The use of complementary and alternative medicine (CAM) is increasing. Access to CAM through primary care referral is common with some of these referrals occurring through existing NHS contracts. Yet currently little is understood about General Practitioners (GPs) referrals to CAM via an NHS contract.

This exploratory qualitative study was designed to explore UK GPs experiences of referring patients to CAM under an NHS contract.

Semistructured interviews were conducted with 10 GPs in the UK, purposively sampled, who referred patients under an NHS contract to a private CAM clinic, staffed by medically qualified CAM practitioners. Qualitative methodology making use of the framework approach was used to undertake the interviews and analysis.

The decision of GPs to refer a patient to CAM through an NHS contract is complex and based on negotiation between patient and GP but is ultimately determined by the patients’ openness and motivation towards CAM. Most GPs would consider referral when there are no other therapeutic options for their patients. Various factors, including clinical evidence, increase the likelihood of referral but two overarching influences are crucial: (a) the individual GPs positive attitude to, and experience of CAM, including a trusting relationship with the CAM practitioner; and (b) the patient’s attitude towards CAM. In-depth knowledge of CAM was not a vital factor for most GPs in the decision to refer.

A CAM referral only took place if the patient readily agreed with this therapeutic approach, and in this respect it may differ from referrals by GPs to conventional medicinal practitioners. Such an approach, then, relies on patients having a positive view of CAM and as such could result in inequity in treatment access. Increasing knowledge about and evidence for CAM will assist GPs in making appropriate referrals in a timely manner. We propose a preliminary model that explains our findings about referrals considering patients need as well as the medical process. As data saturation may not have been achieved, further investigation is warranted to confirm or refute these suggestions.

To suggest how to improve primary epilepsy care by assessing the strengths and weaknesses of epilepsy care in general practice by reviewing practice records in relation to qualities and outcomes framework (QOF) indicators and epilepsy guidelines.

Concerns have been raised about epilepsy care in the UK. The general practice QOF indicators offered the first opportunity to take on structured epilepsy care in the UK. The QOF includes targets for this condition and national guidelines list key priorities to improve care. This study explores how general practice systems are delivering this care.

A case notes review in 27 practices in the north-east of England. Adults with epilepsy were identified from practice morbidity registers and a READ code search. Data from 1333 patients were collected on the frequency and location of epilepsy review, type of epilepsy and classification of seizures, epilepsy medication ordering, and individual and practice demographic data. The data were entered into SPSS for frequency analysis and grouped for further analysis: Primary Care Trust (PCT), age and medication ordering groups (satisfactory, moderate or poor).

Of the patients, 24% did not have a record of type of epilepsy and about a third of patients had no seizure classification recorded. One-fifth of patients were not reviewed in the previous year but of those who were, the majority were seen in general practice. Seizure frequency was not recorded in the last 12 months in one-quarter of patients. Adherence and recording of seizure information were related to age of patient. Epilepsy registers were inaccurate. The findings suggest that epilepsy care can be improved by using review and monitoring systems to ensure a complete and accurate epilepsy register and appropriate annual clinical and medication review.

To identify and quantify clinical features associated with a future diagnosis of type 2 diabetes, and to record pathways to the diagnosis of diabetes.

The risk of type 2 diabetes posed by particular symptoms is largely unknown, especially in unselected populations like primary care. The current mode and setting of diagnosis in the UK are undescribed.

This was a population-based case–control study in seven general practices in Bristol, UK. In this study, 105 cases with newly diagnosed diabetes, and 105 age- and sex-matched controls were studied. Their primary care records for two years before diagnosis were examined for symptoms previously reported to be associated with diabetes and for abnormal investigations. Differences between cases and controls were analysed by conditional logistic regression. In cases, the pathways to the diagnosis of diabetes were categorised.

In all, 42 (40%) adults with newly diagnosed diabetes were asymptomatic at diagnosis and 84 (80%) were first detected in primary care. Five clinical features were independently associated with diabetes in multivariable analyses. Likelihood ratios for these were: thirst 36 (95% confidence interval 3.0, 440), P = 0.005; weight loss 5.7 (1.3, 26), P = 0.022; skin infections 4.6 (1.7, 12), P = 0.002; fasting glucose >5.6 mmol/L 38 (2.2, 640), P = 0.012; and random glucose >5.6 mmol/L 15 (2.5, 94), P = 0.003. The median time period between the onset of symptoms and diagnosis was short (8 days) in patients presenting with thirst, but much longer for those with weight loss (294 days) and skin infections (463 days). Over a quarter of patients had raised blood glucose readings, which were not followed up in the two years before diagnosis was made.

