Primary Care Capacity Research Articles

Measuring primary care: the standard primary care year

Numerous reports highlight the problem of declining primary care capacity in the USA, especially in rural and remote areas. The reasons for declining primary care capacity are elusive. Little progress is likely without better definitions, tools, and approaches. The author proposes a standard primary care workforce year to adjust each primary care form for losses due to specialization, lower levels of practice activity, lower primary care volume, and shorter career length. The author reviewed studies to create a standard primary care year estimate representing the total primary care contribution for each of the five training forms of primary care over the career length of the graduate. The standard primary care year was the product of four factors: (1) the career length in years; (2) the percentage estimated to remain in primary care; (3) the percentage active in practice; and (4) the percentage of primary care volume compared with a family practitioner. A best determination was made regarding the value of each of the four factors for each primary care form. Because specialization rates increased substantially to decrease primary care contributions, the estimate for each form also had to be linked to each class year of graduates. Family practice is the best example of a permanent primary care training form with 29.3 standard primary care years expected over a 35 year career. Other training forms appear to be more flexible with graduates able to choose primary care or specialty care depending on policy and market forces. The 2008 pediatric residency graduates can be expected to serve 17.6 years of primary care. Internal medicine resident primary care contributions have been reduced by 50% in the past decade to 5.3 years with international medical graduate internal medicine contributions decreasing to 2.5 years. Physician assistant estimates have decreased to 6 years, while nurse practitioner estimates have declined below 3 years per graduate. Without changes in policy or training, the USA must graduate 11.7 international medical graduate internal medicine residents, or 10 nurse practitioners, or 5.5 US internal medicine residents, or 4.8 physician assistants, or 1.7 pediatric residents to equal the same primary care contributions as one family physician. With decreasing rural and underserved distribution levels in the flexible forms, the numbers of graduates needed to match the family practice rural primary care year and underserved primary care year contributions are even higher. The primary care year is a versatile tool that can help to estimate primary care contributions across different forms of primary care. Specialization takes a huge toll on primary care capacity. Progressive failure to retain primary care makes expansions of graduates an ineffective and costly intervention. Without graduating more who remain in primary care, the USA can expect consistently lower primary care levels. Primary care contributions of progressively shorter duration could explain the perceived rapid collapse of primary care, particularly when studies of primary care fail to involve the most recent months of changes.

Building Interprofessional Primary Care Capacity in Mental Health Services in Rural Communities in Newfoundland and Labrador: An Innovative Training Model

The benefits of interprofessional care in providing mental health services have been recognized, particularly in rural communities where health services are limited. In addition, there is a need for more continuing professional education in mental health intervention in rural areas. Although interprofessional collaboration and continuing education have both been proposed to address the paucity of mental health services available in rural areas, there have been no programs developed in which the two components have been combined. This paper describes the development, implementation, and evaluation of an interprofessional continuing education program specifically designed to enhance rural mental health capacity.

A Common Factors Approach to Improving the Mental Health Capacity of Pediatric Primary Care

To expand the mental health service capacity of pediatric primary care, we ask whether there are evidence-based skills to allow providers to 1) immediately begin treatment for children with emotional and behavioral problems while diagnostic procedures are being pursued, and 2) offer evidence-based care to children who do not meet criteria for a specific diagnosis. We discuss why the epidemiology of child mental health problems poses difficulties for disorder-specific mental health interventions, and review evidence that "common factors" contributing to the outcome of mental health treatments define a core set of skills that primary care providers might use to complement disorder-specific interventions.

