The critical importance of a closer and structural involvement of primary care in research has been increasingly recognized over the last several years, and has been the object of extensive conceptual and institutional debates and proposals. There is, however, still a gap between the consistency of the recommendations and their translation into practice.

Based on the most recent literature on the integration of the paradigm of efficacy (evidence-based medicine) with the one on outcomes-effectiveness, as well as on the experience gained with large collaborative studies performed by Italian general practitioners (GPs), the paper discusses the reasons for giving priority to what could be done to bridge the gap and the conditions of feasibility.

Specifically, the results obtained most recently in a large-scale, epidemiological and experimental project with a prospective cohort of ∼12 500 subjects included by 860 GPs across the country in the field of cardiovascular risk prevention (the Rischio e Prevenzione Study) provide the concrete framework for an agenda of action proposed as a way forward, which appears to be highly critical for visibility and cultural autonomy of GPs also at the European level.

In early 2010, Liverpool Primary Care Trust (PCT) undertook a project to establish whether a care profiles methodology could be used to commission end-of-life (EoL) services. The Department of Health (DH) originally used them for a variety of services in the 1990s. The project sought to adapt the original care profiles structure for commissioning purposes, and produce a series of care profiles that would cover the full EoL care pathway.

The DH required PCTs in England to undertake local reviews of EoL services ahead of its publication of the National EoL Strategy in 2008. Related cross-sector work in Liverpool highlighted the need for a means of specifically commissioning EoL services. It was contended that care profiles offered the opportunity to set service requirements in respect of skill mix, delivery, quality and outcomes for each stage of the EoL pathway, which could be costed subsequently.

An iterative approach was adopted involving workshops and consensus, based on action learning events, which incorporated and adapted past approaches for developing care profiles. Four half-day workshops were held, each targeting one EoL stage, with the outputs evaluated by an external reference group. A full cross-section of commissioning, provider and service user interests were involved.

The project was successful, with its recommendations subsequently used to commission EoL services across Liverpool. It was concluded that the basic service requirements for EoL care are the same, irrespective of the related disease. The strength of care profiles is their simplicity and flexibility. They complement and augment integrated care pathways, and by requiring the recording of outcomes throughout the care process, they aid quality and audit processes. They should be transferable to other conditions, with benchmarking enabling improved efficiency. They represent the type of clinically relevant and detailed vehicle essential for clinical commissioning groups.

Community Health Workers (CHWs) play a key role in the functioning of Primary Health Care. However, little research on the performance of CHWs has been conducted in Kenya. This study aims to describe their performance and to determine which factors most impacted the performance of CHWs in Kenya.

A total of 750 CHWs were identified as potential subjects. However, appropriate data were submitted by 172 CHWs because of rejection and loss of their reporting status. Data on CHWs were collected through questionnaires, and information about their performance was gathered from their supervisors.

Approximately 60% of the CHWs were active. CHWs over 40 years of age were likely to display good performance in their job (P < 0.001). In addition, the performance of CHWs was influenced by training partners (P < 0.03).

Older CHWs were likely to perform well. Furthermore, their performance was influenced by their training partners.

The purpose of this paper is to review methods and tools for mapping, visualising and exploring geographic information to aid in primary health care (PHC) research and development.

Mapping and spatial analysis of indicators of locality health profiles and healthcare needs assessment are well-established facets of health services research and development. However, while there are a range of different methods and tools used for these purposes, non-specialists responsible for managing the use of such information systems may find knowing where to start and what can be done a relatively steep learning curve. In this review, health and sociodemographic datasets are used to illustrate some key methods, tools and organisational issues, and builds upon two recent reviews in this journal, respectively, focusing on geographic data sources and geographic concepts. Those familiar with mapping and spatial analysis should find this a useful review of current matters.

A thematic review is presented with illustrative case studies relevant to PHC. It begins with a section on visualising and interpreting geographic information. This is followed by a section critiquing analytical methods. Consideration is given to software and deployment issues in a third section. Content is based on domain knowledge of the authors as a team of geographic information scientists and a public health practitioner working in tandem, with its scope restricted to routine applications of mapping and analysis. Advanced techniques such as spatio-temporal modelling are not considered, neither are methodological technicalities, although guidance on further reading is provided.

