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Between 1990 and the time of writing, 1,849 people have died in police custody or otherwise following police contact in England and Wales, with people from racially minoritised backgrounds over-represented in use of force and restraint related deaths. Drawing upon research undertaken by the authors, alongside bereaved families, this paper approaches these deaths as a form of institutional killings, surfacing the norms, cultures and values which systematically omit, obfuscate and mystify the violence of police action and inaction that eventuates these deaths. We contend that the police use of lethal force is therefore embedded and enmeshed within the processes, attitudes and behaviours of the police as an institution – both historically and in the present – which shapes how those killed encounter the police, how their deaths are (re)presented and how their bereaved families experience the processes which follow. The article argues that these processes follow a predictable pattern, with a similar lack of accountability also observable across other aspects of the criminal justice sector in relation to state deaths. [ABSTRACT FROM AUTHOR]

Objective: Blood tests are commonly used in primary care as a tool to aid diagnosis, and to offer reassurance and validation for patients. If doctors and patients do not have a shared understanding of the reasons for testing and the meaning of results, these aims may not be fulfilled. Shared decision‐making is widely advocated; yet, most research focusses on treatment decisions rather than diagnostic decisions. The aim of this study was to explore communication and decision‐making around diagnostic blood tests in primary care. Methods: Qualitative interviews were undertaken with patients and clinicians in UK primary care. Patients were interviewed at the time of blood testing, with a follow‐up interview after they received test results. Interviews with clinicians who requested the tests provided paired data to compare clinicians' and patients' expectations, experiences and understandings of tests. Interviews were analysed thematically using inductive and deductive coding. Results: A total of 80 interviews with 28 patients and 19 doctors were completed. We identified a mismatch in expectations and understanding of tests, which led to downstream consequences including frustration, anxiety and uncertainty for patients. There was no evidence of shared decision‐making in consultations preceding the decision to test. Doctors adopted a paternalistic approach, believing that they were protecting patients from anxiety. Conclusion: Patients were not able to develop informed preferences and did not perceive that choice is possible in decisions about testing, because they did not have sufficient information and a shared understanding of tests. A lack of shared understanding at the point of decision‐making led to downstream consequences when test results did not fulfil patients' expectations. Although shared decision‐making is recommended as best practice, it does not reflect the reality of doctors' and patients' accounts of testing; a broader model of shared understanding seems to be more relevant to the complexity of primary care diagnosis. Patient or Public Contribution: A patient and public involvement group comprising five participants with lived experience of blood testing in primary care met regularly during the study. They contributed to the development of the research objectives, planning recruitment methods, reviewing patient information leaflets and topic guides and also contributed to discussion of emerging themes at an early stage in the analysis process. [ABSTRACT FROM AUTHOR]

Background: Around 43% of emergency department (ED) attendances can be managed in general practice. Strategies to address this include directing appropriate patients to GPs working in or alongside EDs (GPED). Views of GPs choosing to work in GPED roles may inform planning and implementation of GPED services as well as wider general practice provision. Aim: To explore the experiences and motivations of GPs choosing to work in GPED services in England, and to identify factors that may support or hinder GPs working in GPED roles. Design and setting: Thematic analysis of 42 semi-structured interviews of GPs working in 10 GPED case sites across England. Method: Qualitative GP interviews from a mixed-methods study of GPs in GPED roles were thematically analysed in relation to research aims. Results: Four themes were generated: the 'pull' of a portfolio career; the 'push' of disillusionment with general practice; professional reciprocity; sustainability of GPED services and core general practice. Flexible, favourable working conditions, collaboration, and professional development made GPED an attractive workplace, often as part of a portfolio career or after retiring from core general practice. Working in GPED services was largely driven by disillusionment with core general practice. Both GPED and core general practice were thought to benefit from GPED GPs' skills. There were concerns about GPED sustainability and destabilisation of core general practice. Conclusion: GPED may extend the clinical careers of experienced GPs and support recruitment and retention of more recently qualified GPs. Despite some benefits, GPED may destabilise core general practice and increase pressure on both environments. [ABSTRACT FROM AUTHOR]

