Network development in the NHS in the UK has, by and large, not been based on evidence. Now, following perceptions of failure, some are calling for networked approaches to be abandoned. This paper reviews the evidence in two ways: factors which are known to motivate individuals and organizations to join networks; and the essential elements of network design necessary to ensure sustainability.

Aim: To describe the scope and nature of research capacity building activity within academic departments of general practice and rural health in Australia. Method: Document review of Annual Reports for the years 2000 and 2003 of 17 university departments of general practice and rural health, funded through the Research Capacity Building Initiative (RCBI) of the Primary Health Care Research, Evaluation and Development (PHCRED) Strategy. Results: The review indicated that from 2000 to 2003, departments increased their activities in all areas of research capacity building activities. Mentoring and/or supervision other than higher degree students increased from 14 in 2000 to 266 in 2003. Twenty-two research networks involving over 1377 participants were operating in 2003. All departments were involved in collaborations either as part of grant applications, research projects or educational activities. Over 3630 people participated in 189 educational activities in 2003 compared to over 624 people attending 103 activities in 2000. Compared to $10.98 million in 2000, departments had obtained more than $15.6 million for research projects in 2003. While there were more peer reviewed papers published in 2000 (n = 178) compared to 2003 (n = 130), these 17 departments gave 187 conference presen-tations. Conclusions: This review shows that the RCBI has contributed towards a considerable increase in research activities in these university departments of general practice and rural health. This has provided a major boost to primary health care research in Australia. These activities would have been unlikely to occur without the support and assistance of the PHCRED Strategy. Clearly, the full impact of the RCBI will take some time to evolve.

Background: We previously studied clinical outcomes in two cohorts of emergency admissions of patients aged over 70 to one district general hospital (DGH) or five community hospitals (CHs) finding no differences in death, readmissions, or quality of life at 6 months after admission. Our objectives in this study were to examine the use and cost of medication and use and cost of investigations in the two different hospital settings. Methods: We identified and priced all medication taken on admission, during the hospital stay, and on discharge, and identified all investigations. The main outcome measures were number and cost of medications and investigations during the stay, and the difference in the patients' routine medication before and after the hospital stay. Results: Three hundred and seventy five patients were studied (DGH 170, CH 205). The median (inter-quartile range (IQR)) number and cost of drugs used during the hospital stay was higher in DGH patients: 11 (8, 17) drugs than CH patients: 8 (5, 11); (P < 0.001), costing £35 (13, 90) and £16 (6, 45) respectively (P < 0.001). DGH patients had a mean of 0.55 drugs added to their routine medication, at an extra projected cost of £9.50 per month, whereas CH patients had an average of 0.11 drugs removed from their routine medication at a projected cost saving of £1.35 per month (P = 0.012 for number and <0.001 for cost). More investigations were performed in the DGH than the CH; DGH median (IQR) £260 (180, 410); CH median £40 (9, 110). Conclusions: Considerable extra resources are used in emergency admissions of the elderly to a DGH. However, these extra resources do not appear to yield mortality or morbidity benefits.

Aims: To gain structured feedback on a qualitative research methods training programme delivered to primary care researchers over a period of ten years. To examine dilemmas and challenges and how these had been resolved. To examine how the programme could be further developed. Background: The Wolds Primary Care Research Network's (WoReN) qualitative research methods training programme was developed and evolved in response to the needs of primary care practitioners and researchers and the NHS Research Agenda. Methods: Information on participants' professional backgrounds: which workshops they attended; their evaluation sheets, comments; and personal appraisals were collected from 1996 to 2006. Structured telephone conversations with a number of participants and ongoing informal feedback from participants added to this information. Numbers and ranges of professionals attending workshops were ascertained, how far they travelled to workshops and further degrees obtained by them, within the decade, were also noted. Findings: We found a lack of similar training elsewhere. A wide range of people attended workshops, especially general practitioners (GP) and academic researchers. Other practitioners were a significant presence however, and included nurses, pharmacists, health visitors and professions allied to medicine. Participants were prepared to attend extended workshops and to travel significant distances to them. Participants preferred a continuous cycle of workshops rather than discreet sessions, in order for them to consolidate their learning and to develop at their own pace. Practical exercises reflecting the qualitative research process were considered very conducive to learning and participants also appreciated one-to-one consultations about their work and longer-term, ongoing support as they progressed through their projects. Workshop design needed to continually reflect the changing requirements of participants, employers, funders, potential trainers and national NHS requirements. A new audience for training was identified in supervisors not versed in the qualitative paradigm.

