Family Practice Advance Access originally published online on August 4, 2007
Family Practice 2007 24(5):454-460; doi:10.1093/fampra/cmm034
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Priorities in identifying unmet need in older people attending general practice: a nominal group technique study
a Department of Primary Care and Population Sciences, Royal Free and University College London Medical School, University College, London
b The Claybrook Centre, West London Mental Health Trust, London
c School of Medicine, Imperial College, London, UK
Correspondence to Dr Vari Drennan, Department of Primary Care and Population Sciences, Royal Free & University College London Medical School, University College London, Holborn Union building, Archway Campus, London N19 5NF, UK. Email: v.drennan{at}pcps.ucl.ac.uk
Received 4 January 2007; Revised 21 May 2007; Accepted 17 June 2007.
 |
Abstract |
|---|
 Top Abstract IntroductionStudy objectivesMethodsResultsFeasibilityAcceptabilityDiscussionLimitations of the studyConclusionsDeclarationReferences |
|---|
Background. Primary care practitioners are encouraged to identify unmet need in older people, but the best mechanisms for doing this are not known.
Objective. To identify common unmet needs, as perceived by older people and professionals, that could be enquired about during routine encounters in primary care.
Methods. This was a nominal group technique qualitative study conducted with older people in London and primary care professionals working in the same localities. Subjects were seven nominal groups of 5–12 participants each, four with culturally diverse user groups recruited through local community and voluntary sector resources and three with primary care professionals (GPs and nurses). Group interviews were conducted with two facilitators and one observer recording field notes and were tape-recorded and transcribed for data collection.
Results. Older people and professionals share some ideas about unmet need, but there are important differences. Older people may emphasize their autonomy and right to make choices, while professionals may use epidemiological knowledge to justify their own agendas, which may be considered intrusive. Nominal groups can be useful tools for capturing perspectives of different groups, but prioritization of themes identified by nominal groups may not always be feasible.
Conclusions. Unmet need is a complex concept, with different interpretations according to the perspective taken. Professionals relying on epidemiological knowledge to guide their enquiries about unmet needs in older patients may find that the needs that they identify are not perceived as unmet, or even meetable, by their patients.
Keywords. Ageing, health promotion, preventive medicine.
|
Introduction |
|---|
|
TopAbstractIntroductionStudy objectivesMethodsResultsFeasibilityAcceptabilityDiscussionLimitations of the studyConclusionsDeclarationReferences |
|---|
There is evidence of consistent under-detection of health problems in older people by primary care practitioners.1,2However, there is also a lack of clarity on optimal methods for reducing this under-detection in general practice.3–5 Multi-dimensional identification of problems with associated action may improve survival, functional abilities and reduce admission to hospital and care homes.6 In the UK, the National Service framework for Older People promotes a shared multi-dimensional assessment process for older people presenting complex problems to health and social care services, and at the same time argues that primary care professionals should actively explore unmet needs each time an older person consults.7 It is not practical to use a multi-dimensional assessment tool in an ordinary surgery consultation with a GP or practice nurse when average appointment times are 10 minutes.8 There is a need for a shorter tool that builds on existing information rather than forming a comprehensive assessment in its own right. Studies using comprehensive assessments reveal a common pattern in unmet need.9 In the time-pressured environment of a surgery consultation, it is only practical to explore the most important unmet need(s), which raises the question: important to whom and on what criteria?
