Empowerment has gained prominence in health care as an ideal to underpin practitioner – client/patient relationships. Its advocates see it as preferable to paternalistic or authoritarian models and practices, partly because of the humanistic values that shape it and partly because it is believed to improve efficiency in health care delivery because it makes compliance to treatment regimes and to health promoting advice more likely. However, as Cheek notes in her paper, there are plenty of situations in which it is difficult to find anything approaching empowerment in practice. This paper, which develops Cheek's arguments further, examines some of the historical and philosophical origins of empowerment, traces its trajectory through post-World War II societies into health and welfare values and finally asks whether nurses and other health care workers face significant contradictions if they are to take seriously the call to ‘empower’ their patients.

Recording of smoking status in general practice was compared according to the presence or absence of four diseases in which smoking cessation is important (asthma, hypertension, ischaemic heart disease and diabetes). Five of seven practices in one locality of Leicester took part. Our aims were to discover whether patients with these diseases were more likely to have a record of smoking status in their general practice notes than patients without them, and to examine the accuracy of this record compared with results from a patient questionnaire. For all diseases included, the proportion of records containing data on smoking status was higher if the disease was present than if it was not. When adjusted for age and sex, differences in recording reached statistical significance for asthma, diabetes and ischaemic heart disease, but not for hypertension. Smoking rates, as estimated from both the GP record and the postal questionnaire, were lower for all disease groups, but for asthma this did not reach statistical significance. In all disease groups GP data overestimated smoking prevalence compared with the postal questionnaire. We conclude that practices targeted their recording of smoking to those with smoking-related conditions, but achieving higher and more accurate rates of recording in those with smoking-related diseases remains a priority.

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

The PATCH project was an intersectoral initiative between health, social and education services in Lanarkshire, Scotland which provided support at home from two experienced children's nurses for parents of children with complex disability. The project was funded by the Scottish Executive Health Department Innovations Fund for Children's Services for two years from April 2000. This article reports results of an external independent evaluation of parents' and agency members' perceptions of the PATCH service. Audiorecorded interviews were obtained from members of eight families and eight agencies. Issues related to the two key aspects of support addressed in the project, carer training and partnership working, are presented. The skilled approach to training adopted was successful in creating a network of carers, both lay and professional, which resulted in improved respite and rest for parents. Effective partnership working resulted in improved communication, the development of an innovative child record, effective help in crises and improved service co-ordination. Together, the training and partnership elements of the PATCH service addressed practical, emotional and social dif. culties experienced by families. The freedom to work flexibly and to approach agencies directly and the ability to cut across established organizational structures were significant factors in improving support for families. A number of key aspects of nursing expertise and possible outcome indicators for such a service are presented.

This paper identifies some of the key questions that researchers should address in relation to community nursing practice in the UK. The paper begins with a brief overview of the nature and impact of change within the UK health service and the way this has impacted on community nursing. It argues that the nature and scale of such change means that it is important to investigate any resultant threats to the safety of patients and clients, to the quality of their care and to the capacity of the service to meet health care needs. However given the difficulties associated with identifying links between the quality of care and policy driven change, the author argues that a more appropriate approach would be to focus on investigating the effectiveness of practice and seeking explanations for variation in practice. The paper makes reference to the complex knowledge base used in community nursing practice and acknowledges the challenges for nurses in internalising messages from the social science disciplines in order to strive to achieve effective practice. Drawing on some current research studies the author then highlights the importance of developing a better understanding of the interpersonal skills used in practice. The author then moves on to consider wider issues of practice including delegation, supervision and teamwork, arguing that insufficient attention has been paid to effectiveness in these domains. In concluding, the author makes the case that questions should be pursued in all these areas with a focus on exploring variation in practice so that a broader more theoretically based understanding of what is effective in practice can be achieved.

