Primary care research networks are considered to be fundamental to the development of a relevant research base in primary care. Networks must be responsive to members' research and training needs in order to evolve. The aims were to gather information about the perspectives, barriers to participation, research interests and training needs of primary care staff interested in participating in the North Central Thames Primary Care Research Network (NoCTeN). A postal questionnaire survey documented training needs and barriers to initiating or developing practice-based research. Focus groups were convened to gain an understanding of needs and explore practical means of addressing these needs. Seventy per cent of practices (57/82) responded to the questionnaire survey. Two focus groups were convened with general practitioners, and one group with practice nurses. Clinical commitments were considered the greatest barrier to research participation. Respondents were keen to participate in research relevant to their practice population. Training was viewed as ideally being project specific and practice based. Mentoring schemes were advocated, together with methods to encourage primary care staff to develop research ideas and access appropriate training. Although there were common themes, there were also differences between general practitioners' and nurses' perceived needs. Investigation of members' perspectives and needs enables networks to respond appropriately and practically. Addressing barriers should encourage members to participate in research and increase primary care-based research activity.

The majority of people with psychosocial problems confide in relatives or friends rather than their GP or other professional but the advice and information handed out, although well intentioned, may be misinformed. Others consult key personnel within their community who also may be ill-equipped to give constructive help. In a disadvantaged inner city area, it might be expected not only that stress would be prominent in people's lives and affect their health, but also that there would be barriers to seeking professional help. This project investigated whether working in partnership with a community, enabling its members to identify their own support, development and training needs and meeting those needs by adaptation of a recognized basic counselling skills course, was an effective way of helping that community cope with its own psychosocial problems, increasing its transferable skill base. Evaluation was conducted by means of individual interviews and focus groups. Participants perceived that the training that they had undertaken was valuable and that they were now better listeners with increased confidence and more likely to offer appropriate responses to those seeking their help. Several were motivated to undertake further training and others gained confidence to seek further professional help for themselves. Spending time allowing a community to define its own training needs whilst working on familiar territory is a cheap, effective, non-threatening way of putting information, basic counselling and relationship building skills into a disadvantaged urban community without causing dependency but instead encouraging them to seek further training enhancing employability. The skills introduced into that community remain and can be used to the full for themselves and others especially in relation to psychosocial problems. As the project used a well-recognized course and can be adapted to the needs of local people, it is likely to be transferable to other areas.

What people know and how people feel about type 2 diabetes will affect demand for early identification of the disease at an asymptomatic stage. This paper reports on the selected findings from a broader study of the attitudes and perceptions of GPs, nurses and patients about screening for type 2 diabetes. Purposive sampling was used to identify several practices across north-east England, and data were collected via semi-structured interviews with GPs, nurses and patients from these practices. Interview transcripts were analysed by drawing on the principles of grounded theory, with the aid of NUD*IST software. This paper focuses upon the perceived seriousness of this condition, and the implications such perceptions may have in practice. Results indicate a marked variation in perceptions of seriousness between health practitioners and patients. This diversity can be explored via three overlapping frameworks identified during the study: medical, political and personal. A medical framework suggests that individuals' perceptions are guided by a medical model. This links the seriousness of type 2 diabetes with concepts of prevention and cure, a need for individual lifestyle change, bias towards younger patients and anticipated use of medication. In short, diabetes is perceived to be more serious as it becomes more medicalized. A political framework views seriousness in terms of national incentives and priorities, a recognized need for a centralized push for early detection and financial inducements. Diabetes detection is not generally thought to be attractive politically compared with systematic cancer screening. A personal framework suggests that perceptions of seriousness are determined by individual attitudes, knowledge and experiences of diabetes. The findings offer important insights into how perceptions of the seriousness of type 2 diabetes may influence detection and management of this disease in primary care.

Primary Care Groups and Primary Care Trusts have the task of achieving an integrated health care service, serving local communities. A regional Education and Training Consortium commissioned a 1-year study to provide information in order to develop a workforce strategy that aimed to achieve this agenda. The study involved individuals who plan, provide and/or manage primary and community health care service in three Health Authorities, working in partnership. The three phases of data collection included focus groups, individual interviews and a survey, which produced qualitative and quantitative data. The findings outlined in this paper primarily focus on practice nurses and integrated care. Several tensions emerged in this context which could inhibit the development of integrated care. These included conflict within professional relationships, inequality in pay and working conditions, a lack of understanding of how integrated care would or could translate into practice and turbulent environmental contexts. We argue, these tensions often created gaps between policy, practice and professional discourses which, unless acknowledged and understood may result in integrated care remain a health, but unachievable, rhetoric.

