During the period 1997–2002 ResNET and PRO˜Net, the primary care research networks for Buckinghamshire and Oxfordshire respectively, awarded small bursaries to network members to support local research. The bursaries were designed to assist researchers undertaking small, largely unfunded projects. The intention was to encourage research activity that could be shown to lead to evidence-based practice. The bursaries took a broad view of research activity, including enabling projects, skills training and dissemination of findings. A total of £6818 was awarded to 19 applications involving 22 individuals. Semi-structured interviews were carried out with 19 of the recipients plus two correspondences via email to explore a wide range of outcomes and the effects on personal and professional development. Tangible outcomes included six published papers to date, six international conference presentations and 10 national presentations with many local presentations or network newsletter articles as well as securing additional external funding of £117500. The awards enable locally based research that contributes to the agenda of linking practice development with the implementation of findings at the local level essential to improving patient care. In addition, there are perceived benefits to individuals in developing their personal and professional skills, which in turn aid recruitment and retention in primary care.

Focus groups are used increasingly in general practice research, especially where a qualitative method is required to answer exploratory questions. Recently teleconferencing has been used to conduct focus groups in research on rural general practitioners, where distance makes face-to-face focus groups difficult and where anonymity of participants is important. This paper discusses advantages and disadvantages of using teleconferencing as a means of undertaking focus groups and provides examples of research where this has been used. We conclude that focus groups, conducted using teleconferencing, are an appropriate method in research on general practitioners, and can be particularly useful, when conducting research in rural and remote areas, and when anonymity of participants is desirable.

A randomized controlled trial was conducted to assess the efficacy of a computerized therapy programme for depression and anxiety, ‘Beating the Blues’, compared with cognitive-behaviour therapy provided by clinical psychologists and treatment as usual by general practitioners (GPs). The aim of the paper is to describe the study, the problems that were encountered when GPs agreed to recruit participants during consultations and to outline possible solutions to these problems. After three months only five participants had been recruited prompting modification of the study design. After one year only 17 patients had been recruited and the study was discontinued. The GPs indicated that the randomization procedure compromised their traditional role of providing patients with the best possible treatment. This produced role conflict that was resolved by GPs adhering to their care-giving role at the expense of recruiting to the study. GPs also felt that discussion of research took too much time during consultations and was inappropriate given that patients were often somewhat distressed. They also did not see the three treatment arms as equally acceptable, which resulted in GPs failing to recruit patients in case they were randomized to what they considered to be inferior treatments. Competing demands that rendered the study a low priority were also reported. We incorporated suggested solutions to these problems into the study which was rerun and completed after one year with 40 patients having been recruited.

The epidemiological evidence regarding physical activity and health has triggered, within health care, an interest in the development of physical activity promotion, in an attempt to address concerns regarding levels of physical inactivity within the population. These initiatives have varied during the past decade, from public health campaigns, to the development of nationally recognized training qualifications. By far the most prolific physical activity programme that has developed however, has been the ‘exercise referral scheme’. These schemes now exist in most towns and cities, providing a formal link between local primary care and leisure provision. However, professional bodies in both medicine and exercise, responsible for the care of their members, have expressed concerns over the duty and quality of care that exists within such schemes. Research too, has provided conflicting evidence regarding their efficacy for health improvement. As such, national recommendations have been produced and published by the Department of Health to set and maintain standards in this growing area of service delivery.

This case study of professional practice provides one innovative approach to ensuring that a countywide exercise referral scheme is a successful conduit for raising physical activity levels, and thus, health. By employing professionals from exercise science to deliver the Proactive Management Service, Somerset Physical Activity Group have devised a unique approach to ensuring and maintaining the quality of service delivery to the patients referred onto the exercise referral scheme within Somerset.

The case study concludes with lessons learnt from these developments and proposals for the future, including, establishing a national register of exercise referral schemes and the importance of addressing the competencies of both health professionals and leisure professionals, who are involved in such schemes.

Certain observations arose from the implementation of multicentre research on ‘ecotherapy’. Very diverse community groups of people with a range of disabilities, undertaking horticulture and nature conservation as a therapeutic and social enterprise, provided an unexpected conception. We coined the term embracement to capture the meaning of an activity we found in many ‘bottom-up’ examples of social inclusion. Self-organizing groups grow by the members’ choosing to embrace a common identity, which included and integrated health, social and environmental dimensions. Embracement is self-directing, spontaneous and collective, with the potential group members being the driving force.