Geographical perspectives are now playing a significant role in PHC delivery, and for those engaged in informatics and/or managing population-level care, understanding key geographic information systems methods and terminologies are important as is gaining greater familiarity with institutional aspects of implementation.

To ascertain how new funding arrangements, introduced in New Zealand's 2001 Primary Health Care (PHC) Strategy, have impacted on the expansion of nurses’ role in general practice.

Nurses are central to the new policy that was designed to improve the health status of New Zealanders and reduce inequalities in health. Nurses were to be a crucial part of the PHC team, expanding their current roles to provide increased access to appropriate services. This paper investigates how the new funding arrangements, introduced as part of the policy, have impacted on the expansion of nurses’ roles and consequently the realisation of the policy goals.

Semi-structured interviews were undertaken with 128 key stakeholders five years after the introduction of the PHC Strategy, and surveys were completed by practice nurses, general practitioners and practice managers in purposively selected practices within the 20 participating Primary Health Organisations.

There has been substantial growth in the development of nursing roles for some nurses in general practice; however, this expansion has not been universal and one of the main reasons for this is the way funding devolves at the practice level. One of the consequences of the policymakers not taking into account the business model of the majority of general practices, is the resulting overarching goal of the strategy not being realised, and inequalities in health status remaining.

To describe and evaluate a community-based musculoskeletal service, commissioned by National Health Services North East Essex Primary Care Trust (PCT), in terms of patient-reported outcomes and satisfaction.

Persistent musculoskeletal conditions, including back and neck pain, are costly in terms of primary and secondary healthcare resources. Most patients are assessed and managed by general practitioners (GPs), with referral when necessary to secondary care services.

Patients consulting for at least four weeks for back or neck pain were referred by their GP according to patient preference to either a chiropractor or osteopath or physiotherapist working in the independent sector. Patients completed questionnaires at baseline and at discharge from the service.

Questionnaire data were obtained from 696 patients, 97% of whom were seen within two weeks. About half (51%) had had their pain for less than three months, and of the remainder 49% for more than 12 months. Patients received on average six treatments. Using the Bournemouth Questionnaire, the Bothersomeness scale and the Global Improvement Scale, approximately two-thirds (64.6%, 67.8% and 69.9%, respectively) reported improvement at discharge, and approximately 65% a significant reduction in medication. Almost all (99.5%) patients were satisfied with the service. Similarly, almost all (97%) patients were discharged from the service with advice on self-management; the remainder were recommended for secondary care referral.

This service improved patient access and choice resulting in shorter waiting times and effective outcomes. An impact analysis of the first 12 months of the service by the PCT showed a reduction in primary care consultations and in inappropriate referrals to secondary care.

Early intervention can help to reduce the burden of disability in the older population, but many do not access preventive care. There is uncertainty over what factors influence case finding in older patients in general practice.

To explore factors associated with case finding for hypertension, hyperlipidaemia and diabetes mellitus in older patients.

Two thousand four hundred and ninety-one patients aged 65 years and above were recruited from three large practices in suburban London before the introduction of the Quality and Outcomes Framework (QOF) completed a questionnaire on health, functional status, health behaviours and preventive care.

Those not reporting heart disease, diabetes or hypertension were included in a secondary data analysis to explore factors influencing uptake of preventive care measures. Approximately one-third denied having had a blood pressure check in the previous year. They were more likely to have had little contact with doctors and to have an unhealthy lifestyle (smoking and a high-fat diet). One-third reported a cholesterol test in the previous five years. Cholesterol measurement was reported more often by men and those with a high body mass index. Those with unhealthy lifestyles (smoking and high-fat diet), those who had only received the state pension and those who limited their activities because of a fear of falling were less likely to report cholesterol measurement. About 10% reported a fasting blood glucose measurement and were more likely to consult more often and have more medications, but they were less likely to have a high-fat diet. Preventive care uptake was associated with frequent contacts with doctors, but overall the uptake of preventive care was low. Older people with healthier lifestyles were more likely to have primary preventative care interventions. These findings provide a baseline against which the effect of the QOF on the care of older people can be measured in future studies.

