South Africa like many countries is moving towards a system of community care for people with mental health problems. This is set against a backdrop of under-resourced and overburdened services. These problems are particularly apparent in the township communities. The aim of this study was to devise an education programme for South African volunteer health workers using principles adapted from the UK evidence base for psychosocial intervention (PSI) and to evaluate the impact of the education programme on community volunteer health workers' knowledge about mental health issues. A stakeholder consultation exercise was held to explore: the context of South African services; the transferability of the UK evidence base and educational strategies to South Africa; and to inform the design of an educational programme. Evaluation of the community volunteer educational programme was undertaken using pre- and post-education focus groups. Twenty-one volunteers working with mentally ill people in the community from one township attended a three-day, six module course. After the course, volunteers: were able to articulate a greater range of aetiological and contributing factors to the development of mental health problems, including stress vulnerability and traditional belief frameworks; could describe a more humanistic model of mental health identification; identified a wider range of both formal and informal helping strategies; were more aware of the negative impact of interpersonal behaviours for people with mental health problems. Volunteer involvement has been confined to communicable diseases in South Africa. Volunteers educated about mental health care could assist in the South African policy of ‘horizontal’ integration of services into primary care from their current ‘vertical’, specialist-orientated structures.

The role of physician assistant has been established in the US for some time, and has proved a useful and effective adjunct to the medical profession. A similar role is being developed in England by the National Practitioner Programme, and this article reports the early progress of a pilot that is training primary care Medical Care Practitioners (as they are called) (MCPs) in Waltham Forest. Three trainees, all former nurses, are currently undergoing a two year programme of study and placement in general practice. It is anticipated that MCPs will be able to see up to half of the cases at present seen by general practitioners (GPs). The pilot has had to face many challenges. The role has needed to be defined, and its basis in a ‘medical model’ was not originally fully understood; training has had to be devised and provided ‘on the hoof’, before national competency and regulatory frameworks have been developed and agreed; the senior input required from the Primary Care Trust and its higher education provider has been substantially in excess of funding support received. Despite the commitment of pilot participants, a pilot is probably the wrong change management model for the creation of a new health care profession.

The constipating effect of opioids used in cancer pain is widely acknowledged. Opioids account for about a half of constipation in cancer patients, making constipation one of the most prevalent side effects of cancer analgesia. Scottish Intercollegiate Guidelines Network (SIGN) guideline 44 (7.4.1) states explicitly that the appropriate intervention for opioid-induced constipation is a combination of softening and stimulating prophylactic laxatives. Previous literature suggests such practice is not commonplace, implicating a knock-on negative effect to patients' quality of life and highlighting the need for audit in this area. An audit of bowel management in Fife primary care was carried out comparing laxative prescribing practice before and after the publication of SIGN 44: Control of pain in patients with cancer. The data for the audit included all opioid prescriptions including both cancer and non-cancer patients. It was found that publication of SIGN 44 had no significant effect on adherence to the guideline by general practitioners in Fife, at six-, 12- and 18-months post-publication. Implications for quality of life and improving bowel management are discussed.

Historically, few randomized controlled trials (RCTs) have been conducted in primary care and problems have been experienced applying this methodology in these settings. In 2001, The Leeds Evaluation of Efficacy of Detoxification Study (LEEDS) was developed. This RCT aimed to compare two detoxification drugs to inform best practice for the treatment of opiate users presenting to primary care requesting detoxification. This paper presents descriptive data from a postal survey of 12 general practitioners (GPs) from 10 primary care practices who were involved in the LEEDS trial. The questionnaire was sent out in November 2004, used open and closed questions and was self-administered. It uncovered factors that affected patient recruitment, GPs' views on the trial and their experience of randomizing opiate using patients. Flexible solutions to overcoming recruitment difficulties are presented alongside idealistic solutions to the problems experienced. The implications of our experiences of conducting this RCT in primary care practices are discussed in the light of conducting RCTs in primary care settings. This will benefit other research teams and clinicians who may be planning to use a similar research methodology.

