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 assessments of patients aged 75 years and over that were built into the 1990 contract for general practice have failed to enthuse primary care teams or to make a significant impact on the health of older people. The lack of an evidence base for these checks, and the absence of any training programme for practice staff involved in the assessment of older people, both appear to be important factors contributing to the failure of this approach. Alternative methods for improving the health of older people who are living at home are being sought. This paper describes the use of a model of community-oriented primary care (COPC) to initiate innovative care for older people in four exemplar practices in an inner-city area of London. Pump-priming funding was supplied for a 2-year period by one health authority, with the proviso that all innovation must be self-sustaining. The project was supported by an academic department of primary care, which promoted discussion about objectives and priorities, provided the evidence base for interventions considered by the practices, supported staff and created an evaluation framework, but avoided any prescriptive intervention in the process of innovation. All four practices have successfully identified different problems that need attention in their local populations of older people, and developed different projects focused on particular needs among older people. The effectiveness of the COPC method in promoting change in these practices was sufficient for the health authority to fund a second stage, extending the method to 40 practices over a 2-year period.

Primary care trusts (PCTs) will play a major role in commissioning and evaluating new services in primary care. Several studies have discussed the problems associated with conducting evaluative research in primary care generally. However, few GP commissioned services have been formally evaluated, so little is known about the feasibility of such research in the PCT setting. This study uses a tool called force field analysis to identify factors that drive and restrain a primary care-based randomized controlled trial (RCT) of a newly commissioned service for patients with psychosocial problems in primary care, and also to suggest strategies for building on positive factors and reducing negative ones. It involves discussion with general practitioners (GPs) and other primary health care team (PHCT) members in practices with access to the service. Several important dynamics emerge from the analysis with regard to the likely success of evaluation of a new service. These are availability of research skills and funding, prior beliefs about the service and participation in primary care, existing evidence of effectiveness and financial accountability, research design and awareness and ownership in primary care. This study provides evidence that force field analysis can serve as a helpful tool for anticipating and identifying barriers to, and partnerships and actions needed for, successful evaluative research in primary care. It can also facilitate the development of practical strategies to aid successful service evaluation. We suggest that the strategies identified by this study could usefully inform plans for future evaluations in the setting of the PCT.

The current government has given priority to two different objectives in reorganizing the National Health Service (NHS) in England and Wales. The first objective is to create a primary care-led NHS by organizing commissioning of hospital and community health services by new primary care organizations. The second objective is to improve quality and performance in the NHS and to assess this using evidence in various ways. Previous research has suggested that the changes GPs wish to make to services are often not based on published evidence. This suggests a conflict between the two principal objectives intended to drive the reorganization of the NHS. The aim of this study was therefore to explore these issues further. An interviewer-administered questionnaire survey was conducted on one general practitioner and one public health physician from each of four total purchasing pilots (TPPs) in Wales and their four host health authorities, respectively. The main outcome measures were the types of evidence used, and the extent to which evidence impacted on decisions. Access to evidence and views about its usefulness are also reported. It was found that more high-quality evidence was used in support of disease-specific than in support of non-disease-specific changes to care. Evidence played a greater role in decisions to change services that were purchased by health authorities, or provided by TPPs, than it did in changes to services purchased by TPPs. Similarly, higher quality of evidence was used when making decisions to change services that were purchased by health authorities or provided by TPPs, than for services that were purchased by TPPs. It is concluded that there is a mismatch between the availability of conventional, disease-specific evidence directed at the delivery of care, and the need for other kinds of evidence for commissioning changes in the organization of care. This means that we need research and development to develop new methods and new types of evidence so that we can assess the benefits of commissioning in a primary care-led NHS.

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 aim of the study was to obtain information about factors that contribute to the maternal competence of first-time mothers when the child is 3 months old. Data collection was by structured questionnaires. The sample consisted of 271 first-time mothers, who completed the questionnaires when their infants were 3 months old. The multivariate method used was a stepwise regression analysis. According to multivariate analysis, seven predictors remained in the model to explain maternal competence. The better the mother felt about succeeding in child care, the more balanced was her state of mind, and the more cheerful and easy-going the child was, the greater was the mother's competence. Younger mothers, those who received more concrete support from members of their social network and those who were more attached to their child showed better competence. Those mothers who received more guidance on breastfeeding from public health nurses also showed greater maternal competence. The research findings suggest that important factors that contribute to the maternal competence of first-time mothers include maternal resources, social support received from those close to the mother, and guidance on breastfeeding from public health nurses.

