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The article presents the summaries of papers on dermatology presented at the main plenary sessions. The National Health Service (NHS) Plan 2000 proposed the development of specialist general practitioners (GPs) to take referrals from other GPs in specialties including dermatology. The NHS Modernization Agency Action on Dermatology program funded pilot site studies of dermatology GPwSI, services and preliminary results were encouraging. By the end of 2005, all referrals from primary care will be performed electronically using a referral template. Currently only a proportion of referrals are electronic, allowing comparison with established paper referrals.

Background This paper presents insights into patient experiences of changes in workforce composition due to increasing deployment in general practice of practitioners from a number of different professional disciplines (skill mix). We explore these experiences via the concept of 'patient illness work'; how a patient's capacity for action is linked to the work arising from healthcare. Methods We conducted four focus group interviews with Patient Participation Group members across participating English general practitioner practices. Thematic analysis and a theoretical lens of illness work were used to explore patients' attempts to understand and navigate new structures, roles and ways to access healthcare. Results Participants' lack of knowledge about incoming practitioners constrained their agency in accessing primary care. They reported both increased and burdensome illness work as they were given responsibility for navigating and understanding new systems of access while simultaneously understanding new practitioner roles. Conclusions While skill mix changes were not resisted by patients, they were keen to improve their agency in capacity to access, by being better informed about newer practitioners to accept and trust them. Some patients require support to navigate change, especially where new systems demand specific capacities such as technological skills and adaptation to unfamiliar practitioners. [ABSTRACT FROM AUTHOR]

Currently in the UK and Ireland, after a hip fracture most patients do not receive bone protection medication to reduce the risk of refracture. Yet randomised controlled trial data specifically examining patients with hip fracture have shown that intravenous zoledronate reduces refracture risk by a third. Despite this evidence, use of intravenous zoledronate is highly variable following a hip fracture; many hospitals are providing this treatment, whilst most are currently not. A range of clinical uncertainties, doubts over the evidence base and practical concerns are cited as reasons. This paper discusses these concerns and provides guidance from expert consensus, aiming to assist orthogeriatricians, pharmacists and health services managers establish local protocols to deliver this highly clinically and cost-effective treatment to patients before they leave hospital, in order to reduce costly re-fractures in this frail population. [ABSTRACT FROM AUTHOR]

Decision-makers in UK health and social care are routinely asked to draw on evidence of 'what works' when designing services and changing practice. However, this paper argues that too much focus to date has been placed on a narrow definition of what constitutes valid 'evidence' (and one that privileges particular approaches and voices over others) and a simplistic conception of the decision-making function. As a result, policy and practice have too often been dominated by medical and quantitative ways of knowing the world, with such research approaches assumed to be more valid than other forms of enquiry. In contrast, the paper calls for a more inclusive notion of 'knowledge-based practice', which draws on different types of research, the tacit knowledge of frontline practitioners and the lived experience of people using services. This, the paper argues, will lead to a more nuanced approach to 'the evidence' and -- ultimately -- to better and more integrated decisions. Against this background, the paper outlines a suggested research agenda for those seeking to develop decision-making within these areas. [ABSTRACT FROM AUTHOR]

Modern slavery is crime of extreme exploitation. It includes the use of coercion, force, deception and abuse of vulnerability for such purposes as trafficking, labour, sexual exploitation, forced criminal activity and domestic servitude. It is a topic of growing interest in the UK and beyond as it has emerged as an issue of considerable scale and consequence. To date, debates have been dominated by a law enforcement perspective. Less apparent has been an articulation of the implications of modern slavery for the health sector. This is despite growing evidence of the dire physical and mental health consequences for survivors. This paper addresses this gap by examining a series of issues relevant to UK health systems. After describing what is modern slavery and the nature of the problem, we identify how the health sector has responded to date. We then articulate how health services and public health can more coherently and systematically meet the challenges of modern slavery through policy and practice. Finally, we present a call for the health sector to position itself as a central to the wellbeing of survivors and as a fundamental ally in modern slavery prevention. [ABSTRACT FROM AUTHOR]

This paper uses the recent history of marketization and privatization in the UK National Health Service as a case study through which to explore the relationship between health-care organization and health-care goods. Phases and processes of marketization are briefly reviewed in order to show that, although the scope of both marketization and privatization reforms have, until recently, been very heavily circumscribed (and can only be understood in the context of the rise of managerialism), they have nonetheless had a major impact on the "value field" of UK health services. The second half of the paper draws upon the concerns of the critics of market-style reforms to set out and explore the ways in which organizational reform and the shifts in institutional norms consequent upon it construct health-care goods and argues that the investigation of this organization-goods axis ought to have a central place in health-care ethics. [ABSTRACT FROM AUTHOR]

This paper explores the need for better links between research and practice in relation to work with children and health inequalities. Despite continuing discussion about the need to improve dissemination of research activity in general, study of this area remains largely neglected. As a result, despite the rhetoric, the research and practice gap continues to exist. An attempt to remedy this was undertaken through the support of a user fellowship as part of the UK Economic and Social Research Council Health Variations Programme. The paper describes a number of activities that were undertaken during the fellowship, and discusses the implications of these for improving connections and minimizing the research and practice 'gap'. It argues that a need exists for researchers to develop innovative dissemination strategies and suggests that potential exists for an interactive model of dissemination. Such a model implies a more active role for users of research in the shaping of research agendas. [ABSTRACT FROM AUTHOR]