Remote Patient Monitoring

Telemedicine and e-HealthVol. 14, No. 2 MEDICAL CONNECTIVITYRemote Patient MonitoringKevin D. BlanchetKevin D. BlanchetSearch for more papers by this authorPublished Online:24 Mar 2008https://doi.org/10.1089/tmj.2008.9989AboutSectionsPDF/EPUB ToolsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited byHealth technology diffusion: Case of remote patient monitoring (RPM) for the care of senior populationTechnology in Society, Vol. 66Use of real-time videoconferencing to deliver physical therapy services: A scoping review of published and emerging evidence18 June 2019 | Journal of Telemedicine and Telecare, Vol. 26, No. 10Remote Patient Monitoring in IBD: Current State and Future Directions7 March 2018 | Current Gastroenterology Reports, Vol. 20, No. 2Increasing the Capacity of Primary Care Through Enabling Technology27 February 2017 | Journal of General Internal Medicine, Vol. 32, No. 4Challenges of integrating patient-centered data into clinical workflow for care of high-risk infants12 August 2014 | Personal and Ubiquitous Computing, Vol. 19, No. 1The Use and Misuse of Biomedical Data: Is Bigger Really Better?6 January 2021 | American Journal of Law & Medicine, Vol. 39, No. 4Health Technology Assessment of Telemedicine for Patient Suffering from Heart Failure2 May 2013Improving Health Care Outcomes through Personalized Comparisons of Treatment Effectiveness Based on Electronic Health Records1 January 2021 | Journal of Law, Medicine & Ethics, Vol. 39, No. 3A Point-to-Point Simple Telehealth Application for Cardiovascular Prevention: The ESINO LARIO Experience. Cardiovascular Prevention at Point of Care Mara Malacarne, Giorgio Gobbi, Paolo Pizzinelli, Alessandro Lesma, Alberto Castelli, Daniela Lucini, and Massimo Pagani9 February 2009 | Telemedicine and e-Health, Vol. 15, No. 1 Volume 14Issue 2Mar 2008 InformationCopyright 2008, Mary Ann Liebert, Inc.To cite this article:Kevin D. Blanchet.Remote Patient Monitoring.Telemedicine and e-Health.Mar 2008.127-130.http://doi.org/10.1089/tmj.2008.9989Published in Volume: 14 Issue 2: March 24, 2008PDF download

La atención primaria y el poder resolutivo del sistema de salud: un estudio desde los profesionales

To identify professionals' view of the problem-solving capacity of primary care in the health system.Interpretative study, based on the Grounded Theory method and the focus-group technique.Eight primary care centres.In all, 198 professionals: 86 physicians, 69 nurse and 43 who were not health professionals.Data were obtained by: open questions in the focus groups, recording and transcription of the contributions; division of the text into autonomous sense units; sense units grouped by their common characteristics; inductive definition of each category; relationship between categories and triangulation of inter-team data.The problem-solving capacity of professionals should be characterized by: care for the bio-psycho-social demands and needs of the population; the integration of the following dimensions of professional competence: communication and teamwork; the promotion of prevention and public education. However, health-care daily practice prioritised quantitative parameters linked to reactive actions that were distant from the singularity of patients' pathologies.The desired problem-solving capacity of primary health care is threatened by excessive quantitative measurement, by shortcomings in human resources and facilities, and by the well-known lack of time in health-care delivery.

