Ethics have long been recognized as underpinning primary health care. While discrete understandings of ethics have developed to support many areas of health care and research, there has been little attempt to formulate an ethics framework which is focused on primary health care. Developments both within and external to primary health care practice make it timely to address primary health care ethics; in particular, government initiatives contained in Shifting the Balance of Power, the increasing emphasis on evidence based practice, and the greater recognition of patient rights within English law resulting from the Human Rights Act 1998. A starting point to formulating an ethics framework would be to define the domain of primary health care. We can then identify those areas particular to primary health care which raise issues of conflict and change and which would benefit from ethics guidance.

This study aimed to explore the accident prevention activities of primary care organizations (PCOs) and the views of their board members regarding accident prevention. Qualitative study using semi-structured telephone interviews of 17 board members of PCOs (primary care groups and primary care trusts) in the National Health Service (NHS) Trent Region was undertaken. Accident prevention activity varied substantially between PCOs. The reduction of home hazards was a frequent focus of the PCOs’ accident prevention initiatives. Board members did not see accident prevention as their biggest priority in health improvement, although they had positive attitudes towards it. Local morbidity and NHS guidance were seen to be key determinants of PCOs’ priorities in health promotion. There was little reference to any strategic planning for accident prevention. Information to support accident prevention could be more timely and relevant to PCOs’ needs. The degree of involvement with outside agencies in accident prevention work varied substantially. Collaboration between agencies may be held back by mutual lack of knowledge and differences in culture and priorities. It was concluded that accident prevention appears to be receiving less attention in PCOs than other national health priorities. They may need more support for developing strategies for accident prevention and better provision of information so that they can identify local problems which can be addressed by preventative activities. The accident prevention plans contained in health improvement programmes should be monitored.

During recent years, private sector complementary medicine has grown as a significant provider of health care in the UK, and according to many current definitions, this provision may be classified as primary health care. In the context of a relative paucity of dedicated research investigations, and through a combined questionnaire (n = 426) and interview survey (n = 49), this paper provides some base-line evidence on the national sector, considers the previous employment of private therapists, their reasons for practicing, the range of modalities practiced and the positives they gain from this form of caring and business ownership. Although some younger therapists had moved straight from their education into private practice, the most common scenario was for middle-aged persons to enter the sector directly from skilled professional jobs and hence had radically changed their careers. Many were formerly employed in caring-related professions such as nursing, social work and teaching. Often therapists had been disillusioned with particular aspects of their former jobs. However, more frequently, they were simply attracted by the therapies themselves, the conceptual paradigms which underpin them and to the different experiences of business ownership and caring practices. Little is known about private complementary medicine, and it is argued that dedicated studies could build the initial evidence presented here, particularly within the rubric of primary health care research.

This paper describes a number of themes that emerged from a qualitative research study into the effects of a parenting programme on family life (Mockford, 2000). Existing research points to many valuable outcomes of parenting programmes including improved maternal psychosocial health (Barlow and Coren, 2000), improved relationships (Grimshaw and McGuire, 1998; Smith, 1997) and reduced child behaviour problems (Barlow, 1999; Patterson et al., 1993; 2002b). There has, however, been little qualitative work undertaken with parents who have attended a parenting programme. The findings from this study show that in addition to many positive consequences, there were a number of unintended consequences of attending a parenting programme. In particular, women spoke of the difficulties that they faced at home when trying to apply the techniques that they had learned on the parenting programme. These difficulties included gaining the support of partners in implementing the techniques learned, changing their established habits and those of their partners, finding the time to parent together, and incorporating the techniques into their already busy lives. These findings also suggest that a change in one parent’s approach to parenting may result in increased discrepancies in parenting techniques between the parent who attended the programme and the parent who did not, and that this may result in parental conflict.

