One barrier related to practice concerns about the validity of the researcher. Some concerns are understandable: for example, many practice managers refused to speak to the researcher until they had seen a letter on NHS North West-headed paper confirming the details of the project. However, once they had received the official NHS letter, many still refused to speak to the researcher after they had received letters, giving new reasons for their lack of participation such as a lack of time.
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Most reception staff and practice managers claimed that they had never received the letters or poster packs (image below) which were sent out about the project. If they did acknowledge receipt, however, many indicated that they believed it was not an important issue for their practice, and so had not paid much attention to them.
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Another significant barrier to engagement was attitude and, in particular, a lackof awareness or understanding about trans people. Very few practice managers understood what was meant by ‗transgender people‘ and were unwilling toengage in this research. This was extremely disappointing, given that the study aimed to support practices by providing up-to-date evidence about trans patients‘ needs.