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

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

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

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

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

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

The NHS Plan promises that letters about patients will be copied to them as of right. Yet, beyond a few small studies, little is known of the views of clinicians and patients about the process, and few have any experience of it. The aim of this study was to elicit the views of clinicians and patients about the idea of copying general practitioner (GP) referral letters to patients (part one), and to describe the experiences of GPs and patients actually involved in the process (part two). The setting was one health district in the north of England (part one) and three research practices in the same district (part two). A questionnaire survey was used to elicit the views of 214 consultants, 260 GPs and 584 patients (part one), and semi-structured interviews to assess the experience of 11 GPs and 48 patients involved in the process of copying referral letters (part two). The main outcome measures were the perceived and reported benefits and disadvantages of copying referral letters to patients and the practical implications of making this a routine activity. In the first part of the study, replies were received from 148 hospital consultants (70%), 144 GPs (55%) and all the patients in an opportunistic waiting-room sample. Seventy-six of these consultants (55%) but only 49 of the responding GPs (34%) thought that referral letters should be routinely copied to patients. This compares with 499 (85%) of the patients surveyed who were in favour of this in principle. Potential benefits suggested by clinicians included better informed patients and improved communication. There were concerns about making patients anxious and about the difficulty of writing letters that were both comprehensible to patients and informative to colleagues. In the second part of the study, GPs involved in copying letters to patients experienced no major problems in writing letters that patients could understand but which were also fully informative to consultants. There was some increase in administrative workload. A sense of increased openness in the communication process was reported. Patients valued seeing a copy of their referral letter and few admitted to any major problems in understanding its content. In general, they felt better informed about their illness and better prepared for their outpatient appointment −44 patients (91%) thought copying letters should become routine practice. In this study, carried out before the NHS Plan was published, a majority of consultants supported, with some reservations, the idea that patients should receive a copy of their GP referral letter. Surveyed GPs anticipated major difficulties in copying letters to patients, and most were not in favour of this becoming routine practice. Patients and GPs actually involved in copying letters reported important benefits but also identified issues which will need to be addressed before copying letters can be effectively implemented as a routine activity.

This multistakeholder study looked at the current provision of care for patients with multiple sclerosis (MS) within North Hillingdon, from the perspective of both the patient and the healthcare professional. Using in-depth interviews and focus groups, the study explored the patients' perception of their current care provision and unmet needs. Six main themes emerged from the research: lack of support at diagnosis; lack of information (both short and long term); social isolation; the impact on the family and carers; nonpresentation of other medical problems; inequality of access to care, and a lack of continued and co-ordinated care. The multidisciplinary focus groups and questionnaires carried out with hospital consultants, doctors, GPs, practice nurses, district nurses and physiotherapists echoed these themes. The main proposal that emerged from the data was to have an individual with expert skills and knowledge in managing MS, to be appointed at Primary Care Trust (PCT) level. This proposal would allow a best possible model of care to be offered to all patients with MS across a PCT, and in so doing meet demands of clinical governance.

This literature review focuses on patient satisfaction with skill mix in primary care. This is an important, rapidly changing, topic as the range of health professionals working alongside GPs increases and the roles of staff change. The review is intended to assist primary care organizations in developing skill mixes that meet patients' preferences and needs.

A number of characteristics that influence the type of services that patients want were discovered. Older people and those from ethnic minorities want a ‘traditional’, GP-led service. Access is important to younger people and those in full-time work. Those from lower socio-economic groups value nurses, but have found the increasingly complex organization of services a problem. There are different levels of knowledge and expectations about health services and information on the skills and knowledge of professionals, what they do and the links between them, needs to be available.

A number of aspects of care are important to patients. Patients liked nurses as they were good communicators, formed good therapeutic relationships, gave information on illnesses and spent more time. The location of services is important and patients liked services provided in the home or community. Continuity of care is key, but has been presented as old fashioned and reorganizations may have reduced continuity; skill mix could be viewed as forming a barrier between doctor and patient, but personal lists and teams where practices are divided into smaller units with shared support may help. The competence of health professionals is clearly vital and patients considered nurses competent, although they had concerns about nurses and pharmacists taking on some new roles.

The literature focuses on patients' views about doctors and nurses, although they also want a wider range of services and professionals available in primary care: occupational therapy, link workers, CAB advisers, pharmacist advice and mental health workers. Despite being satisfied with nurses, some patients still wanted to see a doctor next time or felt that a doctor should be available. GPs can help build awareness and confidence in patients about the roles and contribution of the team.