Primary care research networks were established in Scotland to encourage research in primary care and build capacity. The aim of this descriptive study was to evaluate the primary care research network in Dumfries and Galloway, a rural area of Scotland, by describing the methods used and the outcomes in terms of research training and completed projects. All primary care professionals working in the region were offered an initial grant to buy time for research training to develop their own research ideas. Those attending the two day research training course were encouraged to submit a protocol for funding and Local Research Ethics Committee approval. Of the 605 and 717 primary care professionals circulated in the first and second years, 23 (4%) and 11 (2%), respectively applied for a research training grant. Of these, eight completed a research project together with a further six who had previous research training. Eleven (79%) of the 14 completed projects were the subject of oral presentations and 11 were submitted for publication in peer-reviewed journals. Only a small minority of professionals working in primary care will want to develop their own research, and this requires support, protected time and long-term mentoring. Building research capacity in primary care involves a number of activities ranging from funding academic units, to giving opportunities for non-academics to undertake research. These distinctions are important for decisions about appropriate funding and support.

With the increasing focus on collaborative, interprofessional models of service delivery in many parts of the world, it is crucial that nurses be able to demonstrate confidence in the value they add to the health system. As the largest group of health professionals, nurses must serve as change agents in strengthening health systems and influencing the development of appropriate health policy. This requires that nurses have a solid understanding of what is their unique role in contributing to attainment of desired health outcomes in the populations they serve. In this article, the role of nurses in health care is reviewed, with commentary on some areas in which nurses are currently underutilized in health care delivery, whether employed in community or institutional settings. Data from research conducted in Canada suggest that nurses have a tendency to define themselves by the tasks or activities they perform and seem unable to clearly articulate their special role in health care. Strong leadership and a willingness by nurses to re-orient their practice will be required to ensure that the potential for harnessing the knowledge, experience, capabilities and commitment of nurses in advancing health care reform shifts from rhetoric to reality.

The purpose of this article is to explore the processes that enable home care nursing services to provide good quality care. The focus is on how quality care is defined by nurses, patients and carers, and palliative care provision is used as an exemplar. The international policy scene is one of escalating costs and shortage of qualified nurses, which has resulted in a variety of forms of skill mix. In addition there has been an emphasis on partnership working with patients and carers, who are encouraged to participate in care giving. The article draws upon data generated in studies conducted by the author and colleagues over a 10-year period. The main conclusions of the article are that nurses, patients and carers were able to articulate the essential components of high quality care and that these elements fitted the structure, process and outcome framework first described by Donabedian (1969). In addition, forming a good relationship and rapport with the patient and family is viewed as a critical pre-requisite to quality care. It is noteworthy that the awareness contexts first described by Glaser and Strauss (1965) are still a relevant framework for analysing nurse patient and carer interactions. Finally it is suggested that the quality indicators identified in this article could be used as a useful starting point to develop criteria for judging quality of provision in palliative and supportive care services.

Participant recruitment is often the rate-limiting step in clinical trials, but the methods used and the processes involved in recruitment are rarely reported. Although various methods will often be adopted, there is a dearth of information about the factors which facilitate or impede recruitment to trials. Such information is potentially very valuable to researchers. The present pilot study aimed to recruit a minimum of 30 participants through primary care to a randomized controlled trial (RCT) of three interventions for older adults with depression. The aim was to determine how recruitment to RCTs in primary care may be optimized. A wide range of recruitment methods was used, including both direct general practitioner (GP) referrals and self-referrals. Potential participants were informed about the study in a variety of ways, including GP recruitment when attending surgeries, contacting suitable patients identified from the GP database, posters and leaflets in the GP surgery, and the specific targeting of older people by the distribution of leaflets at 'flu clinics. Both GP referrals and direct referrals were successful. Interestingly and rather unexpectedly, the greatest numbers of individuals were recruited by self-referral. No differences were found between these two groups as to the severity of their depression. Recruiting from primary care can be successful, if primary health care teams are willing to work in partnership with researchers, and if researchers are willing to be flexible and try many approaches. In particular, the study found that cultivating self-referrals was a profitable strategy, which was not what had been initially expected with this particular target group of older people with depression. These self-referrals were a cost-effective method of recruitment, each costing around one-third less than those recruited by other methods, and without them the recruitment targets would not have been met.