Achieving good response rates to population surveys from hard to reach groups in deprived areas can be challenging.

To explore and compare different approaches to improving response rates in an economically deprived multicultural area.

Following a lower than anticipated response rate in a pilot study for a postal questionnaire survey of chronic pain (79/653 (12%)), we conducted a second pilot involving a shorter postal survey and separate collection of more detailed information in a waiting room survey. The second postal survey used a shorter questionnaire, telephone data collection from non-responders by study team members rather than telephone reminders from practice receptionists, and involved a nested randomised-controlled trial (RCT) of hand-addressed versus printed-address envelopes. Both pilots involved subjects randomly selected from the practice registers.

The second pilot postal survey using shorter questionnaires yielded considerably more responses (240/642 (37%)). Our RCT showed that hand-addressed envelopes achieved a slightly higher response rate although not large enough to justify its use in our main study. The waiting room survey was successful in collecting more detailed data from lengthy questionnaires.

A range of methods of questionnaire administration may be required when conducting a survey with a hard to reach group in a deprived and ethnically diverse population. Postal and telephone administration can be used to collect a small amount of data. Face-to-face administration and recruitment can be successful for longer questionnaires.

Secondary prevention and self-management of coronary heart disease (CHD) are of major importance to people who survive myocardial infarction (MI). This can be facilitated by cardiac rehabilitation (CR; the formal health service programme) and informal CHD self-help groups. Non-participation is an important issue, yet it is poorly understood. Rehabilitation difficulties and prevention challenges have been identified among people following MI, but the particular experience and perspective of CR and CHD group non-participants are largely unknown.

The study aimed to understand non-participation in CR and CHD self-help groups from the perspectives of the non-participants and to provide insight into their experience and that of their ‘significant others’ in rehabilitating in the absence of these resources.

In-depth interviews were conducted with 27 people who had not participated in either hospital-based CR or a CHD group, 6–14 months post-MI, and 17 ‘significant others’ in Lothian, Scotland.

Factors influencing non-participation fell into three broad themes ‘No need/no point’, ‘Not worth it’, and ‘Not possible’. In the latter two categories, non-participation in these resources was often considered a ‘missed opportunity’ and needs had remained unmet. Shifts between categories could occur over time. Non-participation was linked to rehabilitation difficulties for some people and family members. Recommendations to enhance post-MI support are made.

The natural disaster in South-East Asia had a great impact in Sweden affecting many individuals and families. In this paper, a series of strategies from Ersta Association for Diaconal Work (Ersta) are described to reach survivors by the tsunami of 26 December 2004, from January 2005 to August 2007.

To find out what needs the survivors had and how professionals may work and take care of their needs during similar events in the future.

An immediate empathic effort took place at Ersta; thanks to good funding and many qualified professionals. This is a retrospective, mainly descriptive study of those strategies.

The work included training of group leaders, support groups, memorials and rituals, weekly Open House meetings, individual contacts, weekend gatherings, day seminars most marketed through Erstas’ website, advertisements and word of mouth. A total of 180 trainers/group leaders countrywide were trained and 25 became engaged at Ersta. Through the website and an unknown number of phone calls, an estimated 1362 adults, teenagers and children, grieving, injured and traumatised were reached.

The Ersta project was in many ways successful, but could not be sustained, due to lack of enough collaboration with other voluntary organisations and change of leadership. Meeting other survivors and the structure of the activities were appreciated. There was much benefit from support groups. Questions arose about how to act efficiently and when to intervene, early or/and later. Particularly to consider, early signs of resilience among survivors, their own initiatives and networks such as ‘naturally emerging groups’.

Extended collaboration between the authorities is necessary as well as continuous evaluation. A new law aimed at a more divided individual and societal responsibility. A new body (2009) under the Ministry of Defense will coordinate future resources, starting at the parish.