As our communities become more and more diverse, those undertaking research into community nursing practice have a responsibility to incorporate a multi-ethnic perspective into their studies. Primary Care NHS Trusts are increasingly powerful institutions in respect to addressing the needs of minority ethnic groups. As with other public bodies, they need to demonstrate that they are promoting race equality in order to comply with the Race Relations (Amendment) Act 2000. Research into the experiences of families affected by sickle cell disorders and thalassaemia are employed to illustrate nursing accountability for the quality of patient and client care.

The objectives are to describe the establishment of a community pharmacy research network, to give an overview of projects undertaken, to address issues around recruitment, maintenance and support, to report the findings of three postal surveys of pharmacy staff who participated in the network, and to explore views and attitudes towards research. Three self-completion questionnaires were distributed to staff in network community pharmacies over a three-year period. The questionnaires consisted of statements on attitudes to research and experiences of participating in research projects. Demographic information (employment status, gender, etc) were also collected. Network community pharmacies in the north of England participated in five research projects. The response rates to the staff surveys ranged from 100% to 53%. Staff showed high levels of interest in research and enjoyed the variety of participating in projects with different data collection techniques. More than half of the sample felt that participating in research had improved relationships between staff and customers in their pharmacy. A similar percentage also felt that the quality of the advice they gave to customers improved as a result of involvement in specific projects. Data from both the projects and the questionnaires suggest that the network has achieved its aim of involving more community pharmacists in research. Further, despite changes in personnel in some of the pharmacies, attrition was low and pharmacists and their staff appeared motivated to continue their involvement in research.

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

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

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

This paper describes how a health needs assessment of a specified community was conducted using action research. The study involved local people and a multiagency steering group, within a primary health care setting. Community development approaches were applied because of the potential it has to address some of the fundamental issues that lead to poor health. A multimethod approach was used to gather data using quantitative and qualitative approaches. Six focus groups, with varying sections of the community, were used to elicit community perceptions of their health needs. Data triangulation was used in order to identify differences and similarities in each of the methods. The outcomes identified disparities in health needs between the areas assesseddue to differences in socio-economic variances. One area experienced a greater level of deprivation using the Jarman index. The most common forms of ill health in the community were heart disease, cerebrovascular disease, asthma and diabetes. The assessment identified a need for more health promotional work to be carried out by health care professionals, i.e., annual health checks. A number of outcomes confirmed the existence of well-known difficulties in accessing health care, such as difficulties with physical distance to secondary care services, as well as the length of the waiting time at the outpatient departments. It was also apparent that there was a poor understanding of primary health care services and the role and function of the varying health care professionals, particularly amongst the ethnic minority population. The assessment highlighted a number of issues, including obvious benefits, which may accrue from this process for primary care groups and primary care trusts in identifying the health needs of their local populations and subsequent development of the health improvement programmes with the health authority. The discussion raises issues concerning the impact that these changes have on collaboration between varying professional groups and users of services in the planning and delivery of services in order to reduce inequality in health.

The aim of this study was to investigate the opinions of patients with chronic pain conditions, as regarded the following points: the feeling of having their pain experience unconditionally accepted (confirmed) at the meeting with the district nurse, their opinions regarding the treatment and knowledge of the chronic pain and the wellbeing related to the chronic pain condition, and whether their opinions changed after the introduction of trained district nurses as ‘pain advisers’. A study area (SA) with five primary health care centres (PHCCs), and a control area (CA) with seven were selected. Before and after the introduction of one ‘pain adviser’ at each PHCC within the SA, the district nurses in both areas were asked to register all the patients older than 16 years with chronic pain conditions whom they were in contact with. A total of 84 (34 SA, 50 CA) patients in 1996 (67% of all the patients who received a questionnaire in 1996) and 60 (43 SA, 17 CA) patients in 1998 (77%) answered a questionnaire. The study showed that patients with chronic pain conditions felt confirmed at the meeting with the district nurse. Furthermore, the patients considered that the pain influenced their well-being to a rather great extent. The advice and recommendations and/or information and education received were also found to be valuable to these patients. After the introduction of ‘pain advisers’ into the SA, some improvements were found in both areas. In the SA only, the patients reported less pain and more knowledge with which to understand the pain as a result of the advice and recommendation and/or the information and education.