The divergence in beliefs about health, illness and disease between lay people and medical professionals has been well known for a long time.10,11 Older people's concepts of health and illness reflect those of other lay groups in society and are contingent on socio-demographic and contextual factors.12,13 The concepts range from health: as an absence of disease, as a source of strength to resist illness and dependence and as having the capacity to function in everyday life.14 Multiple and sometimes conflicting beliefs are held simultaneously.15 Studies reporting older people's reluctance to seek help for problems16 and declining treatment or services for identified problems17,18 provide evidence of this divergence, although other considerations such as social identity in old age, appropriateness and acceptability of services could provide other explanations.19 Health professionals also draw on multiple concepts of health disease and illness,20 but doctors are often characterized as primarily defining health as the absence of pathological disease.21
There are few published accounts of older people's priorities for primary care in addressing unmet need. This is despite policies for user inclusion,22 particularly of older people,23 in public service development. An older people advisory group to a national UK charity prioritized ‘dealing with problems of sight, hearing, teeth and feet, managing continence problems and pain, dealing with the emotional consequences of loss and bereavement and picking up early signs of diabetes or other conditions’.24 There is similarly little published of primary care health professionals' priorities for older peoples health; more common are accounts of primary care professionals negative attitudes to identifying or addressing unmet need in older people.25,26 This paper sets out to address this by reporting on a study using a nominal group technique (NGT). NGT is a structured and focussed group interview that allows for the generation of ideas and addresses some of the problems of more informal groups, such as their domination by some members and some ideas.27 NGT is a potentially powerful learning and development tool28 which has a particular role in analysing health care problems29 and can help bridge the gap between researchers and practitioners. More commonly used with health care professionals, NGT has been used specifically to identify patients and health professionals' priorities in primary care.30 This study formed part of a larger project to develop a short clinical tool to aid identification of unmet need in older people in primary care. The overall results of this study are published elsewhere.31
|
Study objectives |
|---|
|
TopAbstractIntroductionStudy objectivesMethodsResultsFeasibilityAcceptabilityDiscussionLimitations of the studyConclusionsDeclarationReferences |
|---|
- (i) To identify and prioritize which unmet (hidden) health or social needs a GP or nurse should ask about during routine consultations.
- (ii) To explore the different perspectives of older service users and health professionals on the identification of unmet need.
|
Methods |
|---|
|
TopAbstractIntroductionStudy objectivesMethodsResultsFeasibilityAcceptabilityDiscussionLimitations of the studyConclusionsDeclarationReferences |
|---|
Seven nominal groups were conducted, with 5–12 participants in each (Table 1). The groups were purposively selected to represent as diverse a range of views as possible and to seek views of those traditionally ‘hard to reach’ such as older people from ethnic minorities. Four user groups were conducted, one in an general voluntary group setting (Age Concern Day Centre), one in a local community group, one in an African Caribbean and one in an Asian Elders group. Three of these were held with groups of older people who met together on a regular basis for social activities. One was convened specifically with volunteers from a community older people's organization. Three professional groups were held, two for GPs and one for practice nurses. The methodology was identical for all groups.
|
Each group was co-facilitated by members of the research team experienced in nominal group methods and a user representative of the research team. The Asian elders group was also co-facilitated by a local representative who translated the discussion into Gujarati for non-English speaking participants.
The group discussions were designed to follow the same NGT process27: introduction and clarification of the research task; silent generation of ideas; generation of ideas as a group (offering ideas in turn for recording on a flip chart); refining the list by adding, merging or removing ideas; individually ranking the five most important ideas; and group review of the aggregate ranking and then closure. The introduction included obtaining consent from participants and the closure phase included the invitation of all participants to a research feedback event. Each group was asked to generate a priority list of important unmet needs that they felt would be appropriate to be introduced in a routine GP or practice nurse consultation with an older person. Unmet need was defined as a problem that an older person had, that may be hidden or not immediately obvious to their doctor or nurse and that had not been adequately addressed either by themselves, their family and friends or professionals. The discussion was recorded by an observer taking detailed notes and by audiotape that was later transcribed.
The NGT creates two types of data. The first is the written ideas and prioritization, validated by the group as part of the process. The second is the wider discussion generating and clarifying the ideas. This second type of data was transcribed and a content analysis32 undertaken by two members of the research team independently and then compared. A Local National Health Service Research Ethics Committee reviewed the study.
|
Results |
|---|
|
TopAbstractIntroductionStudy objectivesMethodsResultsFeasibilityAcceptabilityDiscussionLimitations of the studyConclusionsDeclarationReferences |
|---|
Identifying the unmet needs for general practice consultations
Each group through the generation of ideas and subsequent discussion identified a list of ‘unmet needs’ that could potentially be addressed in the context of a routine consultation with a GP or practice nurse. The ideas list from the nurse group is given as an example (Box 1).
There was consensus across both user and professional groups on many areas of potential unmet need, such as physical health, medication, mobility, sensory problems, emotional or mental health, memory and social isolation. These grouped into nine domains. The domains of unmet need that were raised in the ‘generation of ideas’ element of all the NGT groups are presented in Box 2, showing those that were identified by user and professional groups.