This paper is based on the External Audit-Ethnically Sensitive Practice (EA-ESP) project which was undertaken within six primary and secondary health care settings. This project is used as an example of how the clinical audit model can be used to monitor and review health and social work practice in the UK. The paper examines quality, compares approaches to evaluation, and suggests that audit can be a useful tool for agencies in obtaining user and staff views on many areas of practice but in particular on equal opportunities, anti-racism and anti-oppression. Attention is drawn to audit within broader evaluative and review approaches already employed by social work academics and practitioners. The issue of quality and how it can be measured is considered through an analytical comparison with approaches which employ action research and other evaluative means in the process of review. Audit is explored in the context of a growing need for the development of monitoring and review systems which provide evidence to support and develop professionalism within social work. External audit is explored and compared to internal audit. Finally, the need for the development of quality services in anti-racist and anti-oppressive work is highlighted and it is suggested that audit can be a cost-effective and efficient way of achieving this. [ABSTRACT FROM AUTHOR]

This article examines the extent to which the refusals of British conscientious objectors (COs) to fight during the First World War were pathologised through the lens of physical and mental health, and the ways in which such a pathology impacted their treatment in penal establishments. It argues that the government compromised the physical as well as the mental health of absolutist COs. The article also analyses the effects of the state's pathologising efforts upon objectors, and the methods through which the physical bodies of COs were utilised against, or annexed by, the authorities. Drawing on Cabinet Minutes, Prison Commissioner Reports, and COs' personal letters and memoir materials, it suggests that the case of COs offers an interesting comparison with the complex ways in which the phenomenon of 'shell-shock' was beginning to be understood in both somatic and psychological terms. [ABSTRACT FROM AUTHOR]

This paper explores health care in one Lancashire working-class community during the golden age of biomedicine. Both the biomedical and alternative medical services available in the town are examined. The services provided by one community ‘wisewoman’; ranging from the respectable, such as midwifery, to the illegal, including abortion are a key focus. This case study is used as a way to engage with a larger theme in the history of medicine, namely, the tension between orthodox biomedical science and more traditional and alternative approaches to health care. The ways in which during the early twentieth century, traditional healing networks found ways to survive despite the increasing power and reach of biomedicine are demonstrated. This evidence points to the complexity of working-class attitudes to medical authority and practice during the period in question. In Rochdale, the working-class community remained slow to accept the orthodox challenge to traditional beliefs concerning health and healing. [ABSTRACT FROM PUBLISHER]

Introduction: The cost of treatment and follow-up of cancer patients in the UK is substantial. In a budget-constrained system such as the NHS, it is necessary to consider the cost-effectiveness of the range of management strategies at different points on cancer patients' care pathways to ensure that they provide adequate value for money. Sources of data: We conducted a systematic literature review to explore the cost-effectiveness of follow-up strategies of patients previously treated for cancer with the aim of informing UK policy. All papers that were considered to be economic evaluations in the subject areas described above were extracted. Areas of agreement: The existing literature suggests that intensive followup of patients with colorectal disease is likely to be cost-effective, but the opposite holds for breast cancer. Areas of controversy: Interventions and strategies for follow-up in cancer patients were variable across type of cancer and setting. Drawing general conclusions about the cost-effectiveness of these interventions/strategies is difficult. Growing points: The search identified 2036 references but applying inclusion/exclusion criteria a total of 44 articles were included in the analysis. Breast cancer was the most common (n = 11) cancer type followed by colorectal (n = 10) cancer. In general, there were relatively few studies of cost-effectiveness of follow-up that could influence UK guidance. Where there was evidence, in the most part, NICE guidance broadly reflected this evidence. Areas timely to develop research: In terms of future research around the timing, frequency and composition of follow-ups, this is dependent on the type of cancer being considered. Nevertheless, across most cancers, the possibility of remote follow-up (or testing) by health professionals other than hospital consultants in other settings appears to warrant further work. [ABSTRACT FROM AUTHOR]

The scope of protection from harm and abuse is rapidly expanding, and practice frameworks have tended to transfer and adapt child protection procedures for the protection of other groups. However there has been little in-depth analysis of the theoretical perspectives that underlie interventions within particular fields and almost nothing across areas such as significant harm to children, elder abuse and domestic violence. Scant attention has been paid to different time periods and national contexts. This paper, which draws on material presented and discussed during an Economic and Social Research Council (ESRC) seminar series, adopts a lifespan approach to understanding harm and abuse and explores how this can reveal insights for a more generic understanding and practice in protection services. The paper provides varying social constructions and varying recognition of concepts of harm and abuse, not least by ‘victims’, who frequently reject that role. Examining responses to harm and abuse suggests that formal systems tend to assume clear ‘victims’ and ‘perpetrators’ and that service categories can be unhelpful as they may not reflect experiences or address the wider contexts in which these are embedded. The lifespan approach provides a means for comparing and contrasting issues raised within specific areas of need and service delivery. It is an orientation which raises new questions about understanding harm and abuse and helpful insights which have implications for both policy and practice. [ABSTRACT FROM PUBLISHER]