A Note from the Editor

A Note from the Editor Virginia M. Brennan As the country watches the 2008 presidential campaign take shape, with health care prominent on the horizon, many people soldier on without any care or without adequate care, their health often compromised by structural factors, awaiting policy that truly addresses their needs. Among the cornerstones of public policy in this area are the constructs of Health Professional Shortage Area (HPSA) and Medically Underserved Area (MUA), first introduced by federal legislation during the 1970s. In an important paper in the present issue, Thomas Ricketts and colleagues from the Sheps Center of the University of North Carolina at Chapel Hill describe the development of a theory-based, data-driven replacement for the HPSA and MUA designation systems. The authors write in the article published here, "The proposed rule changes were approved by the Secretary of Health and Human Services on March 26, 2007 and a 'notice of proposed rulemaking' will appear in the Federal Register sometime in 2007. After a 6-month comment and review period, which may result in modifications to the proposal, the final rule is scheduled for publication in early 2008." We are proud to be publishing this important paper. In a related paper, Jiexin Liu asks whether, in addition to having fewer doctors, people in HPSAs suffer from worse health. Using survey data of 10,940 adult West Virginians, Liu finds that living in an HPSA is indeed associated with worse general health status, poor physical health, and less access to medical services (though not to inpatient care), confirming the intuitive rationale behind the construct of HPSAs. Another topic addressed in the present issue is what Joshua Yang and Marjorie Kagawa-Singer of UCLA call ethnicity-specific care. Their Commentary concerns the advisability and feasibility of creating ethnicity-specific subsystems of care as a strategy for increasing access to care for cultural and linguistic minorities. They recount in depth the historical experiences of the Chinese community in San Francisco on the basis of systematic exploration of archival documents and semi-structured interviews. In doing so, they reconstruct the evolution of that community's ethnicity-specific health care infrastructure, including the origin and evolution of Chinese Hospital, and create an organizational development model for ethnicity-specific health care organizations and infrastructures. The authors conclude by making policy recommendations for developing ethnicity-specific sub-systems of care. Nathan Consedine and colleagues from Long Island University in Brooklyn delve into a related question when they investigate whether the way a message concerning breast cancer screening is framed (in terms either of what one would gain by getting screened or of what one would lose by not getting screened) is associated in any clear way with the income level and/or ethnicity or race of the person to whom the message is directed. Contrary to expectation, they find no main effect for framing condition. Income proved an important moderator of framing effects, interacting with both condition and race to influence screening. [End Page vii] Also from New York, on the subject of care for immigrant populations as part of medical education, Robert Karp and colleagues from the State University of New York (SUNY) Downstate Medical Center in Brooklyn report on a program addressing pediatric residents' knowledge, awareness, and practices around patients' immigration status and eligibility for government funded health and nutrition benefits. After assessment and training of the residents, the faculty used posters to remind them and their clinic's largely immigrant population about immigrants' rights to care. Another report concerning health professional students comes from Carmen Patrick Mohan and Arun Mohan. They describe the HealthSTAT model of professional development, a student-run advocacy program that uses team-based leadership and peer-to-peer learning to cultivate inter-professional collaboration and community partnership in service to the poor and underserved of Georgia. Also in the area of medical education, Mina Silberberg and colleagues from Duke University report on a clinic run by a federally-qualified health center and Duke's medical center. Showing how the clinic expands the community's primary care capacity, combining advantages of big and small settings, and of its dual affiliation, the authors present a workable system that similar town...

Neighborhood Clinics: An Academic Medical Center—Community Health Center Partnership

This report describes a clinic run by a federally-qualified health center and an academic medical center. The clinic expands the community's primary care capacity, combining advantages of big and small settings, and of its dual affiliation. Survey data suggest the clinic prevents health care delays and lowers emergency department use.

Developing the mental health workforce capacity in primary care: implementing the role of graduate primary care mental health workers in England

The scale of current demand on primary care services from people seeking help with common mental health problems places enormous pressure on the existing front line workers in general practice. The paucity of training opportunities and competing pressures to deliver improved services across a range of general practice targets remains a major challenge for primary care professionals. The impact of government policy, to improve both access to and choice of treatments, has raised public expectations.The commissioning of the graduate workforce, the graduate worker in primary care mental health (GWPCMH), commenced in 2002, in response to the publication of target numbers detailed in the Priorities and Planning Framework, (DoH, 2002). It signalled a determination to expand the workforce provision and improve the quality of care for service users with common mental health problems.This paper examines the scale of common mental health problems, the policy response and the commissioning process. Particular attention is given to examining the barriers that have been shown to affect implementation, identifying the key influencers and the resources required to train these workers.

