Network development in the NHS in the UK has, by and large, not been based on evidence. Now, following perceptions of failure, some are calling for networked approaches to be abandoned. This paper reviews the evidence in two ways: factors which are known to motivate individuals and organizations to join networks; and the essential elements of network design necessary to ensure sustainability.

Background: We previously studied clinical outcomes in two cohorts of emergency admissions of patients aged over 70 to one district general hospital (DGH) or five community hospitals (CHs) finding no differences in death, readmissions, or quality of life at 6 months after admission. Our objectives in this study were to examine the use and cost of medication and use and cost of investigations in the two different hospital settings. Methods: We identified and priced all medication taken on admission, during the hospital stay, and on discharge, and identified all investigations. The main outcome measures were number and cost of medications and investigations during the stay, and the difference in the patients' routine medication before and after the hospital stay. Results: Three hundred and seventy five patients were studied (DGH 170, CH 205). The median (inter-quartile range (IQR)) number and cost of drugs used during the hospital stay was higher in DGH patients: 11 (8, 17) drugs than CH patients: 8 (5, 11); (P < 0.001), costing £35 (13, 90) and £16 (6, 45) respectively (P < 0.001). DGH patients had a mean of 0.55 drugs added to their routine medication, at an extra projected cost of £9.50 per month, whereas CH patients had an average of 0.11 drugs removed from their routine medication at a projected cost saving of £1.35 per month (P = 0.012 for number and <0.001 for cost). More investigations were performed in the DGH than the CH; DGH median (IQR) £260 (180, 410); CH median £40 (9, 110). Conclusions: Considerable extra resources are used in emergency admissions of the elderly to a DGH. However, these extra resources do not appear to yield mortality or morbidity benefits.

Objectives: To explore users' views on increased availability of emergency contraception (EC) from two new providers of EC. Context: EC was previously available from general practitioners (GPs), Family Planning Centres, Accident and Emergency Departments and Brooke Advisory Centres. Recently, EC has also become available from pharmacies and Walk-in Centres (WiCs). Design: Qualitative study using in-depth interviews. Setting and Participants: Twenty-nine women from two (WiCs) and two pharmacies in Avon. Results: Women selected their provider on the basis of convenience and accessibility. WiC users valued the advice and personal nature of the contact with WiC nurses. Women who accessed EC from a pharmacy were amenable to answering questions to obtain EC but did not see this as a time to receive contraceptive advice. Women's attitudes to pharmacy supply of EC may be related to its associations as a place of business. Phrases such as over-the-counter may reinforce this notion, reflecting the business-like nature of the questioning and the impersonal nature of the interaction. While women considered the increased availability of EC to be generally positive, some had concerns about younger women accessing EC, particularly from a pharmacy. Conclusions: Women had a favourable view of their provider of EC, whether from a pharmacy or WiC. Concerns about pharmacy access may be related to its associations as a place of business where consumers have more power in the encounter. For some, this type of ‘easier’ access was considered inappropriate for younger users.

Background: Confidentiality is an important issue for adolescents when using health services, but many health professionals consider objections from parents an obstacle to providing confidential care for this age group. Whereas health professionals and young people consider general practice an appropriate setting for adolescent health promotion, little is known about parents' views. Objectives: The main objective was to explore the views of parents of adolescents regarding confidentiality and the role of general practice in promoting teenage health. A secondary objective was to investigate parents' self-reported health behaviours, and their awareness of such behaviours in their own adolescent children. Methods: Postal questionnaire sent to the parents or guardians (n = 631) of all 14–15-year-old patients on two general practice registers in Hertfordshire, UK. Results: Few parents (2%) were aware of practice policy on confidentiality, and many (48%) did not think that adolescents aged under 16 years should always have the right to confidential consultations. Most parents (64%) considered general practice an appropriate setting for health advice for adolescents and a fifth of them said that there was at least one health-related topic they would like to discuss with a general practitioner (GP) or nurse in relation to their adolescents' health. Parents' own health risk behaviours were correlated with those reported for their children. Conclusion: Information about confidentiality and general practice-based health services for young people needs to be provided clearly to parents as well as to adolescents, particularly as some parents of adolescents may have reservations about confidentiality. The majority of parents consider general practice to be an appropriate setting for adolescent health promotion.