Background: Rates of blood testing in primary care are rising. Communicating blood test results generates significant workload for patients, GPs, and practice staff. Aim: To explore GPs' and patients' experience of systems of blood test communication. Design and setting: Qualitative interviews with patients and GPs in UK primary care in both urban and rural practices in the West of England. Method: A total of 28 patients and 19 GPs from six practices were recruited, with a range of socioeconomic and demographic characteristics. Patients were interviewed at two time points: a) at or soon after their blood test and b) after they had received their test results. The GPs who requested the tests were also interviewed (they could complete a maximum of two interviews about different patients). Eighty qualitative interviews were undertaken; 54 patient interviews and 26 GP interviews. Results: Methods of test result communication varied between doctors and were based on habits, unwritten heuristics, and personal preferences rather than protocols. Doctors expected patients to know how to access their test results. In contrast, patients were often uncertain and used guesswork to decide when and how to access their tests. Patients and doctors generally assumed that the other party would make contact, with potential implications for patient safety. Text messaging and online methods of communication have benefits, but were perceived by some patients as 'flippant' or 'confusing'. Delays and difficulties obtaining and interpreting test results can lead to anxiety and frustration for patients. Conclusion: Current systems of test result communication are complex and confusing, and mostly based on habits and routines rather than clear protocols. This has important implications for patient-centred care and patient safety. [ABSTRACT FROM AUTHOR]

Background: Systems to detect and minimise unwarranted variation in clinician practice are crucial to ensure increasingly multidisciplinary healthcare workforces are supported to practise to their full potential. Such systems are limited in English general practice settings, with implications for the efficiency and safety of care.Aim: To evaluate the benefits and limitations of a continuous, risk-based, consultation peer-review system used for 10 years by an out-of-hours general practice service in Bristol, UK.Design and Setting: A qualitative study in South West England.Method: Semi-structured interviews with intervention users (clinicians, peer reviewers, and clinical management), analysed by inductive thematic analysis and integrated into a programme theory.Results: Twenty clinicians were interviewed between September 2018 and January 2019. Interviewees indicated that the intervention supported clinician learning through improved peer feedback, highlighting learning needs and validating practice. It was compared favourably with existing structures of ensuring clinician competence, supporting standardisation of supervision, clinical governance, and learning culture. These benefits were potentially limited by intervention factors such as differential feedback quality between clinician groups, the efficiency of methods to identify learning needs, and limitations of assessments based on written clinical notes. Contextual factors such as clinician experience, motivation, and organisational learning culture influenced the perception of the intervention as a support or a stressor.Conclusion: The findings demonstrate the potential of continuous, risk-based, consultation peer review to support clinicians in an increasingly multidisciplinary general practice workforce to efficiently and safely practise to their full potential. The programme theory provides a theoretical basis to maximise the benefits and accommodate the potential limitations of this methodology. [ABSTRACT FROM AUTHOR]

In the context of a racialized moral panic around serious youth violence, we have seen a resurgence of calls to increase the presence of police in English schools in recent years. As well as a lack of popular and political opposition, there is a dearth of critical academic consideration of the placement of police in schools, and even less from a Critical Race Theory perspective. Given that teachers' perspectives are relatively absent from academic and popular debates, this paper draws upon data from semi-structured interviews with 24 secondary school teachers. In doing so, the paper argues that an increased police presence in school will impact negatively upon learning environments, create a culture of low expectations, criminalize young people, and feed a school-to-prison pipeline. Noting that racially minoritized students will be affected most harshly, the article provides empirical evidence to warn against the presence of police in schools. [ABSTRACT FROM AUTHOR]

Background: Continuity of care is a core principle of primary care related to improved patient outcomes and reduced healthcare costs. Evidence suggests continuity of care in England is declining.Aim: To confirm reports of declining continuity of care, explore differences in decline according to practice characteristics, and examine associations between practice populations or appointment provision and changes in continuity of care.Design and Setting: Longitudinal design on GP Patient Survey data reported annually in June or July from 2012 to 2017, whereby the unit of analysis was English general practices that existed in 2012.Method: Linear univariable and bivariable multilevel models were used to determine decline in average annual percentage of patients having a preferred GP and seeing this GP 'usually' according to practicelevel continuity of care, rural/urban location, and deprivation. Associations between percentage of patients having a preferred GP or seeing this GP usually and patients' experiences with the appointment system and practice population characteristics were modelled.Results: In 2012, 56.7% of patients had a preferred GP, which had declined by 9.4 percentage points (pp) (95% CI = -9.6 to -9.2) by 2017. Of patients with a preferred GP, 66.4% saw that GP 'usually' in 2012; this had declined by 9.7 pp (95% CI = -10.0 to -9.4) by 2017. This decline was visible in all types of practices, irrespective of baseline continuity, rural/urban location, or level of deprivation. At practice level, an increase over time in the percentage of patients reporting good overall experience of making appointments was associated with an increase in both the percentage of patients having a preferred GP and those able to see that GP 'usually'.Conclusion: Patients reported a steady decline in continuity of care over time, which should concern clinicians and policymakers. Ability of practices to offer patients a satisfactory appointment system could partly counteract this decline. [ABSTRACT FROM AUTHOR]

