Qualitative in-depth interviews with 30 professionals from eight NHS maternity units in England that provide services for large proportions of women of black Caribbean, black African, Indian, Pakistani and Irish descent.

All the professionals reported providing care to both UK-born and migrant mothers from ethnic minorities. Most of them felt that they could differentiate between UK-born and migrant mothers based mainly on language fluency and accent. ‘Westernized dress’ and ‘freedom’ were also cited as indicators. Overall, professionals found it easier to provide services to UK-born mothers and felt that their needs were more like those of white English mothers than those of migrant mothers. UK-born mothers were generally thought to be assertive and expressive, and in control of care-related decision-making whereas some South Asian Muslim women were thought to be constrained by family influences. Preconceived ideas about ethnic minority mothers' tolerance of pain in labour, use of pharmacological pain relief measures and mode of delivery were recurring themes. Women's education and social class were felt to be major influences on the uptake of maternity care, regardless of ethnicity.

Professionals appeared to equate the needs of UK-born ethnic minority women with those of white English women. Overall, this has positive implications for care provision. Despite this, specific behavioural expectations and unconscious stereotypical views were evident and have the potential to affect clinical practice.

The assessment of the appropriate site of care was based on analysis of hospital discharge data for all hospitals for the selected diagnosis related groups in the Emilia-Romagna region for 2001 to 2005. The necessity for acute hospital admission was based on the severity of a patient's principal diagnosis, co-morbid diseases and, for surgical admissions, procedure performed.

From 2001 to 2005, potentially inappropriate medical admissions of more than one day decreased from 20,076 to 11,580, a 42% decrease. Inappropriate admissions decreased in both public and private hospitals but there remained a higher rate of inappropriate admissions to private hospitals. Potentially inappropriate medical admissions accounted for 128,319 bed-days in 2001 and 68,968 bed-days in 2005, a reduction of 59,351 bed-days. Potentially inappropriate surgical admissions decreased from 7383 in 2001 to 4349 in 2005, a 41% decrease. Bed-days consumed by inappropriate surgical admissions decreased from 23,181 in 2001 to 13,660 in 2005.

The Emilia-Romagna region has succeeded in reducing the use of acute hospital beds for patients in selected diagnosis related groups. However, there are still substantial numbers of admissions that could potentially be treated in less costly settings.

Qualitative study using semi-structured interviews with 33 policy- and decision-makers purposively sampled from the UK National Health Service (NHS) (national, regional and local levels), academia and voluntary organizations. Interviews were transcribed, coded and emergent themes identified using framework analysis aided by NVivo software.

Policy-makers and planners were generally enthusiastic about models to assist in decision-making through: predicting trends; assessing the effect of interventions on health inequalities; quantifying the impact of population level and targeted interventions, and facilitating economic evaluation. The perceived advantages of using models included: more rational commissioning; the facility for scenario testing; advocacy for population level interventions and off-the-shelf synthesis to aid real time decision-making. However, although participants were aware of models to support decision-making, these were not being used routinely. Some participants felt that models oversimplify complex situations and that there is a lack of shared understanding as to how models work. Factors that increase confidence in decision support models included: rigorous validation and peer review, the availability of user-support and increased transparency.

Policy-makers and planners were generally enthusiastic about the use of models to support decision-making, illustrating the potential uses for models and the factors that improve confidence in them. However, existing models are often not being used in practice. So new models that are fit for practice need to be developed.

Qualitative, semi-structured interviews were conducted with 43 purposively sampled UK stakeholders, including pharmacist and nurse supplementary prescribers, doctors, patient groups representatives, academics and policy developers. Analysis of transcribed interviews was undertaken using a process of constant comparison and framework analysis, with coding of emergent themes.

Stakeholders generally viewed SP positively and perceived benefits in terms of improved access to medicines and fewer delays, along with a range of facilitators and barriers to the implementation of this form of non-medical prescribing. Stakeholders' views on the economic impact of SP varied, but safety concerns were not considered significant. Future challenges and implications for policy included SP being potentially superseded by independent nurse and pharmacist prescribing, and the need to improve awareness of SP. Several potential tensions emerged including nurses' versus pharmacists' existing skills and training needs, supplementary versus independent prescribing, SP theory versus practice and prescribers versus non-prescribing peers.

