The aim of this study was to improve clinical management through rationalization of repeat prescribing in an inner-city practice with a high percentage of older adults with extensive comorbidity through systematic review and cost containment. Outcome measures were based on an analysis of PACT data for level and cost of prescribing before and after the systematic reviews, reported patient and staff satisfaction with changes and the identification of drug interactions. The formalization of a 28-day prescribing cycle and systematic review every 6 months was almost universally acceptable to patients and staff. The systematic review led to a decrease in prescribing costs of 12% over 2 years. The number and cost of wound dressings decreased by almost 50%. The prescribing of inappropriate medications, over-the-counter drugs, benzodiazepines and combinations of drugs that interacted was reduced. The study demonstrates that monitoring and rationalization of repeat prescribing can reduce costs and improve quality of care. In addition, increased surveillance on the part of the reception staff improved communication both between members of staff and between members of staff and patients. This led to increased confidence in repeat prescribing among all staff.

The objectives of this study were to identify the variation in primary care provision in primary care groups (PCGs), to describe the developmental challenges that they face, and to show where investment in primary care should be targeted. Face-to-face semi-structured interviews and postal questionnaires were used. The setting was a 15% (n = 72) random sample of PCGs in England, stratified by NHS region, and the study subjects were PCG Chief Officers, Chairs and health authority PCG leads, as well as PCG board members. In total, 21 PCGs (31%) reported no GP recruitment and retention problems and anticipated none in the next 5 years, but 13 PCGs (19%) had major problems. A total of 13 PCGs (19%) had no problems with staff shortages in general. Problems with access were often confined to particular areas or practices. Fundholding services that were either discontinued or under threat included counselling, physiotherapy, complementary medicine and outreach clinics. A total of 22 PCGs (24%) planned to redistribute GMS cash-limited budgets to practices, but 44 PCGs (49%) had no such plans. In addressing poorly performing practices, the emphasis was against taking punitive action. It is concluded that PCGs have inherited diverse practice groupings which have not previously been united in a single organization. Most of them face staffing problems, but few have developed detailed workforce plans. The main priorities for investment are prescribing support, information, nursing staff and clinical governance. Many PCGs had discontinued fundholding services in the interests of equity. Without a committed workforce, and an infrastructure to support improved services, the goal of improved services for all will be difficult to achieve.

Exercise promotion schemes often fail to keep people exercising after the first few months. However, schemes that promote walking have been associated with longer-term adherence to exercise. Health Walks is a community-based exercise programme that emphasizes brisk walking activity. In the first year of an important new scheme in the Thames Valley, over 700 people took part. A survey was designed to determine the motivation of the participants and the benefits of the scheme. It was mailed to all of the participants in the scheme, of whom 48% replied. The evaluation found that 90% of participants said that they would continue walking on the scheme. In addition to physical fitness, the countryside and the social aspects of the walks were important motivating factors. The majority of the participants were women, in higher social classes and over 50 years of age, indicating the efficacy of this type of activity for older participants. The average number of walks taken each month was only three, yet participants perceived that there were health benefits. This may be due to the additional exercise which participants engaged in outside the organized scheme. Over half of the participants said that they were doing more walking, in addition to the Health Walks, and relied on their car less for short journeys. Primary care groups and trusts only need to provide minimal support to develop and co-ordinate walking schemes, in contrast to traditional exercise prescription schemes. Further research is needed to examine whether ‘walking for health’ schemes encourage people to adopt healthy lifestyles.

The purpose of this systematic overview was to assess the evidence for the effectiveness of public health nursing interventions when carried out by the strategy of home visiting of clients in the pre- and postnatal period. This is an update of a larger overview first collecting literature to 1993, then updated to the end of 1995, and now updated to 1998. The search of published and unpublished literature related to home visiting resulted in retrieval of a total of 211 articles, including 149 articles relevant to all age groups and including all interventions implemented by various professional and nonprofessional groups, where the intervention was considered to be within the scope of practice of public health nursing in Ontario. When the relevance was limited to interventions where the intervenor was known to be a nurse, and the clients were in the pre- or postnatal period, there were 20 articles with quality ratings of ‘strong’ or ‘moderate’ included in this update for the systematic review, and 8 additional articles in this update. There were no reported negative effects of home visiting in the 12 strong articles. Positive outcomes included improvement in children's mental development, mental health and physical growth, reduction in the mother's depression, improvement in maternal employment, education, nutrition and other health habits, and government cost saving. There is no proven impact on low birth weight, gestational age or neonatal morbidity or mortality, although the studies had inadequate sample sizes to demonstrate a difference in such relatively rare occurrences. As a delivery strategy, nurses visiting pre- and postnatal clients in the home can produce significant benefit, particularly with interventions of high intensity and with clients who are considered to be ‘at risk’ due to factors such as low income and low educational achievement.

Coronary heart disease is one of the biggest killers in the UK (Department of Health, 2000), with myocardial infarction accounting for the largest proportion of admissions to acute hospitals. In an era in which the speed of initiation of treatment is paramount in terms of achieving maximum potential benefit, the reasons for delay in seeking medical assistance remain poorly understood. Utilizing an interpretive approach informed by phenomenology, this exploratory study describes and analyses the process of help seeking in terms of the experience of patients from the onset of symptoms to seeking medical assistance. A total of 10 patients with confirmed myocardial infarction were interviewed within 6 days of hospital admission. From the data, it was possible to identify four headings under which to categorize factors which might influence delay in help seeking, namely symptoms, cognitive evaluation of symptoms, behavioural response to symptoms, and the influence of others present during the experience. A model of help seeking is proposed which explains the interrelationship between the categories, describes the patient experience, and suggests the process by which individuals may come to seek medical assistance. It is recommended that interventions that will influence cognitive evaluation of symptoms, and the behavioural response to symptoms, should be further explored in order to expedite the process of help seeking in acute myocardial infarction.