Most patients with type 2 diabetes are diagnosed in primary care. Many are asymptomatic at diagnosis. Earlier diagnosis of diabetes may be possible by considering diabetes in patients with weight loss and skin infections, and ensuring that borderline abnormal tests are adequately followed up.

The research question for this study was: Are there within-group disparities in Hispanic women’s knowledge of heart attack and stroke symptomology?

Hispanics constitute the fastest growing group in the US and have surpassed other racial and ethnic groups to become the largest US minority. Hispanics make up about one-third of the US population, and hence are a group of significant interest for health care providers. Few studies have examined heart attack and stroke symptom awareness among adult Hispanic women, a group at high risk for delays in treatment. Research is needed to elucidate their knowledge of warning symptoms for these vascular events.

Behavioral Risk Factor Surveillance Survey data from states using the 2003–2005 Heart and Stroke module were examined by multivariate techniques. To maximize the representativeness of the sample, three years of survey data (2003–2005) were amalgamated into a single dataset. If a given state administered the Heart and Stroke module in multiple years, only the data from the most recent year were included in the merged dataset. In the final analysis, data from 23 states, one territory and the District of Columbia were included in the combined 2003–2005 database. The unweighted sample size for the population of interest for the years 2003–2005 was 3146. For analysis these data were weighted to represent 2 641 024 Hispanic women aged 18 years and older who answered questions about heart attack and stroke symptoms.

Adult Hispanic women earning low scores on the heart attack and stroke knowledge questions were more likely to have less than a high school education, be uninsured, live in a household with an annual income of <$35 000 and not have a primary care provider.

These results suggest that strategies to educate Hispanic women on signs and symptoms of heart attack and stroke might benefit from targeting women in these groups.

To analyse the experience of a pilot programme designed to shift care from hospital to the community.

The white paper, Our Health, Our Care, Our Say, published in England in 2006, set out a vision for the future of primary care and community services. A key component of this vision is to provide care closer to home. The NHS Institute for Innovation and Improvement established a pilot programme in five field test sites to explore the scope for bringing about shifts in care from hospital to the community. This paper reports the results of the evaluation of the programme.

A comparative case study design was used including interviews with key stakeholders at different points during the pilot programme, participation in discussion groups, documentary analysis, and collation of activity and output statistics. By comparing evidence drawn from 14 projects in the five field test sites, the evaluation was able to identify the impact of different factors on the progress of the projects.

All of the projects made some progress in taking forward their plans to shift care, although there were wide variations in what had been achieved at the end of the test and learn phase. Key factors influencing progress were the existence of a receptive context for change, project focus, organisational leadership, project management, stakeholder analysis, clinical engagement and leadership, overcoming barriers to change, aligned incentives, training and support, measuring and monitoring progress, and the timescale for change. A critical requirement in programmes of this kind is ‘getting the basics right’ through dogged attention to project and change management. Also important is ensuring that the evidence on change management and quality improvement is acted on by those leading change programmes.

The professional practice environment of hospital-based nurses has been the focus of considerable attention over the last few decades. More recently, attention has been paid to the community nursing environment, and this study considers the context of public health nursing in New Zealand.

The purpose of the study was to identify the organizational attributes that public health nurses consider important, and those that are considered less important, for professional practice and to rate the presence of these attributes within the public health nurses’ work environment.

In all, 167 public health nurses across New Zealand assessed the importance and presence of 48 organizational attributes in the nursing work environment using the Nursing Work Index-Revised (NWI-R). This instrument was developed from work with Magnet hospitals in the US and is designed to measure attributes of the professional nursing environment. Frequency distributions and difference scores were calculated using SPSS-PC.

Results showed that there was strong agreement that most NWI-R attributes were considered important for professional practice, the most highly endorsed relating to support from the organization, education/orientation and staffing. However, agreement that these attributes were actually present in the current work environment was much less strong. Participants also generated additional ideas for attributes considered important for public health nursing practice and these were categorized under four headings concerning specialty practice, resources, networking and education/research.

The purpose of this study was to investigate the circumstances of opioid prescription among general practitioners (GPs) in the UK.