SP appeared to be broadly welcomed by stakeholders and was perceived to offer patient benefits. Several years after its introduction in the UK, stakeholders still perceived several implementation barriers and challenges and these, together with various tensions identified, might affect the success of supplementary and other forms of non-medical prescribing.

Using micro-data from three nationally representative surveys of the Irish population undertaken in 1987, 1995 and 2001, multivariate models of GP utilization are estimated.

There is little evidence that proximity to the income threshold results in significant differences in GP visiting. The most significant difference is between medical card and private patients, rather than between private patients on differing incomes. There is also little evidence that the differential in GP visiting between private patients on different incomes changed over time.

While recent commentary has focused on the plight of individuals just above the income threshold for free GP care, these results suggest that the key difference in GP visiting is between those with, and without, eligibility for free care. If private patients are prevented from accessing GP care due to cost, this is as much an issue for those at the top of the income distribution as for those at the bottom.

Semi-structured interviews were conducted with 131 health professionals to understand their experiences of implementing open disclosure in 21 providers in Australia.

Health professionals are positive about open disclosure and are applying the model to patient–clinician communication encounters more generally. Workforce and systems competencies enable clinicians and health service managers to implement open disclosure principles and practices, although a propensity to hide errors, wavering commitment and to exacerbate the problem inhibits implementation as policy intends. The gap between policy objectives and their implementation limits the benefits to health professionals.

Health services must develop organizing capabilities if open disclosure is to be implemented as intended. Activities should identify and address factors that impede implementation and enable workforce and system competencies to develop. These activities will allow health services to adapt central open disclosure policy to local conditions and to embed its principles and practices organization-wide.

The evaluation comprised: interviews with service providers at 30 sites, supplemented by interviews with commissioners, GPs and hospital doctors at 12 sites; economic case studies in six sites; and patient surveys at 30 sites plus at nine conventional outpatient services. Outcomes comprised: staff views of service organization and development, impact on primary and secondary care, and benefits for patients; cost per consultation and cost per patient in new services compared to estimates of the price of services if undertaken by hospitals; patients' views of waiting time, access, quality (technical and interpersonal), coordination and satisfaction.

New services required high initial investment in staff, premises and equipment, and the support of hospital consultants. Most new services were added to existing hospital services so expanded capacity. Patient reported waiting times (6.7 versus 10.1 weeks; p = 0.001); technical quality of care (96.2 versus 94.5; p < 0.001), overall satisfaction (88.2 versus 85.4; p = 0.04); and access (72.2 versus 65.8; p = 0.001) were significantly better for new compared to conventional services but there was no significant difference in coordination or interpersonal quality of care. Some service providers expressed concerns about service quality. New services dealt with less complex conditions and undercut the price tariff applied to hospitals thus providing a cost saving to commissioners. There was some concern that expansion of new services might destabilize hospitals.

Moving specialist care into the community can improve patient access, particularly when new services are added to existing hospital services. Wider impacts on health care quality, capacity and cost merit closer scrutiny before rollout.

The search strategy began with 10 electronic databases (e.g. CINAHL, Medline). Published quantitative studies were included that examined the factors that contribute to leadership or the development of leadership behaviours in nurse leaders. Quality assessments, data extraction and analysis were completed on all included studies.

A total of 27,717 titles/abstracts were screened resulting in 26 included manuscripts reporting on 24 studies. Twenty leadership factors were examined and categorized into four groups – behaviours and practices of individual leaders, traits and characteristics of individual leaders, influences of context and practice settings, and leader participation in educational activities. Specific behaviours and practices of individual leaders, such as taking on or practising leadership styles, skills and roles, were reported as significantly influencing leadership in eight studies. Traits and characteristics of individual leaders were examined in six studies with previous leadership experience (three studies) and education levels (two of three studies) having positive effects on observed leadership. Context and practice settings had a moderate influence on leadership effectiveness (three of five studies). Nine studies that examined participation in leadership development programs all reported significant positive influences on observed leadership.