Background: The UK National Health Service Emergency Departments (ED) have recently faced increasing attendance rates. This study investigated associations of general practice and practice population characteristics with emergency care service attendance rates.Methods: A longitudinal design with practice-level measures of access and continuity of care, patient population demographics and use of emergency care for the financial years 2009/10 to 2012/13. The main outcome measures were self-referred discharged ED attendance rate, and combined self-referred discharged ED, self-referred Walk-in Centre (WiC) and self-referred Minor Injuries Unit (MIU) attendance rate per 1000 patients. Multilevel models estimated adjusted regression coefficients for relationships between patients' emergency attendance rates and patients' reported satisfaction with opening hours and waiting time at the practice, proportion of patients having a preferred GP, and use of WiC and MIU, both between practices, and within practices over time.Results: Practice characteristics associated with higher ED attendance rates included lower percentage of patients satisfied with waiting time (0.22 per 1% decrease, 95%CI 0.02 to 0.43) and lower percentage having a preferred GP (0.12 per 1% decrease, 95%CI 0.02 to 0.21). Population influences on higher attendance included more elderly, more female and more unemployed patients, and lower male life-expectancy and urban conurbation location. Net reductions in ED attendance were only seen for practices whose WiC or MIU attendance was high, above the 60th centile for MIU and above the 75th centile for WiC. Combined emergency care attendance fell over time if more patients within a practice were satisfied with opening hours (-0.26 per 1% increase, 95%CI -0.45 to -0.08).Conclusion: Practices with more patients satisfied with waiting time, having a preferred GP, and using MIU and WIC services, had lower ED attendance. Increases over time in attendance at MIUs, and patient satisfaction with opening hours was associated with reductions in service use. [ABSTRACT FROM AUTHOR]

Background: Around 1 million primary care consultations happen in England every day. Despite this, much of what happens in these visits remains a 'black box'.Aim: To create an archive of videotaped consultations and linked data based on a large sample of routine face-to-face doctor-patient consultations with consent for use in future research and training.Design and Setting: Cross-sectional study in 12 general practices in the west of England, UK.Method: Up to two GPs from each practice took part in the study. Over 1 to 2 days, consecutive patients were approached until up to 20 eligible patients for each GP consented to be videotaped. Eligible patients were aged ≥18 years, consulting on their own behalf, fluent in English, and with capacity to consent. GP questionnaires were self-administered. Patient questionnaires were self-administered immediately pre-consultation and post-consultation, and GPs filled in a checklist after each recording. A follow-up questionnaire was sent to patients after 10 days, and data about subsequent related consultations were collected from medical records 3 months later.Results: Of the 485 patients approached, 421 (86.8%) were eligible. Of the eligible patients, 334 (79.3%) consented to participate and 327 consultations with 23 GPs were successfully taped (307 video, 20 audio-only). Most patients (n = 300, 89.8%) consented to use by other researchers, subject to specific ethical approval.Conclusion: Most patients were willing to allow their consultations to be videotaped, and, with very few exceptions, to allow recordings and linked data to be stored in a data repository for future use for research and training. [ABSTRACT FROM AUTHOR]

