Patients living with chronic pain are typically resource intensive, their care requirements are long term and referral to secondary care is not always expeditious. To provide more appropriate, accessible and cost-effective care, Tower Hamlets Primary Care Trust reviewed the needs of the patients, their current care and the numbers requiring treatment for non-malignant chronic pain, initially starting with musculoskeletal pain.

We estimated the number of people with chronic pain being treated outside general practice by the NHS in Tower Hamlets. A working group established set criteria to define a chronic pain patient. We surveyed appropriate clinicians to determine the approximate number of patients who fitted our inclusion criteria, the approximate number of follow-up appointments they required and their care pathways. Secondly, we estimated the cost of care for chronic pain patients using NHS national tariff and reference cost data. We also took a convenience sample of chronic pain patients and recorded their history of care.

The routes and pathways of care are complex and multiple. We estimate between 4.0% and 5.5% of new patients in rheumatology, orthopaedics, occupational therapy and musculoskeletal physiotherapy and up to 90% in the pain clinic are people living with chronic pain. The cost of this care ranged from £296 for a course of physiotherapy to £1911 for a patient seen in physiotherapy, orthopaedic and the pain clinics.

There is no facility in current management information services that identifies people being treated for non-specific chronic pain; therefore, estimating both the numbers and costs for treating these people is difficult. National tariff and notional cost data provide estimates only, of an ‘average patient’; the real cost of these patients is unknown.

In recent years several factors have affected the public’s relationship with health care research: increased data protection legislation and the resultant consent requirements; access to unforeseen levels of both information and misinformation through mass media; and a growing culture of personal choice which may have eroded the perceived importance of activities whose benefits are societal rather than personal. This article considers these factors and their implications and highlights the need for health care researchers to engage more effectively with the public in order to ensure its continued support.

Health care systems are changing around the world; family doctors need to adapt and prepare for future challenges.

To consider the present status of family doctors, anticipated changes in health care systems, the challenges these will bring and possible solutions.

Collaborative enquiry amongst members of the International Federation for Primary Care Research Networks (IFPCRN). Six strategic questions were addressed by 37 contributors from 23 countries. Responses were collated and contributors invited to further comment on the interim report.

Present status: Despite wide variability, common problems relate to delivery systems, funding and policy, lack of evidence-based medical practice, education and research. Role of family doctors: There is wide variability in roles and often poor interaction with other caregivers. Anticipated changes: An expansion of the family physician model is anticipated, alongside shortages of family doctors in the face of increased health care needs, increased complexity of problems and the shift to ambulatory care. Advances in information technology may be useful. Anticipated challenges and proposed actions: Address quality issues. This requires audit and quality assurance, promoting adaptability, promoting group practices and teamwork, coordinating care, incorporating information technology and ensuring ethical relationships with industry. Improve education and continuing professional development: Improved education and continuing professional development are needed, as are measures to prevent burnout and retain the workforce. Develop a robust research enterprise: Research in primary care is needed to develop relevant guidelines. Improve support for family doctors: Providing excellent patient care is essential for improved status and support. Achieving this requires engagement with policy makers, academic institutions and the public.

While there is great variability across different countries, common themes relate to present status, anticipated changes in health systems and the responses needed from family medicine.

To investigate whether general practitioners (GPs) in countries with different levels of cardiovascular risk would make different risk estimates and choices about lipid-lowering treatment when assessing the same patients.

Primary prevention of coronary heart disease should be based on the quantitative assessment of an individual’s absolute risk. Risk-scoring charts have been developed, but in clinical practice risk estimates are often made on a subjective basis.

Mail survey: Nine written case simulations of four cases rated by the Framingham equations as high risk, and five rated as low-risk were mailed to 90 randomly selected GPs in Stockholm, as a high-risk area, and 90 in Sicily as a low-risk area. GPs were asked to estimate the 10-year coronary risk and to decide whether to start a lipid-lowering drug treatment.