Background: Primary health care has recently undergone and is continuing to experience significant change. One issue is the increased emphasis on population health. Public health is at the centre of recent United Kingdom government policy as well as international policy. This paper describes the adoption of a specialist practitioner public health nurse role as a resource for public health practice development. The issues raised by the approach to practice and service development are located within discourses on leadership, modernisation and change in health and social care. The discussion is guided by critical theory approach to facilitate exposure of the factors influencing decisions and consequences of decisions. Evaluation method: The evaluation design drew on the theories of change approach which focuses on ‘surfacing assumptions’ underpinning a change process. Purposive sampling was used to identify a range of stakeholders to the post. Individual interviews were conducted with 11 stakeholders from management, nursing, social work and medical roles. Four focus groups were conducted with health visitors. Findings: Thematic analysis identified three issues that relate to a specialist role aimed at public health capacity development; location of the specialist role within existing teams, the routes available to providing public health subject leadership and sharing expert knowledge, potential for conflict or tensions between specialist and other roles. Conclusions: Capacity to address the public health agenda is being developed at the same time as the modernisation of leadership. The role and impact of historical organizational structures and approaches to management and leadership must be acknowledged. The research indicated that specialist posts have positive potential in relation to public health practice developments. Key success factors included involving the generalist in the rationale development of such a role, sharing expectations of the impact of all roles and where to locate the specialist role with respect to existing teams and structures.

The emerging UK national research network in neurodegenerative diseases and dementias aims to promote large-scale community-based studies of therapeutic interventions, based in primary care. However, trials in primary care settings can be problematic, a common difficulty being the recruitment of a large enough sample. The article discusses recruitment issues in a multi-centre randomized controlled trial of differing educational approaches to improving dementia care in general practice. Sample size calculations based on community studies of prevalence may be misleading in intervention trials which may recruit practices with atypical demography. Recruitment rates for practitioners in this study were lower than expected. Professionals excluded themselves from the study mainly due to pressures of time and staff shortages, and we detected both ambivalent attitudes to primary care research and a perception that research into dementia care was not a high priority. Evaluation of the quality of care may be perceived as criticism of clinical practice, at a time when general practice is undergoing major administrative and contractual changes. Variations in Research Ethics Committee conditions for approval led to different methods of recruitment of patients and carers into the study, a factor which may have contributed to disparate levels of recruitment across study sites. Patient and carer levels of recruitment were lower than expected and were affected partly by carers' time pressures and other family commitments, but largely by problems in identifying patients and carers in the practices. The development of research potential in primary care is at an early stage and studies reliant on patient recruitment in general practice must allow for multiple obstacles to enrollment. This is particularly relevant for studies of dementia care, where the prevalence of dementia in a demographically average population is low and the incidence very low, compared with other disabilities. Professionals may give dementia low priority in allocating practice time for research projects, and strategies to address this problem are needed.

Objectives: To explore users' views on increased availability of emergency contraception (EC) from two new providers of EC. Context: EC was previously available from general practitioners (GPs), Family Planning Centres, Accident and Emergency Departments and Brooke Advisory Centres. Recently, EC has also become available from pharmacies and Walk-in Centres (WiCs). Design: Qualitative study using in-depth interviews. Setting and Participants: Twenty-nine women from two (WiCs) and two pharmacies in Avon. Results: Women selected their provider on the basis of convenience and accessibility. WiC users valued the advice and personal nature of the contact with WiC nurses. Women who accessed EC from a pharmacy were amenable to answering questions to obtain EC but did not see this as a time to receive contraceptive advice. Women's attitudes to pharmacy supply of EC may be related to its associations as a place of business. Phrases such as over-the-counter may reinforce this notion, reflecting the business-like nature of the questioning and the impersonal nature of the interaction. While women considered the increased availability of EC to be generally positive, some had concerns about younger women accessing EC, particularly from a pharmacy. Conclusions: Women had a favourable view of their provider of EC, whether from a pharmacy or WiC. Concerns about pharmacy access may be related to its associations as a place of business where consumers have more power in the encounter. For some, this type of ‘easier’ access was considered inappropriate for younger users.