Prescription of opioids for chronic pain, particularly non-malignant chronic pain, remains controversial. In the midst of this controversy, patterns of actual prescription and influences on these patterns are not well understood.

A mail survey was posted to 1192 GPs and it was returned by 414 (35.0%). The survey addressed the frequency and reluctance in GP prescription of opioids for chronic pain. It also sampled their attitudes and concerns about opioids, including their views on appropriateness and effectiveness, adverse effects and potential social pressures presumed to impact on prescribing.

Overall, 57.9% of GPs reported they sometimes, frequently, or always, prescribe strong opioids for chronic pain, which was of significantly lower frequency than for prescribing of weak opioids, non-steroidal anti-inflammatory drugs (NSAIDs) or tricyclic antidepressant medications. Similarly, 69.1% reported a reluctance to prescribe strong opioids for chronic non-malignant pain, which was a significantly greater reluctance than for cancer pain, for example. GPs who were men, younger, had fewer years experience and worked full time (as opposed to part time), were more likely to prescribe opioids. Practice guideline use was unrelated to prescribing but those with specialty training were more likely to prescribe. Interestingly, a majority of GPs (83.0%) felt that opioids are effective for chronic non-malignant pain; however, they worry about long-term commitment (such as managing dosing and repeat prescriptions), addiction and other adverse events.

Based on multivariate analyses, both frequency of prescribing and reluctance were predicted by a combination of concerns about effects on patient behaviour, professional competency concerns and degree of belief in opioids as an effective option. These results may suggest a need for additional GP training in the management of analgesics for chronic non-malignant pain.

Knowledge is recognized as a crucial organizational resource, which it has been suggested, increases in value through use. However, tensions exist between applying generalized scientific and academic knowledge to practice and incorporating local, experiential and tacit understanding in our knowledge base for practice. Knowledge management and transfer are frequently advocated as the means to increase service capacity within existing resource levels. In the NHS knowledge management and transfer tends to adopt a social constructivist approach, which favours the application of scientific evidence to practice, consequently the tacit and experiential knowledge of practitioners and service users is often excluded from formal knowledge-transfer processes.

This paper describes a systematic process that was used to formalize tacit nursing knowledge in child and adolescent mental health (CAMH) and link it into the pre-existing scientific and academic literature.

The paper goes on to describe how this process was modified and transferred to work with parents of children referred to CAMH services.

The paper illustrates the differing strands of pre-existing scientific and academic knowledge valued by nurses and parents. It highlights how involving service users in identifying scientific and academic knowledge that they find useful can focus attention on strands of pre-existing knowledge previously overlooked by professionals and service providers and thus enhance the value of this knowledge as an organizational resource. The paper also demonstrates how the tacit and experiential knowledge of nurses and services users can be transformed into more formalized knowledge, which can then be incorporated into organizational knowledge-transfer processes.

Primary health care service delivery in New Zealand is in an exploratory phase as primary health organizations determine new models of service delivery to reduce the incidence and impact of chronic disease. As organizations have restructured from predominantly primary care providers, the incorporation of a population approach to practice is welcomed but has provided some challenges for providers and funders alike as they reorient and extend practice parameters and determine the most effective methods of service delivery.

To describe and critically examine the underpinning assumptions of a new service delivered through a primary health organization to reduce the impact and burden of chronic disease with a focus on lifestyle risk factors, acting on obesity, nutrition, physical activity and smoking.

‘Heartbeat Tararua’ is a community-based lifestyle change programme focusing on the issues of obesity, nutrition, exercise and smoking and provides both clinical care for high-risk clients as well as operating a community-based prevention programme. The simplistic health education–behaviour change model was identified as problematic in the population approach and the high-risk service alone was unable to address all clients who expressed an interest. A revised population approach was sought that encompassed the existing community capacity and encouraged sustainable change in the community. Drawing from the public health evidence base a revised framework was recommended with a set of strategies based on social–psychological and ecological models with participatory and empowerment approaches. The work demonstrates a skilled practice team well able to reflect on practice, willing to seek advice and work towards establishing new models of primary health care service delivery.

The voluntary sector has long been recognised as making an important contribution to individual and community health. In the UK, however, the links between primary health care services and the voluntary and community sector are often underdeveloped. Social prescribing is an innovative approach, which aims to promote the use of the voluntary sector within primary health care. Social prescribing involves the creation of referral pathways that allow primary health care patients with non-clinical needs to be directed to local voluntary services and community groups. Such schemes typically use community development workers with local knowledge who are linked to primary health care settings. Social prescribing therefore has the potential to assist individual patients presenting with social needs to access health resources and social support outside of the National Health Service.