Maternal and infant health in primary care following childbirth is an important area which has recevied little research attention. Very little is known about primary health service use following childbirth and its determinants. The aim of this exploratory study was to test the hypothesis that place of birth is independently associated with mother and baby consultation patterns in the first year of life. This is a descriptive study of 453 pregnancies of 338 mothers from an inner city general practice between 1987 and 1996. There were 86 intended home births, 126 intended domino births and 240 intended hospital births, with one woman unbooked. Of these, 69 women had home births, 97 had domino births, 286 women had hospital deliveries and one baby was born in an ambulance. The outcome of interest was mother and baby consultation rates in the year following birth. In an attempt to control for pre-existing ill health we also calculated the women's consultation rate in the year prior to conception and substracted this from the mother and baby consultation rate in the year following birth. We analysed the data according to both intended and actual place of birth. Women intending a home birth had fewer mother and baby consultations in the year following birth compared to women intending domino births, who in turn had fewer consultations than women intending hospital care during labour (P < 0.001). This gradient persisted when pre-existing maternal ill health was accounted for. A similar gradient of increasing consultation rates through home births, domino birth, normal vaginal delivey in hospital and assisted delivery in hospital was demonstrated when data were analysed according to actual place of birth. Other maternal characteristics independently associated with increased mother and baby consultation patterns were: primiparity, manual occupational class, not breastfeeding, maternal smoking, infertility prior to pregnancy, and recorded anxiety, depression or life events before or after birth. Women intending and having a home birth were older (P < 0.001) and less likely to be primiparous (P = 0.055) or of manual occupational class (P < 0.001). Babies born at home were heavier (P < 0.001), and women experienced less perineal trauma (P < 0.001) and were more likely to breastfeed at birth (P < 0.001). The conclusion we draw from this cohort of births, is that there is an association between women intending a home birth and women who actually have home births and lower mother and baby consultation rates postnatally, when compared with women having normal vaginal domino or hospital births. This is independent of maternal age, parity, smoking during pregnancy, occupational class, a history of infertility or miscarriage in the year prior to conception, anxiety, depression or life events in the year prior to conception or after birth, breastfeeding, sex of baby and birth weight.

The recent interest in the issue of domestic abuse has highlighted its adverse impact upon womens' health, together with the need to improve health care responses. Whilst this has implications across health services, the raised awareness of domestic abuse as a health care issue is particularly important for primary care. This is not only due to the nature of primary care contact with women experiencing domestic abuse, but also because the current modernization of primary care, which includes organizational change, enhanced public health, increased partnership working and new forms of service delivery, provides an ideal opportunity to improve the services which are delivered to women experiencing domestic abuse. There are, however, a number of challenges to achieving real changes in practice. These include the complexities of domestic abuse which will always be competing with other clinical priorities, as well as the complexities of primary care which crosses a number of organizational and professional boundaries. Moreover, whilst the recognition that domestic abuse is a health care issue is to be welcomed, concerns relating to the medicalization and professionalization of what is essentially a social problem are highlighted.

In the context of widespread discussion about a crisis in GP recruitment and retention we review available evidence and comment on underlying policy dynamics. There have been a number of attempts to improve recruitment and retention, and examples of salaried schemes and personal medical service pilots are discussed. The results of a postal survey to health authorities requesting information on existing salaried schemes are reported. Forty health authorities responded to the survey, of which 30 had developed a scheme. These schemes had been established to address recruitment and retention issues, provide higher professional training for GPs, provide care to specific groups of patients, to support underperforming practices, and to help practices develop their range of services and address PCG/T health priorities. We then comment, in some detail, on one particular scheme as an example – the Bradford salaried non-principal scheme. The background to the scheme is described, as is the process of selecting both scheme GPs and host practices. The impact in terms of personal and professional development of the salaried GPs is discussed. Evaluation of the scheme from the perspective of the salaried GPs (via a focus group) found that the main attractions of the scheme were the opportunity to gain experience of inner city general practice without the commitment to a partnership, opportunities for professional development, and support from the peer group of salaried GPs. A number of concerns were raised relating to the clarity of their role in the practices, in particular, the extent to which the salaried GPs were being used to absorb practice workload rather than, as proposed, to facilitate practice development.

The objective of this study was to determine the views of Somerset GPs, on the quality of communication from hospitals, with particular reference to the cancer patient. A questionnaire was designed as a result of focus group discussions with 22 GPs. This questionnaire was then sent to all Somerset GPs, of whom 312 participated. The questionnaire was designed to ascertain the perceived quality of communication from hospitals. The results of the study concluded that most GPs believe good communication is more important with cancer patients than with other patients. Written communication was regarded as being very good with the exception of discharge information which should provide more detail on follow-up and treatment plans. However, more detail was desired on potential side effects of treatment and recommended action, as well as on prognosis. It was generally felt that greater use of fax and e-mail would be helpful.

Non-attendance in general practice is increasing. In contrast to hospital non-attendance little research has been undertaken on the topic. The aim of this study was to identify the characteristics of non-attending patients and to determine the reasons for general practice non-attendance, so that strategies to reduce it could be devised. Four hundred and ninety-three consecutive non-attenders from five practices in Exeter, Devon were studied. A questionnaire was sent enquiring about the reasons behind the patient's non-attendance and possible strategies to reduce future non-attendances. Of 17 264 appointments 493 (3.9%) were not attended. Females accounted for 278 (56.4%) of the non-attenders. The highest number of non-attenders was in the age group 25–44 years. One hundred and seventy-four (35%) responded to the questionnaire, of whom 60 (35% of responders) had forgotten the appointment. Strategies to reduce general practice non-attendance should focus on assisting the patient to remember the appointment.

