly assisting people with diabetes and providing information to people supporting others with a diagnosis of diabetes. We propose that the logs provide a valuable means of acquiring information about the form and nature of diabetes-related communication and signposting within community pharmacy.

Recent years have seen an increase in critical analyses of discourses of policy and practice. However, some argue that this form of scholarship is not central to understanding the concerns of day-to-day practice in the health care context. We propose the converse and contend that critical analyses have particularly important contributions to make because they challenge us to examine what are largely taken for granted aspects of practice. One context in which such examinations have been instructive is primary healthcare. This article is intended to further the dialogue on the ways the culture concept is taken up in health care. We use the case of culture and health to illustrate the ways discourses are taken up in local and official contexts and to demonstrate how different discourses and related institutional practices, shape individuals' relationships with others in the community context.

Background: The increased incidence of chronic disease in recent years represents a significant challenge for the National Health Service. This coupled with substantial reforms in recent years has resulted in many changes in the delivery of healthcare, such as the proliferation of new nursing and midwifery roles. One such role is the Respiratory Nurse Specialist. Aims: The aim of this paper is to explore the role of the RNS from the post-holder and service perspective. This includes examining the organizational infrastructure, working relationships, career paths, perceived benefits and enablers and barriers required to make this role successful. Methods: A naturalistic case study methodology was adopted and a variety of data collection approaches were used. These included semi-structured interviews with the post-holder, line manager and Director of Finance, non-participant observation of practice, review of job description, audit data and other relevant documentation relating to the post. Findings: Findings revealed evidence of the role being innovative and effective. These related to the role context; role delivery, skills and knowledge required; the personal characteristics of the post-holder, the impact on multidisciplinary integrated working and the response to the needs of patients and communities. Conclusions: This case study illustrates the value and potential of nurses to lead and co-ordinate the care for patients with chronic diseases, and specifically the provision of a high-quality respiratory service.

Although the need for lifelong learning, with implications for the development of all primary healthcare team members has been emphasized by policy documents and the new General Medical Services (nGMS) contracts, inter-professional facilitators and barriers for lifelong learning have not been fully investigated. This article presents common facilitators and barriers to lifelong learning as perceived by both implementers and recipients of a regional primary care workforce development strategy. It is based on a wider formative explorative evaluation study involving semi-structured interviews and focus groups in 22 primary care trusts (PCTs) and associated general practitioner (GP) practices in South East England. Twenty-nine strategy implementers, comprising Associate Deans, Lifelong Learning Advisors, Primary Care Workforce Tutors, GP Tutors, PCT Educators, were interviewed and 12 took part in two focus groups. Thirty-one strategy recipients, GPs, Practice Managers, Practice Nurses were also interviewed. Interviews and focus groups were recorded, transcribed verbatim and analysed using thematic framework analysis. This study provides evidence that traditional cultures, marked by a lack of inter-professional learning still exist in primary care settings and may obscure lifelong learning. Common facilitators to both implementers and recipients were influential professional networks, managerial and peer support, recent policy changes and protected learning time. Common barriers to both groups were insufficient organizational support, time constraints, lack of funding and boundaries between PCTs and general practices. Strategies to overcome barriers and reinforce facilitators need further exploration. PCTs and general practices should become learning organizations that provide continuous learning opportunities, support collaboration and foster links between organizations and individuals. Lifelong learning development can only flourish when a support system is created, composed of clearly allocated time, budgets and a sustainable support framework.

Smokers aged 65 and over have been identified as a priority group for smoking-cessation interventions. However, despite confirmation of the benefits of cessation in later life and compelling evidence that interventions can be effective, studies have shown that members of the primary care team often fail to target this population. If these professionals are to be encouraged to broach the subject of smoking cessation with older people, it is important that barriers to the effective provision of interventions are uncovered. This article reports findings from a qualitative study that sought to do this by exploring the knowledge, attitudes and practice of members of the primary care team in relation to smoking/smoking cessation in later life. A purposive sample of health visitors, district nurses, practice nurses and general practitioners (n = 41) working in the west of Scotland was recruited. Data were collected during face-to-face interviews using a semi-structured interview schedule. The interviews were transcribed and then analysed using content analysis procedures. While the participants were generally convinced of the benefits of cessation many believed that few older people manage to stop smoking successfully. A pessimistic view of the success rate of older smokers appeared to negatively influence practice. In addition, a number of the participants lacked confidence in their own counselling skills and/or had limited awareness of smoking cessation resources and specialist services. These factors also appeared to preclude the provision of effective smoking-cessation interventions. Finally, there was little awareness of the content of the UK Smoking Cessation Guidelines. The findings from this study, and a parallel study that explored the health beliefs of older smokers, have been used to develop smoking cessation training designed specifically for members of the primary care team who have contact with older people who smoke. The efficacy of the training is currently being evaluated.