Background: Confidentiality is an important issue for adolescents when using health services, but many health professionals consider objections from parents an obstacle to providing confidential care for this age group. Whereas health professionals and young people consider general practice an appropriate setting for adolescent health promotion, little is known about parents' views. Objectives: The main objective was to explore the views of parents of adolescents regarding confidentiality and the role of general practice in promoting teenage health. A secondary objective was to investigate parents' self-reported health behaviours, and their awareness of such behaviours in their own adolescent children. Methods: Postal questionnaire sent to the parents or guardians (n = 631) of all 14–15-year-old patients on two general practice registers in Hertfordshire, UK. Results: Few parents (2%) were aware of practice policy on confidentiality, and many (48%) did not think that adolescents aged under 16 years should always have the right to confidential consultations. Most parents (64%) considered general practice an appropriate setting for health advice for adolescents and a fifth of them said that there was at least one health-related topic they would like to discuss with a general practitioner (GP) or nurse in relation to their adolescents' health. Parents' own health risk behaviours were correlated with those reported for their children. Conclusion: Information about confidentiality and general practice-based health services for young people needs to be provided clearly to parents as well as to adolescents, particularly as some parents of adolescents may have reservations about confidentiality. The majority of parents consider general practice to be an appropriate setting for adolescent health promotion.

General practice is a principal point of access for individuals who experience problems associated with cannabis use, including dependence on the drug. However, there are no clear guidelines on advice or clinical interventions for primary care practitioners regarding this area. Whilst it has been suggested that specific services to deal with cannabis users are required (Stephens et al., 1993) we have neither a clear idea of how many individuals in local populations may need support to give up or reduce cannabis use, nor of the knowledge or practice of GPs in relation to patients that use cannabis. This study examined GPs’ knowledge of cannabis-related harm, and their own responses and practice in treating patients who present for help. A postal questionnaire was sent to 155 general practitioners in Wandsworth, of which 97 (63%) completed questionnaires were returned. The results showed that GPs in Wandsworth are aware of the risks associated with cannabis use, and are also motivated to improve their knowledge base. Attitudes towards the appropriate setting and approach to treatment interventions were mixed, with some believing that cannabis users could be treated in primary care and others preferring onward referral to specialist drug ser-vices. However, given that 46% (n = 47) of our sample had been approached by a patient wishing to stop using cannabis, effective primary care interventions are required. The study argues for improved primary care engagement with cannabis users seeking support via clear guidelines and training of practitioners, improved signposting to specialist services and shared care, and further consideration of issues around the recording of information relating to cannabis use. In addition, more national and strategic clarity regarding the potential harm of using cannabis, as well as treatment options and care pathways would be welcomed.

Aim: In this article the authors illustrate using a case study approach how primary care professionals can use the combination of geodemographic data with hospital episode statistics (HES) to predict the location of people ‘at risk’ of diabetes mellitus (Type 2 diabetes) in the population of England. This approach facilitates social marketing of those ‘at risk’. Method: Geodemographic segmentation data for all households was combined with HES for 2001–2002, to predict population groups ‘at risk’ of Type 2 diabetes. Using a case study approach and quantitative data analysis techniques, a profile of the undiagnosed and ‘at risk’ population of Slough Primary Care Trust was created at town, ward and street levels. Recent literature on social marketing was applied to predicate a discussion of the theory and practice of social marketing that was most likely to succeed in dealing with the prevention of Type 2 diabetes, via the reduction of obesity and overweight in the population. Discussion: The increase in lifestyle-related diseases, such as, Type 2 diabetes that are linked with the rise in overweight and obesity and create large disease management costs for the National Health Service (NHS) are of great concern to primary healthcare professionals and governments throughout the westernized world. Until recently, public and government responses have been very reactive in respect of population groups most in need of lifestyle change. Approaches to the identification of ‘sub-populations’ most at risk of Type 2 diabetes and targeting of these is of direct relevance to the preventive work of primary care professionals. Conclusion: Geodemographic data overlaid onto official NHS and other routinely collected data, can aid the identification and targeting of groups most vulnerable to overweight and obesity, through social marketing approaches including direct mail, telephone canvassing and door-to-door communication channels.