Overall risk estimate was lower in Stockholm than in Sicily for both high-risk cases (median 20.8; interquartile range (IQR) 13.5–30.0 versus 29.1; IQR 21.8–30.6; P = 0.033) and low-risk cases (6.4; IQR 2.2–9.6 versus 8.5; IQR 6.0–14.5; P = 0.006). Swedish GPs were less likely than Sicilian GPs to choose to treat when their estimate of risk was above the recommended cut-off limit for treatment, both for the entire group (means of GPs’ decision proportions: 0.64 (0.45) and 0.92 (0.24), respectively, P = 0.001) and for high-risk cases (0.65 (0.45) and 0.93 (0.23), P = 0.001).

The cardiovascular risk level in the general population influences GPs’ evaluations of risk and subsequent decisions to start treatment. GPs’ risk estimates seem to be inversely related to the general population risk level, and may lead to inappropriate over- or under-treatment of patients.

Some primary care physicians provide less than optimal care for depression (Kessler et al., Journal of the American Medical Association 291, 2581–90, 2004). However, the literature is not unanimous on the best method to use in order to investigate this variation in care. To capture variations in physician behaviour and decision making in primary care settings, 32 interactive CD-ROM vignettes were constructed and tested.

The primary aim of this methods-focused paper was to review the extent to which our study method – an interactive CD-ROM patient vignette methodology – was effective in capturing variation in physician behaviour. Specifically, we examined the following questions: (a) Did the interactive CD-ROM technology work? (b) Did we create believable virtual patients? (c) Did the research protocol enable interviews (data collection) to be completed as planned? (d) To what extent was the targeted study sample size achieved? and (e) Did the study interview protocol generate valid and reliable quantitative data and rich, credible qualitative data?

Among a sample of 404 randomly selected primary care physicians, our voice-activated interactive methodology appeared to be effective. Specifically, our methodology – combining interactive virtual patient vignette technology, experimental design, and expansive open-ended interview protocol – generated valid explanations for variations in primary care physician practice patterns related to depression care.

To evaluate an approach to multidisciplinary case management that is embedded in primary health care.

Case management has been advocated in order to coordinate health and social care for vulnerable elderly people and avoid unnecessary hospital admissions. However, it is unclear who should undertake this.

This case study reports on an approach developed in a semi-rural general practice in Cambridgeshire, UK, and later adopted locally. Data evaluated included practice records, minutes of project meetings over a three-year period and comments from members of the primary care team.

Key elements of the approach were a register of vulnerable people, regular inter-disciplinary meetings and administrative support to follow-up decisions. Practitioners from a range of health and social services participated. Of the 937 people aged 75 and over, 54 (5.8%) were registered as vulnerable, along with five who were younger. After initial efforts to identify those at risk, new registrations fell. Of these 59 patients, 39 (66%) were admitted to hospital over the three years and practitioners believed that the project had prevented admissions. The monthly meetings also enabled professionals from different services to share information, coordinate their work and learn about local services.

By adopting a systematic approach to sharing intelligence about those at risk, extended primary care teams are able to provide case management for the vulnerable elderly. This integrated approach also provides a forum for practitioners to learn about local services. However it involves a significant time commitment. There is a need for further research to assess the cost-effectiveness of the approach in preventing avoidable admissions and improving health and quality of life for older people.

To evaluate a new service development whereby a nurse and a paramedic working in partnership attended non-urgent emergency calls.

The demand for emergency ambulance services both nationally (in the UK) and internationally has been steadily increasing. A large proportion of calls made to the emergency ambulance service are classified as non-urgent. An alternative response to these calls may release the standard ambulance service to attend more urgent calls. A pilot project was initiated in order to provide an alternative response to non-urgent emergency calls in an Ambulance Trust in England with support from the local Primary Care Trust. This alternative response comprised a district nurse or an emergency nurse practitioner dispatched with a paramedic to visit low-priority emergency calls. The pilot service was trialled during a 15-week period in 2003–2004.