BOX 2 Potential unmet needs identified by user and professional groups.
| |||||||||||||||||||||||||||||||||||||
Within the physical health domain, the older user groups all identified the regular measurement of blood pressure as a specific valued activity, an activity not specifically mentioned by the professional groups. Professionals identified eight other domains of potential importance that were not raised by users, such as housing, poverty, nutrition, self-care, incontinence and alcohol. The older users highlighted the problems associated with caring for sick relatives themselves and the need for information on any medical problems, which were not raised as issues by professional groups.
There was a broad consensus across all four user groups about important unmet needs and little differences were identified between the views expressed from the groups of different ethnic origin. Similarly, there were little difference in the ideas generated between the GPs and the nurses groups.
The prioritization or ranking process where participants were asked to select which five of unmet needs were most important was found to be difficult for all groups. This was particularly so for the user groups, who were unable to complete this last stage of the process. Analysis of the transcripts of each group discussion reveals two overarching themes with both users and professionals that illuminate both their ideas and their difficulties in prioritization. These were themes of feasibility and acceptability.
|
Feasibility |
|---|
|
TopAbstractIntroductionStudy objectivesMethodsResultsFeasibilityAcceptabilityDiscussionLimitations of the studyConclusionsDeclarationReferences |
|---|
All groups, user and professional challenged the feasibility of undertaking the opportunistic identification of unmet need in routine consultations. This challenge arose from a number of different concerns. Both professionals and users pointed to the demand upon and the time constraints of usual general practice consultations as prohibitive barriers to exploring unmet needs. Many users described short to the point consultations with GPs:
My doctor always has a full waiting room. I see him and then when the five minutes is up and you've got your prescription and that's the end of it, you know. I don't think he can be interactive like this in five minutes. Male 4, (User group 4)
The professionals not only recognized the constraints of a normal surgery consultation but some pointed to the complexity of the needs of some older people:
The elderly need more than ten minutes in consultation. They don't come very often and have polypharmacy and polypathology. GP3 (GP Group 1)
Another challenge from both professional and user groups was the implied presumption of homogeneity in older people. Members of the user groups argued that similar ages did not automatically result in the same health issues. The professionals argued likewise. The practice nurse group pointed out that prior knowledge from medical records and previous consultations shaped the types of questions they would pose of unmet need. The consensus opinion in the nurses group was that open-ended questions provided an opportunity for the patient to bring their own agenda into the consultation and allow for that heterogeneity. There was less consensus on this in the GP groups. Examples of open questions that were suggested included:
Any changes since last time? How are things at home? Nurse 5 (Nurse Group)
In all the user groups, individuals identified that some GPs appeared to be disinterested in the problems they, as older people, brought to them and therefore unlikely to pursue a proactive, preventative approach:
Some doctors, after you are 65, they don't want to know you. Female 3 (User group 2)
There was generalized agreement among the users that the doctors' communication style was pivotal in creating the consultation in which unmet needs might be discussed. As part of this discussion, there were extensive narratives of problems in gaining appointments in general practice, in attending both practices and hospital outpatient appointments and waiting times for social service/occupational therapy assessments. Most of the problematic narratives in primary care were matched by a briefer, more positive narrative from another member of the group, illustrating the diversity of experience.
|
Acceptability |
|---|
|
TopAbstractIntroductionStudy objectivesMethodsResultsFeasibilityAcceptabilityDiscussionLimitations of the studyConclusionsDeclarationReferences |
|---|
A second overarching theme was the acceptability of identifying unmet needs in general practice consultations. Competing views were offered. One user group identified that some people might not want to ‘bother’ the GP with problems and proactive questions would, in a sense, give permission for those to be raised. In contrast, views were raised in other groups that the process was unacceptable as it implied deficits in them as adults by virtue of their age alone:
Really, I don't think its necessary because I know I'm alright.... We've still got our marbles. Even though we're getting old! Female 6 (User group 1)
Some people questioned its acceptability on the grounds that it ignored the choices and responsibilities patients have:
We are the person who have to help along the National Health Services by doing things, by telling the doctor things, not expecting the doctor to do it all. Male 2 (User group 3)
|
Discussion |
|---|
|
TopAbstractIntroductionStudy objectivesMethodsResultsFeasibilityAcceptabilityDiscussionLimitations of the studyConclusionsDeclarationReferences |
|---|
This study of lay and professional perspectives on health needs in later life has identified two aspects of direct clinical and practical relevance: the first is the different perspectives of users and professionals and the second is different views of mechanisms required to elicit unmet needs in consultations.