Building Primary Care Capacity in Palliative Care: Proceedings of an Interprofessional Workshop

Building Primary Care Capacity in Palliative Care: Proceedings of an Interprofessional Workshop

Bursaries, writing grants and fellowships: a strategy to develop research capacity in primary health care

BackgroundGeneral practitioners and other primary health care professionals are often the first point of contact for patients requiring health care. Identifying, understanding and linking current evidence to best practice can be challenging and requires at least a basic understanding of research principles and methodologies. However, not all primary health care professionals are trained in research or have research experience. With the aim of enhancing research skills and developing a research culture in primary health care, University Departments of General Practice and Rural Health have been supported since 2000 by the Australian Government funded 'Primary Health Care Research Evaluation and Development (PHCRED) Strategy'.A small grant funding scheme to support primary health care practitioners was implemented through the PHCRED program at Flinders University in South Australia between 2002 and 2005. The scheme incorporated academic mentors and three types of funding support: bursaries, writing grants and research fellowships. This article describes outcomes of the funding scheme and contributes to the debate surrounding the effectiveness of funding schemes as a means of building research capacity.MethodsFunding recipients who had completed their research were invited to participate in a semi-structured 40-minute telephone interview. Feedback was sought on acquisition of research skills, publication outcomes, development of research capacity, confidence and interest in research, and perception of research. Data were also collected on demographics, research topics, and time needed to complete planned activities.ResultsThe funding scheme supported 24 bursaries, 11 writing grants, and three research fellows. Nearly half (47%) of all grant recipients were allied health professionals, followed by general practitioners (21%). The majority (70%) were novice and early career researchers.Eighty-nine percent of the grant recipients were interviewed. Capacity, confidence, and level of research skills in ten core areas were generally considered to have improved as a result of the award. More than half (53%) had presented their research and 32% had published or submitted an article in a peer-reviewed journal.ConclusionA small grant and mentoring scheme through a University Department can effectively enhance research skills, confidence, output, and interest in research of primary health care practitioners.

A new direction for community services

The new White Paper telling us what the government wants for patients in need of primary care services is a long-winded read. It is 230 pages of what is currently happening and what changes need to be achieved to enhance primary care capacity, particularly in areas presently under-served, and to achieve diminished hospital admission. Following the furore of the RCN decision to apply for a judicial review, Patricia Hewitt issued a statement to the effect that PCTs could maintain their provider function if this was in the interest of local people. But life in health care is never simple and Our Health, Our Care, Our Say makes the situation quite clear: the tendering and procurement process is to be applied to the community setting. Alternative providers, such as the independent sector and social enterprise organisations, are now invited to tender for business and will need to negotiate with commissioning PCTs and practice-based commissioners on levels of service and costs.

Setting directions for capacity building in primary health care: a survey of a research network

BackgroundThe South Australian Research Network 'SARNet' aims to build research capacity in primary health care, as part of a national government-funded strategy to integrate research into clinical practice. Internationally, research networks have been a fundamental part of research culture change, and a variety of network models exist. The 'SARNet' model uses a whole system, multidisciplinary approach to capacity building and supports individuals and groups. We undertook a descriptive baseline survey in order to understand the background and needs of SARNet members and to tailor network activities towards those needs.MethodsA questionnaire survey, assessing members' professional background, research experience, and interest in research development and training, was sent to all members who joined the network in its first year. The visual 'research spider' tool was used to ascertain members' experience in ten core research skills, as well as their interest in developing these skills. Individuals were asked to classify themselves into one of four categories of researchers, based on previous research experience. These self-assessment categories ranged from non-participant to academic.ResultsNetwork membership was diverse. Of the 89 survey participants, 55% were general practitioners or allied health professionals. Overall, most survey respondents indicated little to moderate experience in 7 out of the 10 skills depicted in the 'research spider'. In comparison, respondents were generally highly interested in developing their research skills in all areas. Respondents' research skills correlated significantly with their self-assessed category of research participation (Spearman rank correlation, r = 0.82, p < 0.0005). Correlations between research category and publication record (Gamma association, γ = 0.53, p < 0.0005) or funding record (Gamma association, γ = 0.62, p < 0.0005) supported the internal validity of the survey instrument.ConclusionLiterature describing evaluation of the impact of networks is scarce. Our survey questionnaire could provide a useful instrument for evaluation of both networks and capacity building initiatives. The survey including the 'research spider' tool provided valuable information about members' needs and interest in strategies to develop their research skills. Initial needs analyses as well as on-going evaluation of network activities are important to include into the business plans of research networks, in order to ensure the network's effectiveness and support of its membership.

