The Canadian health care system is under increased pressure to reform. While some advocates lobby for more physicians and more resources to fix the ailing system, many reports point to another potential solution – implementing primary health care (PHC). Implementing PHC will not be easy. Even though there is substantial evidence to support the efficacy and cost effectiveness of PHC, its implementation will require substantial changes in practice. Community-based research (CBR) has the potential to be the catalyst for the type of change that is required. A multidisciplinary, multisectoral inquiry team has been funded to use CBR to reconceptualize and transform PHC service delivery in British Columbia, Canada. Although the research project is in its initial phase, it is anticipated that the research will provide new, holistic, and comprehensive frameworks for practice. This paper describes the process used to bring about these changes.

In the UK, the Department of Health recognizes the importance of research activity to improve patient care, but the amount of research activity relating to primary care is scant. Few have considered managerial and organizational aspects relating to developing research capacity in primary care and none have examined this from the perspective of organizations responsible for managing primary care at a local level. Yet these organizations have a critical role in increasing the amount of appropriate health services research and developing a research culture. A qualitative analysis of focus group workshops was performed to identify issues associated with developing research capacity within a primary care trust (PCT) covering a single local authority borough in England. All staff attached to the PCT were invited to attend facilitator-led focus groups and asked to consider from an individual and organizational perspective: What will enable them to increase the use of and participation in research? What barriers exist? What opportunities exist or could exist to develop this in the PCT? Themes were identified using content analysis based on written records from the focus groups. Issues relating to developing research capacity were grouped into the following categories: What is research? Training; Resources; Managerial; and Organizational issues. Research was not seen as an integral component of the daily or routine work of most people in a health care organization. Managerial and organizational issues were a considerable barrier to developing research capacity. Lack of appreciation and support for research by managers and lack of structures to facilitate research within the organization prevented research capacity being developed. Primary care management organizations need to work with service managers to encourage the incorporation of research activity into the routine work of staff. Greater dialogue is needed between individuals, service managers and academics to ensure that appropriate research is carried out to support the organization in meeting its explicit objectives. More work is needed to understand the perceptions of research from a managers’ perspective and to develop constructive ways to gain their support for a research agenda.

Whilst much good practice relating to research support for rural PCTs undoubtedly exists, little has been published about the processes that facilitate such successful support. This paper outlines the nature of a collaborative venture between a Research & Development Support Unit, HRDNoW, and a Primary Care Research Network, CumbReN in providing research support to three rural PCTs in North Cumbria. In doing so, the paper highlights how research capacity is built through a combination of inputs at an individual and organisational level and looks specifically at the outcomes of this collaboration.

General practitioners have always had special interests. Recent policy initiatives in the UK, organizational changes and changing attitudes by the Royal Colleges have meant that there is an increasing interest in the development of a new role for GPs with special interests (GPSIs). This paper considers what methodology is best suited to examining change, while that change is still developing. Specifically, it offers a model that identifies different forms of knowledge; anticipated, explicit and tacit and considers how these can combine in an evaluative model for innovations in primary care. The paper goes on to identify potential benefits and risks of a shift towards GPSIs. It develops a picture of GPSI services in one PCT and focuses on two disciplines, orthopaedic medicine and urology. Views of those GPs providing these services are reported and are linked with the possibilities that a new form of general practice might emerge without general practitioners.

The National Institute for Clinical Excellence (NICE) guideline for diabetes patient education offers little to inform National Health Services (NHS) Trusts in the curriculum design of self-management education programmes. The study aim was to conduct a patient-needs assessment of the educational curriculum content and support needs for Type 2 diabetes self-management. Different stages of the condition were chosen to identify whether needs remained constant or changed with time and experience. Six focus groups were convened for people who had recently received a new diagnosis or changed therapy. Twenty-three participants were recruited from primary care and the media in the UK. The educational curriculum support needs comprised: access to care and support, continuity of health care professional, lay support, high-quality care and support, and a positive cognitive appraisal of experiences. Needs were broadly similar irrespective of the new change situation. The current emphasis on lay support concurs with a proportion of the needs of our study participants. Motivational communications with patients need to be prioritized to enable patients to address therapeutic goals.