The first aspect identified is that the perspectives of lay people and professionals overlap significantly around a largely medical agenda, but with unique differences for each group. We characterize these differences as ‘active agent’ from the lay perspective and ‘epidemiological/intrusive’ from the professional perspective. Active agents are older people who are thinking about their health and well-being, solving problems and seeking help only when they so choose. This can include choosing not to respond to a symptom if they did not want to; or it could be expressed as an informed willingness to take a risk with their health. The epidemiological/intrusive perspective allows professionals to draw conclusions about individuals from population data, and pursue their own agenda in consultations. Knowing that depression and disability are associated then allows a family practitioner to ask a patient with, say, extensive osteoarthritis, about depression, even if this has not been raised by the individual.
The common ground between lay and professional perspectives shown in Box 2 contains a predictable medical agenda constructed around illness, medication use and access to services. Disabilities—mobility loss, visual function loss and hearing problems—are also shared, matching the scale and impact of these problems. Both these categories are essentially tractable, with potential for significant improvement in the quality of life of older people, and there is nothing surprising about the agreement between lay and professional perspectives. Our study identified social isolation as an unmet need, but there is little evidence that this need can be met effectively.33 Service providers experience significant levels of concern and frustration, and a sense of powerlessness in meeting the needs of isolated older people.34 Professionals encouraged by current policy to identify unmet need, and who heed the endorsement by older people of social isolation as such a need, may find themselves seeking a problem for which they have, as yet, no solution.
Perspectives unique to professionals ranged from an ecological view of ill-health being related to poverty, poor housing and nutrition, through a concern with frailty (falls, self-care) to topics that are highly personal and sensitive (incontinence, intimate relationships, alcohol misuse). These perspectives focus on the older person as the object of external forces, or becoming increasingly dependent, or concealing important hazards and risks. Older people themselves express a view where they are active as carers, and in need of more information about their health. The two perspectives could not be more different, and the differences are relevant to the second aspect identified in this study, the way in which unmet needs are identified.
The second aspect identified that there were different views of mechanisms required to elicit unmet needs in consultations. Again the user groups presented older people as active agents in consultations, rather than passive recipients. The professionals are divided about techniques they should adopt in trying to elicit unmet need, between those taking a checklist approach and those preferring a conversational style of working with older people. Our findings suggest that practice nurses were just as likely as GPs to want to use open-ended, conversational styles of enquiry, and less enthusiastic about checklist approaches to identifying unmet need. The anecdotal perception that nurses are more structured in their thinking and practice, and therefore more systematic than doctors, is not supported by our data.
Both users and professionals in the study challenged the feasibility of the proactive search for unmet needs in general practice consultations, raising questions for protocols or guidance5 that encourage such ‘proactivity’. Both users and professionals in this study disputed the premise that similar age in patients equated to similar or standardized health problems. Indeed, the issues raised of acceptability prompt the question as to whether this type of proactive searching for unmet needs embodies an epidemiological/intrusive professional philosophy that is at odds with other professional values and public policies that decry ageism in health and social care services.5
These findings and questions of feasibility and acceptability influenced the larger study aimed at developing a brief assessment instrument. As a consequence, we shifted the emphasis from creating an instrument to creating a heuristic i.e. a set of ‘rules of thumb’ to be used in general practice.31
|
Limitations of the study |
|---|
|
TopAbstractIntroductionStudy objectivesMethodsResultsFeasibilityAcceptabilityDiscussionLimitations of the studyConclusionsDeclarationReferences |
|---|
This is a small-scale study, offering some findings that can be generalized at a theoretical level. It used a NGT with both professionals and users, and user groups failed to complete all stages of that process. The participants, particularly the users, were not easily deflected from narratives of aspects of health and social care they considered more important. Both professionals and users challenged the feasibility and acceptability of the initial question on identifying unmet needs in routine consultations in very illuminative ways but ultimately in ways that rendered the last NGT phases impossible. This highlights the potential difficulties of using a structured approach such as NGT with a potentially controversial topic generating a broad range of views. In the larger study, this problem was addressed through supplementary consultation processes with users and professionals.31 In the UK, government policies advocate greater consultation with the public in prioritizing primary care services and commissioning, although there is yet no one accepted method for doing this.35 We would suggest that this experience should add a note of caution to those considering using NGT with the public.