These findings suggest that leadership can be developed through specific educational activities, and by modelling and practising leadership competencies. However, the relatively weak study designs provide limited evidence for specific factors that could increase the effectiveness of current nursing leadership or guide the identification of future nurse leaders. Robust theory and research on interventions to develop and promote viable nursing leadership for the future are needed to achieve the goal of developing healthy work environments for health care providers and optimizing care for patients.

Qualitative semi-structured interview study. Twenty-four clinicians were interviewed during 2006: one general practitioner and one practice nurse in 12 general practices in eastern England with a broad range of sociodemographic and organizational characteristics.

Participants reported substantial improvements in teamwork and in the organization, consistency and recording of care for conditions incentivized in the scheme, but not for non-incentivized conditions. The need to carry out and record specific clinical activities was felt to have changed the emphasis from ‘patient led’ consultations and listening to patients' concerns. Loss of continuity of care and of patient choice were described. Nurses experienced increased workload but enjoyed more autonomy and job satisfaction. Doctors acknowledged improved disease management and teamwork but expressed unease about ‘box-ticking’ and increased demands of team supervision, despite better terms and conditions. Doctors were less motivated to achieve performance indicators where they disputed the evidence on which they were based. Participants expressed little engagement with results of patient surveys or patient involvement initiatives. Some participants described data manipulation to maximize practice income. Many felt overwhelmed by the flow of policy initiatives.

Payment for performance is driving major changes in the roles and organization of English primary health care teams. Non-incentivized activities and patients' concerns may receive less clinical attention. Practitioners would benefit from improved dissemination of the evidence justifying the inclusion of new performance indicators in the QOF.

We searched Lexis-Nexis to find newspaper reports about the use of medical records for research from 1 June 2005 to 30 November 2006. Following screening for relevance, we generated a coding scheme and classified articles using this, assisted by QSR N6 software.

Our analysis shows that much newspaper coverage portrays the use of medical records as uncontentious, but also presents ethical arguments for and against such research. Arguments in favour of access to medical records emphasize the public interest and patients' legitimate expectations that research will be carried out. Arguments against such use emphasize the importance of confidentiality and the violation of rights of privacy. Our findings highlight that there is no single dominant position on the rights and wrongs of access to medical records by researchers. Within newspaper reporting in this area, patient voices are currently noticeable by their absence.

Use of medical records for research raises important ethical questions, in particular regarding the balance between the rights and interests of the individual and the public interest benefits of the research. Understanding how these positions are represented within the mass media is important because the media can inform and influence the public's views and public policy. Empirical research into patient views is needed.

The study included 438 outpatients who were referred for and underwent a gastroscopy or colonoscopy. GPs used a ranking of waiting times for different levels of clinical priority, called ‘homogeneous waiting groups’. Specialists also assigned a priority level for each patient as well as evaluating the appropriateness of the referral and the presence of significant endoscopic disorders. Agreement between GPs' and specialists' priority assessments was evaluated by the kappa statistic.

Most referrals (74.4%) were deemed low priority by GPs, with no maximum waiting time assigned. The level of agreement between GPs and specialists as regards patients' priorities was poor or moderate: for gastroscopy the kappa was 0.31 (weighted kappa 0.47) and for colonoscopy 0.44 (weighted kappa 0.46). There was an association between the proportion of significant disorders identified with endoscopy and the priority assigned to the referral (2 = 18.9, 1 df, p < 0.001). The overall proportion of referrals deemed inappropriate by specialists was 22.1%.

There is value in liaison between GPs and specialists for achieving timely referrals and avoiding delayed diagnosis though higher levels of agreement need to be achieved.

One hundred semi-structured interviews were undertaken with hospital staff who were either members of, or who came into contact with, the outreach service in eight hospitals in England.

Outreach services had two main impacts on the delivery and organization of hospital care, reflecting the organizational and educational aims of the policy. First, on the organization of patient care: it was suggested that care was more timely, there were fewer referrals to the intensive care unit (ICU) and ICUs felt more able to discharge patients to hospital wards. There were also perceived to be improved links between ward nurses and medical teams and improved morale among ICU nurses. Second, on the confidence and skills of ward staff (nurses and junior doctors): increased contact on the wards resulted in more opportunities to share critical care skills. However, there remained concerns about the sustainability of improved skills and some respondents felt that junior doctors were becoming de-skilled.