This paper evaluates the cost effectiveness of the pilot service by examining both the resource use and the outcomes of the service.

It was found that introducing this service to the current provision would increase the overall cost to the ambulance services. However, a reduction in conveyance rate to the hospital was observed as people could be treated on-scene. A reduction in conveyance rate to the hospital would lead to reduced admissions to accident and emergency departments and subsequent hospitalization. This paper provides an indication that further development of this type of service has the potential to be cost effective, if the wider health care economy is considered, as the cost savings made in secondary care could more than balance the costs to the Ambulance Services in providing such a service.

Reports of work absence usually come from self-report or company absence records; however, these records are limited to just one company. Electronic recording of sickness certification in primary care medical records may provide an alternative source of data, but its relation to other sources of sickness absence information is unknown. Comparing general practitioner electronic sickness certification records with self-reported work absence would enable the comparability of these electronic records to be established.

To investigate the comparability of electronic medical records of sickness certification in primary care, with self-reported work absence.

Analysis included 292 primary care low-back pain consulters who consented to medical record review. A within-group design was used to match electronic records of sickness certification with self-reported sickness absence.

Overall 95% of the electronic medical records of sickness certification matched with self-reported absences; 96% in employed consulters and 95% in unemployed consulters. In all, 94% of employed participants were a direct match, 2% a consistent match and 4% a mismatch. Including consistent matches increased matching to 97% in employed consulters and to 100% in unemployed consulters. Electronic records of sickness certification in general practice are a useful method of analysing sickness absence in the population, as they are comparable with other sources of data. Additionally, electronic records of sickness certification will allow the investigation of sickness absence where data from one company are too limited and self-report is not available or unreliable. To facilitate the use of electronic medical records of sickness certification, data need to be accurately recorded and evaluated or audited to ensure completeness and validity. Furthermore, methods should be developed to ensure straightforward linkage between sickness certification records and other data held on the electronic medical record.

Depression in young people is not necessarily self-limiting, and is frequently associated with affective disorders and impaired psychosocial functioning in adult life. Early recognition of and response to depression in teenagers could be an important task for general practitioners (GPs), but there are multiple obstacles to achieving this.

To explore GPs perceptions of the opportunities and difficulties of working with teenagers, and of specifically recognizing and responding to depression.

Nine GPs who had taken part in a developmental project on diagnosing and treating depression in young people. All worked in an Inner London Medical Centre.

Semi-structured interviews transcribed and analysed thematically.

Two over-arching themes that emerged from the interviews were that teenagers were perceived as being qualitatively different from adults in the ways they used general practice, and that GPs were uncomfortable with making a diagnosis of depression in young people. Within the first theme, we identified sub-themes, including failure of teenagers to engage with services, parental involvement, complex presentations and lack of time. Within the second theme, the sub-themes were surprise, normalization of depressed mood and challenge to the validity of psychiatric diagnosis in this age group.

Professional development in general practice that addresses this topic needs to modify two perceptions; that depressed mood is in some sense ‘normal’ in this age group, and that teenagers are so different in their use of services that the management of depression (if it is recognized at all) is problematic.

Statistics from primary health care in Sweden, as well as from other Nordic countries, have been sparse. The electronic patient records (EPR) will be an increasingly important source of clinical information. The aim of this study was to investigate types of encounters, managed diseases and health problems, and characteristics of patients and general practitioners (GPs) in everyday general practice using EPR.

A multi-centre, cross-sectional database study of EPR in primary health care in Stockholm, Sweden. Twenty-six randomly selected GPs with 20 randomly selected encounters each. Main outcome measures were the number and distribution of diseases and health problems, age and gender of patients and GPs, and type of encounter.