This small exploratory study in one local area in Scotland aimed to identify health visitors' perceptions of public health nursing and the factors that influenced their capacity to adopt a broad public health role in line with current policy direction in Scotland. The literature review focused on the historical and political context of public health nursing and the extent to which health visitors across the UK have managed to shift practice towards a greater emphasis on community focused public health work. This study involved 10 qualitative interviews with practising health visitors, who had at least 2 years' experience and trained prior to September 2001 when the public health nursing course replaced the health visiting course in Scotland. Participants identified a range of barriers to local implementation of the model of public health nursing practice set out in recent national policy. Findings suggested that theoretical perspectives of public health and leadership issues for health visitors perpetuate the dominant clinical agenda in their work setting. Although participants were generally willing to develop wider public health work they identified a number of constraints related to the perceived higher value given to clinical duties. This was reinforced by the low priority given to public health work at all levels within the organization and by primary care team colleagues. The study found participants felt powerless to influence change and were frustrated by unrealistic expectations of their ability to develop their public health nursing role without adequate support and planning infrastructure. Dominant themes that emerged from the investigation reinforce the need for effective leadership and application of social science theory to enable public health nurses to challenge the perceived dominant biomedical approach to public health in primary care.

Background: Failure to reach recruitment targets is a widespread problem in RCTs (randomized controlled trials). This paper presents experience of recruiting patients into the PRIDE trial which was carried out in one Primary Care Trust (PCT) in the North West of England. Aim: The aim of this feasibility study was to test the effectiveness of a new model of care for the management of late-life depression. Method: GPs (general practitioners), PNs (practice nurses) and community nurses were invited to refer patients into the study. Over 100 patients were needed (at least 50 in each arm of the trial) for the study to be sufficiently powered. On-target recruitment of over 100 patients over 18 months was achieved. Findings: Data obtained from conversations and from semi-structured interviews with health professionals is presented to give possible explanations for this successful recruitment. Not all practices in the PCT engaged with the study, and the most common reasons given by GPs and their staff for non-participation was being single handed or already having a heavy work-load. All community nurses spoken to agreed to refer patients to the study but only five referrals were made by this group over the course of the study. The main reasons primary care professionals did agree to participate and continue to refer patients was that they felt the trial was offering a local and relevant service to an under-served patient group. The very simple referral process was also an important factor. In addition, the Trial Nurse was perceived to be responsive, responding quickly to referrals made and providing regular and detailed feedback which was perceived to help and support the health professionals in the future management of the patient.

An interpretive qualitative study was conducted to examine public health nurses' (PHNs') practice in fostering citizen participation and collaborative practice and the impact of a decade (1992–2002) of health care restructuring. This article presents the perspectives of public health management and a public policy analysis as they relate to PHNs' primary health care practice in Nova Scotia, a province in Eastern Canada. Seven face-to-face interviews were conducted with public health management from across Nova Scotia and 26 relevant public policy documents were analyzed. Three major themes emerged from the coded transcripts and the document analysis: (1) opportunistic shifts in values: constraining structures, operations, and governance; (2) insufficient funding and infrastructure support; (3) opportunities and challenges to PHN capacity and competency. The emergent themes illustrate the unique population health perspective and day-to-day contested realities of public health and PHN practice. The study provides preliminary understanding of PHNs' primary health care practice in Nova Scotia that may resonate with other national and international settings. This knowledge can form a basis for more research to explore the PHNs' practice in the organizational context in which it is embedded. This study was undertaken at a pivotal time in Nova Scotia as the provincial government embarked on primary health care renewal to improve the health of Nova Scotians. The success of this study is in large part attributable to the collaborative effort of university researchers and public health decision makers.