The aim of this article is to explore how the development of the theoretical and strategic basis of school nursing offers a vehicle for the delivery of an effective public health strategy for children and adolescents. Through a critical examination of the status and scope of school nursing within the UK and US health care systems it is clear that a deficiency exists regarding the theoretical and strategic basis for the functioning of school nursing. Consideration is given to the concept of the school nurse as ‘navigator’ for the child along the trajectory of the school health journey. This novel approach to school nursing needs to be developed theoretically and evaluated for effectiveness. A rapid review of the evidence to support school nursing interventions has revealed that the evidence base for school nursing interventions/actions remains very weak, thereby challenging the ability of school nurses to deliver desired outcomes for the present ambitious public health agenda. We argue that a planned approach to developing the evidence for school nursing, based on the UK Medical Research Council (MRC, 2000) framework for the evaluation of complex interventions, could help to ensure a robust role for the school nurse. This acknowledgement and development of a novel approach to school nursing could contribute to policy implementation around public health goals for the school-aged population.

Lymphoedema is a chronic condition that leads to reduced quality of life through its negative impacts on physical, psychological, and social aspects of health. Limb swelling leads to discomfort and pain, reduced movement and function, and acute inflammatory episodes. Individuals experience altered body image and self-esteem impacting on social interaction. There is evidence that specialist management of the condition leads to improved quality of life. Concern regarding the adequacy of lymphoedema services led to the commissioning of a needs assessment by the Core Cancer Review Group in Fife, Scotland. The needs assessment used a variety of methods. Current services were located through consultation of known providers and databases. Existing databases were analysed to find out the number of people requiring the service: hospital admissions and diagnoses were analysed alongside a survey of primary practices in Fife. Access to existing services was explored through a telephone survey of referrers (n = 44), and qualitative interviews with five service providers and five clients. At the time of the study, non-palliative National Health Service (NHS) provision consisted of one part-time clinician; the service provided was under pressure from rapidly increasing referrals. However, consensus from referrers, providers, and clients indicated that there were obstacles to achieving diagnosis and referral, especially for those with non-cancer-related lymphoedema. This was primarily due to poor referrer awareness of the condition, its management, and existing services, for example, only seven per cent of those surveyed would refer to existing specialist services. Delayed referral is a significant issue, as prompt intervention leads to more positive treatment outcomes. As a result of the needs assessment, recommendations were made to increase staffing levels, promote awareness of the condition and related services, and improve geographical and multidisciplinary coordination of the service.

This research describes the onset of 13 health conditions and death among 38 adults with spinal cord injuries (SCIs) and 149 adults with traumatic brain injuries (TBIs) compared to adults without disabilities in the same primary care setting, using a retrospective cohort design. The subjects were accrued from an urban and a rural practice, both affiliated with a university family medicine department. Survival analyses, using Cox proportional hazard models, were used to model the onset of each of the health conditions. The results indicated adults with SCI had an increased risk for onset of chronic obstructive pulmonary disease and depression. Individuals with TBIs had an increased risk for onset of anxiety, chronic obstructive pulmonary disease, dementia, depression, and seizures. Neither group had increased risk for asthma, cancer, coronary artery disease, congestive heart failure, diabetes, hypertension, obesity, or transient ischaemic attack. The only conditions with increased risk were those previously identified as secondary to traumatic injury. The other conditions including death did not have higher incidence among the study group, during 7–9 years of retrospective follow-up.