This study attempted to elucidate the meaning of hope as it occurred in the lived experience of seven homeless people residing in a cold weather shelter and to identify strategies that are used to maintain hope. It adopted a hermeneutic, phenomenological method and produced an emerging theory comprised of five key themes. These were: expectancy with hope experienced as future imagined reality, a way out of present difficulties and concretely linked to having one's own home; connectedness perceived as a meaningful relationship between self and others (family, friends and the shelter) which sustained hope; view from the street experienced as a dichotomy between hope/joy and hopelessness/despair; emotionalism expressed as a barrage of varied and often conflicting emotional states which either strengthened or depleted hope and brokenness described as a feeling of being worn down and drained of energy due to the constant struggle for survival in harsh conditions on the street, which weakened hope. The study provided a clearer understanding of the meaning of hope from a homeless person's point of view. At the end it ponders the possible implications for primary health care nursing.

In England & Wales at least 140 000 people present at hospital annually following an episode of deliberate self-harm (DSH), and 12% to 16% make a repeat attempt. The time of greatest risk of repetition is within three months of an attempt. Around 50% of these patients visit their GP in the four to eight weeks after an episode of DSH. Guidelines for the aftercare of patients who have self-harmed in general practice may reduce repetition rates and could possibly have an impact on suicide rates. The aim of this study was to develop a clinical practice guideline for the aftercare of DSH patients in general practice. A modified Delphi technique was used with a consensus group consisting of GPs with an interest in mental health, psychiatrists, a psychologist, a specialist nurse, a voluntary organization and patients with a history of self-harm. The template for the guidelines was based on ICD-10 PHC. Consensus was reached on all points after two rounds of the Delphi and the guidelines were formatted to facilitate their use in the GP consultation. There is a difficulty developing guidelines for common problems where the evidence base is weak. The use of formal consensus methods can be employed but it must be acknowledged that the validity of the resulting guideline is related to the composition of the consensus group, the identification and analysis of any relevant evidence and the method of guideline dissemination. The guidelines are being evaluated in a randomized controlled trial of a general practice based intervention to reduce repeat deliberate self-harm.

Objective: The care of patients with chronic diseases such as rheumatoid arthritis is increasingly shared between primary health care and hospital specialist teams. Studies that have informed guidelines for the shared care of patients with rheumatoid arthritis have not included patients' perceptions and preferences. The objective of this study was to explore the experiences and views of patients with rheumatoid arthritis concerning the clinical care they had received from general practitioners (GPs) and specialist hospital doctors.

Design: Semi-structured interviews analysed using grounded theory techniques.

Setting and Participants: A purposeful sample of twelve people receiving clinical care from specialist rheumatologists and GPs. All participants had received a diagnosis of rheumatoid arthritis at least two years previously.

Results: Most participants valued regular review by rheumatologists highly, and looked to them for help with all aspects of their arthritis care. They felt that specialists had greater knowledge concerning disease management than GPs, but both groups of doctors were similarly empathic. The GPs' role was perceived to be important mainly in early diagnosis and first referral to the hospital specialist but less so in the provision of continuing care or help with psychosocial issues. Participants valued the accessibility of GP services. Advice from any source about aids and welfare benefits was often haphazard.

Conclusions: People with rheumatoid arthritis prefer to have regular contact with a rheumatologist rather than obtaining care for their arthritis mainly from their GP. This has implications for the move from secondary to primary care.

There is an emphasis on developing partnerships throughout the Department of Health and other Government departments. Health Action Zones (HAZs) highlight the need for flexible working across boundaries at a local level. How to evaluate these partnerships in a manner that is practicable, pragmatic, straightforward for researchers and non-researchers alike is an issue that needs to be addressed. This paper assesses the potential of a community based evaluation tool – the Theories of Change Model – as an approach to evaluating partnerships. The model was applied to a very focused partnership between the Nottingham HAZ Evaluation Manager and the Local Co-ordinator of Trent Focus (an organisation funded by the NHSE Trent, to promote research and development in primary care). The aim was to provide an opportunity to portray the usefulness and limitations of implementing a theory based approach to ‘valuing’ primary care partnership working at a local level. The evaluation process itself was an important element of the formulation and implementation of the partnership. It helped to decide the aims and objectives of the partnership and proposed a theory as to why the partnership was worth investing in. At a minimum, if applied at the inception of a new partnership, the model was seen as a very useful planning tool. The process was very time consuming and to be most effective, needed the commitment from all key stakeholders involved in the partnership. This paper is an attempt to provide researchers/evaluators, in the widest sense, with a possible framework that would allow organizations to acknowledge, justify and address complex partnership working for health gain. This paper is of importance to anyone interested in defining and measuring desired processes and outcomes from partnership working.

Objective: To identify the barriers to successful discharge practices in a general hospital medical service.

Design: Focus groups with health professionals and in depth interviews with patients were used to identify and explore themes arising from the concept of a good discharge. Thematic analysis was undertaken to identify and link the concepts highlighted.