This study investigated adolescent experiences of familial involvement in adolescent peer relations and school attendance. The data were gathered through semi-structured interviews with Finnish adolescents (n = 19; aged 12–16 years). The data were analysed by qualitative content analysis. Positive familial involvement was described as enablement, continual conversations about adolescent activities, actual support and taking an active role in adolescent activities. Negative involvement included negligence, criticism, restrictiveness or coercion. The findings are discussed with reference to previous research, and implications for adolescent and family health promotion are noted.

The East London and Essex Network of Researchers (ELENoR) funded a project to develop R&D capacity among practice nurses. The ELENoR nurses forum chose the topic, which was ‘Older people’s experiences of primary care’, using qualitative interviews as the main method. The project was designed to enable nurses to participate as much or as little as suited their individual circumstances, and whatever their previous R&D experience. Compulsory training was provided, and ELENoR paid for all the time which was given to the project, travel expenses incurred and so on. This paper reviews the project, drawing on oral and written communications by participants and the personal experience of the authors.

Nine nurses from eight practices carried out 58 interviews, and four collaborated in the analysis. Those participating report a number of outcomes. Their own confidence in their ability to do research has increased; the work enabled them to reflect on their practice and to make changes (e.g., to how they provide health education to those with diabetes; making appropriate referrals to specialist services); and as a result of the participating nurses’ report, her practice team is reviewing particular aspects of how diabetes is managed. Two papers reporting the findings have been submitted for publication, one of which is published, and papers have been presented at national and international conferences.

The project represents a successful small-scale capacity building exercise achieved at a modest cost.

The National Service Framework (NSF) for coronary heart disease (CHD) requires that all people with established CHD are identified and managed systematically; accurate and complete electronic patient records (EPRs) are thus essential. This project aimed to first establish the completeness and consistency of recording electronic information about CHD (diagnosis, risk factor monitoring and aspirin usage) across a group of general practices and secondly, to provide feedback on their performance. The third part of the project planned to evaluate the effect of this feedback on the general practices’ electronic data recording but this is not reported in this article. Twenty-two of 26 general practices in one Primary Care Trust (PCT) participated. A random sample of 75 people with a Read code for CHD and/or who were taking one or more of five drugs used in CHD were selected from each of the 15 practices using Egton Medical Information Systems (EMIS) to manage their EPRs. The remaining seven practices used Torex electronic clinical system and from each of these practices, a random sample of 25 patients with a Read code for CHD was selected. Sample sizes were pragmatic rather than being chosen for possible statistical significance. At each practice the patients’ paper patient records and EPRs were searched for information about CHD diagnosis, risk factor monitoring and aspirin usage. Results were fedback and discussed with each individual practice and presented to the PCT. Electronic recording of CHD diagnosis was fairly complete but recording of risk factor monitoring and aspirin usage was more inconsistently recorded. Providing feedback to the general practices raised practitioners’ awareness of strengths and weaknesses in their electronic record keeping. Work to improve EPRs needs to be ongoing, to ensure that there is complete and easily accessible information about people with CHD so that their care management can be planned and implemented effectively.

General medical practitioners (GPs) and members of the primary care team have a pivotal role in supporting unpaid carers in their caring role and helping them to maintain their own health and well-being. This paper investigates the difference that caregiving makes to individuals’ access to and use of GP and primary care services. It is based on longitudinal analysis of carers’ contacts with GPs, and a review of the literature including evaluations of measures to improve primary-care-based support for carers. Men increase their consultation rates with GPs when taking on a caring role. In contrast, women who look after someone in the same household and carry heavy caring responsibilities have relatively less contact with GPs than expected. According to the literature, carers report a range of difficulties accessing primary health care. A five-fold typology is described covering barriers arising from: professional responses to the carers’ role; the way services are organized and delivered; language or culturally held beliefs and practices; carer or care recipient characteristics; and unmet information needs. Various measures to improve carers’ access to primary care have been introduced to overcome these barriers, but robust evidence of cost and utility is required to judge their acceptability and effectiveness for both carers and GPs. Although good practice guides, quality standards and evaluation tools are available to help improve primary care support for carers, further investigation of carers’ help-seeking for health care, and the factors involved, is required to underpin the prospects for developing a genuine partnership between unpaid carers and health professionals.