Background: The ubiquitous use of communication technologies has led to an expectation that a similar approach should extend to health care. Despite considerable rhetoric about the need for general practices to offer alternatives to face-to-face consultations, such as telephone, email, and internet video consultations, the extent to which such technologies are actually used at present is unclear.Aim: The aim of the survey was to identify the frequency and range of ways in which general practices are providing (or planning) alternatives to face-to-face consultations.Design and Setting: A postal survey of practices around Bristol, Oxford, Lothian, the Highlands, and the Western Isles of Scotland.Method: A postal questionnaire survey was sent to each of the GPs and practice managers of 421 practices between January and May 2015.Results: A response was received from 319/421 practices (76%). Although the majority of the practices reported that they were conducting telephone consultations frequently (n = 211/318, 66%), fewer were implementing email consultations (n = 18/318, 6%), and most (n = 169/318, 53%) had no plans to introduce this. None were currently using internet video, and 86% (n = 273/318) had no plans to introduce internet video consultations. These findings were repeated in the reported use of alternatives to face-to-face consultations at an individual GP level. Optional free text responses were completed by 28% of responders, and offered an explanation for the (often perceived) barriers and incentives for implementation.Conclusion: Despite policy pressure to introduce consultations by email and internet video, there is a general reluctance among GPs to implement alternatives to face-to-face consultations. This identifies a substantial gap between rhetoric and reality in terms of the likelihood of certain alternatives (email, video) changing practice in the near future. [ABSTRACT FROM AUTHOR]

Background Continuity of care may affect the diagnostic process in cancer but there is little research. Aim To estimate associations between patient. doctor continuity and time to diagnosis and referral of three common cancers. Design and setting Retrospective cohort study in general practices in England. Method This study used data from the General Practice Research Database for patients aged .40 years with a diagnosis of breast, colorectal, or lung cancer. Relevant cancer symptoms or signs were identified up to 12 months before diagnosis. Patient.doctor continuity (fraction-of-care index adjusted for number of consultations) was calculated up to 24 months before diagnosis. Time ratios (TRs) were estimated using accelerated failure time regression models. Results Patient.doctor continuity in the 24 months before diagnosis was associated with a slightly later diagnosis of colorectal (time ratio [TR] 1.01, 95% confidence interval [CI] =1.01 to1.02) but not breast (TR = 1.00, 0.99 to 1.01) or lung cancer (TR = 1.00, 0.99 to 1.00). Secondary analyses suggested that for colorectal and lung cancer, continuity of doctor before the index consultation was associated with a later diagnosis but continuity after the index consultation was associated with an earlier diagnosis, with no such effects for breast cancer. For all three cancers, most of the delay to diagnosis occurred after referral. Conclusion Any effect for patient.doctor continuity appears to be small. Future studies should compare investigations, referrals, and diagnoses in patients with and without cancer who present with possible cancer symptoms or signs; and focus on 'difficult to diagnose' types of cancer. [ABSTRACT FROM AUTHOR]

AimTo map the availability and types of depression and anxiety groups, to examine men's experiences and perception of this support as well as the role of health professionals in accessing support.BackgroundThe best ways to support men with depression and anxiety in primary care are not well understood. Group-based interventions are sometimes offered but it is unknown whether this type of support is acceptable to men.MethodsInterviews with 17 men experiencing depression or anxiety. A further 12 interviews were conducted with staff who worked with depressed men (half of whom also experienced depression or anxiety themselves). There were detailed observations of four mental health groups and a mapping exercise of groups in a single English city (Bristol).FindingsSome men attend groups for support with depression and anxiety. There was a strong theme of isolated men, some reluctant to discuss problems with their close family and friends but attending groups. Peer support, reduced stigma and opportunities for leadership were some of the identified benefits of groups. The different types of groups may relate to different potential member audiences. For example, unemployed men with greater mental health and support needs attended a professionally led group whereas men with milder mental health problems attended peer-led groups. Barriers to help seeking were commonly reported, many of which related to cultural norms about how men should behave. General practitioners played a key role in helping men to acknowledge their experiences of depression and anxiety, listening and providing information on the range of support options, including groups. Men with depression and anxiety do go to groups and appear to be well supported by them. Groups may potentially be low cost and offer additional advantages for some men. Health professionals could do more to identify and promote local groups. [ABSTRACT FROM AUTHOR]

Objectives: To examine the skills and expertise required and used by non-clinical call-handlers doing telephone triage and assessment, supported by a computer decision support system (CDSS) in urgent and emergency care services. Methods: Comparative case study of three different English emergency and urgent care services. Data consisted of nearly 500 hours of non-participant observation, 61 semi-structured interviews with health service staff, documentary analysis, and a survey of 106 call-handlers. Results: Communication skills and 'allowing the CDSS to drive the assessment' are viewed by the CDSS developers and staff as key competencies for call-handling. Call-handlers demonstrated high levels of experience, skills and expertise in using the CDSS. These workers are often portrayed simply as 'trained users' of technology, but they used a broader set of skills including team work, flexibility and 'translation'. Call-handlers develop a 'pseudo-clinical' expertise and draw upon their experiential knowledge to bring the CDSS into everyday use. Conclusions: Clinical assessment and triage by non-clinical staff supported by a CDSS represents a major change in urgent and emergency care delivery, warranting a detailed examination of call-handlers' skills and expertise. We found that this work appears to have more in common with clinical work and expertise than with other call-centre work that it superficially resembles. Recognizing the range of skills call-handlers demonstrate and developing a better understanding of this should be incorporated into the training for, and management of, emergency and urgent care call-handling. [ABSTRACT FROM AUTHOR]