The establishment of primary care trusts (PCTs) is a radical reorganization of the NHS. This paper examines primary care groups (PCGs) making an early change to trust status, comparing them with those adopting a longer timetable for the change. The data are derived from the National Tracker Survey of primary care groups and trusts (random sample of 72 PCGs, 15% of the 481 PCGs in England, and five purposively sampled early PCTs) conducted in 1999 and 2000. The main source of data consisted of interviews with Chief Officers (response rates: 1999, 100%; 2000, 97%). In total, 43% of PCGs had become PCTs by April 2001, and 90% expect to become PCTs by April 2002. Integration of primary and community health services, focusing on local needs and innovation in service development, were common reasons for wanting to become a PCT. These trusts were more likely to cite autonomy as a reason, and were also more likely to believe that they had the support of professional stakeholders, but a substantial minority reported that they did not have the active support of GPs and other primary care staff. Although early trusts had slightly more experience of GP-led commissioning, there was no evidence that they were performing better than later trusts in their core functions of developing primary care, improving quality and commissioning services. The rapid progress from PCGs to PCTs does not seem to reflect the process of developmental learning and building on experience initially envisaged by government. Evidence from earlier NHS reforms indicates that time taken to build capacity, develop relationships and secure stakeholder support is associated with success. There appears to be a tension between central control over the implementation of NHS reforms and the desire to devolve budgets and responsibilities to local level.

This paper is concerned with how roles within one group general practice are perceived to have been affected by the introduction of the nurse practitioner into the primary health care team (PHCT) for a 2-year pilot period. The data presented are from data elicited during a single round of interviews with patients ( n = 30) and two rounds of interviews with all medical and nursing staff within the primary health care team on two occasions (40 interviews). The patient interviews were undertaken in the first year of the study, and interviews with staff were undertaken within 6 months of the commencement of the study and during the final 6 months. The overall aim was to evaluate the feasibility of the role and its possible future application to other primary health care settings. This paper will discuss the findings of that aspect of the study relating to the effects on role boundaries between doctors and nurses, and between nurse practitioner and nurses, midwives and health visitors in the practice as perceived by the patients, nurses and doctors involved. The nurse practitioner in this particular practice was a very experienced practice nurse with a wide range of knowledge and skills which she brought to the nurse practitioner role. This, together with well-organized teaching and supervision in the practice setting and a structured programme of formal education, resulted in a highly effective practitioner who was generally seen to have blurred the boundary lines between medical and nursing roles.

Community staff nurses account for a significant proportion of the community nursing work-force, yet little attention has been paid to their training and education. This study explored the views of a range of different community nurses (n = 68) working in one inner-city community trust with regard to the skills and learning needs of community staff nurses. In addition to the community staff nurses (n = 28), the views of the health visitors (n = 15), district nurses (n = 19) and nurse mangers (n = 6) within the trust were explored. The study utilized three methods, namely semi-structured interviews, focus groups and a postal questionnaire, with the data from each being triangulated. This paper focuses on the learning needs of community staff nurses. The findings suggested the need for a practice-based, integrated approach to the education and training of these nurses informed by the needs of patients, the individual nurse, the nursing team, the organization and the wider community. A period of induction into community-based nursing is recommended to facilitate the transfer from a hospital-based to a community-based staff nurse's role.

This paper focuses on one aspect of a research study exploring qualified and student nurses' constructed meaning of nursing in a community context. Uncertainty and risk were particularly important factors in the practice constructions reported by qualified nurses. However, this aspect of practice did not constitute a significant element of the clinical curriculum, and students displayed a limited appreciation of these concepts. The visibility and articulation of these aspects of practice may therefore need to be enhanced to develop a more accurate appreciation of practice in the community context, as well as refining the education agenda for this aspect of health care. Four types of uncertainty were identified in this research, namely uncertainty as a consequence of an unpredictable practice context, uncertainty created by the nurse–patient power balance, uncertainty created by exposure to diverse needs and finally, facing risk and dealing with uncertainty when alone. By drawing on a range of literature, the particular dimensions of risk and uncertainty experienced in community practice are differentiated. It is argued that as a core tenet of the practice experience it is timely and appropriate to review perceptions of risk and uncertainty. Acknowledging these as an accepted part of practice may not only facilitate the practitioner's ability to manage the experience but also allow learners to develop their appreciation and understanding of risk and uncertainty.

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.