An increasing number of general practitioners (GPs) are personally practising complementary and alternative medicine (CAM) to treat their NHS patients. While research on CAM is beginning to emerge we still know very little about CAM practice in primary care. Researchers have largely concentrated upon exploring CAM consumption and broad orthodox CAM provision. A small body of work has begun to examine CAM practice from the GP therapist's perspective and this work has highlighted the constraints and difficulties associated with CAM integration in general practice. Despite such limitations, direct integration continues apace and this raises the question: what clinical and practice benefits are GPs possibly gaining from CAM integration? This is an area that still lacks focused research attention and this paper, exploring the positive gains of integration as perceived by GP therapists, provides a first stage towards filling this research gap. A study, based upon 25 in-depth interviews with GPs practising CAM, was undertaken to explore GP therapists' understandings and experiences of their complementary practice. This paper presents one area of findings produced from the analysis of the GPs' accounts. Analysis reveals that GP therapists identify a number of positive clinical gains associated with their direct integrative practice. These are: filling gaps and successfully treating conditions for which conventional medicine proves ineffective; providing safer techniques in medical cases where the practitioner suspects or anticipates potential side-effects from conventional treatments; and helping maintain job satisfaction and relieve boredom for the practitioner. These findings are discussed within the context of contemporary CAM provision and consumption and recent circumstances affecting general practice. Set within this context, the findings provide an important addition to our current understanding of the increasingly close relationship between CAM and general practice. In conclusion, it is argued that the positive gains experienced by GPs practising CAM should not be ignored by those considering the future provision and practice of CAM within the general practice environment.

Primary care groups and trusts (PCG/Ts) are key to the successful implementation of the NHS information strategy, Information for Health. This study describes the current levels of IM&T within PCG/Ts and their constituent general practices and examines the ability of PCG/Ts to support the delivery of national targets. Results are derived from the National Tracker Survey of Primary Care Groups and Trusts, which uses a stratified sample of 72 (15%) of PCG/Ts.

The findings indicate that although PCG/Ts are beginning to identify their priorities and work on the huge development agenda in primary care, they may have difficulties meeting both local and national targets. PCG/Ts need additional, appropriately skilled staff and better information to support the planning process. They also need access to high quality data from a range of sources to support their key functions. The quality of data currently available to PCG/Ts is generally perceived by IM&T leads as being poor and is seriously hindering progress. The paper concludes that there is a gap between the vision described in the national information strategy and the ability of local organizations to deliver targets. If the national strategy is to be implemented successfully it may need to be adapted in the light of the findings presented.

Ten primary health care clinics in the Gaza Strip were randomly selected from the five regions that form the Gaza Strip (Southern region, Gaza City, Middle region, Khan-Younis and Rafah). The objective of the present study was to investigate the prevalence of mental health problems among patients attending primary health care clinics in the Gaza Strip. Six hundred and sixty-one randomly selected primary health care patients from the five regions were surveyed using the HSCL-25. Seventy-three per cent of patients visiting primary care clinics in the Gaza Strip had psychiatric symptoms consistent with psychiatric disorders. The prevalence of mental health problems among females was higher (76.8%) than males (67%). Previously married and single patients reported more distressing symptoms than married people. The results also revealed that the prevalence of mental health problems was higher among patients living in refugee camps. Civic status was not associated with mental health problems.

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

The government intends to invest heavily in intermediate care services by the year 2004. The term ‘intermediate care’ de. es precise definition, but is said to include a number of community-based services, including those provided by district nurses. Enhanced district nursing may be one solution to providing care for many elderly patients who are thought to be inappropriately admitted to acute hospitals. The feasibility of this option has yet to be tested, but district nursing enjoys public confidence and is well placed within the primary care framework to ensure continuity of care. This paper describes a national postal survey of district nursing provision within all community trusts in England conducted in 1998 to explore a picture of the structural and organizational factors which impinge on the delivery of intermediate care by district nurses. The Handbook of Community Nursing was used to identify those with designated responsibility for district nursing within trusts. A response rate of 83% (n = 148) was attained. The majority of responding trusts reported a lack of resources to deliver more intensive levels of care. When trusts were ranked according to their performance on six key variables thought to be related to the delivery of intermediate care only two achieved the maximum score. Over half of the trusts scored 3 or less. The findings from this survey indicate a curious neglect of the district nursing service and suggest that considerable investment is needed if district nurses are to deliver an intermediate level of care.