The aim of this paper is to explore the concept of social prescribing and discuss its value as a public health initiative embedded within general practice.

The rationale for social prescribing and existing evidence are briefly reviewed. The paper draws on a case study of a pilot social prescribing scheme based in general practice. Data collected during the development, implementation and evaluation of the scheme are used to illustrate the opportunities and limitations for development in UK primary health care.

The potential for social prescribing to provide a mediating mechanism between different sectors and address social need is discussed. The paper argues that social prescribing can successfully extend the boundaries of traditional general practice through bridging the gap between primary health care and the voluntary sector. The potential for wider health gain is critically examined. The paper concludes that social prescribing not only provides a means to alternative support but also acts as a mechanism to strengthen community–professional partnerships. More research is needed on the benefits to patients and professionals.

To understand the experience of terminal care and health care access for Gypsy Travellers, to inform palliative and primary care service provision.

Little contemporary research of UK English Romany Gypsy Travellers is available. This ethnic group is often overlooked in ethnic minority health research.

Access to Gypsy Traveller communities was through non-health care channels and required the development of trust through repeated contact over time. English Romany Gypsy Travellers at two Traveller sites participated in face-to-face contacts. Data collection was through field observation and seven semistructured interviews with Gypsy Traveller women who had experience of caring for relatives who were dying. In addition, data were collected over two years through discussion in a members-only Gypsy and Traveller interest e-mail forum.

The culture of Gypsy Travellers is distinct but diverse. Hygiene is important as is discretion and sensitivity to the information requirements of the patient and family. Gypsy Travellers are aware that their mobility (voluntary or enforced) can negatively impact on health care. Home care for the terminally ill is often preferred to hospital care often due to poor understanding of their cultural and personal needs by health care professionals and due to an aversion to ‘bricks and mortar’. Care may be provided by the extended family. Palliative care provision should consider the needs of Gypsy Travellers including respect for their culture and support for caring at home.

As part of a replication study after the randomized controlled trial (RCTs) in the Netherlands, the impact was assessed on health services utilization and expenditure of two self-management programmes for older adults with osteoarthritis (OA) of the knee and hip.

Evidence-based patient education and exercise programmes, developed and tested in RCTs, are often insufficiently diffused among practitioners and primary healthcare providers and tend to have a modest reach in the population. Large-scale adoption in primary healthcare can be improved if programmes are feasible and effective in real life.

The programmes were conducted in real-life conditions by primary healthcare providers (local health centres, home-care providers, physical therapy centres). Pre-test/post-test data were collected for consultation of the general practitioner (GP), medical specialist, physical therapist, and for the use of OA medication, as well as for the expenditure for physical therapy and OA medication.

In total, 20 Knee and 20 Hip programmes were carried out by 18 providers. The Knee programmes were attended by 204 participants and the Hip programmes by 169 participants. Physical therapy and use of OA medication for both programmes and consultation of the medical specialist for the Hip programme decreased. No effect was observed for consultations of the GP. Expenditure for physical therapy and use of OA medication could not be assessed, due to difficulties to obtain sufficient reliable data from participating health insurers. Both programmes produced similar outcomes in real-life conditions compared to their RCTs. The implications are discussed as to accurate data collection on OA expenditure, future cost-utility and cost-effectiveness studies, and the large-scale implementation of the programmes in the Dutch primary healthcare system.

Sexual health in Northern Ireland (NI) is poor compared with the rest of Europe with increasing incidences of sexually transmitted infections and one of the highest rates of teenage pregnancy. Traditionally, sexual health services have been provided in a fragmented way by a wide range of different providers but recent sexual health strategies have flagged sexual health as a key activity within the primary care setting.

The main aim of the study was to assess the sexual health promotion activities within the primary care setting across one Health and Social Services Board in NI.

A series of semi-structured interviews with both general practitioners (GPs) and practice nurses (PNs) was conducted to assess their views on the key issues in relation to sexual health in primary care. A questionnaire survey was also conducted with these health professionals to elicit information about sexual health promotion activities within the primary care setting.