Research activity, interest and skills in a health and social care setting, a snapshot of a primary care trust in northern England: implications for collaboration and capacity

International and UK National Health Service policy has focused attention on the need to develop research capacity in primary care, with the emphasis on collaboration between professional groups and across organizations including health and social care, and the academic context. The results of a survey of research activity, interest and skills in a health and social care community, in Northern England, are reported. The survey targeted primary care trust (PCT) staff, general practice staff and social services staff seconded to the PCT, and a response rate of 31% was achieved. Twelve per cent of respondents were involved in research, with research active professionals typically involved in between one and three projects. PCT staff reported a significantly higher level of research activity, research skills and research interest than general practice or social care staff. The holding of a master's degree was associated with a greater desire to lead or collaborate in research. All three groups expressed a preference for practice-based research training and other forms of research support were identified, including protected time, apprenticeship, mentoring and funding advice. The results of this survey have been valuable in terms of research governance, forming research strategy, and impact on capacity via training and support for the health and social care community within a newly formed research alliance between a district general hospital, a PCT and social services, including an academic advisory group. The paper concludes that a holistic approach to research capacity building should inform changing policy and research funding in the UK.

The 'Designated Research Team' approach to building research capacity in primary care

Trent Focus, a Research and Development Support Unit, have introduced the ‘Designated Research Team’ (DRT) approach to building research capacity. This approach funds protected time to develop research ideas and skills for a team with limited research experience. This paper uses the example of a successful team of podiatry researchers to illustrate the approach to, and outcomes of, a DRT. It draws on documentary analysis of meeting notes and annual reports, and team members’ views collected during a recorded reflective session of the team at the end of the funding period. The DRT were successful in achieving agreed outcomes, including completing the project, submitting and publishing in peer reviewed journals, and presenting at conferences. They were also able to attract further funding, and engage with international collaborations and research activity. The unique contribution of this paper is that it focuses on facilitating factors to building research capacity based on a practice example. These include: enabling protected time, effective managerial support, applied and timely research training at relevant levels to expertise, immediate access to supervision and mentorship, a critical mass of research expertise within the team, and an encouraging workplace environment. Importantly, research undertaken was seen as a means to improve practice and the status of the professional group. ‘Accessible’ academic support including outreach work and attitudes of the team members and supervisors towards teaching and learning were important. Process factors enabling success include the use of project management techniques, clear delegation of tasks, effective lines of communication and accountability, and high levels of social capital and commitment between team members. The paper highlights ways forward to using these facilitating factors to build further research capacity, and to use this approach to highlight other areas of research capacity outcome measures.

Barriers and opportunities to developing research capacity in primary care trusts: the views of staff attached to a primary care trust

In the UK, the Department of Health recognizes the importance of research activity to improve patient care, but the amount of research activity relating to primary care is scant. Few have considered managerial and organizational aspects relating to developing research capacity in primary care and none have examined this from the perspective of organizations responsible for managing primary care at a local level. Yet these organizations have a critical role in increasing the amount of appropriate health services research and developing a research culture. A qualitative analysis of focus group workshops was performed to identify issues associated with developing research capacity within a primary care trust (PCT) covering a single local authority borough in England. All staff attached to the PCT were invited to attend facilitator-led focus groups and asked to consider from an individual and organizational perspective: What will enable them to increase the use of and participation in research? What barriers exist? What opportunities exist or could exist to develop this in the PCT? Themes were identified using content analysis based on written records from the focus groups. Issues relating to developing research capacity were grouped into the following categories: What is research? Training; Resources; Managerial; and Organizational issues. Research was not seen as an integral component of the daily or routine work of most people in a health care organization. Managerial and organizational issues were a considerable barrier to developing research capacity. Lack of appreciation and support for research by managers and lack of structures to facilitate research within the organization prevented research capacity being developed. Primary care management organizations need to work with service managers to encourage the incorporation of research activity into the routine work of staff. Greater dialogue is needed between individuals, service managers and academics to ensure that appropriate research is carried out to support the organization in meeting its explicit objectives. More work is needed to understand the perceptions of research from a managers’ perspective and to develop constructive ways to gain their support for a research agenda.

