To have any prospect of recruiting one third of all presentations of Bell's palsy in Scotland all general practitioners, accident and emergency departments and unscheduled care services had to be involved. In addition regional otolaryngology services were required. As it was considered possible that some patients might present through their dentists we initially hoped to include this group in recruitment. However, in the end recruitment was restricted to three dental hospital sites and they contributed only one participant.
Keeping it simple
As it was unlikely that individual general practitioners or accident and emergency doctors would be involved more than once in the trial it was essential that their role should be clearly delineated and relatively simple to carry out and that instruction should be available relatively easily. Recruiting doctors' involvement was restricted to diagnosis followed by determining the patients' interest in participating, excluding patients who were not eligible and a telephone referral to the on-call otolaryngology doctor. The trial process actually constituted a reduction in workload for most general practitioners who would normally be expected to follow-up patients. The trial also offered immediate access to specialist assessment which would not be provided under normal care. Both of these attributes were found to be very attractive to general practitioners during the planning phase of the trial.
It was essential that all hospital otolaryngology staff to whom the referrals would be made (generally junior staff working both during the day and out-of hours) knew about the trial and their role in it and that any briefing was regularly repeated to ensure that new members of staff were informed. Prior to the start of recruitment otolaryngology staff were briefed during visits from regional research associates; thereafter departments (where necessary) were updated six-monthly, immediately after the twice-yearly redistribution of staff in otolaryngology departments.
Publicising the trial
Doctors need to be reminded regularly of an ongoing trial of a condition which occurs relatively sporadically . In addition, there is a high turnover among staff in accident and emergency departments and training grades in general practice and otolaryngology. A variety of strategies publicising the trial were set in motion.
The responsibility for keeping doctors informed about the on-going trial was taken on by SPPIRe  (Scottish Professionals and Practices Interested in Research) the Scottish national primary care research framework. All general practitioners in the four participating regions of Scotland were sent a mail-shot outlining the trial and explaining how to take part. We emphasised the importance of the condition and the simplicity of involvement. The mail-shots were in colour designed to be attractive and, based on evidence from the literature, we highlighted the benefits to patients  and remuneration to general practitioners  for taking part and letters were signed by well know local general practitioner 'champions' . Separate mail-shots went out to non-principal doctors and registrars. The trial was also highlighted in Local Medical Committee briefings to general practitioners. We estimate each quarterly mail-shot took about a day of researcher time in each of the four participating regions
A&E departments were kept informed by literature and posters from the centre; similarly general practice co-ops through literature and posters distributed with SPPIRe's help and NHS 24 by direct contact with the study centre. We found that the most attention-grabbing poster was one showing photographs of a patient at onset. Every mail-shot included the project's web address.
This had a simple web address , was clear and easy to navigate, with instructions on how to take part in the trial and was regularly updated with information on the progress of the trial. The site was easily found with simple Google terms.
In order to heighten and maintain the profile of the study we contacted professional magazines, national press and radio. We were fortunate that a medical graduate and former sufferer who regularly works in a variety of media, Graeme Garden, offered to speak to media colleagues on our behalf to provide his insight into the condition. In all we had two professional magazines, several newspaper articles, a radio programme and a media website dealing with the topic during recruitment. We took advantage of two BMJ articles on Bell's palsy to respond with details of the study. All of these activities may have helped to keep the study in the eye of our target group for recruitment. Such activities did take several days in terms of planning, writing and interviews but could reasonably be fitted in around the general working of the project.
We took every opportunity to raise awareness and build the profile of the study including conference presentations and workshops. However, these exercises connected with relatively few recruiting general practitioners and emergency room staff, and it is hard to know what impact if any they had on recruitment.
Regular feedback on the trial
In the quarterly mailings to general practitioners organised by the SPPIRe nodes we took the opportunity both to let them know that the study was still ongoing and the current recruiting status.
Following negotiation with primary care Research and Development departments, general practices were offered £51 for recruiting patients into the trial and for any ongoing explanation and care that might be required. In rare cases this fee was intended additionally to cover the situation where a patient preferred to use their general practitioner surgery rather than their home for the researcher's visits.
Out-of-hours recruitment and follow-up
With a condition as alarming as Bell's Palsy, it is likely that sufferers will seek attention soon after onset so we anticipated that presentations were likely to occur out of normal working hours. Also treatment had to be started within a relatively short time window. It was essential therefore to have a system to capture this. Additionally as many sufferers would quickly return to work follow-ups were scheduled at convenient times. The research team was therefore prepared to both recruit and follow-up cases outside of normal working hours. Of the cases that were recruited 28% randomised outside normal working hours (5% NHS24, 7% accident and emergency department, 16% out of hours general practitioner). With regard to subsequent follow-ups 10% were carried out at weekends and 22% were carried out before 8.30 AM or after 6.30 PM on weekdays.