The mean age of the patients was 51.2 years, 30.2% were aged 75 years or older, and 57.5% were women. The mean number of managed problems per encounter was 1.4. The most common specific diagnoses were essential hypertension (9.3% of the encounters) and acute upper respiratory infections (8.8%). Older patients had more health problems in each encounter (P = 0.000001). GPs differed regarding the characteristics of their patients, including sex, age and number of health problems managed at each encounter. The patients of different GPs differed regarding sex, age and number of health problems managed. Female and male patients had different diagnostic panoramas and they had a tendency to encounter a GP of the same sex (odds ratio 1.5, P = 0.053).

We found that two diagnoses (essential hypertension and acute upper respiratory infections), four diagnostic groups, women and the elderly are predominant. Female and male patients have different diagnostic panoramas and they have a tendency to encounter a GP of the same sex. GPs differ regarding the characteristics of their patients, including sex, age and number of health problems managed at each encounter.

Front-line NHS staff undertake small research projects to answer questions about local patients and services, but these projects often face considerable challenges. This paper reports on one such project.

The study used structured interviews in order to find out about the knowledge of nutrition among Bangladeshis using an NHS Walk-in Centre.

Time constraints posed considerable difficulties in progressing and completing the study; flaws in the methodology emerged; and underpinning assumptions about health promotion and ethnic minority health beliefs were open to challenge.

Despite this, some findings were valuable and have considerable potential as a stimulus to critical thinking among practitioners about their own attitudes, as well as raising issues that future research would find it useful to address.

This paper presents findings from an ethnographic study that examined how qualified district nurses’ conceptualized their role in relation to family carers and how they performed this aspect of their role.

A participant observational study involving fieldwork and in-depth interviews with six district nursing teams was undertaken over a 12-month period. Interview transcripts and fieldnotes were analysed by drawing upon the principles of dimensional analysis.

District nurses acted on the assumption that family carers would, by choice or default, provide care. Family carer support was conceptualized as a means of promoting self-care and the patient’s independence from nursing services. The rationale for providing family carer support was based largely on service capacity rather than on carer needs and preferences. Six characteristics of district nursing support for carers were identified: enabling, supporting, mediating, care substitution, crisis prevention and crisis intervention. Family carers were not recipients of district nursing support in their own right but were dependent upon the cared-for person receiving nursing care. This in turn was conditional upon others (general practitioners and hospitals) making appropriate patient referrals. Family carer support was also conditional upon effective communication and family carer receptiveness.

As the scope of home-based nursing continues to increase, district nurses need to take a more active stance in providing family carer support and adopt a family rather than patient-focused approach in order that family carers might be supported more effectively.

To explore health professionals’ experiences of barriers and facilitators to referring patients for pulmonary rehabilitation in a primary care setting.

Pulmonary rehabilitation involves a multidisciplinary teamwork approach to improving the quality of life for people with chronic obstructive pulmonary disease. This study aimed to find out about health care professionals’ experiences when referring patients. Reports suggest that a health care professional’s attitude towards a treatment affects the willingness of patients to accept advice.

Five focus group interviews were undertaken with 21 health professionals from North Midlands, UK. Data were analysed using a thematic analysis drawing on the techniques of grounded theory.

Chronic disease management has been delegated to Practice Nurses in many cases leaving some nurses feeling unsupported and some General Practitioners feeling deskilled. Problems with communication, a lack of adequate and timely local service provision, a difficult referral process, time pressures and lack of information were barriers to health care professionals making an offer of pulmonary rehabilitation. An explanatory model is proposed to describe how addressing barriers to referral may improve health care professionals views about pulmonary rehabilitation and therefore may mean that they present it in a more positive manner.

The chronic care model (CCM) has been widely used in a variety of health care settings to guide system improvement for chronic illness care, including diabetes care. However, the evidence base for the specific components of the model has not been systematically reviewed. This review aimed at examining the extent to which interventions featuring the CCM components improve diabetes care and determining the relative effectiveness of different CCM components.