This paper will explore the similarities and contrasts between the United Kingdom, Netherlands and Australian systems of maternity service delivery, focusing on the status of midwives as primary care providers. Increasingly, women in western industrialized nations are subject to medical models of maternity care. These medical models stem from the field of obstetrics, which has an increasing influence in determining service provision in all three countries. The World Health Organization has stated that midwives are the most appropriate primary carers for women during pregnancy and childbirth. Yet the rise of obstetrics as a dominant model of care has displaced midwives as primary carers, giving greater privilege to an obstetric construction of pregnancy and childbirth. While midwives are educated to understand and support normal physiological birth and assess and respond to deviations (wellness model), by contrast, obstetricians are educated to assess risk and address concerns through active clinical management (illness model). It will be argued that the fundamental difference between midwifery and obstetric views of pregnancy and childbirth rest on the differing perceptions of wellness and illness; that the obstetric view has gained broad dominance as a result of unequal power relationships; and, that this in turn has altered service delivery to privilege medical models of care. While service delivery in the UK and Australia has tended to follow a similar pattern of dislodging midwives as primary carers, the Netherlands system of maternity care, while broadly resisting the displacement of midwives as primary carers, is nonetheless provided within a medicalized framework. By contrast, in the UK and Australia there is an increasing awareness of the need to reconfigure maternity services to give greater autonomy to midwifery practitioners, a situation that is not as relevant in the Netherlands. The conclusion highlights the need to develop core principles to strengthen maternity care systems in order to ensure that midwives are not further alienated from service provision, and that strong midwifery workforces can be sustained. The discussion is based on research undertaken during a study tour of the United Kingdom and Netherlands by the author.

This paper presents a section of the findings of a case study of a newly established community rehabilitation team (CRT) comprising physiotherapists, occupational therapists and nurses. The findings reported here address issues of interdisciplinary teamwork that arose during the project. All eight members of the team were interviewed as well as three ex-team members. The data were collected by semi-structured interviews and analysed using thematic content analysis (Strauss and Corbin, 1990). The findings suggest that when recognized barriers to teamwork are eradicated, such as geographical separation and different employers, teams such as the CRT can achieve high levels of teamwork. A problem that took longer for the CRT to resolve, however, was that of flexible working across traditional professional and hierarchical role boundaries. The paper concludes that the difficulties that need to be overcome when a new team and new service are established concurrently, should not be underestimated.

Recent guidelines on hyperlipidaemia recommend the calculation of individual coronary risk, at least for patients without previous cardiovascular disease. Although tables and computer programs exist, the estimates are often made on an intuitive basis. The aim of the present work was to study Swedish general practitioners’ (GPs) and medical students’ ability to estimate the 10-year risk of coronary events for hypercholesterolaemic patients. Two hundred randomly selected Swedish GPs and 73 medical students in their final year of medical school were asked to estimate coronary risk for 10 written case descriptions with different cholesterol levels (at least 5.5 mmol/l) and combinations of other risk factors. Both primary and secondary prevention cases were represented. The risk estimates were compared with the estimates from the Framingham equation and a Swedish equation. The interindividual differences in estimated risk were remarkable for both GPs and students. Both GPs and students underestimated coronary risk, especially for high-risk patients. GPs tended to be more accurate than students in ranking the cases. Cases with previous coronary heart disease were not recommended treatment to the extent that the guidelines recommend. Both GPs and students were quite accurate in estimating absolute risk increase attributable to successive cholesterol increases in a scenario with other risk factors kept constant. It was concluded that GPs and medical students need help to differentiate more accurately between patients at high and low coronary risk, and greater effort should be made to communicate the advantages and difficulties involved in multiple risk assessment. The requirements for decision support are discussed. More evidence is needed on the validity of the Framingham equation for new population samples.

The execution and incorporation of research into practice is influenced by the relevance and credibility of the work undertaken. Part of this process can be to identify priority research questions from the service provider perspective. We sought to obtain a multidisciplinary consensus on priority research questions around the broad issue of prescribing in an inner London Primary Care Group locality. Participants were drawn from general practice, primary care nursing and community pharmacy. This paper explores how two formal consensus methods were used to facilitate multidisciplinary participation within the research arena, and the extent to which a convergence of opinion between professional groups was obtained. The use of a structured nominal group interview technique abated professional dominance and generated a diverse array of research questions. An iterative Delphi process secured a wide consensus of opinion regarding the relevance of these questions to practice. The richness of the research questions generated was attributed to the consultation process and the ability of the consensus methods used to capture the multidisciplinary perspective. The practice based research questions identified were diverse and suited to a collaborative research approach.

This paper was motivated by the adverse results of a study that evaluated implementation of a structured health needs assessment tool in health visiting. It examines the conceptual basis of three approaches to needs assessment, exploring their relevance to the purpose of health visiting and their links with prioritizing, targeting and promoting health in practice. It is intended to help health visitors, their managers and service commissioners to explain and understand the different requirements and expectations in each approach.

British Government policy emphasizes that targeting and prioritizing are the means by which inequalities can be redressed and resources directed towards those in greatest need. Needs assessment processes are increasingly invoked as the mechanism through which health visiting services can best be deployed. Health visitors are expected to help identify service priorities and to target their efforts effectively and efficiently. Access to services and user empowerment are also important aspects of the NHS modernization agenda. These concepts are fundamental to health promotion, which has been the consistent underlying purpose of the health visiting service since its inception.