Central to the original Alma Ata declaration was the notion of a system, which included the fostering of health through multisectoral collaboration. This aspect often gets referred to as comprehensive health care, in counter distinction to a selective primary health care model, which emerged immediately following the conference, as the former, though laudable in intent, was argued to be unworkable. Indeed from a global perspective, comprehensive primary health care, if noticed at all in the culture of western medicine, was relegated to being of relevance in ‘other’ places: so-called developing countries. Nevertheless, at the beginning of a new century, in a vastly different world to that of the 1970s, it is the central contention of this paper that it is still possible to assert that the primary health care model is still relevant – in all countries of the world. The work on the ‘social determinants of health’ increasingly adds weight to the arguments against the irrationality of an overemphasis on medical technical interventions to the neglect of the health-enhancing or health-threatening contexts in which people live out their lives. Consequently it is now becoming possible to think and plan the management of health, not just the management of disease.

Concerns over low uptake of cervical screening among minority ethnic women have spurred much research and practical activity to address the problem. Due to theoretical and methodological difficulties, research in this area has tended to focus on the communication deficit of women, without addressing the social context. This has not only hindered a wider theoretical understanding of the problem but, also, has perpetuated ineffective health promotion practice in this area. Using a participatory action research (PAR) approach, the project ‘Woman-to-woman: promoting cervical screening to minority ethnic women in primary care’, tackled the problem by involving both health professionals and women from the communities. Working in partnership, both professional and lay participants identified the problems from their own perspectives and generated solutions to resolve them. An intervention strategy was formulated in which bilingual women from the communities were recruited as community health educators to provide an informed link between their respective communities and the primary care sector. The outcomes of the intervention were evaluated by all participants. This paper aims to introduce PAR as an alternative approach by presenting an overview of the study. It begins by highlighting some of the common theoretical and methodological problems encountered by researchers; and then introduces the research framework of PAR and describes the research processes. A case observation is presented to illustrate the depth of understanding of the screening processes that can be obtained using this approach. The project has demonstrated that applying PAR cannot only lead to meaningful discoveries and insights into the problem of minority ethnic women and cervical screening, but also change in health promotion practice, which would have been difficult to achieve using a conventional research model. However, this study has also revealed major limitations of PAR, which need to be addressed if the approach is to be further developed.

Devolved accountability for primary care has been introduced into the UK through a range of local contracts for personal medical services (PMS) authorized by the 1997 NHS (Primary Care) Act. These four exemplary case studies illustrate the PMS pilot programmes and represent a diversity of emerging organizational developments that appear to be responding effectively to different health care needs and environments. This is particularly apparent at those sites targeting the most marginalized patient groups where interprofessional collaboration and interagency partnerships are characteristic of a new and broader primary health care approach. Elsewhere the PMS pilots retain and indeed may extend some of the more restrictive practices of the conventional primary medical care model. Future policy formulation, therefore, needs to promote flexible management structures and processes which can support, through local contracts, the further development of more comprehensive and population-based primary care.

The policy thrust in the health system in many developing countries over the last decade has been on reforming structures. This paper examines such reforms in the light of the principles of primary health care that were adopted at the Alma Ata conference in 1978 and which are re-emerging as underpinning the current WHO global policies. It concludes that many of the reforms at best did not strengthen PHC and at worst ran counter to it.

The objective was to explore the feasibility of prospective recruitment of general practice patients to a future trial on the effects of paracetamol on the symptoms of the common cold. In October 2000, recruitment letters were sent by a general practitioner to 276 patients aged between 18 and 75. 65 patients returned signed consent forms. Postal packs were sent to the first 60 of these patients to reply. They contained a daily diary, symptom score questionnaires, an EQ-5D questionnaire, a pack of paracetamol tablets, and detailed instructions. When a cold developed and symptoms reached a specified level, one gram of paracetamol was taken four times daily for two days and questionnaires were completed for four days. Telephone interviews and crosschecking of data were used to identify difficulties in completing the study. The overall recruitment rate was 24% (65/276) with 95% confidence interval 19% to 29%. Recruitment was significantly higher (p < 0.001) amongst patients registered with the main researcher (43% (29/68)) than with other doctors in the practice. The response rate, i.e., those who returned completed study packs, was 77% (46/60). Thirty participants experienced a cold and returned their data during the six months of the study, representing 50% (30/60, 95% Cl 37% to 63%) of participants and 11% (30/276, 95% Cl 7% to 15%) of those initially approached. The mean cumulative four-day symptom score was 34.6, standard deviation 14.7. The EQ-5D health status on day four was 0.89. We conclude that a prospective postal recruitment method in general practice is a potentially useful method of conducting research on the common cold. A better response is obtained when the initial letter is signed by the patient's own doctor.