We systematically searched MEDLINE (1966 to December 2004), the Cochrane Effective Practice and Organisation of Care and the Cochrane Controlled Trials Register to identify interventions featuring one or more system components of the CCM for diabetes care. Outcome measures included HbA1c, blood pressure and blood lipid control. We used random-effects meta-analysis and meta-regression for quantitative synthesis of data.

In all, 69 studies (43 randomized controlled trials and 26 controlled before–after studies) met inclusion criteria and were included in this review. Overall, included studies reported a mean reduction of 0.46% (95% CI 0.38, 0.54) in HbA1c, mean reduction of 2.2 (95% CI 0.9, 3.5) mmHg in systolic blood pressure, mean reduction of 1.3 (95% CI 0.6, 2.1) mmHg in diastolic blood pressure and mean reduction of 0.24 (95% CI 0.06, 0.41) mmol/L in total cholesterol. For specific CCM components, interventions that addressed delivery system design reported the largest improvements in patient outcomes, followed by those employing a self-management support component. Interventions involving decision support or clinical information systems reported relatively smaller effect sizes.

Interventions featuring CCM components for diabetes care produced small-to-moderate improvements in a range of patient intermediate outcomes. The findings support the concept of the CCM in which the state of development of various aspects of primary care service systems defined in this model appear to be important factors in the quality of care provided to people with diabetes.

To evaluate the antibiotic prescribing of prescriber-trained nurse practitioners in a primary care setting.

As of 1st May 2006, legislation was introduced extending the prescriptive powers of appropriately trained nurses and nurse practitioners to nearly equal that of fully registered doctors. Following this increase, we believe that it is important to ensure that these new powers are being used judiciously. In this paper, we focus on a particular aspect of prescribing: that of antibiotics in a primary care setting. We examine how the prescriber-trained nurse practitioners’ prescribing of antibiotics compares with the practice guidelines on prescribing.

An audit of all consultations for six months following 1st May 2006 by the three nurse practitioners trained to prescribe was conducted. Where an antibiotic was prescribed, the anonymous clinical detail was compared with the appropriate practice guideline. The antibiotic-prescribing habits of doctors were identified from a literature search using Medline, by using UK-wide data provided by the Prescriptions Pricing Authority and from the practice Primary Medical Services review.

The nurse practitioners were found to prescribe antibiotics in a total of 1296 out of 3211 consultations at an average monthly rate of 41 per 100 consultations. The most common antibiotics prescribed in descending order of frequency were as follows: amoxicillin; flucloxacillin; erythromycin; pencillin V; cefalexin and trimethoprim. Of the antibiotics prescribed during this period, 1065 were found to adhere to practice guidelines and 200 did not. A further 31 were deferred prescriptions. Off-guideline prescribing was accompanied by clear clinical indication as to the reason for the prescription identified in the medical record. Overall prescribing rates in this study of 80 per 100 consultations (including items other than antibiotics) are comparable with those published in the literature.

Prison health care in England, including primary care, is now incorporated into the National Health Service; the impetus for the change is in part due to concern about standards of health care within prisons. The demographic characteristics and health status of patients within prisons are relatively well understood, as are the problems faced by health care professionals. Less is known about current health care provision.

To describe the organisation of primary health care and specialised services in prisons and compare services available to different types of prison.

A piloted questionnaire was sent to the governors of all prisons in England and Wales for completion by the health care manager.

Completed questionnaires were received from 122 (89%) of 138 prisons. The survey showed a low use of information technology (IT). Problems were reported with the recruitment and retention of general nurses in more than 50% of prisons. Prisoners in category A/B (higher security) prisons had available to them a greater range of health care services compared with those in other prisons. The results suggest that provision of services for chronic diseases and improvements in IT are needed. Problems with the recruitment and retention of general nurses need addressing. The reasons why lower-security prisoners are receiving a narrower range of specialised health care services compared with higher-security prisoners need justifying.