In this discussion paper, three approaches to needs assessment are unravelled, which focus on prioritizing, targeting and health promotion. It is suggested that these different purposes relate, in turn, to the expectations and requirements of public health, organizational efficiency and user empowerment. There are important benefits associated with each of the three approaches, but their underlying principles, purposes and requirements differ. Failure to appreciate such differences can lead to misunderstandings, confusion and even offence. A single instrument cannot successfully meet the expectations of all three approaches to needs assessment. Instead, a needs assessment system is necessary, to meet the contradictory requirements of public health, organizational efficiency and user empowerment.

Current government policy aims to create a wider ‘community of public health practice’ within local systems, working in a coherent and coordinated way in partnership with local people to reduce health inequalities. However, for this to happen policymakers and practitioners across the public sector have to reconsider boundaries, role definitions, professional identities and responsibilities. On the basis of documentary analysis and fieldwork involving interviews with individuals from various sectors and nonparticipant observation of public health nursing and primary care organizations within two local health economies in England, the paper explores the ways in which these processes of reconfiguration have been developing in local health systems. It illuminates new exclusions and tensions emerging from inherent contradictions in national policy and from difficulties individuals have thinking beyond existing spatial, conceptual and organizational boundaries and divisions. Paradoxically, therefore, rather than opening up new spaces for public health practice these tensions may ‘force’ some people back into narrower more traditional roles or ultimately out of public health altogether. The paper also uses the notion of communities of practice to explore issues of ‘agency’ in professional practice – that is the way in which individuals reflexively construct their practice and in so doing engage with or resist the relevant policy imperatives. The research illuminates some of the boundaries that are operating to discourage people from engaging with public health. This analysis suggests people may need more time and support to respond constructively to the new public health agenda. Without this, potential members of the wider public health workforce may respond defensively and resist alignment to public health goals in order to protect their embattled workspaces.

Eating disorders of all kinds are common and serious in adolescents and young women. Recent government policies have suggested that adolescent mental health strategies should be developed. They have also laid emphasis on early intervention, accessible local provision and have identified eating disorders as a priority. It is acknowledged that services at primary care level for adolescents with eating disorders are sporadic or nonexistent. It was considered that a service user perspective would be beneficial in contributing to assessing the needs of adolescents with eating disorders. The research project was established to identify the service provision used, if any, by adolescent sufferers of eating disorders and what, in their opinion, would have been desirable at that time. The research consisted of a semi-structured interview with a sample of recovered adult participants to establish their experiences of services they had received as adolescents. Additionally the participants were asked what further help they felt would have been beneficial and where that help would have been usefully situated. The main findings suggest that the majority of health professionals are ill informed and not acutely conscious of the needs of eating disordered adolescents. Only counsellors within the voluntary sector agency showed any real understanding and an ability to help constructively. It was concluded that there is a real lack of help at primary care level and that schools should play a wider role in educating adolescents in a positive belief in themselves and in the destructive nature of an eating disorder.

This qualitative study describes the impact of deploying general practitioners (GPs) as primary care physicians (PCPs) in three Accident and Emergency (A&E) departments in Greater Manchester as part of a Health Action Zone initiative to promote integration of systems of care more responsive to the needs of inner city population groups. The setting was three Accident and Emergency Units in Greater Manchester. Semi-structured interviews with the PCPs and key A & E staff (n = 32) before the PCPs were deployed, then at intervals throughout the project. Interviews were audiotaped and transcribed. Transcripts were analysed using constant comparison to identify emerging themes. Key themes centred on the assumptions and negotiation surrounding the emerging roles of the PCPs (as seen by themselves and other staff), particularly the conflict between operational (day-to-day work with patients) and strategic (forward planning) roles. The PCP appeared to act as a catalyst for the view that patients were not presenting “inappropriately”, rather, the problems presented at A&E might be best dealt with in different parts of the healthcare system, or by different personnel, and it is the service currently available that is inappropriate. By deploying the GP in a new role as PCP, but with the traditional autonomy associated with being a GP, and allowing him/her to develop the role according to local need, the new service evolved to identify and meet the needs of patients more appropriately. The use of the expanded role of the GP may be more successful in achieving ‘joined-up’ services than deploying other professional groups, such as nurses, to fulfil a specific role.

