Patients living with chronic pain are typically resource intensive, their care requirements are long term and referral to secondary care is not always expeditious. To provide more appropriate, accessible and cost-effective care, Tower Hamlets Primary Care Trust reviewed the needs of the patients, their current care and the numbers requiring treatment for non-malignant chronic pain, initially starting with musculoskeletal pain.

We estimated the number of people with chronic pain being treated outside general practice by the NHS in Tower Hamlets. A working group established set criteria to define a chronic pain patient. We surveyed appropriate clinicians to determine the approximate number of patients who fitted our inclusion criteria, the approximate number of follow-up appointments they required and their care pathways. Secondly, we estimated the cost of care for chronic pain patients using NHS national tariff and reference cost data. We also took a convenience sample of chronic pain patients and recorded their history of care.

The routes and pathways of care are complex and multiple. We estimate between 4.0% and 5.5% of new patients in rheumatology, orthopaedics, occupational therapy and musculoskeletal physiotherapy and up to 90% in the pain clinic are people living with chronic pain. The cost of this care ranged from £296 for a course of physiotherapy to £1911 for a patient seen in physiotherapy, orthopaedic and the pain clinics.

There is no facility in current management information services that identifies people being treated for non-specific chronic pain; therefore, estimating both the numbers and costs for treating these people is difficult. National tariff and notional cost data provide estimates only, of an ‘average patient’; the real cost of these patients is unknown.

To investigate whether general practitioners (GPs) in countries with different levels of cardiovascular risk would make different risk estimates and choices about lipid-lowering treatment when assessing the same patients.

Primary prevention of coronary heart disease should be based on the quantitative assessment of an individual’s absolute risk. Risk-scoring charts have been developed, but in clinical practice risk estimates are often made on a subjective basis.

Mail survey: Nine written case simulations of four cases rated by the Framingham equations as high risk, and five rated as low-risk were mailed to 90 randomly selected GPs in Stockholm, as a high-risk area, and 90 in Sicily as a low-risk area. GPs were asked to estimate the 10-year coronary risk and to decide whether to start a lipid-lowering drug treatment.

Overall risk estimate was lower in Stockholm than in Sicily for both high-risk cases (median 20.8; interquartile range (IQR) 13.5–30.0 versus 29.1; IQR 21.8–30.6; P = 0.033) and low-risk cases (6.4; IQR 2.2–9.6 versus 8.5; IQR 6.0–14.5; P = 0.006). Swedish GPs were less likely than Sicilian GPs to choose to treat when their estimate of risk was above the recommended cut-off limit for treatment, both for the entire group (means of GPs’ decision proportions: 0.64 (0.45) and 0.92 (0.24), respectively, P = 0.001) and for high-risk cases (0.65 (0.45) and 0.93 (0.23), P = 0.001).

The cardiovascular risk level in the general population influences GPs’ evaluations of risk and subsequent decisions to start treatment. GPs’ risk estimates seem to be inversely related to the general population risk level, and may lead to inappropriate over- or under-treatment of patients.

Some primary care physicians provide less than optimal care for depression (Kessler et al., Journal of the American Medical Association 291, 2581–90, 2004). However, the literature is not unanimous on the best method to use in order to investigate this variation in care. To capture variations in physician behaviour and decision making in primary care settings, 32 interactive CD-ROM vignettes were constructed and tested.

The primary aim of this methods-focused paper was to review the extent to which our study method – an interactive CD-ROM patient vignette methodology – was effective in capturing variation in physician behaviour. Specifically, we examined the following questions: (a) Did the interactive CD-ROM technology work? (b) Did we create believable virtual patients? (c) Did the research protocol enable interviews (data collection) to be completed as planned? (d) To what extent was the targeted study sample size achieved? and (e) Did the study interview protocol generate valid and reliable quantitative data and rich, credible qualitative data?

Among a sample of 404 randomly selected primary care physicians, our voice-activated interactive methodology appeared to be effective. Specifically, our methodology – combining interactive virtual patient vignette technology, experimental design, and expansive open-ended interview protocol – generated valid explanations for variations in primary care physician practice patterns related to depression care.

Depression in young people is not necessarily self-limiting, and is frequently associated with affective disorders and impaired psychosocial functioning in adult life. Early recognition of and response to depression in teenagers could be an important task for general practitioners (GPs), but there are multiple obstacles to achieving this.

To explore GPs perceptions of the opportunities and difficulties of working with teenagers, and of specifically recognizing and responding to depression.

Nine GPs who had taken part in a developmental project on diagnosing and treating depression in young people. All worked in an Inner London Medical Centre.

Semi-structured interviews transcribed and analysed thematically.

Two over-arching themes that emerged from the interviews were that teenagers were perceived as being qualitatively different from adults in the ways they used general practice, and that GPs were uncomfortable with making a diagnosis of depression in young people. Within the first theme, we identified sub-themes, including failure of teenagers to engage with services, parental involvement, complex presentations and lack of time. Within the second theme, the sub-themes were surprise, normalization of depressed mood and challenge to the validity of psychiatric diagnosis in this age group.

Professional development in general practice that addresses this topic needs to modify two perceptions; that depressed mood is in some sense ‘normal’ in this age group, and that teenagers are so different in their use of services that the management of depression (if it is recognized at all) is problematic.

To explore health professionals’ experiences of barriers and facilitators to referring patients for pulmonary rehabilitation in a primary care setting.

Pulmonary rehabilitation involves a multidisciplinary teamwork approach to improving the quality of life for people with chronic obstructive pulmonary disease. This study aimed to find out about health care professionals’ experiences when referring patients. Reports suggest that a health care professional’s attitude towards a treatment affects the willingness of patients to accept advice.