Critical care outreach services have had a positive impact on the delivery and organization of hospital care. In attempting to share critical care skills, however, these services can experience a tension between the aims of service delivery and education – a tension which is partly resolved by sharing skills in the clinical and organizational context of direct patient care.

Paper and computer-based medical records were reviewed for all drug prescriptions over an 18-month period for 3400 randomly selected adult patients (18–75 years) stratified by BMI, from 23 primary care practices in seven UK regions. Drug costs from the British National Formulary at the time of the review were used. Multivariate regression analysis was applied to estimate the cost for all drugs and the ‘top ten’ drugs at each BMI point. This allowed the total and attributable prescribing costs to be estimated at any BMI. Weight loss outcomes achieved in a weight management programme (Counterweight) were used to model potential effects of weight change on drug costs. Anticipated savings were then compared with the cost programme delivery. Analysis was carried out on patients with follow-up data at 12 and 24 months as well as on an intention-to-treat basis. Outcomes from Counterweight were based on the observed lost to follow-up rate of 50%, and the assumption that those patients would continue a generally observed weight gain of 1 kg per year from baseline.

The minimum annual cost of all drug prescriptions at BMI 20 kg/m² was £50.71 for men and £62.59 for women. Costs were greater by £5.27 (men) and £4.20 (women) for each unit increase in BMI, to a BMI of 25 (men £77.04, women £78.91), then by £7.78 and £5.53, respectively, to BMI 30 (men £115.93 women £111.23), then by £8.27 and £4.95 to BMI 40 (men £198.66, women £160.73). The relationship between increasing BMI and costs for the top ten drugs was more pronounced. Minimum costs were at a BMI of 20 (men £8.45, women £7.80), substantially greater at BMI 30 (men £23.98, women £16.72) and highest at BMI 40 (men £63.59, women £27.16). Attributable cost of overweight and obesity accounted for 23% of spending on all drugs with 16% attributable to obesity. The cost of the programme was estimated to be approximately £60 per patient entered. Modelling weight reductions achieved by the Counterweight weight management programme would potentially reduce prescribing costs by £6.35 (men) and £3.75 (women) or around 8% of programme costs at one year, and by £12.58 and £8.70, respectively, or 18% of programme costs after two years of intervention. Potential savings would be increased to around 22% of the cost of the programme at year one with full patient retention and follow-up.

Drug prescriptions rise from a minimum at BMI of 20 kg/m² and steeply above BMI 30 kg/m². An effective weight management programme in primary care could potentially reduce prescription costs and lead to substantial cost avoidance, such that at least 8% of the programme delivery cost would be recouped from prescribing savings alone in the first year.

Theory-based literature review including an analysis of the intended and unintended impact of choice-related policies in health care in the UK, European Union and USA. Selected papers focused not only on offering choice to individual patients but also evidence of the impact of choice by patients' agents such as GPs, and on the impact of introducing choice in education and social services.

Choosing between hospitals or primary care providers is not currently a high priority for the public, except where local services are poor, e.g. they have long waiting times and where individual patients' circumstances do not limit their ability to travel. When patients become ill, they are increasingly likely to wish to rely on a trusted health practitioner to choose their treatment. Better educated populations make greater use of information and are more likely to exercise choice in health care. The increase in inequality which this could produce might be reduced by specific provision of information and help, enabling less advantaged populations to make choices about health care. There was little evidence in the literature that providing greater choice will in itself improve efficiency or quality of care.

Although patients may themselves make limited use of choices, the existence of choice may, in theory, stimulate providers to improve quality of care. Patients do, however, want to be more involved in individual decisions about their own treatment, and generally participate much less in these decisions than they would wish.

Using conjoint analysis, experienced neurologists and vascular surgeons ranked 10 diagnostic strategies defined in terms of four characteristics. Clinicians' preferences were analysed using an ordered probit model and compared with those obtained using a risk neutral expected value (EV) model developed to predict the consequences of each strategy as if the clinicians' sole goal were to optimize patient outcome. Results were tested for internal consistency and robustness to key model assumptions.