The results have shown that promoting sexual health within the primary care setting is often ad hoc and often does not target the ‘at-risk’ population. As such, GPs and PNs tend not to discuss sexual health with non-heterosexual clients or those with learning disabilities due to lack of awareness and training. Health professionals feel inadequately trained to engage in effective sexual health promotion and to provide enhanced sexual health services. Personal embarrassment and lack of time were also identified as barriers for providing effective sexual health care.

Health professionals within the primary care setting require additional training to deal with the sensitive and complex issues inherent in the area of sexual health.

The aim of this paper is to explore school nurses’ experiences of teaching Sex and Relationships Education (SRE) as part of the primary school curriculum. In particular, it focuses on the questions that the children ask during the lessons and the strategies the nurses employ in managing those questions.

School-based SRE is an important aspect of children’s education. However, it is a highly politicised and controversial area, which is a matter of concern to a number of stakeholders. In the primary school setting, school nurses are commonly involved in delivery of the programme. Their input is particularly valued, because they are ‘specialist outsiders’ who create an environment that is conducive to discussion of sensitive topics. To date, there is little understanding of the skills that they employ in managing the educational needs of primary school children within the confines of a pre-agreed school curriculum.

Semistructured focus group interviews were conducted with small groups of school nurses from a single geographical location in the Midlands region of England. Data were analysed using a thematic analysis approach.

Data identified the ways in which the nurses viewed and responded to the children’s agenda, which was realised in the form of questions. In particular, it focuses on what they deemed to be inappropriate questions and the basis on which this label was applied. Five strategies for managing these inappropriate questions were identifiable from the data. Their deployment is explored in relation to the tensions implicit in the realisation of sexualised realities in a classroom setting.

To describe the research project component of the BSc in Primary Health Care and to discuss the issues faced by students and faculty in attempting to complete a student-led research project.

Medical schools increasingly expect medical students to undertake research as part of intercalated BSc’s or in self-selected study modules. This research has historically been laboratory based, ‘piggybacking’ onto existing projects. Projects initiated by students themselves and studies in primary care or community settings are more unusual.

A qualitative study, based on interviews with students and examiners, triangulated with data from the peer review process and personal observations on the running of the course.

A London medical school, running an intercalated BSc in Primary Health Care.

We interviewed 24 of 26 students and two external examiners during the interview period of the study. Students successfully undertook research, from initial question through to publication. Overall, 90 dissertations were completed since 1997, of which half used a qualitative methodology (45/90). Ten projects have subsequently been published; there were also 16 conference presentations and 6 research letters. Themes from the interview data include: the students’ strong sense of project ownership, the difficulties of being a novice researcher, the difficulties posed by the research governance hurdles, the beneficial and for some students adverse impact (stress and coping with unsuccessful projects) and finally, the impact on their careers.

Students gain considerably from this learning process, not only by undertaking their own research, but they also gain in terms of acquisition of transferable skills such as critical appraisal and improved self-directedness. Project completion and publication rates suggest that programmes developing undergraduate initiated research projects can be as successful as those for other novice researchers. The student-led project is a fragile endeavour, but currently is sustainable.

This study was part of a major project studying the metabolic syndrome in Finnish men. The final sample composed of 273 (39%) men who voluntarily completed the Health Behaviour Questionnaire.

To identify key determinants of health behaviour and health beliefs in middle-aged men, and to analyse how they are associated with underlying health covariates.

A stepwise logistic regression model was used to estimate the adjusted odds of the outcome by socio-demographic, health-behaviour, health-belief and clinical factors.

Five models were developed: (1) use of medications, (2) alcohol consumption, (3) self-rated health status, (4) burnout, and (5) motivation to change unhealthy behaviours. Existing illness or injury and occupation had the strongest associations with medication use, in which industrial workers were more likely to use medications than office personnel. A positive association was found between alcohol counselling by family members and less use of alcohol. Lack of illness or injury, good dental health, and normal waist circumference had the strongest associations with perceived good health. Depression and insomnia were the most significant predictors for burnout. Men who exercised 4–7 times a week, or who used alcohol infrequently or not at all, were over two times more likely to be motivated than inactive men.

Many relevant predictors that were significantly associated with the selected key determinants of health behaviour and health beliefs of middle-aged men were found in this study. The promotion of regular physical activity and healthy lifestyles among middle-aged men is currently one of the most important priorities of preventive work in primary health care. More gender-specific studies are needed to obtain a deeper understanding regarding men’s health issues.