The sustained movement towards a more primary health care led National Health Service in the UK has involved individuals and organizations developing more effective ways of working. This has resulted in changes to the structure and functioning of primary care organizations, the development of new workers and, in some instances, handing over work to other health and social care agencies. These changes have contributed to what for many staff is a turbulent organizational and practice environment. Data from a 3-year project, commissioned by the North West Development Agency, is used to explore how staff involved in these changes dealt with this turbulence; 350 staff working within 18 Primary Care Trusts participated in the study. A multi-methods approach was used which facilitated an iterative analysis and data collection process. Thematic analysis revealed a high degree of congruence between the perceptions of all staff groups with evidence of a generally well-articulated, but often rhetorical view of the organizational and professional factors involved in the changes experienced. This rhetoric was used by individuals as a defense mechanism in dealing with the turbulence of change. The article discusses how these defense mechanisms need to be recognized and understood by managers so that a more supportive organizational culture is developed.

National Health Service (NHS) Direct is a 24-h patient-led telephone advice service, based in England and Wales, which aims to help callers self-manage problems and reduce unnecessary demands on other NHS provision. Despite its rapid expansion as a source of health information and advice, little empirical work has investigated its impact and effectiveness. This paper reports on a study that aimed to evaluate the contribution of NHS Direct to the quality of care and its impact on health services within one part of the United Kingdom (UK). A postal survey of callers who had contacted NHS Direct between June 2004 and January 2005 with abdominal pain or cough and/or sore throat was conducted. Of 268 callers, over 90% reported they had followed the advice given by NHS Direct to self-care or to contact another health service. Fifty-one of the callers were referred to an Accident and Emergency department and, of these, 39 (76%) received a prescription and 20 (39%) were admitted to hospital. One hundred and forty-four callers were referred to a General Practitioner (GP) and, of these, 88 (61%) received a prescription and 21 (15%) were admitted to hospital. Of the 69 callers advised to self-care, 47 (68%) reported that they did not receive any further intervention while 18 (26%) reported they had subsequently contacted a GP and been given a prescription for medication. The paper concludes that most referrals made by NHS Direct to another health service were justified by the interventions received by patients. However a significant minority (26%) of callers referred to GPs did not receive any further intervention and there was some duplication of service use. Health professionals need to be aware that patients might have previously contacted another health service and provide advice on effective use of services.

Background: A dietary assessment website for use in the primary health care setting has been developed. The website allows patients, referred from their general practitioners (GP), to self-report their dietary intake. Data from the website feeds to a dietitian who develops individualised dietary advice for the patient. Aim: The aim of this article is to describe the usability testing of the dietary assessment website with its potential users. Methods: Testing was broken into two phases. Forty-two free-living adults with metabolic syndrome volunteered, 17 completed phase 1 and 10 completed phase 2, with a 64% rate of completion. Phase 1 participants spoke aloud as they progressed through the self-administered dietary assessment website under researcher observation. Observed difficulties in website use and need for assistance was recorded and the website underwent modifications between phases. Only four participants in phase 1 required large amounts of assistance. Phase 2 participants progressed through the website without observation or using the think-aloud protocol. This simulated the environment in the GP practice within which the website was to be implemented. All participants completed pre- and post-use questionnaires assessing feelings toward use, computer experience and problems encountered. Findings: Questionnaires were thematically analysed for relationships between website use and participant feelings. Time taken to use the website was recorded automatically. Website features were grouped into ‘action classes’, for example selecting food items, and times taken were calculated for each class. Comparisons (t-tests) were made between the action classes for the two phases. Average time taken to select the food items was 31 min and 24 min for phases 1 and 2, respectively. Total time taken was approximately 1 h and varied by 4 min between phases. Time taken to complete the dietary assessment was comparable to a face-to-face diet history with a dietitian. The website was found to be highly user friendly with little assistance being required for most levels of computer experience. Dietary management may be overlooked by GPs, yet by offering different methods of accessing dietitians, management may improve.