Primary care research — what in the world is going on?

Primary care research has been described as a "lost cause", and, although this claim has been strongly refuted, general practitioners publish less research than their colleagues in surgery, medicine and public health. Despite a fivefold increase in Australian general practice research papers from the 1980s to the 1990s, fewer than half of these focused on clinical topics. Trying to establish a global figure for expenditure on general practice and primary care research is difficult, but data show that public expenditure for primary care research is minimal in Australia, New Zealand, the Netherlands and the United Kingdom--fewer than 1.50 dollars per capita in 2002-2003. Compared with hospital- and laboratory-based research, primary care receives significantly fewer resources, ranging from 3.2% of total public expenditure on health and medical research in the Netherlands to 6.8% in New Zealand. Government-led investment in interventions such as strengthening primary care departments and colleges and supporting primary care academics, establishing practice-based networks, fostering international initiatives for cross-national efforts, and engaging individual primary care practitioners in research projects, are all required to build research capacity in primary care.

Variation in emergency department visits for conditions that may be treated in alternative primary care settings

The purpose of this report is to examine Ontario's geographic variation in emergency department (ED) visits for conditions that may be treated in alternative primary care settings. We studied all visits to Ontario EDs in 2002/03 and calculated county-specific age-standardized rates. Overall in Ontario, there were 3174 ED visits per 100,000 population aged 1-74 for conditions that could be treated in alternate primary care settings, but rates varied widely across counties. They were higher in rural counties with rates up to 7-fold higher than the provincial average. Urban counties had lower rates, some were less than one-third of the provincial average. Further research is needed to determine the relationship between ED utilization and primary care capacity.