Against a background of decreasing age at sexual debut, local Brook staff voiced concerns about the increase in clinic attenders under the age of 14 years, who appeared to engage in risky behaviours. This exploratory study, carried out with service providers in a young persons sexual health clinic, aimed to discover what issues staff felt were important to 11–14 year-old girls, in order that a future study be conducted with the young girls themselves. Service providers from two Brook Advisory Centres were interviewed. The interviews were semi-structured and analysed using content analysis. Many of the issues that staff identified as important to young girls mirrored current research findings with older adolescents. These were: alcohol consumption, peer pressure, low self-esteem and confidence, and a lack of knowledge around sexually transmitted infections. However, a new issue to emerge was the high proportion of young girls attending the clinic for the emergency contraceptive pill despite not knowing whether they had had intercourse or not. The study also found that staff perceived the need to understand issues from the perspective of the young girls themselves.

Staff identified a necessity for improved sex education and education around peer pressure and assertiveness, whilst topics for future research which emerged from the study findings included issues of self-esteem, dynamics of peer/media pressure and why young girls feel that they need to have sex.

There has traditionally been a low level of engagement of primary care practitioners with research. In the UK, primary care trusts (PCTs) now have some responsibility for the encouragement of research and development in primary care. The aim of this study was to assess the current level of research activity and capacity for research within a PCT. A questionnaire, incorporating a recently developed and validated research and development culture index, was sent to all 572 health care professionals and staff under the auspices of North Tyneside Research PCT. Data analysis used nonparametric tests of association including chi-squared, Mann–Whitney U and Spearman's rank order correlation. There was a 50.3 per cent response rate to the questionnaire. Groups more likely to show an increased capacity for research included those with postgraduate qualifications and those in post for the least time. General practitioners were less likely than other professional groupings to declare personal skills or aptitude for research. The two most important factors thought to contribute towards the development of a culture of R&D were having access to people to support development and changes in professional practice and having access to training and development opportunities. The use of the R&D culture index enabled groups to be identified that may be more research interested and can therefore be targeted to increase research capacity. The R&D culture index could be used by other PCTs wishing to define and develop research capacity in primary care.

Department of Health efforts to make primary care more effective depend on the availability of relevant research findings. This implies a need for management and organization research, but it is not clear what role practice managers will play in this. The priority given to research governance also raises questions about how best to manage research in primary care. The aims of this study were to identify practice managers' involvement in research, their attitudes to research and their training needs. To do this, we conducted a postal survey of all general practices in East London and Essex. Of the 622 practices, 510 employed a manager. Of these, 232 responded, giving a 45% response rate. One hundred and forty-five (62%) respondents had been involved in research and 90 had been as a practice manager. Forty-five (20%) had some research training. Most had a positive attitude to research. The most commonly requested training topic was ‘How to manage research projects’. They wanted research to be conducted on delivering effective health care, access and appointments systems, patients' expectations of general practice, team management and their own role in the NHS. We conclude that managers have two distinct roles in research. First, undertaking research into management and service delivery and secondly managing and supporting research in the practice. Most need further training to take these forward. Research networks could do more to involve managers.