This paper reappraises the position of medical refugees in Britain between the 1930s and 1950s. Advocates of reforming British medicine in terms of its knowledge base and social provision emerged as strongly supportive of the medical refugees. By way of contrast, an élite in the British Medical Association attempted to exercise a controlling regime through the Home Office Advisory Committee. The effects of these divisions are gauged by reconstructing the complete spectrum of refugees as a total population. Applying this methodology of population reconstruction provides a corrective to the notion of a cohesive ‘medical establishment’ exercising rigid and discriminatory controls. [ABSTRACT FROM PUBLISHER]

This paper reviews the performance of the National Health Service under the Labour government of Tony Blair. It shows that there have been some dramatic increases in resources going into the service, but also that these do not seem to be delivering the improvements in activities that might have been expected. The paper argues that this is partly because of capacity constraints, but also because the mixture of organizational forms introduced by the government has resulted in misdirected and conflicting incentive structures for the key actors. [ABSTRACT FROM PUBLISHER]

Background and Objectives Understanding the influences of marginalized cultural and social identities as experienced by the African Caribbean diaspora within the context of dementia care is essential to minimize the gaps in current practice and policy in the health care setting. This study explores the impact of marginalized identities upon the meaning-making process, access to services and experience of care provisions through a scoping review and consultancy exercises with key stakeholders. Research Design Fourteen databases were searched using key terms. Primary studies in English, any year, study design, and country of origin were eligible. Titles, abstracts, and full texts were screened for inclusion and data were extracted in stages. Thematic analysis was performed and the findings were discussed in a series of consultation meetings with people with dementia, carers, and health care professionals in Manchester (United Kingdom) and Jamaica. Results The scoping review retrieved n = 1,989 research articles. Nineteen were included, most were qualitative (n = 14), 3 quantitative, and 2 mixed-method. The findings revealed limited insight into cultural and multiple individual identities in explaining conceptualization and service access. Consultation meetings confirmed these findings and highlighted differences in health care services and systems in the United Kingdom and Jamaica. Discussion and Implications This study suggests there is a complex interaction of sociocultural processes that marginalize African Caribbean persons in and across various national settings within the context of dementia care. The study highlights the importance of acknowledging and addressing how prevalent racialized- and class-based divides and related marginalized social locations are reflected in inequities in access to and use of dementia services. [ABSTRACT FROM AUTHOR]

Background: The fate of patients with chronic limb-threatening ischaemia undergoing revascularization or a primary amputation is unclear. The aim of this study was to assess the postoperative outcomes and post-procedural healthcare resource use/costs over 1 year after revascularization or a primary amputation for chronic limb-threatening ischaemia. Methods: The UK Kent Integrated Dataset, which links primary, community, and secondary care for 1.6 million people, was interrogated. All patients with a new diagnosis of chronic limb-threatening ischaemia undergoing revascularization or a major amputation between January 2016 and January 2019 (3 years) were identified. Postoperative events across all healthcare settings and post-procedure healthcare resource use were analysed over 1 year (until the end of 2019). Results: Overall, 4252 patients with a new diagnosis of chronic limb-threatening ischaemia were identified (65 per cent were male and the mean age was 73 years) between January 2016 and January 2019, of whom 579 (14 per cent) underwent an intervention (studied population); 296 (7 per cent) had an angioplasty, 75 (2 per cent) had bypass surgery, 141 (3 per cent) had a primary major lower limb amputation, 11 had a thrombo-embolectomy (0.3 per cent), and 56 had an endarterectomy (1.3 per cent). Readmissions (median of 2) were similar amongst different procedures within 1 year; bypass surgery was associated with more hospital appointments (median of 4 versus 2; P = 0.002). Patients undergoing a primary amputation had the highest number of cardiovascular events and 1-year mortality. In a linear regression model, index procedure type and Charlson co-morbidity index score were not predictors of appointments in primary/secondary care, community care visits, or readmissions after discharge. There were no statistically significant differences regarding post-procedural healthcare costs between procedures over 1 year. Conclusion: Revascularization is not associated with more hospital, primary/community care appointments or increased post-procedural healthcare costs over 1 year when compared with primary amputation, in people with chronic limb-threatening ischaemia. The aim of this study was to use routinely available data, linking community, primary, and secondary care, to assess the fate of patients undergoing a primary amputation or revascularization for chronic limb-threatening ischaemia. A revascularization strategy was not associated with higher costs or more postoperative healthcare appointments/events. [ABSTRACT FROM AUTHOR]