Aims: To characterize 12 Salmonella Virchow isolates from human and avian sources to begin to determine the genetic relationships within the serovar, determine its capacity to invade and induce inflammatory responses in human intestinal epithelial cells and investigate its ability to colonize the chicken gastrointestinal tract. Methods and Results: Multi-Locus Sequence Typing (MLST) revealed that 11 isolates belonged to sequence type 16 (ST16). Pulsed Field Gel Electrophoresis (PFGE) grouped the isolates into two main clusters. All isolates contained genes associated with virulence determined through PCR virulotyping. All the S. Virchow isolates had the ability to invade human epithelial cells and elicit high levels of production of the pro-inflammatory chemokine interleukin-8 (IL-8). Experimental infection of poultry showed S. Virchow colonizes the caeca and spleen. Conclusions: Isolates within the serovar show high levels of genetic relatedness regardless of the source. The data indicates S. Virchow is an invasive and inflammatory serovar, consistent with its association with invasive salmonellosis in humans. Significance and Impact of the Study: The poultry infection experiment included in this study shows S. Virchow can colonize the gastrointestinal tract rapidly and to high levels with the chickens showing no clinical signs of infection. The asymptomatic colonization of chickens indicates an increased ability of S. Virchow to enter the food chain undetected and cause human salmonellosis which because of the invasive and inflammatory nature of S. Virchow seen during the Caco2 invasion assay and previous studies showing its invasive nature in humans and increasing resistance to antibiotics is a public health concern. [ABSTRACT FROM AUTHOR]

The article describes the development of a patient-doctor depth-of-relationship scale designed to measure the depth of the patient-doctor relationship in primary care through a questionnaire which was used in practices in Bristol, England. The authors state that this tool evaluates the value of personal continuity. They suggest that this instrument provides a way to examine the value of patient-doctor continuity to care process and patient outcomes.

Vaccines have made a major contribution to global health in recent decades but they could do much more. In November 2011, a Royal Society discussion meeting, 'New vaccines for global health', was held in London to discuss the past contribution of vaccines to global health and to consider what more could be expected in the future. Papers presented at the meeting reviewed recent successes in the deployment of vaccines against major infections of childhood and the challenges faced in developing vaccines against some of the world's remaining major infectious diseases such as human immunodeficiency virus (HIV), malaria and tuberculosis. The important contribution that development of more effective veterinary vaccines could make to global health was also addressed. Some of the social and financial challenges to the development and deployment of new vaccines were reviewed. The latter issues were also discussed at a subsequent satellite meeting, 'Accelerating vaccine development', held at the Kavli Royal Society International Centre. Delegates at this meeting considered challenges to the more rapid development and deployment of both human and veterinary vaccines and how these might be addressed. Papers based on presentations at the discussion meeting and a of the main conclusions of the satellite meeting are included in this issue of Philosophical Transactions of the Royal Society B. [ABSTRACT FROM AUTHOR]

Objectives: To increase understanding about how evaluations of health policy initiatives are commissioned, conducted and used. Methods: A mapping exercise was conducted to identify evaluation of initiatives promoted by the White Paper 'Our health, our care, our say' in the English NHS. All evaluations were subjected to critical appraisal and 21 were purposively selected as case studies, involving documentary analysis and 60 interviews with those commissioning, conducting and affected by the evaluation. Results: Variation in the types of evaluation being undertaken did not reflect the importance of the initiatives being evaluated. Most evaluations collected evidence about uptake, processes of care and users' perceptions. While some provided useful information about how initiatives could be improved, few provided robust evidence about the benefits or costs of the initiatives. Those who commissioned evaluations had similar concerns to those who conducted them. There was a commitment to the concept of evaluation but little clarity about how findings would be used. Evaluation was often commissioned too late to influence decisions about implementation. Compromises over research design and difficulties collecting data limited the potential to provide robust evidence about benefits. There were tensions between the desire of evaluators for methodological rigour and the needs of service providers for swift, contextually relevant findings. There were concerns about the transparency of methods and results. Conclusions: Considerable public resources are committed to evaluation, but this investment is less productive than it could be. This article specifies several ways in which the use of evaluation of initiatives in health and social care could be improved. [ABSTRACT FROM AUTHOR]