To evaluate the long-term utilisation of strategic communication as a factor of importance when changing work practices among primary care staff.

In many health care organisations, there is a gap between theory and practice. This gap hinders the provision of optimal evidence-based practice and, in the long term, is unfavourable for patient care. One way of overcoming this barrier is systematically structured communication between the scientific theoretical platform and clinical practice.

This longitudinal evaluative study was conducted among a primary care staff cohort. Strategic communication was considered to be the intervention platform and included a network of ambassadors who acted as a component of the implementation. Measurements occurred 7 and 12 years after formation of the cohort. A questionnaire was used to obtain information from participants. In total, 846 employees (70%) agreed to take part in the study. After 12 years, the 352 individuals (60%) who had remained in the organisation were identified and followed up. Descriptive statistics and multivariate analysis were used to analyse the data.

Continuous information contributed to significant improvements over time with respect to new ideas and the intention to change work practices. There was a statistically significant synergistic effect on the new way of thinking, that is, willingness to change work practices. During the final two years, the network of ambassadors had created a distinctive image for itself in the sense that primary care staff members were aware of it and its activities. This awareness was associated with a positive change with regard to new ways of thinking. More years of practice was inversely associated with willingness to change work practices. Strategic communication may lead to a scientific platform that promotes high-quality patient care by means of new methods and research findings.

Australia and England show high rates of psychological distress and mental health problems in young people. Both are high-income countries and have stated their intention to improve the delivery of health care to young people in primary care settings. Australia has an international reputation for improving care through innovative services and educational initiatives. England has taken a different direction and has concentrated more on developing policy and making recommendations to improve access for young people.

To describe a Churchill Fellowship visit to Australia to observe initiatives in primary care based youth-friendly mental health care and to reflect upon the observations, comparing and contrasting with the English model.

The observations and reflections presented draw on field notes from site visits and meeting with key players, accessing web resources and referring to the literature, both grey and published.

Australia offers plurality in health care delivery and innovative responses to addressing youth mental health. There are two key approaches. The first is the development of services specializing in youth mental health. The second approach is to build capacity of existing primary care services to recognize the particular bio-psychosocial needs of adolescents (and their families). In contrast, England has tended to focus primarily on policy development and improving youth access.

The paper draws attention to a number of political, clinical and educational developments in both Australia and England. Both countries demonstrate different strategies in response to the high levels of psychological distress in young people. Learning from colleagues in other settings can inform our own practice. Ultimately responding to young people's mental health needs is best served by youth-friendly policy which prepares clinicians for effective practice, informed by applied research and supported by adequate resources. Investment in young people's health must be a priority for us all.

To identify the appropriate service provider attendees of emergency departments (EDs) and walk-in centres (WiCs) in North East London and to match this to local service provision and patient choice.

An anonymous patient survey and a retrospective analysis of a random sample of patient records were performed. A nurse consultant, general practitioner (GP) and pharmacist used the presenting complaints in the patients’ records to independently stream the patient to primary care services, non-National Health Services or ED. Statistical analysis of level of agreement was undertaken. A stakeholder focus group reviewed the results.

Adult health consumers attending ED and urgent care services in North East London.

The health user survey identified younger rather than older users (mean age of 35.6 years – SD 15.5), where 50% had not seen a health professional about their concern, with over 40% unable to obtain a convenient or emergency appointment with their GP. Over a third of the attendees were already receiving treatment and over 40% of these saw their complaint as an emergency. Over half of respondents expected to see a doctor, one-quarter expected to see a nurse and only 1% expected to see a pharmacist across both services, although WiCs are nurse-led services. More respondents expected a prescription from a visit to a WiC, whereas in the ED a third of respondents sought health advice or reassurance.

A number of unscheduled care strategies are, or have just been, developed with the emphasis on moving demand into community-based services. Plurality of services provides service users with a range of alternative access points but can cause duplication of services and repeat attendance. Managing continued increase in emergency and unscheduled care is a challenge. The uncertainties in prospective decision making could be used to inform service development and delivery.