Despite an extensive evidence-base linking patterns of health with social determinants, recent public health policy has emphasized 'lifestyle diseases' and risk factor modification through behavioural and pharmacological intervention. In England, one manifestation of this has been the launch of the National Health Service Health Check programme. This paper reports findings from a small-scale qualitative study exploring experiences of engaging with a community-based health check in Knowsley, England, among 17 males and 19 females, with varying levels of risk for cardiovascular disease, who agreed to be contacted for the purpose of research at the time they underwent their check. Analysis revealed that the community-based nature of the checks provided opportunities for people to find out more about their health who might not otherwise have done so. Participants expressed a range of responses to the communication of the risk score, often revealing their confusion about its meaning. Changes in behaviour were identified, which participants connected with having had a check. This study raises questions about where, how and by whom health checks are delivered. Emphasis on health checks reflects the dominant individualist ideology, but this study also suggests that the process provides opportunities to enable and empower individuals, albeit in small ways. However, they remain a 'downstream' approach to public health, emphasizing medical and behavioural options for risk factor reduction rather than focussing on primary prevention through changes to the wider environment. Furthermore, although developed as a central feature of the UK's strategy to reduce health inequalities, health checks may widen them. [ABSTRACT FROM AUTHOR]

This paper studies the rising use of commercial medical assistance in early modern England. We measure individual consumption of medical and nursing services using a new dataset of debts at death between ca. 1670 and ca. 1790. Levels of consumption of medical services were high and stable in London from the 1680s. However, we find rapid growth in the provinces, in both the likelihood of using medical assistance and the sums spent on it. The structure of medical services also shifted, with an increase in "general practice," particularly by apothecaries. The expansion in medical services diffused from London and was motivated by changing preferences, not wealth. [ABSTRACT FROM AUTHOR]

This paper critically appraises the impact of the fragmentation of social care and social work. In particular, it examines the impact of splintered services and roles upon employees, service users and carers. The article concentrates upon three interrelated areas as part of a more general critique: first, reliability of services; second, relations with stakeholders; and, finally, the identity of employees. Despite differences across sectors and some largely collateral benefits, it is proposed that fragmentation has promoted inconsistent and unreliable services, the development of superficial relations with users and carers, and the loss of belonging and fractured identities of social care employees. Fragmentation regularly spoils professional identities and generates uncertainty amidst attempts to provide effective or reliable services. Indeed fragmented, disorganised or reductive provisions often generate new risks for the recipients of services. [ABSTRACT FROM AUTHOR]

An introduction to a paper published in this issue is presented, in which the editors mention services for older people, well-being in older people, and social care and housing for older people.

This paper investigates ways in which early modern English recipe collections constructed domestic medicine as broader and more powerful than is often appreciated. It shows that their compilers frequently selected recipes that promised to allow them to address a wide range of surgical ailments, to heal serious surgical conditions medicinally, and to avoid invasive interventions. Claims of remedies' virtues and stories of their successes imagined domestic medicine not only as a ‘first port of call’, but also as a potent counterpart to the work of practitioners; a last resort when practitioners had failed; and as an alternative to the knife. Using the writings of the surgeon John Woodall, it argues that surgeons were sensitive to the attitudes and preferences that motivated this collection. In seeking to discipline surgery, Woodall invoked the stereotypical gentleness of women's and domestic medicine in an effort to inculcate greater discernment in the use of violence. [ABSTRACT FROM PUBLISHER]

This paper examines the controversy surrounding the 1990 ‘Bristol Study’ as an indicator of developments in health activism and medical research in the United Kingdom in the subsequent decade, and as a case study of the motivations prompting people to become activists. Researchers investigating complementary therapies at the Bristol Cancer Help Centre found the therapies were associated with poorer survival prospects. However, the study was later shown to be seriously flawed. Stung by researchers' insensitivity, participants formed the Bristol Study Support Group (BSSG) to lobby for new funding and journal review procedures, and for participants to be co-investigators. Their agenda was symptomatic of activists increasingly seeking to become integral to research processes. Groups like the BSSG were helped by the New Labour party's interest in increasing civic involvement. However, activist participation was limited to research planning and administration, not results interpretation, suggesting that, while activists could influence the politics of 1990s medical research, research practice was immune. [ABSTRACT FROM PUBLISHER]

In the 1930s, Labour-dominated boroughs in central London embarked on an experiment in health and social transformation, at the centre of which was the construction of new health centres. The ‘all-in’ state-run health centres in Bermondsey, Finsbury, Southwark and Woolwich attempted to provide a comprehensive array of primary and preventive health services to working people and families, close to home or work. The centres shared a model of health with several principles in common: a notion of health improvement as linked to broader social transformation through the enhancement of urban space; a seamless integration of preventive and curative health services; care delivered by multidisciplinary teams; accessibility (spatially and economically); didactic education in self-care; and democratic local governance. This paper argues that these Labour borough councils, with the support of the London County Council after 1934, played a key role in ‘making real’ what had been an amorphous health centre ideal. [ABSTRACT FROM PUBLISHER]

The UK Coalition Government's Big Society policy has highlighted the value of the contribution that local people can make to well-being in their own communities, and plans to increase the contribution of community groups and third sector organizations in delivering services. This paper attempts to unpick some of the challenges to delivering health improvement interventions within the Big Society framework, and offers suggestions to reduce risk and preserve the value of the unique contribution that local people can make. The challenges identified are: supporting and developing skills in social enterprise; demonstrating effectiveness to commissioners; supporting local enterprise while mindful of inequality; guarding against the third sector losing its dynamism; using volunteers to replace or complement existing services. We conclude that the drive to increase community sustainability through the involvement of individuals is laudable, and responds to potential flaws in the welfare state. In order to protect the most vulnerable, and ensure equity, any change will take time and resources. More efficient ways of meeting society's needs must be sought, but we recommend that a stepwise, supported and appropriately evaluated approach is essential, and equity of provision across communities and organizations must be a primary concern. [ABSTRACT FROM AUTHOR]

