A substantial proportion of the symptoms of ill health presented in primary care settings are medically unexplained. Low level physical and mental suboptimal functioning, such as tiredness and nagging psychological discomfort are common features of workload and are rarely amenable to immediate and straightforward treatment and cure. Complementary and alternatives medicines (CAMs), with their frequent focus on overcoming an apparently restrictive mind/body dualism, are being increasingly drawn on to manage such symptoms. reflexology is a CAM that, it is claimed, is able to induce improved physical and mental health and overall well-being. To date, there has been little research which addresses this claim. A single blind trial was conducted to test the effectiveness of reflexology in improving levels of tiredness, overall health and perceived well-being in a sample of 34 patients with chronic irritable bowel syndrome currently under the care of a general practitioner, following diagnosis by a gastroenterologist. Both reflexology and nonreflexology (control) groups were found to produce a moderate improvement in symptoms, but there was no statistically or clinically significant difference in outcome between the groups. Thus, no specific benefit of using reflexology was found. On the basis of this study, there is no evidence for the use of reflexology as a means of enhancing patient well-being in primary care. However, the research was conducted with one quite specific patient group. Considerably more research is needed with a range of patient groups and outcome measures before definitive conclusions can be reached.

Problems with regard to the recruitment and retention of general practitioners (GPs) have been largely attributed to disquiet over ongoing government health reforms, together with increased administrative and surgery workloads, low morale and stress. This study aimed to provide empirical evidence of the scale of the workforce crisis in GP recruitment and retention, and the type of initiatives being developed to address local problems. Postal questionnaires were sent to directors of primary care in all 100 health authorities in England, and to directors of postgraduate GP education. Problems associated with recruitment and retention were mainly confined to less attractive locations, primarily deprived urban areas. Sources of new recruits mainly consisted of local training schemes. Numerous initiatives had been set up to address local problems, but these tended to be piecemeal and small scale. Although there was widespread awareness of problems with regard to the recruitment and retention of GPs, there was little evidence of co-ordinated approaches to offset future problems.

Prescribing Analysis and Cost (PACT) data are sent to all GPs to assist them in monitoring their prescribing. Although the quarterly Standard Reports contain a great deal of information it is not known how GPs make use of it. This paper reports on two linked studies which explore GPs' views on PACT Standard Reports and PACT catalogue data. In the first study, interviews were carried out with 21 GPs in 16 practices selected according to criteria related to their prescribing budget. The interview schedule included questions on how the Standard Reports were used and the amount and ease of understanding of the information provided, and on use of PACT Catalogue data. The second study was a questionnaire survey of the 1047 practices in the West Midlands region in which GPs were asked how they used PACT data. Analysis of the interviews showed that GPs' views on the Standard Report varied widely although most found it helpful. Many GPs used the data in a limited way and only used a small part of them. Single-handed GPs and small practices were least likely to make use of PACT data and few practices analysed the data in any depth. Most respondents said that comparing their costs with health authority and national averages was useful for considering where to make changes in their prescribing. GPs indicated they would like the report to include some interpretation of the data with suggestions for changes which could be made. The regional survey confirmed that PACT Standard Reports are only used in a limited way and how they are used varies with practice size. We conclude that PACT Standard Reports were rarely used to analyse prescribing in any depth and GPs need more support in making better use of the data.

There is increasing interest in collecting morbidity data from general practice. We describe our experience from Northumberland MEDICS, one of the first morbidity data collection projects in the UK. All Northumberland practices were invited to participate. Data were initially collected every 3–6 months and included the prevalence of chronic diseases, disability in the over 75s, and recording of health markers, such as smoking status. Thirty-three out of 52 practices participated. There was marked variation in prevalences and recording of health markers between practices. Recorded prevalence of hypertension and diabetes increased steadily from 1994 to 1998. Outcomes, judged by the original objectives, were mixed. However, as the project evolved, evidence emerged that MEDICS was contributing to a culture in which the use of data from practice clinical systems to improve patient care has become a core objective. Key lessons from our experience include appreciating: the importance of data quality and minimising workload for practices; the difficulties practices face in recording morbidity data consistently and systematically; the limitations of GP morbidity data for health needs assessment and commissioning at district level; and the need to focus on providing useful and relevant data for individual practices. MEDICS now covers all 53 Northumberland practices. The project focuses on recording and analysing data to help practices improve structured patient care. Increasingly data collection in general practice in Northumberland is seen as a core activity with the current dataset linking closely with local priorities and reflecting national initiatives such as Clinical Governance and National Service Frameworks.