Total alkalinity (TAlk) has long been used to evaluate the buffering capacity of aquatic systems. TAlk has also been used, together with measurements of either pH or dissolved inorganic carbon (DIC), to indirectly estimate the partial pressure of carbon dioxide (pCO2) in inland waters, estuaries, and marine systems. These estimates typically assume that carbonate and bicarbonate ions comprise nearly all the species contributing to TAlk; however, other inorganic and organic acids have the potential to contribute significant non-carbonate alkalinity. To evaluate the potential for error in using TAlk to estimate pCO2, we measured pH, TAlk, and DIC in samples of river water. Estimates of pCO2 derived from TAlk and pH measurements were higher than pCO2 estimates derived from DIC and pH by 13-66%. We infer that this overestimate is due to the presence of significant non-carbonate alkalinity (NC-Alk). This study also describes the relative proportions of carbonate- and non-carbonate alkalinity measured in 15 river systems located in northern New England (USA) and New Brunswick (Canada). NC-Alk represents a significant buffering component in these river systems (21-~100% of TAlk), and failure to account for NC-Alk (which cannot directly contribute to pCO2) leads to the overestimation of carbon dioxide release to the atmosphere. [ABSTRACT FROM AUTHOR]

Objective: To determine the influence of population, hospital and general practice characteristics on practice admission rates for asthma and chronic obstructive pulmonary disease (COPD) in England. Methods: Cross sectional study using Hospital Episode Statistics (HES), routine population data and primary care data. Admissions for all general practices in England during 2005-06, adjusted for age and sex composition of practice population. Univariable analysis of population, practice and hospital care provision variables, including prevalence and quality data. Significant factors included in multiple regression Poisson model. Results: Admissions from 8169 practices were included. Risk of admission for each condition increased with deprivation, prevalence and smoking. Admission rates were higher in urban than rural practices. Hospital bed availability and distance to the nearest emergency department were also significantly associated with risk of admission. The associations with practice factors including practice size and quality markers varied across conditions. Conclusions: Practice population, geographic and hospital supply factors are consistently associated with asthma and COPD admissions. Higher smoking rates among such patients in a practice are associated with higher admission rates. There is little evidence from this study that other modifiable general practice factors are important in influencing admission rates. [ABSTRACT FROM AUTHOR]

Background In developed countries, primary health care increasingly involves the care of patients with multiple chronic conditions, referred to as multimorbidity. Aim To describe the epidemiology of multimorbidity and relationships between multimorbidity and primary care consultation rates and continuity of care. Design of study Retrospective cohort study. Setting Random sample of 99 997 people aged 18 years or over registered with 182 general practices in England contributing data to the General Practice Research Database. Method Multimorbidity was defined using two approaches: people with multiple chronic conditions included in the Quality and Outcomes Framework, and people identified using the Johns Hopkins University Adjusted Clinical Groups (ACG®) Case-Mix System. The determinants of multimorbidity (age, sex, area deprivation) and relationships with consultation rate and continuity of care were examined using regression models. Results Sixteen per cent of patients had more than one chronic condition included in the Quality and Outcomes Framework, but these people accounted for 32% of all consultations. Using the wider ACG list of conditions, 58% of people had multimorbidity and they accounted for 78% of consultations. Multimorbidity was strongly related to age and deprivation. People with multimorbidity had higher consultation rates and less continuity of care compared with people without multimorbidity. Conclusion Multimorbidity is common in the population and most consultations in primary care involve people with multimorbidity. These people are less likely to receive continuity of care, although they may be more likely to gain from it. [ABSTRACT FROM AUTHOR]