This paper presents the findings of a study designed to explore myocardial infarction (MI) survivors' experiences of their heart attack, to obtain their views on existing services and to gather ideas for a new, community-based cardiac rehabilitation initiative. Despite the increasing emphasis on the consumer ‘voice’ in health service delivery, little research has been published exploring the experience of MI from the patient's perspective. This is of particular significance given the study's location in a disadvantaged urban area where the uptake of conventional hospital-based cardiac rehabilitation is poor. The study is based on qualitative, semi-structured interviews with 20 myocardial infarction survivors in southeast Nottingham. Participants were identified from the list of those invited to participate in a local hospital's cardiac rehabilitation programme. The interviews were carried out in patient's home between one and 12 months after the MI, were tape recorded and subsequently transcribed. Thematic analysis reflected both the issues identified in the interview schedule but also some unexpected findings elucidating the survivors' own perspectives. The paper is structured around four key themes: the story of the heart attack; the way survivors' lives have changed; experiences of existing services and ideas for service development. The paper concludes that MI should be understood as a long-term rather than an acute condition and discusses the implications for service delivery.

There is continuing support both politically and professionally for the provision of mental health care within primary care (Department of Health, 1999; The Scottish Office, 1993; 1997; 1998). However tensions exist between the supply and demand for mental health resources in primary care (Department of Health, 2000). In addition to resources, perceptions of need, knowledge and training are likely to influence the services offered and the uptake of these. This study reviews general practitioners’ (GPs) and patients’ perceptions of need, availability of services and GPs’ ability to access mental health services in two local areas using a new assessment tool. The Mental Health Management Options (MHMO) form, a brief instrument, was developed to provide information about GPs’ preferred and actual management options with people experiencing mild to moderate mental health difficulties seen during routine consultations

Sixteen GPs each completed 10 copies of the MHMO, providing data on 160 consultations. Analysis found that discrepancies arose in 69% (n = 109) of the consultations in relation to the action GPs wished to take but were unable to do so. This was related to the inability to access services, to patients who declined to follow suggested management options and to a lack of time and/or ability to manage the patient.

This study highlighted the barriers GPs face in managing people with mild to moderate mental health problems in primary care but also demonstrated the content validity and utility of the MHMO. The MHMO may be a useful new tool in identifying GPs’ perceptions of patterns of management and gaps in services.

Health for all was identified by the World Health Assembly in 1977 as the desirable main social target for governments, international agencies and the global community. Primary health care was defined at Alma Ata in 1978 and was then seen as the vehicle to achieving health for all. Governments in sub-Saharan Africa embarked on processes to align their health policies and indeed implement them within the PHC framework. PHC in Africa was seen as an overall strategy for achieving health for all, rather than just as the first level of care. Thus countries restructured their entire health systems in the framework of PHC rather than focus on the first level of care only. The mid to late 1980s saw worsening economic performance which was followed by the enforcement of structural adjustment programmes, sociopolitical instability, man-made and natural disasters and the beginning of the HIV/AIDS pandemic. All these wrecked havoc on plans countries had for implementation of PHC. Within this context, the elaborate policies and plans were not fully implemented. Furthermore, there appears to have been a general underestimation of the resources required. Though there was some initial progress in improving health status as shown by some health parameters, health for all was not achieved by any of the countries.