Preferences for positive predictive value (PPV), relative to negative predictive value (NPV), elicited from the clinicians diverged substantially from those estimated by the EV model based on 5-year stroke-free survival (ratios of –0.8 and –32.8, respectively). Conversely, preferences for NPV, relative to test morbidity, from the two models matched closely.

Clinicians attached substantially more importance to the PPV of carotid artery tests than would be justified by ther impact on patient outcomes. Cognitive errors and attitudes to risk are likely to play an important role in explaining this finding. This study casts doubts on the validity of common assumptions made in the evaluation of health interventions, and in clinical and policy decisions.

Logistic regression analysis of English National Health Service national patient survey data is used to identify the aspects of general practice care that are associated with high levels of overall satisfaction among patients.

Confidence and trust in the doctor is the most important factor in explaining the variation in overall patient satisfaction (predicting 82% of satisfaction levels accurately). The seven variables relating to the relationship between patient and doctor have stronger explanatory power than other aspects of the general practitioner (GP) experience. The variables with the lowest overall predictive power are whether the patient was told how long they would have to wait in the surgery (72%), the length of time they had to wait after their appointment time (74%) and ability to get through to the surgery on the phone (74%).

Patients value the quality of their relationship with their doctor more than the appearance of the surgery, accessibility of appointments and their experience in the waiting room. This suggests that, if current restrictions on choice of GP were removed, we would in theory expect a patient's choice to be driven by the quality of the doctor–patient relationship. Once a patient establishes a good relationship with a GP, however, we might expect them to be loyal and therefore unlikely to change practice unless the relationship with the doctor breaks down. Although relationship factors are important to the satisfaction of patients, it is not clear that they will lead large numbers of people to change their GP.

Quantitative data describing all referrals to the seven pilot IMCA services (January 2006–March 2007) and qualitative data from semi-structured interviews with 18 doctors, 21 senior nurses and one discharge planning manager in four general hospitals in England.

Of 127 hospital-based referrals to the seven pilot IMCA services, 29 (23%) were for patients facing serious medical treatments, 52% of whom were judged to lack decision-making capacity due to a learning disability; ninety-eight (77%) were for patients facing a change of accommodation upon hospital discharge, 62% of whom were elderly and lacked capacity due to dementia. While aware of the potential benefits of the IMCA service, clinicians were generally negative about the contribution advocates could make to patients' medical care and thought they could only contribute usefully in a minority of ethically complicated decisions. In contrast, they were more positive about the involvement of advocates in hospital discharge decisions and hoped that they would improve current discharge practice.

Clinicians held ambivalent attitudes towards the involvement of a statutory IMCA service in medical decisions, reflecting beliefs that the service was largely impractical and unnecessary given current procedures for making medical decisions in patients' ‘best interests’. Conversely, clinicians were more likely to support advocacy in discharge decisions because they believed that non-medically qualified advocates could make a valuable contribution to decisions that were seen as predominantly social and where practice was frequently considered deficient. By holding these beliefs, clinicians are failing to have due regard for the IMCA service as a statutory measure for safeguarding patients' interests.

A qualitative study using a semi-structured focus group interview: with 17 family physicians and residents, in a Canadian rural town. Interviews were audio-taped and transcribed verbatim. Thematic content analysis was performed and validated by the constant comparative method, member checking and group debriefing.

Two distinct conceptions of how clinical practice guidelines should assist decision-making emerged. On the one hand, guidelines were seen as helping clinicians to make decisions on behalf of their patient about the best course of action. For interventions with uncertain benefit or that carried significant trade-off for patients, guidelines were seen as a tool that should inform decision-making between physicians and patients, providing them with details about risks, benefits, costs and alternative treatments. The pressure to apply guideline recommendations was perceived as a potential barrier to patient participation in decision-making.

In circumstances where physicians judge patient participation in decision-making to be important, physicians perceive a tension between the need to respect patients' preferences and the pressure to apply guidelines. CPGs should include information that supports shared decision-making, besides their current focus on influencing prescription patterns, costs and health outcomes.

