The Canadian health care system is under increased pressure to reform. While some advocates lobby for more physicians and more resources to fix the ailing system, many reports point to another potential solution – implementing primary health care (PHC). Implementing PHC will not be easy. Even though there is substantial evidence to support the efficacy and cost effectiveness of PHC, its implementation will require substantial changes in practice. Community-based research (CBR) has the potential to be the catalyst for the type of change that is required. A multidisciplinary, multisectoral inquiry team has been funded to use CBR to reconceptualize and transform PHC service delivery in British Columbia, Canada. Although the research project is in its initial phase, it is anticipated that the research will provide new, holistic, and comprehensive frameworks for practice. This paper describes the process used to bring about these changes.

The National Institute for Clinical Excellence (NICE) guideline for diabetes patient education offers little to inform National Health Services (NHS) Trusts in the curriculum design of self-management education programmes. The study aim was to conduct a patient-needs assessment of the educational curriculum content and support needs for Type 2 diabetes self-management. Different stages of the condition were chosen to identify whether needs remained constant or changed with time and experience. Six focus groups were convened for people who had recently received a new diagnosis or changed therapy. Twenty-three participants were recruited from primary care and the media in the UK. The educational curriculum support needs comprised: access to care and support, continuity of health care professional, lay support, high-quality care and support, and a positive cognitive appraisal of experiences. Needs were broadly similar irrespective of the new change situation. The current emphasis on lay support concurs with a proportion of the needs of our study participants. Motivational communications with patients need to be prioritized to enable patients to address therapeutic goals.

The National Service Framework (NSF) for coronary heart disease (CHD) requires that all people with established CHD are identified and managed systematically; accurate and complete electronic patient records (EPRs) are thus essential. This project aimed to first establish the completeness and consistency of recording electronic information about CHD (diagnosis, risk factor monitoring and aspirin usage) across a group of general practices and secondly, to provide feedback on their performance. The third part of the project planned to evaluate the effect of this feedback on the general practices’ electronic data recording but this is not reported in this article. Twenty-two of 26 general practices in one Primary Care Trust (PCT) participated. A random sample of 75 people with a Read code for CHD and/or who were taking one or more of five drugs used in CHD were selected from each of the 15 practices using Egton Medical Information Systems (EMIS) to manage their EPRs. The remaining seven practices used Torex electronic clinical system and from each of these practices, a random sample of 25 patients with a Read code for CHD was selected. Sample sizes were pragmatic rather than being chosen for possible statistical significance. At each practice the patients’ paper patient records and EPRs were searched for information about CHD diagnosis, risk factor monitoring and aspirin usage. Results were fedback and discussed with each individual practice and presented to the PCT. Electronic recording of CHD diagnosis was fairly complete but recording of risk factor monitoring and aspirin usage was more inconsistently recorded. Providing feedback to the general practices raised practitioners’ awareness of strengths and weaknesses in their electronic record keeping. Work to improve EPRs needs to be ongoing, to ensure that there is complete and easily accessible information about people with CHD so that their care management can be planned and implemented effectively.

The integration of information technology into the health care system is central to the UK government’s strategy to improve the delivery of health care. There remains uncertainty about how this new technology is being used by practitioners, and the impact it is having in their everyday work and relationships with patients. The objectives of this study were to identify experiences and attitudes of general practitioners (GPs) about the use of the Internet as an information resource for themselves and for their patients, and their perceptions of the obstacles to using it, and to describe how GPs view the potential and limitations of the use of electronic communication with both fellow professionals and patients, and to explore the perceived impact on the GPs’ roles and relationships. A qualitative study design involving interviews with 24 GPs in North West England was used. The methods involved semi-structured interviews with a purposive sample of GPs to explore their views on the use of the Internet in their day-to-day work. Interviews were recorded and transcribed verbatim. Data was analysed with the interview schedules being modified in the light of emerging themes. There were two main themes: the Internet as an information source for GPs and their patients, and the use of email as a form of communication between themselves and patients, and between health professionals in primary and secondary care. Whilst GPs appreciate that the Internet could offer an exceptional quantity of information that could be used within the consultation and which might improve patient management, they cite many barriers to the effective acquisition and use of such a resource. Similarly, GPs reported limiting their use of the Internet to assist communication between the GP and the patient, and were concerned about the Internet duplicating work rather than reducing it. GPs seemed reluctant to grasp the potential that they perceived that the Internet might offer. The current configuration of primary care, and the role of the GP within it, is likely to limit the uptake and use of the Internet as a means of extending opportunities for patient care.

A holistic approach to care has traditionally been the central tenet of general practice in the UK. However, recent major changes in general practice may be diminishing the importance and/or deliverability of such an approach. We sought to explore the views of Scotland’s general practitioner (GP) principals. We surveyed all 3713 GP principals in Scotland during February to July 2001 by postal questionnaire. Nearly 9 in 10 GPs (87%) felt that a holistic approach was essential to providing good health care, but only 1 in 5 (21%) felt that primary care was currently delivering high-quality holistic care, and only 1 in 15 (7%) felt that the current organization of primary care was conducive to such care. Constraints on holism were thought to contribute significantly to higher rates of prescribing (73% agreed), more referrals to secondary care (63% agreed), and increased demand for complementary therapies (57% agreed). Psychological factors were considered to play an important role in organic physical disease – its causation (67% agreed), course (94% agreed) and reversal (69% agreed) – yet when either the GP or the patient wished to explore issues relating to stress or emotional difficulties the GPs felt significantly constrained, mainly by time and their own stress (mean values (95% CI); 0: not limiting, 10: extremely limiting; time 7.6 (7.49–7.67); stress 4.9 (4.84–5.04); training 4.7 (4.66–4.84); skills 4.2 (4.13–4.30); motivation 3.4 (3.33–3.50)). In this survey Scotland’s principal GPs overwhelmingly endorse the traditional holistic approach of general practice and primary care, but feel that it is failing to be delivered due to organizational and time constraints, with consequent human and financial costs. These results give voice to deep concerns among GPs who remain committed to a holism they are struggling to deliver.