The study reported here is one part of a wider study, evaluating the role of the nurse practitioner (NP) in primary care This part of the study focussed on the views of the primary health care team (PHCT) regarding their experience of working with two NPs. A project to place Master's prepared nurse practitioners (NP) in general practitioner practices was undertaken with the intention of more fully meeting the needs of practice populations in a deprived inner city area. The roles were supported and funded by the health authority and the placements were intended to be time limited with placement and funding to be reviewed. The project incorporated a planned evaluation of the role and this included a study of consultation patterns, caseload and this particular element, a study of PHCT members' attitudes to and experiences of the role. A purposive sample of 27 staff were interviewed using a partially structured interview format. Each interview lasted around 30 minutes with two researchers undertaking both collection and analysis of the interview data. Subsequently, an additional six staff were also interviewed in an opportunistic manner, at their request. The findings identified two main foci of the NP; as an ‘extra pair of hands’ and as a colleague undertaking a different, valuable and complementary service to existing staff. The pivotal role of the receptionist in the integration of the new role in to the practice and the acceptance of it by patients was clear. General practitioners (GPs) exhibited paradoxical views, particularly with respect to problems of throughput; the NP having longer appointments and therefore usually undertaking fewer consultations than GPs in any session, leading to perceptions of an expensive and perhaps less effective service in terms of its effect on the workload. Within the same interview however, GPs discarded throughput as an effective measure of patient care and highlighted the many benefits of NP consultation. This tension between cost and effectiveness would benefit from more effective analysis and evaluation. The members of the PHCT express many different views, often related to their professional priorities, but all appear to support the NP role enthusiastically, considering it a positive step which benefits the team, patient care and choice.

The need for research that is applicable to the most common health problems is well recognized. Some of this research will be in the area of primary care, and family doctors must contribute to the research for it to be effective in improving care. Using a sample of key informants from 10 different countries, this paper explores the extent to which family doctors are involved in research in the various regions of the globe. We find great variability in the level of research being conducted by family doctors at academic institutions and in the development of the community research structures, such as practice based research networks. Despite the problems, family doctors are involved in research in every region assessed, and there is room for optimism that this role will be substantially expanded.

As new organizations with responsibility for the health and health care of their local populations, primary care trusts (PCTs) need to engage with patients and the wider public. This paper identi. es the challenges faced by PCTs in implementing patient and public involvement and reports on a qualitative study of four PCTs in one health district. Findings from two pieces of data collection are reported on: an audit of community involvement activity and 16 semi-structured interviews with individuals working in the PCTs. The findings show that organizational capacity for undertaking patient and public involvement activities increased considerably over an 18 month period. The PCTs were found to be engaging with individuals and groups from the community and voluntary sector through a range of different structures and processes. Considerable commitment to patient and public involvement was reported but there were concerns over implementation. A number of influencing factors were identified including national policy, organizational factors, leadership, workload, access to experienced involvement workers and the pattern of local community activity. The paper discusses the implications for the development of patient and public involvement in PCTs including the importance of cultural change and the need for organizational development. The potential for PCTs to be involved in a range of participatory activities and to work with other partner organizations in localities is also discussed. The paper concludes that, despite challenges, progress can be made in implementing patient and public involvement as a mainstream activity in PCTs.

A variety of nurse practitioner education and training programmes are currently offered. They are designed to prepare experienced nurses to undertake an expanded role and a broader range of activities. Since the introduction of this new nursing role many nurse practitioners are now working in primary care health care teams. This study aimed to investigate how the working patterns of primary care teams have been altered as a result of the introduction of the nurse practitioner into the primary care team, the ways in which nurse practitioners' skills are integrated into the primary care team and other team members' perceptions of this new nursing role. The study was exploratory and a qualitative methodology was chosen. Phase one consisted of three focus groups with three primary care teams including nurse practitioners. Phase two involved audiotaped, semi-structured interviews with nurse practitioners (n = 4) and general practitioners who worked with nurse practitioners (n = 3). The data were subsequently transcribed, reduced and analysed using a theoretical framework appropriate to the research design. Nurse practitioners operated in a variety of ways in primary care. Key clinical activities included triage, physical examination, diagnosis and decisions about the treatment and care of individuals and specific groups of patients. The conditions dealt with by nurse practitioners were generally less complex than those seen by GPs but an element of overlap occurred. The nurse practitioners emphasized the importance of offering patients a choice about whom they prefer to be seen by. Most team members were supportive of the new team member, although some were confused about the role and others were opposed to the introduction of a new specialist nurse post. The findings indicate a need for role clarity, definition and official recognition.

In the UK, older people who are resident in care homes because of their needs for social support and personal care receive their health care from primary health care. Although there is increasing input from district nurses in care homes (Audit Commission, 1999), there is little knowledge or recognition of the primary care nursing contribution. This paper reviews two types of research literature: studies that consider the health care needs of older people in residential care homes that could inform nursing support and interventions in care homes, and research that describes the nursing involvement with these settings. The paper argues that on the basis of the research reviewed many of the health problems older people in care homes experience could be avoided or improved by primary care nursing support and intervention. A reassessment is needed of how the interface between community and residential care is managed so that older people in care homes have access to appropriate health care support.