Background: Outpatient and home parenteral antimicrobial therapy (OHPAT) is becoming increasingly commonplace in the UK, enabling those patients who would previously have been obliged to remain in hospital for intravenous treatment to be managed as outpatients or in their own homes. The OHPAT service at St Mary's Hospital, London, was established in 2004. This paper describes the types of infection, antimicrobial management and outcomes of patients referred to the service in the 3.5 years since its inception. [ABSTRACT FROM PUBLISHER]

The field of men's health has grown markedly over the past few decades. Increased activity specifically relating to men's health promotion in both Australia and the UK has been noted during this period. There has, however, been a reticence to critically examine men's health promotion work within a broader discourse relating to gender and gender relations. Indeed, the vast majority of health-related gender discussion to date has been focused on women's health experiences and their health practices. In this paper, we argue that grounding men's health within this broad gender discourse is important for building an evidence base in, and advancing, men's health promotion work at a range of levels. We specifically explore the research, practice and policy contexts relating to men's health in Australia and the UK, and describe the facilitators for, and barriers to, promoting men's health. We conclude by suggesting that a critical gender lens ought to be applied to current men's health promotion work and provide strategies for researchers, practitioners and policy makers to move towards this new frontier. [ABSTRACT FROM AUTHOR]

The concepts of 'partnership' and 'collaboration' have become amongst the most critical themes of 'new' Labour's social policy, particularly in respect of the delivery of health and social care. Although the terms are rarely precisely defined and hence have become problematic to analyse, in most understandings successful partnerships rely upon good systems of inter-professional collaboration. Through revisiting the extensive literature on the sociology of the professions, and the nature of interprofessional working, this paper will argue that effective collaborative working within health and social care is hard to achieve, particularly in the light of the vast differences in power and culture between various occupational groupings, and the inherently competitive nature of professions jostling for territory in the same areas of activity. It suggests that these issues cannot be resolved unless they are properly understood; a rhetorical appeal to the unmitigated benefits of 'partnership' alone will not produce more effective joint working. In addition, it notes that an appropriate role for social work in the context of partnership working has yet to be defined and proposes specific tasks and values that distinguish the social worker from other related professionals. [ABSTRACT FROM AUTHOR]

Background The Calman-Hine Report in England and Wales and the Campbell Report in Northern Ireland initiated a major reorganization of cancer services with the aim of improving the provision and delivery of care to cancer patients. In this paper, breast cancer patients diagnosed in 1996 and those diagnosed in 2001 are compared in order to examine the extent of service change in Northern Ireland. [ABSTRACT FROM PUBLISHER]

Background: Trials in surgery pose some special problems. This paper examines these with reference to 10 years of methodological research sponsored by the UK National Health Service Research and Development programme. Methods: Solutions to common problems encountered in surgical studies were considered, such as issues of blinding, dependence of results on technical skill and continued evolution of technology. Results: Numerous methodological developments are described, including the tracker trial concept in which trial design can be adapted to take account of technical developments and interim results. The governance of trials, solutions to ethical conundra and the rising importance of databases are also discussed. Conclusion: Like surgery itself, the methodological toolkit for evaluation of surgical procedures continues to evolve. The rules of statistical and scientific probity provide plenty of scope for imaginative design solutions for surgical trials. [ABSTRACT FROM AUTHOR]

This paper presents a critical exploration of the relationship between masculinity, sport and health by reporting findings from a wider qualitative study on lay men's and health professionals' beliefs about masculinity and preventative health care. Recent years have seen a surge of interest in relation to ‘men's health’. In particular, the Department of Health has highlighted how men's connection to sport, fitness and competitiveness can be used in health promotion initiatives to introduce facets of health. In contrast, work in the sociological and feminist literature has raised issues of concern about the relationship between men, masculinity and sport, particularly the links to aggression, misogyny and homophobia. It would appear then that a straightforward ‘men + sport = health’ relationship cannot be assumed. Focus groups and interviews with health professionals and men, including gay and disabled men, were undertaken to facilitate examination of the socially integrative meanings of sport and masculinity, and their relationship to health. Socializing, ‘macho’ culture and the body emerged as three main themes, and the implications of these empirical findings for health promotion are discussed. [ABSTRACT FROM AUTHOR]

For a variety of reasons, GPs are working more and more with unfamiliar patients. The proposed new British GP contract stipulates that in future patients will register with a practice, rather than with a named GP and a recent new definition of general practice did not mention continuing care. There has been persistent confusion about the definition of continuity of care. Evidence for the benefit of patients usually seeing the same doctor is still limited. In this paper we describe some discrete elements of continuity, emphasize the importance of interpersonal continuity and suggest how this may work. The contributions of informational continuity (especially good records) and of excellent consulting skills are put in context. We conclude that further evidence is needed to demonstrate the added value of interpersonal continuity in general practice and that this needs a clear theoretical basis. We propose that such a theory will define the concept of multi-dimensional diagnosis as the key strength of our discipline and that continuity, especially interpersonal continuity, is an important factor in achieving this economically and in a way which satisfies both patients and professionals. [ABSTRACT FROM AUTHOR]