Most evidence on the delivery of diabetes services in primary care has focused on the organization of care rather than on the experiences of health care providers. We evaluated staff satisfaction with respect to access, communication, management advice, and understanding of roles. A postal survey of staff at 35 practices from two inner London primary care organizations was linked to profiles of the practice organization of diabetes care. Data were analysed for 124 staff including 81 doctors and 43 nurses. Only 37 (46%) doctors and 20 (47%) nurses were satisfied with the current system of diabetes care. Overall, there were low levels of satisfaction with access to, communication with, or management advice from other members of the diabetes team. Only 29/81 (36%) of doctors understood clearly either their own role or the role of others but 27/43 (63%) of nurses understood their own role and 23 (53%) understood the role of others. Compared with practices with less satisfied staff, practices where staff were more satisfied showed similar organization of diabetes care in terms of the use of a register, recall system, clinical guidelines, availability of equipment, organization of education programmes or use of audit. Staff were generally dissatisfied with diabetes services, but the level of satisfaction was not associated with practice organization for diabetes care. Since a better team climate has been associated with higher quality care, more work should be done to understand influences on staff satisfaction in the delivery of diabetes care in primary settings.

The aim of this qualitative study was to examine the experiences and needs of patients and carers affected by one of three common neurological conditions and to explore how primary care can contribute to improvements in care. Data was drawn from five focus groups recruited from various geographical locations in the north of England served by seven primary care trusts and four neurological departments. Researchers in a semi-rural practice recruited 38 participants, 15 of whom were male and 23 were female. Ages ranged from 26 to 74 years. The participants were either patients or carers of people with epilepsy, multiple sclerosis or Parkinson’s disease and were recruited from three settings: primary care (two groups), voluntary groups (two groups) and secondary care (one group). The results showed that neurological care could be patchy, overstretched and insensitive to the individual patients’ needs. Communication between patient and health professional, and between different sectors of the health service is poor and often leads to time wasting and delays in treatment. The impact of these conditions on the patient and their family and their preferences for treatment varies. Specialist nurses are highly valued by patients and their families but the service is overstretched and access is difficult. General practitioners (GPs) are valued for their communication skills and their ability to act as advocate for the patient; however, there are doubts about their knowledge of neurological conditions. Problems of service access were identified. The skills of health professionals in general practice can be used to complement those in secondary care. GPs and nurses are considered a valuable resource that could be used better to improve neurological care, particularly in fostering patient participation in decisions about their care. Practice-based commissioning offers an opportunity to review services to make better use of the time and skills of all professionals involved in the provision of care.

There is wide recognition that patient and client assessment by community nurses is central to the provision of high quality care. It is also acknowledged that assessment in the home setting is a complex process requiring a wide range of knowledge and skills. This article identifies two distinct approaches to assessment that have emerged in different contexts around the world. These approaches comprise the formal, structured questionnaire-based assessment that has been developed particularly in response to the requirement to determine service eligibility and the informal, conversation-based assessment that draws on nursing concepts and theories. The article briefly traces the professional and policy influences that have shaped the development of these two approaches before turning to a critical analysis of selected empirical work that has examined their effectiveness. Research undertaken on the structured form of assessment has focused largely on issues of reliability. While the majority of studies indicate that this form of assessment is reliable in identifying patient need, some research highlights its failure to take account of patient and client perspectives. This raises questions about the appropriateness of the nursing interventions that are planned in response to a structured assessment. Less research attention has been devoted to exploring the conversation-based approach to assessment, but this body of work has drawn attention to the potential for practitioners to adopt a controlling influence over the assessment process. Reference is made to research in which the author has collaborated that illuminates the way in which two styles of conversation-based assessment impact differently on patients and clients. The article concludes by identifying the need for further research and argues that a key focus should be the ways in which assessment contributes to care planning and patient outcomes.