Early retirement has become an important labour market trend for workers in professional occupations. General practitioners (GPs), however, are in short supply, and are being encouraged by the government to stay at work beyond the age of 60. In this study, which followed up a questionnaire survey of all general practitioners over 44 working in the Northern Deanery, 21 GPs took part in semi-structured interviews looking at their plans, reasons for, and feelings about, retirement. Interviews were taped, transcribed, and the text coded using themes from the interview schedule and those derived from the data. Findings are reported using a qualitative distinction between ‘happy’ and ‘unhappy’ doctors and on this basis just over two-fifths of those interviewed were ‘unhappy’, all of whom wanted to take early retirement. The major factor influencing these plans to retire was dissatisfaction with their role and none of this group would be persuaded to change their minds by various incentives such as ‘golden handcuffs’. ‘Happy’ doctors who wanted to stay in practice had found ways of accommodating themselves to change and factors outside of work provided no incentive or ‘pull’. This was not the case for ‘happy’ doctors who wanted to leave: they wanted to pursue hobbies and other interests whilst they were young enough to do so. The paper concludes that change is a major factor producing job dissatisfaction among GPs and that future generations of doctors need to be equipped with the means to cope with it, while governments need to consider the merits of stability and continuity.

It is no coincidence that in setting the agenda for primary health care (PHC), it was acknowledged that nurses would have to play a major role in helping to shift the health system away from a predominant focus on illness and cure, toward increased attention to health promotion and disease prevention. The goal in primary health care is to ‘protect and promote the health of all people of the world’ where health is defined in a positive sense as well-being, not merely as absence of illness. Health so defined has always been the concern of nurses.

In this paper, the relationship between modern professional nursing and PHC will be discussed. The notion that advancing the primary health care agenda is inherently within the domain of nursing practice will be developed, citing examples from a PHC project that involved nurses working with family physicians in a primary care practice. The position will be taken that primary health care provides an opportunity to revitalize the nursing workforce, by recapturing the vision of early nursing leaders, such as Florence Nightingale, who recognized the need for social reform in improving population health and understood nurses’ role in achieving that.

Excessive alcohol consumption causes major problems in the UK but is responsive to brief intervention. Excessive drinkers represent 20% of patients on practice lists and present twice as often as others. The potential of health professionals to reduce alcohol related problems contrasts sharply with current practice. Health professionals’ report fears about negative reactions and losing rapport with patients. This study explored patients’ attitudes to and experiences of alcohol and brief intervention in primary health care so that health professionals can provide a service which is more acceptable to patients. The study used a qualitative approach to data collection and analysis. Six focus groups, stratified by age and sex, were conducted with 31 patients from practices in northeast England. A combination of random and purposive sampling was used to recruit patients with a range of perspectives on issues emerging from ongoing data-analysis until data saturation occurred. Many patients had recently altered their lifestyle to improve their health, however, only one reported reducing alcohol consumption. Over half the patients had been advised about their lifestyle but this was not always deemed to be appropriate. Patients responded positively to advice when in an appropriate context and by a health professional with whom they had developed a relationship and rapport. Overall the general practitioner was deemed the preferred health professional to discuss alcohol issues. Brief alcohol intervention is a legitimate role of the general practitioner when carried out in an appropriate context. A National Alcohol Strategy should focus on strengthening the public health campaign in order to support general practitioners in brief alcohol intervention.

In the UK, primary care groups and trusts (PCG/Ts), also known as primary care organizations (PCOs), are the organizations that will drive forward the primary care development agenda outlined by the government. We undertook a study to investigate the views of PCOs on the place of research in primary care development and their role as participants in the research process. The study population consisted of all PCOs in south London (n = 23). An initial structured questionnaire explored the organizations’ perceived research needs, the potential of the primary care research community to meet those needs and their current research activity. This was followed by semistructured interviews during which the participants were asked to discuss their views on the place of research in their primary care development agenda and in particular how research might inform the development of clinical skills and services in the short and medium term. The third stage of the project was an action based workshop at which general practitioners (GPs) and primary care nurses developed research questions arising from the earlier stages of the study. The PCOs identified three key areas of research support: public health, health economics and nursing research expertise. Research support was needed to help them identify population health needs and to evaluate new models of care and shifting professional boundaries. In contrast to traditional primary care research, PCOs required rapid delivery of research results, particularly when these were used to inform the commissioning of services. Our study has highlighted that PCOs have a development agenda requiring rigorous research and evaluation to ensure the best outcomes for patients. The differing skills, roles and responsibilities of PCOs, PCRNs and academic departments show how partnerships might develop to further research and development in primary care.