This case study explores the patient self-presentational aspects of social interactions occurring during nurse practitioner consultations in primary health care. Previous consultation communication research has revealed that styles of patient self-presentation have an effect on the process and outcomes of consultations. However, it is noted that available consultation communication research is focused on doctor-patient interactions. Accordingly, this research aimed to redress the medically focused imbalance in consultation communication research by investigating and identifying the possible effects of patient self-presentation styles on the process and outcomes of nurse practitioner consultations. An observational case study was undertaken in a nurse-led primary care walk-in clinic, utilizing multiple methods of data collection including: direct observations of nurse practitioner consultations, postconsultation semi-structured interviews with nurse practitioners, and a field journal. Two sample groups were used: a purposive sample of 15 patients attending the walk-in clinic with upper respiratory tract infections (URTI), and a convenience sample of six nurse practitioners employed at the same clinic. Five different styles of patient self-presentation were identified, which all had variant effects on the process and outcomes of the nurse practitioner consultation. These styles included: Seekers (patients seeking treatment); Clinical Presenters (patients presenting clinical histories); Confirmers (patients checking the severity of their illnesses); Seekers to Confirmers (patients who initially seek treatment, but who change to a confirmatory style); Anticipators (patients who anticipate their need for treatment). The nurse practitioner participants were found to be flexibly responding to these styles of patient self-presentation, as an attempt to maximize patient satisfaction with their consultations. It is suggested that the observed nurse practitioners were able to flexibly modify their consultation communication strategies in response to different patient self-presentation styles, which helped resolve the tensions existing between the patients’ own reasons for consultation attendance and their actual clinically assessed needs for treatment.

The Government has identified school as a key setting for reducing health inequalities, but many schools fail to support pupils with medical needs, such as asthma. This paper describes a survey designed to elicit the views of asthmatic children in two contrasting general practitioner (GP) practice populations regarding their asthma care, including support at school. A questionnaire was sent to all asthmatic children aged 4–17 in two practices during August 2002. The population in Practice 1 (P1) was mainly white, suburban, with pockets of deprivation, and had a long-established asthma clinic. Practice 2 (P2) had an almost exclusively Asian population, was close to the town centre and did not have a regular asthma clinic. Children from P1 had a higher response rate, 69 of 124 (55%) (compared with 21 of 107, 21% in P2), they also reported lower symptom levels and less use of hospital services, particularly paediatric outpatient clinics. Nurses were perceived as the main source of information and support in P1 (68%), followed by doctors (43%). In P2 this was reversed, nurses being identified by 33%, doctors by 62%. If an asthma problem occurred at school, the vast majority said that they would ask a teacher for help, but they also said that school staff needed more information to help pupils with asthma. These results mirror what is already known from large survey data regarding inequality of access to asthma services. In view of the national shortage of GPs it would seem prudent for Primary Care Organizations to increase investment in delivery of comprehensive asthma management services by practice nurses, school health nurses and pharmacists. This should include support for teachers, who are being expected to cope with increasing numbers of children with medical needs in schools.

This is a preliminary report on a quality improvement project for people with learning disabilities (PWLD) in one London Borough. The strategy document Valuing people required the implementation of a specific activity at two levels: both organizational development and individual health action plans. This activity was called health facilitation. It was left to local services to introduce health facilitation either by extension of existing roles or by creation of new specialist posts. Using neighbourhood renewal funding to improve access to health services, Barking and Dagenham chose to create new posts. This paper will focus on just one of these innovative posts, linked to improving transition planning for school leavers with learning disabilities. There was a pressing local need to improve continuity of care between child and adult services. Multiple methods were used to investigate this new Health Facilitator (HF) role. The HF carried out both service development and person-toperson work, with a wide variety of contacts. Developing ‘signposting’ and appropriate referral systems for young people led to improved access to adult services. In general, this developmental role was seen as making a positive contribution in addressing the gaps in current services for young PWLD. The findings of this evaluation have already led to changes within local services and shaped future workforce planning.

Partnerships and participation are important principles of primary health care and increasingly are advocated in poverty-related health research. These concepts were central to our study of low-income Canadians’ use of health-related services and supports. We created partnerships by including community members on the research team, establishing a community advisory committee, involving community agencies in recruitment and interviews, and obtaining stakeholder perspectives on the research findings. We fostered participation of low-income people by including their perspectives during the design and implementation of the study, reducing barriers for participation, and using peer interviewers. Despite the successes of these strategies for promoting partnerships and participation, challenges emerged in relation to maintaining involvement of stakeholders and ensuring adequate opportunities for research capacity building. Stakeholders and lowincome people identified policy and service delivery changes that would enhance accessibility to health-related services as well as potential barriers that influence change efforts. Participants emphasized the need to view poverty as ‘everyone’s business’, which necessitates participation and partnerships with people living in poverty, with service providers, and with policy influencers. Our findings suggest, however, that people living in poverty encounter barriers to participation, and that further efforts are needed to obtain their input in the development of programmes, services, and policies. We recommend that primary health care research include community partners on the research team, community advisory committees and perspectives of policy makers and service providers. Researchers require adequate funding to develop and maintain partnerships with stakeholders, to train and support vulnerable people in developing skills and confidence as active research participants and to communicate the research to relevant stakeholders. We also recommend that evaluation of the participatory process be built into the research design.