Up to 20% of additional income is being provided to UK general practitioners (GPs) to improve quality of care, through a complex set of quality indicators which relate principally to chronic disease management and organizational aspects of care. Using data from semi-structured interviews with a purposive sample of 20 GPs and responses from 1035 GPs to a questionnaire survey (53% response rate), we describe the initial impact of these incentives. GPs are employing more staff, especially nurses and data entry clerks, and computerizing their clinical records. Patients are more frequently seen in disease-oriented clinics run by nurses. While the health gains associated with the incentives may be realized, GPs predict that there may be unintended consequences, including reduced continuity of care, care fragmentation, neglect of unincentivized conditions, and the risk of damage to their internal motivation.

Although there are often clear benefits from health screening strategies there is also evidence that some individuals experience emotional difficulties when participating, these reactions are often as a result of inconclusive or equivocal results from the screening tests. Most of the research literature explores this from a female perspective – there is less evidence of how men experience the uncertainties of screening. This article presents findings from a qualitative research study exploring the experiences of men who received equivocal results when participating in prostate specific antigen (PSA) testing. The men were drawn from a larger clinical trial to identify men with early signs of prostate cancer. In-depth interviews were conducted with seven men from one general practice in the North of England who had received an equivocal result from PSA testing and subsequent prostate biopsy. Phenomenological analysis revealed five inter-related themes in the men's experiences. The theme pre-conceptions centred around men's beliefs about the links between early diagnosis and was linked to their perceptions about responsibility towards their own health. However, men also reported feelings of uncertainty when receiving results that did not definitely indicate they did or did not have prostate cancer. This uncertainty generated reactions of stoicism towards the equivocal result and subsequent participation in further investigations. However, men also reported that participation in PSA screening did make them feel ‘looked after’. These findings are closely comparable with the literature on women's reactions to screening test uncertainty. This is possibly heightened by the lack of clear evidence about the accuracy of PSA testing to detect prostate cancer. These men participated in order to find out if they had prostate cancer or not and seemed unprepared for the possibility of an equivocal result.

Common mental health problems are highly prevalent in primary care, the UK National Service Framework for mental health demanding that effective and accessible services be made available. Although built upon a strong evidence base, traditional psychological therapies are often limited in terms of their applicability and availability. As a consequence innovative self-help programmes are increasingly being advocated as an alternative means of managing mental health illness within primary care. This study reports the results of a three month evaluation of a self-help service provided by a busy UK urban Primary Care Trust. Levels of utilization, effectiveness and stakeholder acceptability were examined through a combination of quantitative and qualitative data. A total of 662 patients were referred to the self-help clinics over a three month period, 67% of whom attended their first appointment. The mean number of sessions per patient was 2.8 (SD = 2.4), with an average total time of 69.6 min (SD = 48.2). Mean Clinical Outcomes in Routine Evaluation (CORE-OM) scores improved significantly between baseline and three month follow-up (P < 0.001), 39% of patients demonstrating a clinically significant improvement. Both selfhelp therapists and referring general practitioners reported moderate to high satisfaction with the self-help treatment model, with the majority of patients perceiving the intervention to be appropriate to their needs. Data demonstrated that, whilst there was a clear need for a simple self-help service to be based in primary care, the ultimate success of this provision necessitates a well developed infrastructure capable of providing sufficient support and information to ensure that it is flexible and responsive to individual needs.