Background This paper examines recent trends in inequalities in psychological distress associated with the provision of unpaid care by those who look after frail older people and younger disabled adults and children. Caring activities intensified during the 1990s, associated with increasing amounts of time devoted to the more demanding types of care and to those relationships that typically make heavy demands on the carer. Heavy involvement in caregiving is often associated with symptoms of anxiety and distress, and the intensification of care may increase rates of distress in carers relative to that in non-carers. [ABSTRACT FROM PUBLISHER]

Health impact assessment (HIA) has many advocates for its use to identify and optimize the health effects of non‐healthcare interventions. It is an assessment of the health effects, positive and negative, of a project, programme, or policy. Expertise developed in the United Kingdom from a realization that health impacts are often overlooked during the planning stages of development projects but prior planning can avoid detrimental effects. Considering health impacts is now recommended in all continents; the focus has moved from less to more developed countries and upstream from projects to policies. Health impact assessment shares certain concepts and methods with risk assessment, environmental impact assessment, strategic environmental assessment, social impact assessment, and economic assessments. This paper describes the development of health impact assessment and its relation to these other forms of impact assessment. [ABSTRACT FROM PUBLISHER]

Over recent decades, a great deal of effort has been devoted towards developing instruments that can be used to elicit health state values. All of these instruments are conceptually very different from one another and all suffer from serious inherent biases. In this paper I outline the conceptual foundations and empirical limitations of the three principal health state value elicitation instruments. Given that the conceptual parameters internalized within an instrument influence the elicited health state values, I argue that it is necessary to attain a broad agreement on what the appropriate parameters ought to be. When the appropriate conceptual parameters have been identified we will be in a position to develop the methodology of a single standardized instrument. [ABSTRACT FROM PUBLISHER]

Although there are no traditional markets and money prices in the public sector, consumers and providers may respond to signals of organisational performance. We present a simple dynamic model of the demand and supply for elective surgery in the UK National Health Service in which waiting time acts as the prime indicator of performance. The model is tested using a panel of quarterly data for 123 English health authorities over an eight-year period. We find that supply is increasing and demand is decreasing in measures of the previous period waiting time. The results imply that health care systems which are rationed by waiting do respond to indicators of waiting times. The paper adds to the small but consistent body of research which demonstrates that public sector systems respond to important aspects of reported performance. [ABSTRACT FROM AUTHOR]

Background. The White Paper The new NHS, modern, dependable gave the strategic lead at the local level in the new National Health Service to Health Authorities (Boards in Scotland and Northern Ireland). They are expected to lead the development of strategies that will identify the health needs of local people and what has to be done to meet them. These Health Improvement Programmes (HImPs) will be the local strategy for improving health and health care and the means to achieve national targets for each Health Authority or Board area. [ABSTRACT FROM PUBLISHER]

There has been substantial investment by governments and charities in the UK in the development, diffusion and evaluation of innovative practice models and systems to safeguard and support vulnerable children, young people and families. However, understandings of the processes of innovation within the sector are still at a relatively early stage—for example, in relation to what might be expected or planned for at each stage of an innovation journey. As a result, best use may not always be made of opportunities to address deficiencies in provision. To inform this knowledge gap, the literature was reviewed regarding innovation processes and trajectories within children's social care (statutory and voluntary settings) and within the field of social innovation more widely. Ten modellings of the stages of innovation were identified and synthesised into a directional map of six stages that might be commonly expected: mobilising, designing, developing, integrating, growing and system change. This trajectory framework poses key questions for innovators to consider at each stage to inform planning and determine if, when and how an innovation should progress further. [ABSTRACT FROM AUTHOR]

Background In Europe, more than 15 million people live with heart failure (HF). It imposes an enormous social, organizational and economic burden. As a reaction to impending impact on healthcare provision, different country-specific structures for HF-care have been established. The aim of this report is to provide an overview and compare the HF-care approaches of Germany, Ireland, the Netherlands and the UK, and to open the possibility of learning from each other's experience. Methods A mixed methods approach was implemented that included a literature analysis, interviews and questionnaires with HF-patients and caregivers, and expert interviews with representatives from healthcare, health service research and medical informatics. Results The models of HF-care in all countries analyzed are based on the European Society of Cardiology guidelines for diagnosis and treatment of HF. Even though the HF-models differed in design and implementation in practice, key challenges were similar: (i) unequal distribution of care between urban and rural areas, (ii) long waiting times, (iii) unequal access to and provision of healthcare services, (iv) information and communication gaps and (v) inadequate implementation and financing of digital applications. Conclusion Although promising approaches exist to structure and improve HF-care, across the four countries, implementation was reluctant to embrace novel methods. A lack of financial resources and insufficient digitalization making it difficult to adopt new concepts. Integration of HF-nurses seems to be an effective way of improving current models of HF-care. Digital solutions offer further opportunities to overcome communication and coordination gaps and to strengthen self-management skills. [ABSTRACT FROM AUTHOR]