|
Conclusions |
|---|
|
TopAbstractIntroductionStudy objectivesMethodsResultsFeasibilityAcceptabilityDiscussionLimitations of the studyConclusionsDeclarationReferences |
|---|
Unmet need is a complex concept, with different interpretations according to the perspective taken. Professionals relying on epidemiological knowledge to guide their enquiries about unmet needs in older patients may find that the needs that they identify are not perceived as unmet, or even meetable, by their patients. Nominal groups can be useful tools for capturing perspectives of different groups, but prioritization of themes identified by nominal groups may not always be feasible and may require supplementary methods.
|
Declaration |
|---|
|
TopAbstractIntroductionStudy objectivesMethodsResultsFeasibilityAcceptabilityDiscussionLimitations of the studyConclusionsDeclarationReferences |
|---|
Funding: This study was funded by the National Health Service NHS Executive London Regional Office RDC020.
Ethical approval: None.
Conflicts of interest: None.
|
Acknowledgments |
|---|
Thanks to all those who participated in the nominal groups. The Spice Team also includes Frances Blitz, Horton Kennedy, Dr Martin Harris and Professor Martin Orrell. The views expressed here are those of the authors and not necessarily the funders.
|
Notes |
|---|
Drennan V, Walters K, Lenihan P, Cohen S, Myerson S and Iliffe S for the SPICE research group. Priorities in identifying unmet need in older people attending general practice: a nominal group technique study. Family Practice 2007; 24: 454–460.
|
References |
|---|
|
TopAbstractIntroductionStudy objectivesMethodsResultsFeasibilityAcceptabilityDiscussionLimitations of the studyConclusionsDeclarationReferences |
|---|
1 Williamson J, Stokoe IH, Gray S, et al. Old people at home. Their unreported needs. Lancet (1964) 13:1117–1120.
2 Iliffe S, Haines A, Gallivan S, Booroff A, Goldberg E, Morgan P. Assessment of elderly people in general practice. 2. Functional abilities and medical problems. Br J Gen Pract (1991) 41:13–15.[Web of Science][Medline]
3 Fletcher AE, Jones DA, Bulpitt CJ, Tulloch AJ. The MRC trial of assessment and management of older people in the community: objectives, design and interventions [ISRCTN23494848]. BMC Health Serv Res (2002) 2:21.[CrossRef][Medline]
4 Stuck AE, Egger M, Hammer A, Minder CE, Beck JC. Home visits to prevent nursing home admission and functional decline in elderly people: systematic review and meta-regression analysis. J Am Med Assoc (2002) 287:1022–1028.
5 Elkan R, Kendrick D, Dewey M, et al. Effectiveness of home based support for older people: systematic review and meta-analysis. BMJ (2001) 323:719–725.
6 Stuck AE, Siu AL, Wieland GD, Adams J, Rubenstein LZ. Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet (1993) 342:1032–1036.[CrossRef][Web of Science][Medline]
7 Department of Health (England). National Service Framework for Older People (2001) London: Department of Health.
8 Royal College of General Practice. General Practice in the UK: A Basic Overview. Information Sheet No 4 (2005) London: Royal College of General Practitioners.
9 Walters K, Iliffe S, See Tai S, Orrell M. Assessing need from patient, carer and professional perspectives: a feasibility study of the Camberwell Assessment of Need for the Elderly in primary care. Age Ageing (2000) 29:505–510.
10 Helman C. Disease versus illness in general practice. J R Coll Gen Pract (1981) 31:548–552.[Medline]
11 Stacey M. Concepts of Health and the Nature of Healing Knowledge: Biomedicine and Beyond. Chapter 12 in Stacey M the Sociology of Health and Healing (1988) London: Unwin Hyman.
12 Williams RGA. The Protestant Legacy: Attitudes to Death and Illness among Older Aberdonians (1990) Oxford: Oxford University Press.