The aim of this study was to explore the views of Primary Care Organisation (PCO) clinical governance leads on the implementation and development of clinical governance within primary care in the south west region. A grounded theory study using focus groups, research interviews and negotiated feedback reports was designed for use in the primary care setting. The subjects were a purposeful sample of 16 PCG-level clinical governance leads. Four main categories emerged from the data. These included: (1) defining clinical governance; (2) the process of implementing clinical governance; (3) positive aspects of clinical governance; and (4) concerns about delivering clinical governance. At the time of collecting the data (approximately 1 year after the introduction of clinical governance), there was evidence of a culture in primary care where clinicians valued efforts to improve the quality of patient care and enjoyed their own involvement in decision-making at a grass-roots level. However, whilst the concept of clinical governance was received with enthusiasm, the delivery of clinical governance faced challenges. These challenges included the paucity of ear-marked funding, the speed of implementation, the volume of work, and the impact on the clinical governance lead's relationships at home and at work and on his/her emotional wellbeing.

The purpose of the present study was to analyse maternal grief and coping with grief following the death of a child aged under 7 years. The aim was to obtain information to understand mothers' grief, in order to support them after the death of their child. Data were collected through surveys (n = 91). The questionnaire used contained an existing grief reactions checklist and open-ended questions. The data were analysed using a two-way analysis of variance, cross-tabulation and content analysis. The results indicate that the mother's grief was associated with the time elapsed since the child's death. The grief was also associated with the mother's age so that older mothers tended to display more grief reactions of a certain kind (detachment and disorganization) than younger mothers. Younger mothers experienced more personal growth than older ones. The child's age at death was associated with more disorganization among mothers if the child had been aged over 1 year at the time of death. The number of children was also associated with the mother's grief. Mothers displayed more detachment if there were other children in the family than if the child had been an only child.

Data from a cross-sectional sample of 21 620 Swedish-born individuals and 2072 foreign-born individuals, aged 16–74 years were used to examine the association between socio-economic status (SES), country of birth (as an indicator of migration experiences), self-reported health status (SRHS) and diabetes. The survey included 31 foreign- and 446 Swedish-born individuals with diabetes mellitus. After accounting for age, sex, circulatory disease, SES (education, car ownership), social network, physical activity, smoking and body mass index, diabetics demonstrated a 3.7 higher risk of poor SRHS than non-diabetics. Foreign-born individuals had the same risk of self-reported diabetes as Swedish-born individuals. All three SES indicators: low/intermediate attained level of education, no car ownership, or renting a dwelling, were significant independent risk factors of diabetes mellitus after adjustment for age, sex, country of birth, circulatory disease, social network and life style. Moreover, low SES was an important risk factor of poor SRHS among diabetics. There was a nonsignificant borderline association between country of birth and poor SRHS among diabetics. These findings suggest that individuals with diabetes have a substantially increased risk of poor SRHS, and that low SES and country of birth (migration experiences) may contribute to further augment poor health among diabetics.

This study was designed to test the hypothesis that a behavioural programme was used preventatively to try to reduce crying and improve night sleeping in 1- to 12-week old infants compared with educational support or existing services. The objectives were to develop strategies which can be used to inform, help and support parents of new babies. The study was a three-group prospective randomized controlled trial in West Berkshire and South Oxfordshire, making a comparison between a behavioural policy, an educational intervention and existing services. The participants were 610 mothers giving birth to term healthy infants at the Royal Berkshire Hospital, Reading between March and November 1997. The main outcome measures were interruption-free nights i.e., the number of nights each week when parents reported that their baby slept for a minimum of 5 hours; babies' fuss/crying patterns; and mothers' general well-being and approach to parenthood. There were no significant differences between the groups in the amount of fuss/crying, which gradually reduced during the 12 weeks. At 12 weeks of age, more mothers in the behavioural group reported their babies to have had seven interruption-free nights (61%), compared with the educational (53%) and the control groups (50%). This was significant at the P < 0.05 level. The educational and control groups did not significantly differ at any age. At 6 and 12 weeks, mothers allocated to the behavioural policy were more structured in their approach to parenting and rated it more highly for convenience. At 9 months, their babies were more likely to have a regular bedtime routine. Where mothers followed a behavioural programme, 10% more babies slept for a minimum of 5 hours at night without disturbing their parents at 12 weeks of age. This improved sleeping pattern persisted up to 9 months of age. Mothers in this group also reported a greater feeling of control and increased confidence in their ability to cope. The more widespread adoption of a behavioural approach to the management of early infant sleeping should be considered.

