The problem/issue
Most of the medical ethics literature focuses on issues in secondary or tertiary care. Clinicians working in primary care face ethical dilemmas and may require support when making difficult ethical decisions. Primary Care Trusts (PCTs) are new organisations, with a new set of challenges, which may involve ethically difficult decisions. What are the ethical issues arising in primary care, and how do practitioners and managers within primary care think through these issues?

Patient centred
In this study it is the providers of patient care in the primary care setting (clinicians) and commissioners of patient care at all levels within health care (members of PCT Boards) that have been at the centre of the research.

The major part of this research has involved detailed interviews with general practitioners, community nurses, practice nurses, managers and lay members of PCTs. The interviews have focused on their experience of providing care for individual patients and their families, and for setting priorities for provision of health care services for the local population.

The lay members of the PCT Board provided a ‘users’ perspective on many of the issues raised.

Rooted in the real world
The principal source for data in this project was the actual experiences of those working ‘at the coal face’ in primary care, rather than the theoretical medical ethics literature. The ethical concepts and issues emerged from participants’ day to day working experience and were not moulded by the imposition of common theoretical frameworks.

Ethical analysis
The project has required identification of the ethical issues as experienced by those working in primary care, and of the approaches used to thinking through ethical issues in the primary care setting. Ethical language is not often used but moral discomfort is described, for example a GP may worry about whether to lie about a patient’s condition in order to circumvent referral guidelines and get the patient the care that they need, or a manager may worry about ignoring the needs of certain groups of patients in order to ensure that government targets are met. The social context of primary care frames many of the ethical issues identified at a clinical level, while a concept of a duty to care for an identifiable population raised ethical issues for the PCT.

Outputs
To improve professional/service delivery
Findings from the research have informed the development of educational workshops on ethical decision-making for PCT members. These workshops facilitate the development of ethical frameworks and processes for priority setting.

Presentations at academic and professional meetings, and teaching sessions for health professionals working in public health and primary care, has promoted awareness of the issues among the wider health care community.

To further the discipline of medical ethics
There is very little published empirical work in medical ethics in the primary care setting. This study provides an important contribution to this new but growing field. The work will be published in academic journals and presented at national and international meetings. In this way it will contribute to the future development of research in this area.
This study formed the basis of a DPhil thesis submitted to the University of Oxford in 2003.