General practitioner activity is increasingly under pressure to monitor its performance. The involvement of service users in the development and assessment of services is said to be a key feature of this process. This article reports on the acceptability among general practitioners of a patient-completed post-consultation measure of outcome (the Patient Enablement Instrument; PEI), and its use in conjunction with two further indicators of quality, namely time spent in consultation and patients reporting knowing the doctor well. The survey was conducted using focus groups and the administration of a postal questionnaire among a group of general practices that had participated and received feedback from a large quantitative study testing these measures. The focus group study provided useful insights into general practitioners' perceptions of patient assessment of their performance and their concerns surrounding the measurement of general practice activity. The general practitioners' perceptions of the measures under the study were enmeshed within these concerns overall. The PEI was seen as being generally acceptable as a measure of patient assessment of care, and the methods of data collection were acceptable for routine use in general practice. General practitioners who performed better in terms of their feedback scores generally approved more of the proposed measures. However, these general practitioners were not comfortable with the concept of assessment of the clinical interaction by patients, and were anxious to link such assessment explicitly with clinical (disease-related) outcome. Doctors who performed ‘better’ were no more likely than those who performed less well to advocate more use of patient assessment, or to believe that patient assessment of consultations is a reliable quality indicator. These concerns need to be addressed if patients' assessments of their care are to be taken seriously.

The PHASE research programme is an NHS-Executive funded, randomized controlled trial of assisted self-help for common mental disorders, delivered by practice nurses in primary care. The self-help guide – Managing anxiety and depression: a self-help guide published by the Mental Health Foundation – is conceptualized as a ‘health technology’ where the nurse's role is to educate patients how to get the best out of the technology, supervise its safe delivery and monitor its continued use by patients so that they can use it independently with little reliance on nurses or other health professionals. Twenty-three nurses were trained on one of five, 3-day courses to deliver PHASE. As the final task during the training course, nurses were asked to describe what they would say to a patient when delivering PHASE. From these data a qualitative thematic content analysis was used to develop a coding framework which showed that nurses were able to articulate a sophisticated health technology rationale, including relevant psychological models and the principle of an evidence base. This study demonstrates that it is possible to equip primary care nurses with both a highly developed understanding and the knowledge to deliver self-help mental health care. Training nurses using this model moves us away from traditional mental health training courses that have attempted to produce ‘watered down’ versions of specialist practitioners to a more appropriate skills and cultural ‘health technology’ fit for delivering primary mental health care.

The literature shows that patients' positive opinions of general practice care are associated with being older, of lower educational level, lower social status and being married, but there is no association with the sex of the patient. The health related characteristics of patients, such as self-reported health status, chronic condition and utilization of care, also predict judgements of the quality of some aspects of general practice care. This study investigated whether, in addition to individual effects, combinations of patient characteristics can also influence opinions of care, and whether these findings are valid in different European countries.

A self-completion questionnaire was developed and given to consecutive patients in five general practices in each of eight European countries. There were 48 questions covering five aspects of care: availability and access, organisation and co-operation, medical care, relationship and communication, information and support and an overall opinion. There were a further 16 questions on patient characteristics. One way analysis of variance, using SPSS software, was used to compare mean scores for each aspect of care for different values of the patient characteristic. Multivariate analysis was used to investigate the interaction effects between pairs of patient characteristics, which, individually were found to influence opinion. Further tests were made to identify any interaction between the effect of each patient characteristic and the country of residence.

1008 (response rate 63%) questionnaires were completed. The patient characteristics which influence patients' opinions were found to be age, levels of education and professional qualification, length of relationship with the practice, and whether they have a chronic condition. However, there are no interaction effects between these characteristics. Importantly these effects were found to be valid in all countries in this study. The patient characteristics which do not appear to influence opinions of care are sex, levels of utilization of care and self-reported health status.

When surveying opinions of patients about general practice care, since patients of different characteristics will give different views of the same service, the sample of patients whose views are surveyed should aim to account for these predictable differences. Decisions on changes in care provision should be based only on the results of patient opinion surveys in which the characteristics of the sample of patients responding to the survey were taken into account.

The purpose of this explorative study was to ascertain what kind of guidance and support first-time mothers expected from public health nurses (PHN) at child welfare clinics, while they were still on the maternity ward after delivery. Data were collected by an open-ended question as part of a questionnaire between January and May 1995. The sample comprised 219 mothers. Content analysis was applied. Mothers' expectations focused both on the content of support and on the mode of interaction. Mothers expected that issues concerning mainly the child, but also the mother, and the whole family would be discussed at the child welfare clinic. Mothers expected to receive advice and instruction on childcare, that interaction would be individual and family-centred in nature, and that the care would be continuous. Mothers hoped that the atmosphere of interaction would be safe, confidential, peaceful and encouraging. PHNs were expected to have not only professional skill, that is, knowledge and competence, but also a friendly, empathic attitude and a sense of humour. Mothers' expectations of the PHN varied greatly, so the support provided by the PHN should be based on charting the family's need for support, not on routine guidance and counselling. Further research should focus on how the family's need for support changes during the child's first year of life.