Background Between 2005 and 2007, six pilot walk-in centres were opened in or near train stations, to provide health care to commuters. They are run by independent providers on behalf of the NHS, providing access to doctors and nurses. Aim To evaluate the policy of commuter walk-in centres. Design of study Mixed methods evaluation. Setting Six centres in England. Method Site visits, interviews with 28 users, survey of 1828 users, economic estimates, and interviews with six commissioning managers. Results Each centre was located near a train station, although two were not within the main commuter flow. The average number of patients attending each centre on days when the user survey was undertaken was between 33 and 101 per day, considerably lower than the planned capacity of 150-180. Sixty-two per cent (1004/1627) of users identified themselves as commuters within the user survey, and 38% (95% confidence interval = 13% to 62%) had travelled to work by train that day. A large proportion of users worked in the local area (61%). The estimated cost per attendance, based on limited activity and price data, was between £52 and £150 for different centres at estimated current activity levels. Primary care trust managers' plans for the future of the centres involved changing the focus of the service to fit their local health economy. Conclusion Pilot walk-in centres placed near train stations for commuters had low activity levels and high costs. A policy of placing healthcare centres in areas of high worker density may be more successful. [ABSTRACT FROM AUTHOR]

Objective: To examine the implementation of 'Advanced Access' as a means of improving access to primary care. Methods: Qualitative case studies of eight English general practices undertaken as part of a mixed method study. Results: There was considerable variation in the interpretation and implementation of Advanced Access. Practices claiming to operate this system often did not follow its key principles. Differences between practice access systems centred on the use of 'same-day' appointments. The association of Advanced Access with same-day appointment systems was problematic as it both created antagonism to, and diverged from, the Advanced Access model. Practice staff did not necessarily share the conceptualisation of demand that underpinned Advanced Access. Other policies and targets provided further incentives to diverge from the model and these factors were compounded by informal organizational behaviours, notably the exercise of discretion, which led to adaptation. Conclusion: Advanced Access was diluted because it became confused with same-day appointment systems and other incentives and targets. Its guiding philosophy of 'manageable demand' appeared counter-intuitive to staff in the context of general practice, which made its implementation problematic. As a result, the system was adapted and modified. [ABSTRACT FROM AUTHOR]

Objective To evaluate the effectiveness of a practice nurse led strategy to improve the notification and treatment of partners of people with chlamydia infection. Design Randomised controlled trial. Setting 27 general practices in the Bristol and Birmingham areas. Participants 140 men and women with chlamydia (index cases) diagnosed by screening of a home collected urine sample or vulval swab specimen. Interventions Partner notification at the general practice immediately after diagnosis by trained practice nurses, with telephone follow up by a health adviser; or referral to a specialist health adviser at a genitourinary medicine clinic. Main outcome measures Primary outcome was the proportion of index cases with at least one treated sexual partner. Specified secondary outcomes included the number of sexual contacts elicited during a sexual history, positive test result for chlamydia six weeks after treatment, and the cost of each strategy in 2003 sterling prices. Results 65.3% (47/72) of participants receiving practice nurse led partner notification had at least one partner treated compared with 52.9% (39/68) of those referred to a genitourinary medicine clinic (risk difference 12.4%, 95% confidence interval -1.8% to 26.5%). Of 68 participants referred to the clinic, 21 (31%) did not attend. The costs per index case were £32.55 for the practice nurse led strategy and £32.62 for the specialist referral strategy. Conclusion Practice based partner notification by trained nurses with telephone follow up by health advisers is at least as effective as referral to a specialist health adviser at a genitourinary medicine clinic, and costs the same. [ABSTRACT FROM AUTHOR]

The aim of this study was to examine trends in the presentation of cutaneous malignant melanoma at King's College Hospital (KCH) over the last three decades (1970–2000). KCH was one of seven centres that participated in the 1987 Cancer Research Campaign (CRC) publicity campaign aimed at promoting earlier self-recognition of melanoma. Data included patient age at presentation, sex, tumour site, Breslow thickness and histological subtype. The late 1980s saw a threefold increase in the annual number of melanomas and an eightfold increase in thin melanomas compared to the 1970s. The increase occurred in both sexes and was particularly marked after the CRC campaign but numbers had already begun to increase prior to this. The increase has predominantly been thin (Breslow < 1.5 mm) tumours of the superficial spreading variety with a resultant fall in mean Breslow thickness. There has been a decline in the annual number of melanomas since the peak in 1992 which is not explained by increased proportion of in situ tumours. The CRC campaign may have contributed to the documented increase in thin tumours but this trend had begun prior to 1987 suggesting factors other than public awareness and earlier presentation are important. It is encouraging that the number of melanomas has declined over the last 5 years at KCH but it is yet to be seen whether this reflects a real decrease in the incidence of melanoma. [ABSTRACT FROM AUTHOR]

Presents information on a study which determined the level of demand and supply of hours from a nationally representative sample of medical cooperatives in England and Scotland. Method; Results; Discussion. INSETS: What is already known on this topic;What this study adds.