Five focus group interviews were undertaken with 21 health professionals from North Midlands, UK. Data were analysed using a thematic analysis drawing on the techniques of grounded theory.

Chronic disease management has been delegated to Practice Nurses in many cases leaving some nurses feeling unsupported and some General Practitioners feeling deskilled. Problems with communication, a lack of adequate and timely local service provision, a difficult referral process, time pressures and lack of information were barriers to health care professionals making an offer of pulmonary rehabilitation. An explanatory model is proposed to describe how addressing barriers to referral may improve health care professionals views about pulmonary rehabilitation and therefore may mean that they present it in a more positive manner.

To suggest how to improve primary epilepsy care by assessing the strengths and weaknesses of epilepsy care in general practice by reviewing practice records in relation to qualities and outcomes framework (QOF) indicators and epilepsy guidelines.

Concerns have been raised about epilepsy care in the UK. The general practice QOF indicators offered the first opportunity to take on structured epilepsy care in the UK. The QOF includes targets for this condition and national guidelines list key priorities to improve care. This study explores how general practice systems are delivering this care.

A case notes review in 27 practices in the north-east of England. Adults with epilepsy were identified from practice morbidity registers and a READ code search. Data from 1333 patients were collected on the frequency and location of epilepsy review, type of epilepsy and classification of seizures, epilepsy medication ordering, and individual and practice demographic data. The data were entered into SPSS for frequency analysis and grouped for further analysis: Primary Care Trust (PCT), age and medication ordering groups (satisfactory, moderate or poor).

Of the patients, 24% did not have a record of type of epilepsy and about a third of patients had no seizure classification recorded. One-fifth of patients were not reviewed in the previous year but of those who were, the majority were seen in general practice. Seizure frequency was not recorded in the last 12 months in one-quarter of patients. Adherence and recording of seizure information were related to age of patient. Epilepsy registers were inaccurate. The findings suggest that epilepsy care can be improved by using review and monitoring systems to ensure a complete and accurate epilepsy register and appropriate annual clinical and medication review.

To analyse the experience of a pilot programme designed to shift care from hospital to the community.

The white paper, Our Health, Our Care, Our Say, published in England in 2006, set out a vision for the future of primary care and community services. A key component of this vision is to provide care closer to home. The NHS Institute for Innovation and Improvement established a pilot programme in five field test sites to explore the scope for bringing about shifts in care from hospital to the community. This paper reports the results of the evaluation of the programme.

A comparative case study design was used including interviews with key stakeholders at different points during the pilot programme, participation in discussion groups, documentary analysis, and collation of activity and output statistics. By comparing evidence drawn from 14 projects in the five field test sites, the evaluation was able to identify the impact of different factors on the progress of the projects.

All of the projects made some progress in taking forward their plans to shift care, although there were wide variations in what had been achieved at the end of the test and learn phase. Key factors influencing progress were the existence of a receptive context for change, project focus, organisational leadership, project management, stakeholder analysis, clinical engagement and leadership, overcoming barriers to change, aligned incentives, training and support, measuring and monitoring progress, and the timescale for change. A critical requirement in programmes of this kind is ‘getting the basics right’ through dogged attention to project and change management. Also important is ensuring that the evidence on change management and quality improvement is acted on by those leading change programmes.

The voluntary sector has long been recognised as making an important contribution to individual and community health. In the UK, however, the links between primary health care services and the voluntary and community sector are often underdeveloped. Social prescribing is an innovative approach, which aims to promote the use of the voluntary sector within primary health care. Social prescribing involves the creation of referral pathways that allow primary health care patients with non-clinical needs to be directed to local voluntary services and community groups. Such schemes typically use community development workers with local knowledge who are linked to primary health care settings. Social prescribing therefore has the potential to assist individual patients presenting with social needs to access health resources and social support outside of the National Health Service.

The aim of this paper is to explore the concept of social prescribing and discuss its value as a public health initiative embedded within general practice.

The rationale for social prescribing and existing evidence are briefly reviewed. The paper draws on a case study of a pilot social prescribing scheme based in general practice. Data collected during the development, implementation and evaluation of the scheme are used to illustrate the opportunities and limitations for development in UK primary health care.

The potential for social prescribing to provide a mediating mechanism between different sectors and address social need is discussed. The paper argues that social prescribing can successfully extend the boundaries of traditional general practice through bridging the gap between primary health care and the voluntary sector. The potential for wider health gain is critically examined. The paper concludes that social prescribing not only provides a means to alternative support but also acts as a mechanism to strengthen community–professional partnerships. More research is needed on the benefits to patients and professionals.

Sexual health in Northern Ireland (NI) is poor compared with the rest of Europe with increasing incidences of sexually transmitted infections and one of the highest rates of teenage pregnancy. Traditionally, sexual health services have been provided in a fragmented way by a wide range of different providers but recent sexual health strategies have flagged sexual health as a key activity within the primary care setting.

The main aim of the study was to assess the sexual health promotion activities within the primary care setting across one Health and Social Services Board in NI.

A series of semi-structured interviews with both general practitioners (GPs) and practice nurses (PNs) was conducted to assess their views on the key issues in relation to sexual health in primary care. A questionnaire survey was also conducted with these health professionals to elicit information about sexual health promotion activities within the primary care setting.

The results have shown that promoting sexual health within the primary care setting is often ad hoc and often does not target the ‘at-risk’ population. As such, GPs and PNs tend not to discuss sexual health with non-heterosexual clients or those with learning disabilities due to lack of awareness and training. Health professionals feel inadequately trained to engage in effective sexual health promotion and to provide enhanced sexual health services. Personal embarrassment and lack of time were also identified as barriers for providing effective sexual health care.

Health professionals within the primary care setting require additional training to deal with the sensitive and complex issues inherent in the area of sexual health.