Primary care trusts (PCTs) will play a major role in commissioning and evaluating new services in primary care. Several studies have discussed the problems associated with conducting evaluative research in primary care generally. However, few GP commissioned services have been formally evaluated, so little is known about the feasibility of such research in the PCT setting. This study uses a tool called force field analysis to identify factors that drive and restrain a primary care-based randomized controlled trial (RCT) of a newly commissioned service for patients with psychosocial problems in primary care, and also to suggest strategies for building on positive factors and reducing negative ones. It involves discussion with general practitioners (GPs) and other primary health care team (PHCT) members in practices with access to the service. Several important dynamics emerge from the analysis with regard to the likely success of evaluation of a new service. These are availability of research skills and funding, prior beliefs about the service and participation in primary care, existing evidence of effectiveness and financial accountability, research design and awareness and ownership in primary care. This study provides evidence that force field analysis can serve as a helpful tool for anticipating and identifying barriers to, and partnerships and actions needed for, successful evaluative research in primary care. It can also facilitate the development of practical strategies to aid successful service evaluation. We suggest that the strategies identified by this study could usefully inform plans for future evaluations in the setting of the PCT.

The establishment of primary care trusts (PCTs) is a radical reorganization of the NHS. This paper examines primary care groups (PCGs) making an early change to trust status, comparing them with those adopting a longer timetable for the change. The data are derived from the National Tracker Survey of primary care groups and trusts (random sample of 72 PCGs, 15% of the 481 PCGs in England, and five purposively sampled early PCTs) conducted in 1999 and 2000. The main source of data consisted of interviews with Chief Officers (response rates: 1999, 100%; 2000, 97%). In total, 43% of PCGs had become PCTs by April 2001, and 90% expect to become PCTs by April 2002. Integration of primary and community health services, focusing on local needs and innovation in service development, were common reasons for wanting to become a PCT. These trusts were more likely to cite autonomy as a reason, and were also more likely to believe that they had the support of professional stakeholders, but a substantial minority reported that they did not have the active support of GPs and other primary care staff. Although early trusts had slightly more experience of GP-led commissioning, there was no evidence that they were performing better than later trusts in their core functions of developing primary care, improving quality and commissioning services. The rapid progress from PCGs to PCTs does not seem to reflect the process of developmental learning and building on experience initially envisaged by government. Evidence from earlier NHS reforms indicates that time taken to build capacity, develop relationships and secure stakeholder support is associated with success. There appears to be a tension between central control over the implementation of NHS reforms and the desire to devolve budgets and responsibilities to local level.

This paper focuses on one aspect of a research study exploring qualified and student nurses' constructed meaning of nursing in a community context. Uncertainty and risk were particularly important factors in the practice constructions reported by qualified nurses. However, this aspect of practice did not constitute a significant element of the clinical curriculum, and students displayed a limited appreciation of these concepts. The visibility and articulation of these aspects of practice may therefore need to be enhanced to develop a more accurate appreciation of practice in the community context, as well as refining the education agenda for this aspect of health care. Four types of uncertainty were identified in this research, namely uncertainty as a consequence of an unpredictable practice context, uncertainty created by the nurse–patient power balance, uncertainty created by exposure to diverse needs and finally, facing risk and dealing with uncertainty when alone. By drawing on a range of literature, the particular dimensions of risk and uncertainty experienced in community practice are differentiated. It is argued that as a core tenet of the practice experience it is timely and appropriate to review perceptions of risk and uncertainty. Acknowledging these as an accepted part of practice may not only facilitate the practitioner's ability to manage the experience but also allow learners to develop their appreciation and understanding of risk and uncertainty.

The aim of this study was to improve clinical management through rationalization of repeat prescribing in an inner-city practice with a high percentage of older adults with extensive comorbidity through systematic review and cost containment. Outcome measures were based on an analysis of PACT data for level and cost of prescribing before and after the systematic reviews, reported patient and staff satisfaction with changes and the identification of drug interactions. The formalization of a 28-day prescribing cycle and systematic review every 6 months was almost universally acceptable to patients and staff. The systematic review led to a decrease in prescribing costs of 12% over 2 years. The number and cost of wound dressings decreased by almost 50%. The prescribing of inappropriate medications, over-the-counter drugs, benzodiazepines and combinations of drugs that interacted was reduced. The study demonstrates that monitoring and rationalization of repeat prescribing can reduce costs and improve quality of care. In addition, increased surveillance on the part of the reception staff improved communication both between members of staff and between members of staff and patients. This led to increased confidence in repeat prescribing among all staff.

Coronary heart disease is one of the biggest killers in the UK (Department of Health, 2000), with myocardial infarction accounting for the largest proportion of admissions to acute hospitals. In an era in which the speed of initiation of treatment is paramount in terms of achieving maximum potential benefit, the reasons for delay in seeking medical assistance remain poorly understood. Utilizing an interpretive approach informed by phenomenology, this exploratory study describes and analyses the process of help seeking in terms of the experience of patients from the onset of symptoms to seeking medical assistance. A total of 10 patients with confirmed myocardial infarction were interviewed within 6 days of hospital admission. From the data, it was possible to identify four headings under which to categorize factors which might influence delay in help seeking, namely symptoms, cognitive evaluation of symptoms, behavioural response to symptoms, and the influence of others present during the experience. A model of help seeking is proposed which explains the interrelationship between the categories, describes the patient experience, and suggests the process by which individuals may come to seek medical assistance. It is recommended that interventions that will influence cognitive evaluation of symptoms, and the behavioural response to symptoms, should be further explored in order to expedite the process of help seeking in acute myocardial infarction.