The 4H Project is a two year study (February 2001 – January 2003) designed to evaluate the impact of a nurse-led community cardiac rehabilitation service in an inner city area. The population has a high prevalence of coronary heart disease and low uptake of existing services for secondary prevention. Based on initial research exploring the needs of potential service users, the community heart nurse (CHN) delivers a holistic service to postmyocardial infarction patients in their own homes. The CHN has also initiated community-based interventions such as the setting up of support groups and a ‘Walk your Way to Health’ group. The CHN offers specialist advice to primary health care teams and works in close liaison with general practitioners (GPs) and practice nurses. This paper reports on service users’ qualitative evaluation of the CHN role. Semi-structured interviews were carried out with 34 service users, from three weeks to 18 months postmyocardial infarction. The following aspects of the service were seen as important: the sharing of information and the accessible way it was presented; offering coping strategies; confidence building and reassurance; home-based care; easy access to CHN; regular checkups; and the opportunity to meet other patients. Additional services provided by the CHN such as advice on benefits or housing were not widely used, but were appreciated by those who did need this type of assistance. The emerging model of service delivery has both strengths and limitations but is entirely consistent with the increased emphasis on reducing health inequalities and promoting evidence-based care. However, with a relatively small caseload of patients, it is not surprising that a high level of patient satisfaction has been achieved. This paper will therefore include reflection on the difficulties besetting research attempting to evaluate complex, community-based interventions.

In this paper we attempt to explore the meaning, understanding, usefulness and reality of multidisciplinary research in primary care and provide examples. We debate the issues around roles of people in multidisciplinary research, the value of such research and its application to patient care. We also discuss the perceived threats and opportunities to multidisciplinary research, possible reasons for such perceptions, funding, and research governance, education and training issues. We then go on to consider the emerging relationship between primary care organizations (PCOs) and primary care research teams. We specifically address the activities of research general practices and their implications in terms of contributing to multidisciplinary research and training. We question the traditional model of academic research; raise awareness and need for grassroots primary care research and the importance of capacity building through a multidisciplinary model. We have tried to suggest examples and models of multidisciplinary research that can be seamless, include a range of practices and health professionals, and performs research that is contextual, pragmatic and directly beneficial to patients. We feel that for a successful multidisciplinary research workforce in primary care to become a reality, several key areas need to be addressed. Perhaps the most important of these may involve a conceptual change in thinking by all concerned in that we believe that research in primary care should become an integral part of routine primary care in the same way as health professionals routinely see patients or conduct audits. This could, however, only happen if there is commitment, support and a vision for the future of primary care research from decision makers. Local research networks and PCOs need to work closely together in identifying, nurturing and maintaining multidisciplinary research interest.

This paper reports on a study examining the effects of undertaking population-based health needs assessment (HNA) on the knowledge, views and working practices of health visitors. Data were generated through indepth interviews with health visitors who had all utilized a standard mechanism for needs assessment. This was analysed to assess the impact of this work on the research respondents’ knowledge base, their attitudes and approaches to health visiting and their everyday practice. Findings suggest that undertaking health needs assessment increased understanding of public health concepts, enabled a profound reflection on current working practices and increased respondent’s desire to practise differently. However, despite these forces for change, the practitioners in this study found it very difficult to refocus their work in the way they desired due to a combination of inhibiting factors, including custom and practice and the perceptions and demands of others. If health visitors are to expand the scope of their work to incorporate an increased amount of community based activity as the UK Government is proposing, this study would suggest that these inhibiting factors must be addressed not only by health visitors themselves, but also by their employers and other primary care professionals.

Primary care policy and practice in Northern Ireland is unique for two main reasons: unlike elsewhere, Northern Ireland has an integrated health and social services system and the primary care reforms witnessed in many countries have not, as yet, taken place in Northern Ireland. This paper is based on a study in Northern Ireland that aimed to review the role and function of community nursing with reference to new developments in practice, education, research and policy. Service commissioning was one of many areas explored within the study and is the main focus of this paper. The study commenced with focus groups of community nurses (n = 38), general practitioners (GPs) (n = 14) and public representatives (n = 8). This was followed by a two stage Delphi investigation using self-report questionnaires. In addition, data from 34 senior policy makers were collected using semi-structured interviews. The research was primarily carried out in Northern Ireland but involved GPs, community nurses and members of the public from the Republic of Ireland. Findings from all these data sources suggest that there is a perception that community nurses do not have the skills to take a lead role in the commissioning of services, that they require intensive training to take on such roles, and those who do should have equal remuneration with GPs who are involved in service commissioning. Recommendations are offered in the form of action points to guide future practice and policy.