There is increasing concern at the amount and cost of prescribed medicines that are unused or wasted and then have to be disposed of. Previous studies have used health promotion and Dispose Unwanted Medicines Properly campaigns targeted at the patient to describe and quantify the annual cost of waste. The reasons patients return unused drugs to pharmacies have also been explored. The paper focuses on patient explanations for not needing medication; categorized as: over-collection in the past, self-management strategies, changes in medical condition, other changes in patient circumstances, or the repeat medicines policy at the surgery. The aim of the original study was to make a measurable change in prescribed medicines with a reduction in medicines wastage, whilst at the same time achieving improved standards of pharmaceutical care. Information on patient needs and behaviour came from consultation in the pharmacy monitoring forms and interview. The study was based on two medical practices in the West Midlands, UK, comparing an outer city and an inner city population. The participants were general practitioners, pharmacists and 350 repeat prescription patients. Prescriptions were issued for two three-month periods. The outcome was that 23.8% of the prescribed items were not dispensed, at a value of £13.1K, 58% of the medications that would be expected to be regularly supplied were collected. The study suggests that closer professional management at the point of dispensing and an understanding of patient experiences can help reduce the amount of unwanted medication collected by patients.

The integration of information technology into the health care system is central to the UK government’s strategy to improve the delivery of health care. There remains uncertainty about how this new technology is being used by practitioners, and the impact it is having in their everyday work and relationships with patients. The objectives of this study were to identify experiences and attitudes of general practitioners (GPs) about the use of the Internet as an information resource for themselves and for their patients, and their perceptions of the obstacles to using it, and to describe how GPs view the potential and limitations of the use of electronic communication with both fellow professionals and patients, and to explore the perceived impact on the GPs’ roles and relationships. A qualitative study design involving interviews with 24 GPs in North West England was used. The methods involved semi-structured interviews with a purposive sample of GPs to explore their views on the use of the Internet in their day-to-day work. Interviews were recorded and transcribed verbatim. Data was analysed with the interview schedules being modified in the light of emerging themes. There were two main themes: the Internet as an information source for GPs and their patients, and the use of email as a form of communication between themselves and patients, and between health professionals in primary and secondary care. Whilst GPs appreciate that the Internet could offer an exceptional quantity of information that could be used within the consultation and which might improve patient management, they cite many barriers to the effective acquisition and use of such a resource. Similarly, GPs reported limiting their use of the Internet to assist communication between the GP and the patient, and were concerned about the Internet duplicating work rather than reducing it. GPs seemed reluctant to grasp the potential that they perceived that the Internet might offer. The current configuration of primary care, and the role of the GP within it, is likely to limit the uptake and use of the Internet as a means of extending opportunities for patient care.

This article reports on findings from a one-year national evaluation of the Primary School/Primary Care Health Links (PS/PC HL) initiative, commissioned in 2003 by the National Drug Prevention Development Team, on behalf of the Department of Health (DH). The primary aim of the PS/PC HL initiative was to develop links between primary and community health care professionals and primary school children in order to increase the children’s knowledge and understanding of a range of health issues. This involved developing innovative ways in which parents could engage in the health education of their children at primary school level. As part of the evaluation, a questionnaire was sent to parents (n = 69) and children (n = 464) to discover to what extent discussions about health issues, in particular substance misuse, were held at home and what messages children were receiving. In this context, substance misuse includes drugs, alcohol and tobacco. This article also examines children’s attitudes towards smoking and alcohol, and considers how parental influence affects children’s ideas about the acceptability of these substances. The findings indicated that whilst over 65% of parents thought that their children knew a lot about exercise and healthy eating, only 20% thought that their children were well informed about alcohol and drug misuse. Despite 80% of children in our survey reporting that they would prefer to discuss health problems with their parents, substance misuse appeared to be a topic rarely discussed at home. The findings confirm, (i) the need for family and community cohesiveness and (ii) reinforces the need for an increase in parents’ knowledge and motivation in order to (iii) raise their confidence in their conversations with their children about substance misuse. Partnership working between teachers, health professionals and parents would appear to be the ideal in effectively reinforcing health messages to children; however, the authors suggest that the culture of accountability both in the teaching and health professions often hinders this process.