13 Cornwell J. Hard Earned Lives: Accounts of Health and Illness from East London (1984) London: Tavistock.
14 Blaxter M. Health and Lifestyles (1990) London: Tavistock/Routledge.
15 Siddell M. Health in Old Age: Myth, Mystery and Management (1995) Buckingham: Open University Press.
16 Walters K, Iliffe S, Orrell M. An exploration of help-seeking behaviour in older people with unmet needs. Fam Pract (2001) 18:277–282.
17 Drennan V, Iliffe S, Haworth D, Tai SS, Lenihan P, Deave T. The feasibility and acceptability of a specialist health and social care team for the promotion of health and independence in ‘at risk’ older adults. Health Soc Care Community (2005) 13:136–144.[CrossRef][Web of Science][Medline]
18 Runciman P, Currie CT, Nicol M, Green L, McKay V. Discharge of elderly people from an accident and emergency department: evaluation of health visitor follow-up. J Adv Nurs (1996) 24:711–718.[CrossRef][Web of Science][Medline]
19 Howes K, Ebrahim S, Gooberman-Hill R. Help avoidance: why older people do not always seek help Reviews in Clinical Gerontology (2005) 14:63–70.
20 Helman C. Culture, Health and Illness (2000) 4th edn. Oxford: Butterworth Heinneman.
21 St Clare L, Watkins CJ, Billinghurst B. Differences in meanings of health: and exploratory study of general practitioners and their patients. Fam Pract (1996) 13:511–516.
22 Department of Health. The NHS Plan: A Plan for Investment, a Plan for Reform (2000) London: Department of Health.
23 Cabinet Office (England). All Our Futures: Report of the Steering Committee to the Better Government for Older People (2000) Cabinet Office. CAB 212/00, http://archive.cabinetoffice.gov.uk/servicefirst/1998/op/newop.htm (accessed on July 1, 2007).
24 Health and Older People Group. Our Future health :Older Peoples Priorities for Health and Social Care (2000) London: Help Aged.
25 Renwick DS, Connolly MJ. Prevalence and treatment of chronic airways obstruction in adults over the age of 45. Thorax (1996) 51:164–168.
26 Burroughs H, Lovell K, Morley M, Baldwin R, Burns A, Chew-Graham C. Justifiable depression': how primary care professionals and patients view late-life depression? A qualitative study. Fam Pract (2006) 23:369–377.
27 Delbecq AL, Van der Ven AH. A group process model for problem identification and programme planning. J Appl Behav Sci (1971) 7:466–492.[Abstract]
28 Dockery G. Rhetoric or reality? Participatory research in the National Health Service, UK. In: Participatory Research in Health: Issues and Experiences—De Koning K, Martin M, eds. (1996) London: Zed books. 164–176.
29 Van den Ven AH, Delbecq AL. The nominal group as a research instrument for exploratory health studies. Am J Public Health (1972) 337–342.
30 Gallagher M, Hares T, Spencer J, Bradshaw C, Webb I. The nominal group technique: a research tool for general practice? Fam Pract (1993) 10:76–81.
31 Iliffe S, Lenihan P, Orrell M, et al. A short instrument to identify common unmet needs in older people in general practice. Br J Gen Pract (2004) 54:914–918.[Web of Science][Medline]
32 Quinn Paton M. How to Use Qualitative Methods in Evaluation (1987) London: Sage Publications.
33 Findlay RA. Interventions to reduce social isolation amongst older people: where is the evidence? Ageing Soc (2003) 23:647–658.[CrossRef][Web of Science]
34 Russell C, Schofield T. Social isolation in old age: a qualitative exploration of service providers' perceptions. Ageing Soc (1999) 19:69–91.[CrossRef][Web of Science]
35 Ryan M, Scott DA, Reeves C, Bate A, van Teijlingen ER, Russell EM, et al. Eliciting public preferences for healthcare: a systematic review of techniques. Health Technol. Assess. (2001) 5(5).
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  V. Abrahamson and R. Raine Health and social care responses to the Department of Health Heatwave Plan J. Public Health Med., June 20, 2009; (2009) fdp059v1. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. Graffy, J. Grant, S. Boase, E. Ward, P. Wallace, J. Miller, and A. L. Kinmonth UK research staff perspectives on improving recruitment and retention to primary care research; nominal group exercise Fam. Pract., February 1, 2009; 26(1): 48 - 55. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 I. Heath Never had it so good? BMJ, April 26, 2008; 336(7650): 950 - 951. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||