The government's health policy now demands effective collaboration between organizations, between commissioners and providers of care and between health and local authorities, the voluntary sector and the public. Making collaboration work at operational and strategic levels is a significant management challenge. This paper draws on experience and observation of two forms of strategic collaborative venture that have been established with the ultimate purpose of improving the public's health. The first concerned itself with mechanisms for commissioning health and social care services on a locality basis, while the other venture was concerned with the promotion of physical activity across a health authority district. Using a framework which identifies the forms of value attributable to collaborative working, the analysis evaluates the processes of development of the two initiatives and identifies some key lessons for developing sustainable collaborative ventures. The framework used is proposed as being appropriate for the formative evaluation of future collaborative initiatives.

The use of oral anticoagulation therapy in primary care is increasing. We compared general practitioner (GP)-led oral anticoagulation monitoring with a nurse-led service involving near patient testing and computerized decision support (NPT-CDS). The nurse-led NPT-CDS service provided anticoagulation control equivalent to the traditional GP-led service, with identical mean international normalized ratio (INR) values and a nonsignificant trend towards improvement in all other parameters. Recording of indications for anticoagulation and target INR ranges were significantly improved using CDS software. For patients established on warfarin, the GP-led service was costed at £56.88 per patient per year, compared with £63.76 for the nurse-led NPT-CDS service. Patients overwhelmingly preferred the NPT-CDS service for reasons of convenience, avoidance of phlebotomy and improved dosage instructions. Performance of the NPT-CDS service within the National External Quality Assurance Scheme (NEQAS) was satisfactory. In conclusion, nurse-led oral anticoagulation utilizing NPT-CDS is an effective and acceptable alternative to traditional GP-led monitoring. The costs of an NPT-CDS service are higher, but need to be set against factors such as patient satisfaction and escalating GP workload.

The extent to which practice nurses use the best available evidence to inform their activities in cardiovascular disease (CVD) and stroke prevention is not known. This paper reports on a study designed to explore the extent to which practice nurses use the available evidence in the prevention of CVD and stroke, and to explore the associations between research utilization and other individual and organizational factors. A national survey of practice nurses employed in 11 health authorities was conducted. Self-completion questionnaires were returned by 1187 practice nurses (response rate 60.4%). In relation to the risk factors smoking, hypertension, raised plasma cholesterol and lack of exercise, the majority of practice nurses reported interventions which are supported by research evidence. However, only 66% of the respondents recommended nicotine patches for smoking cessation, 42% referred patients for hypertension at levels above those recommended by national guidelines, and only 3.9% followed the latest recommended guidelines for exercise prescription. Statistically significant associations were found between total research utilization scores and a number of individual and organizational characteristics. The study findings are discussed together with their implications for practice and education.

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

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

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