Lymphoedema is a chronic condition that leads to reduced quality of life through its negative impacts on physical, psychological, and social aspects of health. Limb swelling leads to discomfort and pain, reduced movement and function, and acute inflammatory episodes. Individuals experience altered body image and self-esteem impacting on social interaction. There is evidence that specialist management of the condition leads to improved quality of life. Concern regarding the adequacy of lymphoedema services led to the commissioning of a needs assessment by the Core Cancer Review Group in Fife, Scotland. The needs assessment used a variety of methods. Current services were located through consultation of known providers and databases. Existing databases were analysed to find out the number of people requiring the service: hospital admissions and diagnoses were analysed alongside a survey of primary practices in Fife. Access to existing services was explored through a telephone survey of referrers (n = 44), and qualitative interviews with five service providers and five clients. At the time of the study, non-palliative National Health Service (NHS) provision consisted of one part-time clinician; the service provided was under pressure from rapidly increasing referrals. However, consensus from referrers, providers, and clients indicated that there were obstacles to achieving diagnosis and referral, especially for those with non-cancer-related lymphoedema. This was primarily due to poor referrer awareness of the condition, its management, and existing services, for example, only seven per cent of those surveyed would refer to existing specialist services. Delayed referral is a significant issue, as prompt intervention leads to more positive treatment outcomes. As a result of the needs assessment, recommendations were made to increase staffing levels, promote awareness of the condition and related services, and improve geographical and multidisciplinary coordination of the service.

Background: Research in general practice is expanding rapidly but studies are frequently challenged with recruitment difficulties resulting in inadequate sample size, recruitment bias, delayed completion and additional costs. Aim: This study was designed to explore how practice teams make decisions to participate in research, to identify the key influences on the decision making process and to generate for researchers some ways of enhancing recruitment. Method: Semi-structured interviews were conducted with a representative from each of the 11 participating general practices. A thematic analysis of the verbatim transcripts was conducted using the method described by Burnard. Findings: Whilst not having a formal process for considering research requests the criteria used in discussion appeared to be very similar between practices and included the clinical relevance of the research question, clarity of practice responsibilities, realistic expectations and support available. Attention to presentation (style, length, clarity) is also important for engaging attention. Some of the measures to improve recruitment appear to be common sense but the experiences of practices suggested that such measures are not being incorporated routinely by researchers. The need for good project management and cognisance of marketing strategies is also highlighted.

Aims: To assess the feasibility of keeping a log of diabetes-related communication in a community pharmacy and to explore the potential of the logs to reflect diabetes-related communications within pharmacies. Design: A reflective log-keeping exercise (the log designed by the researchers and provided in a booklet form) in community pharmacies of any diabetes-related communication taking place between pharmacy staff and their service users, and any signposting made to and from other relevant health professionals. The study ran for four weeks. Subjects and setting: Nine community pharmacy branches of the Independent Pharmacy Care Centres PLC based in Hull, East Yorkshire and North & North East Lincolnshire. Outcome measures: A description of the form and nature of diabetes-related communication, taking place within the community pharmacy. The research team also sought feedback on the experience of keeping the log. Results: Twenty-two communications were logged; twenty-one involved direct face-to-face contact and one log involved a telephone conversation. Two-thirds of the communications involved conversations with patients with diabetes, a third were with a partner/family member. The conversations captured fell into five categories: sugar free medicines, blood glucose-testing metre, prescription medicines, diabetes specific education/ information and an unclassified category, respectively. The logs demonstrated that communications can involve all members of the staff team, working independently or jointly across their roles in the pharmacy. Conclusion: Community pharmacies in the pilot study were actively involved in providing diabetes health-related information/education and support. Communications involved directly assisting people with diabetes and providing information to people supporting others with a diagnosis of diabetes. We propose that the logs provide a valuable means of acquiring information about the form and nature of diabetes-related communication and signposting within community pharmacy.