The government has stated its commitment to provide equality of access to health care for all and has emphasized the need to take account of users' views. The aim of this review was to search for evidence of adolescents' perceived needs for and access to primary health care services and to evaluate and report on the evidence found. Methods used were systematic searching of data bases and direct contacting of health and related organizations. The main finding was that a substantial minority of teenagers has health-related problems which are not met by current services. The main barriers to accessing primary health care were a perceived lack of confidentiality, embarrassment and unsympathetic staff. Reported access to a school health nurse varied widely (between 5% and 83%). The conclusions were that the barriers to accessing services as identified by teenagers are amenable to staff training, and that taking account of users' views could act as a stimulus for such training.

Aim: To describe a general practice commissioning project including 19 nonfundholding practices in Buckinghamshire: its structure, aims, representativeness, outcomes, costs and sustainability, and lessons learned from the process over the first 18 months.

Method: Examination of project documentation; postal questionnaire to all 73 participating GPs and to eight key players in the Health Authority (response rate 72%); and in-depth interviews with six Health Authority staff and 15 general practitioners (GPs).

Results: A representative structure and process were established for GP involvement in commissioning. 75% of GPs were involved. Mutual understanding improved between the GPs and the Health Authority. Service improvements identified included developments in orthopaedics, community psychiatric nursing, physiotherapy and ophthalmology. Lessons were learned about the importance of open and continued communication; clarity about expectations, accountability, power and responsibility; development of relationships and understanding in joint working; the time required to achieve tangible results; and the need to develop GPs' commissioning skills.

The project cost about £10000 in cash and £32500 in staff time in the first year. Participants perceived their input as sustainable.

Conclusion: The results of the study suggest that the success of Primary Care Groups will depend on ensuring engagement of all parties in the process, clarifying roles, responsibilities and expectations, identifying shared agendas, developing explicit and achievable goals, and a commitment among all parties to implement recommendations. The work and time involved in developing mutual respect and shared understanding, and in developing commissioning skills need to be acknowledged.

This study explored the experiences of gay and bisexual men in primary care. The study was mindful of both the wider context of the HIV epidemic and the increasing acknowledgement of the role of social factors in determining health and well-being. The study informants were 17 gay and bisexual men, all of whom were registered with general practices. Two major barriers to effective communication and possibly treatment were identified. First, despite the fact that all the informants had come out – or disclosed their sexuality – in many areas of their lives, there was considerable anxiety and fear of stigmatisation in relation to doing so in the context of primary care. Second, many practices and practitioners appeared to assume that all their patients were heterosexual; there were few signals in practice environments of any awareness of gay and bisexual men. This generated problems for men wishing to discuss health needs and treatments in relation to their sexuality and to gay social networks; few practitioners had made referrals to any these networks as part of their health promotion strategy. The study raises questions about the organisation of primary care provision and its willingness to acknowledge and form partnerships with gay social networks.

Interest in the role of the nurse practitioner in primary care, as first point of contact for patients with acute illnesses, is well established. Recent studies in the UK have examined the role in the context of a variety of acute presentations and have addressed issues of competence, safety and patient satisfaction. The management of acute presentations involves responsibility for making a diagnosis and, frequently, for recommending medication either on prescription or to be purchased from the pharmacy. As the nurse practitioner role develops in primary care there is a need for evidence of the effective management of specific acute presentations. Protocols have been advocated as a key to the successful introduction of the nurse practitioner role but the legality of their use, particularly in relation to prescribing, remains unclear. The aim of this study was to compare, in one general practice, the management of acute urinary symptoms by nurse practitioners with that of GPs in the context of a protocol. The study was undertaken in two parts: a retrospective analysis of a sample of the records of female patients followed by a patient satisfaction survey. The retrospective analysis examined the use of the protocol in guiding the decision-making of both groups of practitioners and evaluated the outcome for the patient. The outcome indicator used in this part of the study was the need for a repeat consultation within 14 days due to non-resolution of symptoms. The retrospective analysis of records was supplemented by a patient satisfaction survey. In comparison with the GPs, the nurse practitioners' records were more complete, the prescribing rate was lower, the use of laboratory resources was similar and there was no difference in the number of patients who needed to be seen again. In the patient satisfaction study higher levels of patient satisfaction were achieved by the nurse practitioners.