Employment initiatives for people who have experienced mental health problems offer development strategies that could be seen to match the philosophy and circumstances of mental health services in developing countries. Simple strategies to develop employment initiatives with a strong emphasis on self-reliance would appear to fit with current thinking on the promotion of mental health in developing countries (Üstün and Jenkins, 1998). The need for effective models to act as exemplars for programme development has been noted (Üstün and Jenkins, 1998). There are numerous models of employment rehabilitation detailed in the literature that might offer ideas for direction and development, but much of the research has been focused on Western European and North American models. Little attention has been paid to such schemes in developing countries, and therefore what is required is a project to identify emerging and innovative models of employment rehabilitation at a global level. The insights gained would assist in the development of guidelines for working with existing organizations in supporting and promoting good practice in developing countries. Development projects do not take place within a sociocultural vacuum, and indeed their success or failure is inextricably linked to social structures and social interaction. This paper sets out a research agenda for understanding and evaluating employment projects using the concept of ‘social capital’ as a framework.

Urinary incontinence is a common and debilitating problem. Its prevalence increases with advancing age, and heavy reliance on containment products results in high costs for community services, yet evidence exists that effective treatments can be provided in primary care. This quasi-experimental study compared the knowledge, practice and perceptions of their role by community nurses before (Phase 1) and after (Phase 3) the introduction of evidence-based clinical guidelines for continence care. Local guidelines were developed from nationally published guidelines and introduced into two localities of a community NHS trust (the intervention group) with a supporting educational programme during Phase 2. An audit of patient notes showed statistically significant improvements in assessment details recorded by the intervention group, and in the numbers of patients for whom a treatment plan was identified at Phase 3. Data collected from questionnaires, interviews and focus groups showed that the majority of community nurses in both the intervention and control groups believed that their role should involve the assessment and first-line treatment/management of urinary incontinence. However, limitations in their knowledge of continence care and difficulties in enhancing that knowledge base were identified. Three themes relating to role perceptions emerged from interviews, namely assessment skills, patient capacity and role restrictions. The study raises questions about what may constitute realistic expectations of role development for community nurses. Greater development of multidisciplinary teamworking, including enhancement of the link nurse role to provide co-ordination in continence care, could be a way forward.

This paper is based on a qualitative study that was designed to investigate patients' experiences of day case surgery and its outcomes. The study was a part requirement of a Masters course in Community Care Studies, and was conducted in a Welsh Integrated Trust in 1997. A case-study approach employing semi-structured interviews was used. A total of 16 patients were interviewed (5 females and 11 males). Three of the males and all five females had varicose vein repair, and the other eight males had a hernia repair. The findings of the study were that although patients preferred the option of day care surgery and indicated that they would choose this in future, the information given to them and the postoperative care they received were largely inadequate. The interviews demonstrate that the communication between hospital and home care was often inadequate, and that some patients and carers experienced unforeseen difficulties and distress.

The development of integrated nursing teams consisting of district nurses, health visitors and practice nurses based in general practice is a widespread recent change in primary care. This development has been justified by promising to meet the need for a more cost-effective service, through a reduction of duplication in nursing work, improvements in the consistency of advice to patients and the provision of accessible and responsive patient care. This paper reports on topic-led qualitative interview data which were collected as part of a multimethod evaluation of various models of evolving integrated nursing teams. The overall aim of the evaluation was to explore progress towards integration by assessing nurse workload, team effectiveness and staff perception of change. The assessment of workload and team effectiveness is reported elsewhere. Staff perception of change was measured by analysis of interview data collected from 12 teams, 9 months after the implementation of nurse integration in two London health authorities in 1998. A total of 33 interviews explored nurses' interpretation of integrated nursing, their expectations relating to their changing roles and activities and their perceptions of key activities and outcomes relating to the implementation of integrated working. Although achievements were identified, including some changes in clinical practice, in general participants reported a partial and variable understanding of the concept of integrated teamwork, and there was uncertainty reported over changes in professional boundaries. A lack of ownership of the process of change and a dearth of team objectives were reported. Developments towards teambuilding were more common than strategic planning to reorganize the workload of the team collectively according to a local population-based agenda. To implement an integrated approach to primary care nursing, we suggest that there is a need for increased ownership and support for teambuilding strategies and skill development. If integrated nursing is to contribute to health improvements, it is necessary that participants agree on patient-focused objectives that orient towards a collective and locally targeted delivery of care.

This paper describes a pilot study to evaluate the effectiveness of a school-based parenting programme combining the use of both affective (related to feelings) and behavioural strategies. In this paper we describe the intervention, its evaluation and a summary of the quantitative information gathered. The three pre-eminent ways in which parents appeared to have benefited from this particular programme included (1) the support they received in their parenting role from other parents, including a mirroring of problems, (2) the regaining of a sense of control in the parental role, in part through an increase in their capacity to think about matters calmly, and also through the provision of new tools with which to do the job of parenting, and (3) an increased ability to empathize and identify with their children, and a better understanding of the factors which motivate children to behave in particular ways. The capacity to think about matters calmly and the ability to empathize and identify with children appeared to be important factors in the reduction of inappropriate and unhelpful parenting practices such as shouting and smacking. It is suggested that empathy in particular is central to effective parenting, and that these results support the suggestion that there is an important added benefit for parents from programmes which combine behavioural and affective strategies focusing on feelings, relationships within the family, and the parents' own experience of being parented. The limitations of the data are discussed with reference to its reliability and validity, and the need for further research using grounded theory with other groups of parents.