Although the need for lifelong learning, with implications for the development of all primary healthcare team members has been emphasized by policy documents and the new General Medical Services (nGMS) contracts, inter-professional facilitators and barriers for lifelong learning have not been fully investigated. This article presents common facilitators and barriers to lifelong learning as perceived by both implementers and recipients of a regional primary care workforce development strategy. It is based on a wider formative explorative evaluation study involving semi-structured interviews and focus groups in 22 primary care trusts (PCTs) and associated general practitioner (GP) practices in South East England. Twenty-nine strategy implementers, comprising Associate Deans, Lifelong Learning Advisors, Primary Care Workforce Tutors, GP Tutors, PCT Educators, were interviewed and 12 took part in two focus groups. Thirty-one strategy recipients, GPs, Practice Managers, Practice Nurses were also interviewed. Interviews and focus groups were recorded, transcribed verbatim and analysed using thematic framework analysis. This study provides evidence that traditional cultures, marked by a lack of inter-professional learning still exist in primary care settings and may obscure lifelong learning. Common facilitators to both implementers and recipients were influential professional networks, managerial and peer support, recent policy changes and protected learning time. Common barriers to both groups were insufficient organizational support, time constraints, lack of funding and boundaries between PCTs and general practices. Strategies to overcome barriers and reinforce facilitators need further exploration. PCTs and general practices should become learning organizations that provide continuous learning opportunities, support collaboration and foster links between organizations and individuals. Lifelong learning development can only flourish when a support system is created, composed of clearly allocated time, budgets and a sustainable support framework.

An interpretive qualitative study was conducted to examine public health nurses' (PHNs') practice in fostering citizen participation and collaborative practice and the impact of a decade (1992–2002) of health care restructuring. This article presents the perspectives of public health management and a public policy analysis as they relate to PHNs' primary health care practice in Nova Scotia, a province in Eastern Canada. Seven face-to-face interviews were conducted with public health management from across Nova Scotia and 26 relevant public policy documents were analyzed. Three major themes emerged from the coded transcripts and the document analysis: (1) opportunistic shifts in values: constraining structures, operations, and governance; (2) insufficient funding and infrastructure support; (3) opportunities and challenges to PHN capacity and competency. The emergent themes illustrate the unique population health perspective and day-to-day contested realities of public health and PHN practice. The study provides preliminary understanding of PHNs' primary health care practice in Nova Scotia that may resonate with other national and international settings. This knowledge can form a basis for more research to explore the PHNs' practice in the organizational context in which it is embedded. This study was undertaken at a pivotal time in Nova Scotia as the provincial government embarked on primary health care renewal to improve the health of Nova Scotians. The success of this study is in large part attributable to the collaborative effort of university researchers and public health decision makers.

The sustained movement towards a more primary health care led National Health Service in the UK has involved individuals and organizations developing more effective ways of working. This has resulted in changes to the structure and functioning of primary care organizations, the development of new workers and, in some instances, handing over work to other health and social care agencies. These changes have contributed to what for many staff is a turbulent organizational and practice environment. Data from a 3-year project, commissioned by the North West Development Agency, is used to explore how staff involved in these changes dealt with this turbulence; 350 staff working within 18 Primary Care Trusts participated in the study. A multi-methods approach was used which facilitated an iterative analysis and data collection process. Thematic analysis revealed a high degree of congruence between the perceptions of all staff groups with evidence of a generally well-articulated, but often rhetorical view of the organizational and professional factors involved in the changes experienced. This rhetoric was used by individuals as a defense mechanism in dealing with the turbulence of change. The article discusses how these defense mechanisms need to be recognized and understood by managers so that a more supportive organizational culture is developed.

Mandelstam, M. 2007: Betraying the NHS: health abandoned. London: Jessica Kingsley Publishers, 317 pp. £14.99. ISBN: 1843104822.