Subjects: Four focus groups (four to ten participants) and ten in depth interviews were conducted. Purposive sampling was used to capture a full range of views.

Main outcome measures: Themes arising from the focus groups and interviews were analysed to examine barriers to effective discharge practice.

Results: Five major themes emerged from the focus group data including; 1) Communication, 2) Teamwork and Roles, 3) The process of discharge and co-ordination 4) Resources, and 5) Time. Patients discussed their experiences, concerns and lack of knowledge, of the discharge process.

Conclusion: The barriers to influencing the discharge process were shown to be complex and interrelated. The way, in which teams work together is an important factor, which appears not to have been addressed in research into discharge interventions. No single strategy or intervention is likely to be successful in changing discharge practice. Future research to improve discharge should focus on combinations of strategies that target local barriers at the level of the individual, team and organization.

Since 1997, Labour Governments have championed partnership working as part of a commitment to develop a new public health agenda. Multidisciplinary and multiagency working have been placed at the heart of attempts to tackle widening health inequalities, with Primary Care Trusts (PCT) being placed at the forefront of a corporate approach to delivering improvements in individual, community and population well-being. However, observed practice in relation to public health collaboration has rarely met the challenge of past policy prescriptions. Furthermore, we have limited understanding of who is best placed to meet the challenge of securing public health partnerships within a primary care led National Health Service (NHS). This paper reviews the need for PCT involvement in partnership working, assesses the potential contribution primary care nurses can make to the co-ordinated delivery of the new public health agenda, and identifies key issues for policy and practice. It concludes that nurses have the opportunity to play a key role in the development of partnerships for improved public health at the PCT level. However, it also notes that the development of such functions will require an expansion of existing nursing roles, a willingness to take on a more overtly political role, and a deeper consideration of the constituents of successful collaborative action for improved public health.

This paper describes a study undertaken to define dimensions of antibiotic prescribing in selected nursing homes and to consider the factors which might have an impact on practice.

Increasing concerns about antibiotic resistance as a result of inappropriate prescribing was the impetus of the study. Poor interprofessional relationships and inadequate GP visiting arrangements were found to impact on prescribing and patient care. Lack of availability of local sensitivity patterns and inadequate use of the laboratory contribute to the problem. The paper draws conclusions from focus group findings and makes recommendations which could improve practice.

Aspirin is an effective means to prevent recurrence and death in patients with vascular disease. However, the extent to which patients are aware of this is not known. The objective of the study was to compare the use and knowledge of prophylactic aspirin between patients on repeat cardiovascular drug prescriptions and their matched controls. A cross-sectional survey of 600 patients was carried out in a group general practice. The subjects included 200 patients on repeat cardiovascular drug prescriptions (vascular group), and two age–sex matched groups: patients on other repeat prescriptions (nonvascular group) and patients not on repeat prescriptions (control group), sampled from the practice register. Use and knowledge of prophylactic aspirin were the main outcome measures. Aspirin knowledge was 72% in the vascular group; 53% in the nonvascular group, and 58% in the control group. Apart from patients who reported possible contra-indications to aspirin, 77% of patients with repeat cardiovascular drug prescriptions reported using aspirin regularly compared with 16% and 9% in the nonvascular and control groups, respectively. Amongst patients on repeat cardiovascular drug prescriptions, aspirin knowledge was the strongest predictor of aspirin use. To conclude, use of prophylactic aspirin in one practice was appropriate and had overcome the usual socio-demographic barriers to preventive activity. However, there were still significant numbers not using it. Increased usage in patients with vascular disease could be achieved by improving public knowledge of the benefits of prophylactic aspirin.

Antibiotic prescribing for acute otitis media is common and studies have failed to show significant short-term benefits for their use in the treatment of this condition. Antibiotic resistance is an escalating problem related to antibiotic use and the Department of Health has published guidelines advising that they are probably unnecessary in otitis media. The aims of this study were to primarily explore parents' ideas, concerns and experiences when consulting for otitis media in children. Secondly, to develop strategies that general practitioners can use to improve doctor–patient communication and the doctors' ability to negotiate management options acceptable to patients, taking into consideration current evidence-based guidelines. A qualitative research design using focus groups were employed. The study sample interviewed were parents of children. A total of 17 parents representing a range of ages and different socio-economic backgrounds attended the focus groups. Six major themes emerged from the analysis. These themes suggested that parents' were given little information and had a poor understanding of ear infections. They expected the general practitioner (GP) to primarily make a diagnosis followed by an explanation and discussion. Parents also wished to be reassured that their child was not suffering from anything more serious, in particular, meningitis. Most were happy not to have antibiotics prescribed and preferred the doctor to make the decision about the use of antibiotics. Parents were happy to consider seeing a practice nurse when their child presented with otitis media. The strategies recommended for general practitioners is to provide a diagnosis and reassure parents about meningitis and other long-term complications and to be aware that they may overestimate parents' expectations of a prescription. General practitioners should also be flexible in involving them in the decision making process.