Clinical knowledge and experience, and demographic changes, indicated the need to ensure provision of adequate ‘psychogeriatric’ services to provide treatment for mentally ill older people (generally over 65 years). Various factors influenced the provision of these services, including politics, economics and stereotypical negative attitudes towards older people. Clinicians successfully led service developments, often unsupported by central government and local health authorities, despite benefits being noted in the localities where services were established. In 1989, services were available to most of the population of England and the Department of Health officially recognised psychogeriatrics as a medical specialty. [ABSTRACT FROM AUTHOR]

The speciality, Public Health Medicine (PHM), was developed in response to political and health realities in pre-apartheid South Africa (SA), following the lead of the discipline in Britain, SA's previous coloniser. This article describes a 47-year journey from its origins as Community Health through to current practice, based on reviews of archival material, databases of institutional stakeholders involved in trainee education and our own experiences. Embedded throughout PHM's history are tensions between colonial forms of public health education and practice and resistance to these. As found in complementary SA research, and globally, this review shows that concerns about unclear roles, inadequate career paths and professional boundaries have preoccupied and are innate to the speciality. To be institutionalised more definitively in SA, PHM needs to demonstrate its value as a key resource for the functioning of SA's health system and thus improve the health status of her population. [ABSTRACT FROM AUTHOR]

Over the course of a lifetime, the risk of experiencing multiple chronic conditions (multimorbidity) increases, necessitating complex healthcare regimens. Healthcare that manages these requirements in an integrated way has been shown to be more effective than services that address specific diseases individually. One such chronic condition that often accompanies ageing is hearing loss and related symptoms, such as tinnitus. Hearing loss is not only highly prevalent in older adults but is also a leading cause of disability. Accumulating evidence demonstrates an interplay between auditory function and other aspects of health. For example, poorer cardiometabolic health profiles have been shown to increase the risk of hearing loss, which has been attributed to microvascular disruptions and neural degeneration. Additionally, hearing loss itself is associated with significantly increased odds of falling and is a potentially modifiable risk factor for cognitive decline and dementia. Such evidence warrants consideration of new possibilities—a new horizon—for hearing care to develop a holistic, person-centred approach that promotes the overall health and wellbeing of the individual, as well as for audiology to be part of an interdisciplinary healthcare service. To achieve this holistic goal, audiologists and other hearing healthcare professionals should be aware of the range of conditions associated with hearing loss and be ready to make health promoting recommendations and referrals to the appropriate health practitioners. Likewise, healthcare professionals not trained in audiology should be mindful of their patients' hearing status, screening for hearing loss or referring them to a hearing specialist as required. [ABSTRACT FROM AUTHOR]

This article presents information related to various papers published in the issue of "Health Education Research." It also presents the author's view on the evaluation of health education programmes. According to the author, health programmes would be significantly improved if process-oriented research was given a far more dominant role than at present and not regarded as some inferior substitute for outcome evaluation. The current emphasis in the Great Britain is the health education that demonstrate its effectiveness in casting a blight over existing research practices.

Background Medical tourism is a growing phenomenon. This review of the literature maps current knowledge and discusses findings with reference to the UK National Health Service (NHS). Methods Databases were systematically searched between September 2011 and March 2012 and 100 papers were selected for review. Results The literature shows specific types of tourism depending on treatment, eg, dentistry, cosmetic, or fertility. Patient motivation is complex and while further research is needed, factors beyond cost, including availability and distance, are clearly important. The provision of medical tourism varies. Volume of patient travel, economic cost and benefit were established for 13 countries. It highlights contributions not only to recipient countries' economies but also to a possible growth in health systems' inequities. Evidence suggests that UK patients travel abroad to receive treatment, complications arise and are treated by the NHS, indicating costs from medical travel for originating health systems. Conclusion It demonstrates the importance of quality standards and holds lessons as the UK and other EU countries implement the EU Directive on cross-border care. Lifting the private-patient-cap for NHS hospitals increases potential for growth in inbound medical tourism; yet no research exists on this. Research is required on volume, cost, patient motivation, industry, and on long-term health outcomes in medical tourists. [ABSTRACT FROM AUTHOR]

Objective To explore the views of general practitioners (GPs) on the feasibility of collecting supporting information for the Royal College of General Practitioners (RCGP) revalidation portfolio and mapping of this evidence to the General Medical Practice framework for proposed UK medical re-licensing. Design Cross sectional study with a questionnaire. Setting One inner city and one mixed urban/rural primary care organisation in the West Midlands, England and one rural primary care organisation in Wales. Participants 51/69 GPs who submitted a revalidation portfolio from November 2009 to February 2010. Results The majority of GPs considered the majority of work based supporting information was feasible to collect within a 5 year revalidation cycle; most concerns were expressed about providing evidence for extended practice, learning credits, and patient satisfaction and colleague feedback surveys (59%, 63%, 72%, and 77%, respectively, of GPs considered it feasible to collect this evidence) due to workload time constraints and lack of automatic access to evidence from others, which differed by GP work role. Two-thirds of participants (65%) stated that the submission of a portfolio of evidence was a feasible component of GP revalidation, reporting reservations on the appropriateness of patient and colleague feedback surveys and extended practice (55%, 57%, and 59% respectively) to provide objective evidence. GPs requested further clarity on the evidence mapping process. Conclusion Overall, GPs reported a positive response to the RCGP revalidation proposals. Concerns were focused on collecting the newer types of supporting information and the ability of GPs non-principals to collect this evidence. GP revalidation training and preparation is required. [ABSTRACT FROM AUTHOR]

