The objective of this paper is to describe variations in the different models of out of hours general medical services and identify explanations for variation and the possible influence on patient satisfaction and service costs. A cross-sectional survey of all models of out of hours care was undertaken, including co-operatives, deputizing services, practice rotas and rural general practitioners doing their own cover. Fifteen sites were chosen representing 10 models of care, for more detailed case study; 65 semistructured interviews with key informants were conducted within the case study sites. A postal patient satisfaction questionnaire and an economic analysis were also carried out. Out of hours organizations have developed in response to a complex mix of the population served, geography, resources available and political expediency, leading to considerable structural heterogeneity, even within co-operatives. There was little evidence of formal integration with other services. Only the largest co-operatives showed any evidence of utilizing guidelines/protocols or of providing formal staff training. There were clear differences in the structure of out of hours care in urban and rural areas. Increasing the use of centralized call handling and triage will not address the needs of rural GPs, who would still be required to be available for work. Neither patient satisfaction nor costs varied bymodel of service provision. The English out of hours reviewhas outlined an integrated model of service provision with consistent standards within an accountability framework. It would appear that only the largest organizations will be in a position to address these standards and that they are likely to be inappropriate to the needs of GPs in rural areas.

Motor neurone disease (MND) is a devastating neurological terminal condition with no cure. Care is the only option, which sharpens the need for its examination and clarification. This paper reports on a hermeneutic study which addressed the question, ‘What are the lay and professional values of care in the context of motor neurone disease and is there a difference between them which affects care delivery and receipt?’ The study discovered three ways of caring, with most alignment between the two lay groups. The professional carer stance is predominantly functional and illustrates detachment from the experience of living with illness whereas the recipients' needs are holistic. These two value structures, the mechanistic and the hermeneutic, are in tension. To redress this imbalance, support for a dispositional shift in professional values to be more client focused is advocated.

A number of inquiries over the last 20 years have found London's primary care to be deficient when compared with the rest of the country, notwithstanding several development programmes aimed at addressing this inequity. Personal medical services (PMS) pilots were introduced in 1998 to replace the national contract for general practitioners and were intended to offer planners and providers of primary care with more flexibility in meeting local health needs. PMS pilots have proved particularly popular in London. This paper describes the results of a review of 13 first-wave PMS pilots in London. The pilots have resulted in new and flexible primary care organizations, more resources for the primary care workforce and greater access to services for deprived or underserved populations. However, little evidence was found to suggest that PMS pilots impacted greatly on service quality. Personal medical services pilots involve the development of local contracts, although contract management processes remain underdeveloped. Nevertheless, personal medical services pilots may prove successful in addressing some of the relative deficiencies in London's primary care and offer a powerful new tool to the commissioners of primary care to meet the diverse needs of Londoners.

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.

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.

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.

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.

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.