A holistic approach to care has traditionally been the central tenet of general practice in the UK. However, recent major changes in general practice may be diminishing the importance and/or deliverability of such an approach. We sought to explore the views of Scotland’s general practitioner (GP) principals. We surveyed all 3713 GP principals in Scotland during February to July 2001 by postal questionnaire. Nearly 9 in 10 GPs (87%) felt that a holistic approach was essential to providing good health care, but only 1 in 5 (21%) felt that primary care was currently delivering high-quality holistic care, and only 1 in 15 (7%) felt that the current organization of primary care was conducive to such care. Constraints on holism were thought to contribute significantly to higher rates of prescribing (73% agreed), more referrals to secondary care (63% agreed), and increased demand for complementary therapies (57% agreed). Psychological factors were considered to play an important role in organic physical disease – its causation (67% agreed), course (94% agreed) and reversal (69% agreed) – yet when either the GP or the patient wished to explore issues relating to stress or emotional difficulties the GPs felt significantly constrained, mainly by time and their own stress (mean values (95% CI); 0: not limiting, 10: extremely limiting; time 7.6 (7.49–7.67); stress 4.9 (4.84–5.04); training 4.7 (4.66–4.84); skills 4.2 (4.13–4.30); motivation 3.4 (3.33–3.50)). In this survey Scotland’s principal GPs overwhelmingly endorse the traditional holistic approach of general practice and primary care, but feel that it is failing to be delivered due to organizational and time constraints, with consequent human and financial costs. These results give voice to deep concerns among GPs who remain committed to a holism they are struggling to deliver.

This paper reports an evaluation of a counselling service that was introduced into 20 general practices within Bradford City Primary Care Trust. Clinical Outcomes in Routine Evaluation (CORE) Assessment and End of Therapy forms were used to record referral and attendance information along with problems identified and demographic information about clients. There was a large disparity in the number of referrals across practices illustrating a range of influences on take-up of the service. Levels of attrition from referral for counselling to commencing were relatively high (188 invitations: 89 took up counselling). A longitudinal evaluation of outcomes was conducted using the CORE outcome measure and the SF-36 Health Survey Questionnaire. Data was collected at the beginning of counselling, at six months and at 12 months follow-up. We found some indication of positive change relating to severity of problems and ability to engage in social activities. However, evaluators should be aware that high attrition rates can create problems in achieving statistical reliability in contexts where overall population numbers are relatively small and/or the time for data collection is relatively short. In light of the recent growth of counselling within primary care, and the need to evaluate these services, the issues encountered in setting up this counselling service, and in seeking to evaluate it, may be instructive to others. Focus groups with counsellors and practice staff explored the benefits and problems in providing the service within practices.

The need for effective collaboration when working with survivors of domestic violence is an urgent one. This paper outlines an innovative project that will examine the antecedents of homicide by a current or former partner. The early stages of the project including analysis of closed homicide case records and a survey of police officers' experience of collaboration with health and social care providers is presented. Early findings suggest opportunities where intervention could in future situations prevent homicide.

There is increasing emphasis on including patients in decision making about treatment. In order to do this, they need to have access to appropriate information about treatment options. The study reported here reports initial work carried out in the development of a decision analysis tool to assist women about treatment for menorrhagia. Women referred to secondary care with a diagnosis of heavy menstrual bleeding were interviewed. Our study shows that women had limited and often inaccurate knowledge of most treatment options. They expressed feelings of diagnostic uncertainty, the need for a ‘label’ for their symptoms and a perception of the failure of the general practitioner (GP) to provide this. The women in our study referred to secondary care with a diagnosis of menorrhagia do not seem to have had their concerns about their menstrual symptoms addressed prior to the referral. In addition, the women in this study do not feel that their GP has communicated a diagnosis to them. Women must be able to feel that they have been diagnosed in order that treatment options can then be properly discussed, and a shared management decision reached. Reasons for the apparent lack of adherence to guidelines are discussed. There is a need for a decision aid for use in primary care to assist women and their doctors in the management of menorrhagia.