The Future of Generalism in Medicine

What is the future of generalism in medicine? There was a time when financial analysts predicted that 90% of U.S. health care would be organized as managed care built on a primary care, generalist model (1). In the wake of these predictions, residency positions in family medicine and other generalist disciplines grew rapidly. Hospitals and health systems bought or built practices and added so-called primary care capacity to their operations (2). Today, however, the intellectual stratosphere and, more important, the medical marketplace resound with a very different language. Recent publications about generalism are resplendent with words like “crisis” (3), “distress” (4), “dissolution, disillusion” (5), “crossroads” (6), “prosperity and despair” (7), and “reconstruction, renewal, and renaissance” (8). The authors seem preoccupied with the notion that the generalist fields, while offering great value, need to change or may not survive (3–6, 9). The picture is also grim for many generalist physicians and patients in the world of medical practice. The cost of care and the number of persons without health insurance continue to rise, creating obstacles to patients’ receipt of recommended care. Now, we also know that more care is not necessarily better—in fact, when care is fragmented and probably redundant, more care may be worse (10, 11). In the meantime, generalist primary care physicians, while remaining committed to providing high-quality patient care, are struggling. Individual practitioners struggle with low reimbursement for their services, administrative burdens always seem to increase, and inflexible appointment schedules and brief visits satisfy neither patient nor provider (12, 13). Following a decade of increasing interest in generalist residency training, applications to residency programs designed specifically to produce generalists have fallen off dramatically (14). An ever-increasing evidence base indicates that care organized around generalist primary care is the best (15). Despite challenging market forces that make it difficult for generalist physicians to practice the best possible care (2), large and small groups of talented providers, often organized into effective teams, continue to deliver comprehensive, generalist care. Thoughtful individuals devote considerable intellectual energy reviewing published scientific papers and commentary to find examples of generalist care that meets patient expectations and yields good outcomes. Others work on demonstrations and proposing solutions (4, 8, 9, 16, 17) that suggest answers to the question “Whither generalism in medicine, whither primary care?” The answers could lead to ways to improve and deliver more nearly ideal care to all Americans. This supplement contains examples of intellectual energy devoted to proposing solutions. In the fall of 2003, the Robert Wood Johnson Generalist Physician Faculty Scholars program (18, 19), a program designed to promote academic development of talented junior faculty in generalist disciplines, asked current and past scholars and its National Advisory Committee to develop a series of white papers addressing different aspects of the future of generalism and ways to improve and deliver ideal primary care to all Americans. Ten groups of scholars, with each group including at least 1 family physician, general internist, general pediatrician, and senior advisory board member, developed proposals that were presented and critiqued at an annual meeting. Ultimately, 9 of these presentations became papers. The topics that emerged were not too surprising, ranging from generalist research to student interest in generalism to a variety of approaches to develop better systems, improve coordination, move to more “ideal” primary care, and develop more integrated “whole-patient” care. This supplement contains the 4 papers that we, the supplement editors, believed best addressed the question “What is the future of generalism in medicine?” These papers address some of the critical elements that are widely recognized as necessary to produce more ideal care: integration (20), coordination (21), and the need for effective communication to achieve whole-person care (22). The fourth paper focuses on the challenge of creating a system of health care practice and medical education that works to make primary care specialties more attractive to students “short of a major overhaul of economic incentives in favor of generalist careers” (23). A system based in primary, generalist physician practice is arguably the ideal system (15)—whether it is based in a large health care system or in smaller offices and networks. Indeed, primary medical care is essential, and patients want it (24). The papers in this supplement are noteworthy because they offer perspectives on the future of generalism in medicine from persons representing all 3 major primary care disciplines. Their perspective is idealistic and aspirational. In general, the articles contain suggestions that are reasonable ways to work within the existing system of care. They do not suggest changes that are simply not feasible given today’s political climate. The papers are particularly timely today, and they provide a welcome response to the need for innovative thinking and constructive policy formulation to help ensure high-quality care for the public by preserving and enhancing generalist practice.

Addressing the Implementation Challenge: Introducing Primary Care Graduate Mental Health Workers

The introduction of primary care graduate mental health workers (PCGMHWs) is a central element of a national strategy to support the capacity in primary care to respond effectively and appropriately to people presenting with mental health problems. The commitment in the NHS Plan to recruit 1,000 workers across England by 2004 (Department of Health, 2000) has not been easy to deliver. This paper describes the experience and process of introducing these workers in the North West region of England within the context of the challenges of implementing national policy; it identifies elements of the approach which have facilitated implementation and provides a case study which might have broader relevance.

Developing R&amp;D capacity in a primary care trust: use of the R&amp;D culture index

There has traditionally been a low level of engagement of primary care practitioners with research. In the UK, primary care trusts (PCTs) now have some responsibility for the encouragement of research and development in primary care. The aim of this study was to assess the current level of research activity and capacity for research within a PCT. A questionnaire, incorporating a recently developed and validated research and development culture index, was sent to all 572 health care professionals and staff under the auspices of North Tyneside Research PCT. Data analysis used nonparametric tests of association including chi-squared, Mann–Whitney U and Spearman's rank order correlation. There was a 50.3 per cent response rate to the questionnaire. Groups more likely to show an increased capacity for research included those with postgraduate qualifications and those in post for the least time. General practitioners were less likely than other professional groupings to declare personal skills or aptitude for research. The two most important factors thought to contribute towards the development of a culture of R&D were having access to people to support development and changes in professional practice and having access to training and development opportunities. The use of the R&D culture index enabled groups to be identified that may be more research interested and can therefore be targeted to increase research capacity. The R&D culture index could be used by other PCTs wishing to define and develop research capacity in primary care.