Abstract: Background: Inflammatory bowel disease (IBD), a paradigm of chronic illness, requires for its safe clinical management ready access to complete information, not always possible using paper records. Aim: To develop an IBD database (DB) for both individual patient management and collating information across centres. Methods: Access® based, with a minimum dataset. Results: Prospectively collected data for 11,432 patients from 21 centres. Profile Diagnosis: Ulcerative colitis (UC) 56%, Crohn''s disease (CD) 40%, indeterminate colitis 4%. M:F ratio: UC 1.08:1, CD 0.72:1. Median age at diagnosis: UC 39, CD 30years. Operated: UC 16%, CD 47%. Thiopurine use: UC 16%, CD 29%. IBD related mortality: 0.74%. Discussion: A snapshot of this large IBD cohort shows the disease profile across the UK is similar to other large series. Unexpected gaps, sometimes large emerged (e.g. data on smoking and immunosuppression) highlighting the need for clear definition, consistency and completeness of data collection. Clinical management is made easier by the ‘at a glance’ summary, automated clinic letters, and facility for monitoring and audit, but the time required limited its ‘real-time’ use. Conclusion: Our experience shows it is possible to collect data from centres across the country which truly reflects clinical practice. We have learned as much from the process itself as from the data, principally, information needs to be well defined, validated at entry, and updated at every visit, a time consuming sequence which we had underestimated. Our lessons learned may help inform the development of a national database, and support national IBD standards and audit. [Copyright &y& Elsevier]

When long voyages in sailing vessels were commonplace, scurvy was a major health hazard in mariners of all nations. The observations of James Lind (1716-94) and others indicated that citrus fruits had both a preventive and curative role in this disease. In the light of this work, by 1800 the disease had been virtually eliminated from Britain's Royal Navy. However, it continued in the merchant navies of all nations until the latter half of the 19th century. In 1867, the Merchant Shipping Amendment Act was passed by the British Parliament largely as a result of a concerted effort by the Seamen's Hospital Society (SHS), one of whose physicians, Harry Leach (1836-79) was the major proselytiser for improved conditions in the merchant service. Examination of the SHS records before and after this event demonstrate a marked reduction in the prevalence of scurvy in the Port of London. Although other factors-such as the introduction of steam ships, which resulted in faster voyages-were clearly important, the compulsory administration of genuine lime juice under supervision in the merchant service seems to have exerted a significant effect. [ABSTRACT FROM AUTHOR]

Objective Base of thumb OA (BTOA) is a common age-related disease that has a significant negative impact on quality of life, while little is known about the structure and pathways of interface services. Our aim was to assess disease burden, referral pathways, service structure and management pathways in UK interface services. Methods A structured questionnaire was carried out with a participating clinician at each centre to detail the local guidelines and management of BTOA. Five patients referred with BTOA were prospectively identified in each of 32 UK interface centres. Results Most centres (72%) had a local guideline and a standardized treatment regime consisting of education (100%), joint protection (100%), range of motion exercises (84%), strengthening exercises (88%), splintage (100%) and use of assistive devices (78%). No centre routinely offered a steroid injection at the first appointment and no centre had a specific threshold for offering an injection. Injection delivery was variable. Most patients had not been referred previously (82%). Most patients used analgesia (72%), but a minority of patients had been treated with a splint (46%), therapy (43%) and steroid injection (27%) prior to their latest attendance. Conclusion Most BTOA patients newly referred to interface services have been treated with analgesics and have not received comprehensive multimodal intervention. The management of BTOA at interface services is standardized in terms of education, splintage and therapy. However, there is a lack of standardization in terms of both the threshold for, timing of and mode of delivery of injection therapy. [ABSTRACT FROM AUTHOR]

Cardiac nursing takes place within various spheres of health care, reaching into primary, secondary and tertiary care within theses, cardiac expertise falls within four domains: health promotion, cardiac prevention and rehabilitation, acute, chronic and episodic care and palliative care. This paper sets out the possibility for a staged development of the cardiac nurse, which could promote homogeneity in role, skill and practice. A framework ('Expert Cardiac Nurse Pathway') for the United Kingdom, is proposed here, and views on its usefulness throughout Europe are sought. [ABSTRACT FROM AUTHOR]

Cancer registries are a vital source of information on cancer epidemiology and cancer services. Their role has changed dramatically over the past 15 years. A number of factors will affect their future role, including health service changes, information technology, development of clinical datasets and greater demand for both health service and public information. The potential of cancer registration needs to be realized by clinicians and health authorities: how they can use the data, its limitations, and how they can support and influence it through this period of change. A strategic direction is needed so that cancer registries develop into a dynamic, interactive source of knowledge for the twenty-first century. [ABSTRACT FROM PUBLISHER]