In 1985 a watching brief during gravel extraction at Hemington Fields, Castle Donington, Leicestershire, revealed a substantial timber and stone structure buried beneath 2-2.5 m of alluvium. Salvage excavation and a further watching brief have enabled the structure to be identified as a twelfth century mill dam associated with a possible low breast mill. This is the only mill site of this date examined on a major river and has provided important information on medieval water management. Such sites indicate the great potential for archaeology within the floodplain of major rivers and contributes to a survey of palaeochannels in this area of the Trent valley. [ABSTRACT FROM AUTHOR]

The article presents a study of the charcoals obtained from the recent excavations on the Maiden Castle, England and their significance in relation to the vegetation and climatic conditions in prehistoric period. A few specimens of charcoal collected from the site indicated that the wood was partially decayed before carbonizing. The specimens of charcoals were examined from Neolithic, Early Iron Age and Late Iron Age deposits from the site. It was evident that in Neolithic times, the chalk of Dorset was clothed with a closed plant community of woodland. It was observed that composition of plant species were changing slightly in all the three periods and the soil conditions were becoming less favorable for the growth of oak.

The article discusses the highlights of the soirée of the British Ecological Society in the Department of Zoology and Comparative Anatomy in Oxford, England from January 1-3, 1932. Maps showing ant territory and foraging paths of wood ants, insect faunas and an apparatus for recording diurnal and nocturnal activity of mice, are some of the exhibits dealing with animal ecology that are arranged in the department's laboratory.

The article offers information on the incidence of species in relation to soil reaction. It states that with the goal of calculating the effect of reaction in the conditions of nature a number of species were selected of which samples had been collected from a large number of localities. It also mentions that the area covered by the sample extends from Cornwall, Kent, Hertfordshire, Herefordshire, Somerset, Surrey, and Shropshire in England. Various graphical representations of the hydrogen-ion concentration of the localities in which samples were obtained are also presented.

The article deals with a study that examined the factors influencing the extensive woods of Quercus sessiliflora occupying the Malvernian and Silurian strata of the Malvern district in England. The slopes of the Malvern Hills have become grassland, with extensive tracts of Ulex Gallii, Pteridium aquilinum and other woodland species. The researchers investigated soils situated on three very distinct types of rock, including the Silurian Limestones of the Wenlock and Ludlow series. They found that leaching has resulted in the removal of bases, and an actual acidity has developed as shown by the high lime requirement of the surface soil, especially on the flat floor of Coneygree Wood.

The article focuses on the study involving the different wood species in Hertfordshire, England and its significance to soil ecology. The Quercus sessiliflora-Carpinus woods which comprise the largest woodland areas in Hertfordshire together with Quercus robur which were few in accumulation were the subject of this study in relation to the different aspects of botany which includes the phanerogamic flora and the cryptogamic flora. Accordingly, a total of 269 species of vascular plants have been observed throughout the place and 48 of this number represent the trees, undershrubs, shrubs, and the remaining are the herbs. It stresses that animals play an important role in determining the succession phases of wood species especially during vegetation periods.

The article focuses on a study which investigated the history and status of oak-hornbeam woods in Hertfordshire, England. The hornbeam woods in the region are associated with the lighter types of non-calcareous soil. The plant is typically associated with the Quercus Sessiliflora woods of Hertfordshire and the Quercus robur-Capirnus woods. In all the cases examined on the lighter clays and stiff loams, the Quercus robur-Carpinus woods were present. Comparison shows that the soil in the Quercus rubur-Corylus woods contains a small amount of gravel and coarse sand while Quercus sessiliflora woods contains a higher percentage.

The article discusses a review on the evaluations of ten initiatives specifically promoted in the National Health Service (NHS) white paper "Our Health, Our Care, Our Say," published in January 2006. An extensive mapping exercise was made to identify evaluations of the specified initiatives being conducted in England. It indicates that the rhetorical commitment to evaluation was compromised and the investment in evaluation at national and local levels was not as productive.