A generic model structure was developed to describe the incidence and impacts of medication errors in hospitals. The model follows pathways from medication error points at alternative stages of the medication pathway through to the outcomes of undetected errors. The model was populated from a systematic review of the medication errors literature combined with novel probabilistic calibration methods. Cost ranges were applied to the interventions, the treatment of preventable adverse drug events (pADEs), and the value of the health lost as a result of an ADE.

The model predicts annual health service costs of between £0.3 million and £1 million for the treatment of pADEs in a 400-bed acute hospital in the UK. Including only health service costs, it is uncertain whether any of the three interventions will produce positive net benefits, particularly if high intervention costs are assumed. When the monetary value of lost health is included, all three interventions have a high probability of producing positive net benefits with a mean estimate of around £31.5 million for CPOE over a five-year time horizon.

The results identify the potential cost-effectiveness of interventions aimed at medication errors, as well as identifying key drivers of cost-effectiveness that should be specifically addressed in the design of primary evaluations of medication error interventions.

We identified 118 mixed methods studies funded by the Department of Health in England between 1994 and 2004, and obtained proposals and/or final reports for 75. We applied a set of quality questions to both the proposal and report of each study, addressing the success of the study, the mixed methods design, the individual qualitative and quantitative components, the integration between methods and the inferences drawn from completed studies.

Most studies were completed successfully. Researchers mainly ignored the mixed methods design and described only the separate components of a study. There was a lack of justification for, and transparency of, the mixed methods design in both proposals and reports, and this had implications for making judgements about the quality of individual components in the context of the design used. There was also a lack of transparency of the individual methods in terms of clear exposition of data collection and analysis, and this was more a problem for the qualitative than the quantitative component: 42% (19/45) versus 18% (8/45) of proposals (p = 0.011). Judgements about integration could rarely be made due to the absence of an attempt at integration of data and findings from different components within a study.

The HSR community could improve mixed methods studies by giving more consideration to describing and justifying the design, being transparent about the qualitative component, and attempting to integrate data and findings from the individual components.

QOF data were obtained for all PCTs for 2005–2006. National prescribing data for statins was analysed for the same time period. The square of the Pearson correlation was used to assess the association between the two.

The average PCT values for the three QOF indicators for CHD, stroke and diabetes were 78% (range 66–88%), 72% (58–82%) and 79% (67–88%), respectively. The percentage use of simvastatin and pravastatin by PCTs varied from 18–84%, with a mean of 57%. There was no evidence of any association between the use of simvastatin and pravastatin as a percentage of all statin items and success in achieving the QOF targets.

PCTs that had a high proportion of simvastatin and pravastatin use were just as successful achieving cholesterol targets for patients with coronary heart disease, diabetes and stroke as those that used more atorvastatin, rosuvastatin or fluvastatin. This supports the policy to use the less expensive generic statins.

Qualitative semi-structured interviews were carried out with health professionals who were currently caring for patients with heart failure, and observations were conducted at one dedicated heart failure clinic in northern England.

While clinicians acknowledged that patients' ideas and preferences should be an important part of treatment decisions, the widespread acceptance of an evidence-based clinical protocol for heart failure among the clinic doctors significantly influenced the content and style of the consultation.

Evidence-based medicine was used to buttress professional authority and seemed to provide an additional barrier to the adoption of patient-centred clinical practice.

Two rounds of interviews with national stakeholders and senior DHB personnel plus case studies in five districts which included key informant interviews, observation at board meetings and document analysis.

The re-structuring of the health sector in New Zealand appears to have simultaneously enhanced and inhibited the achievement of government objectives. Local decision-making has encouraged greater local responsiveness and new funding arrangements have allayed concerns about inter-regional equity. The system is less commercially oriented than it was during the 1990s and collaboration between DHBs is improving. However, the combination of increased integration of purchasing and provision within DHBs and the focus on financial deficits in the early years appears to have inhibited the development of partnership relationships between DHBs and non-government providers, and of longer-term funding arrangements for high quality providers. Non-government providers perceive that DHBs have a tendency to favour their own providers when allocating contracts.

Decentralized decision-making is starting to make some inroads towards achieving some of the government's objectives with respect to resource allocation and purchasing.

Two discrete choice experiments incorporated into a survey of general practice patients and qualitative methods to support survey development.

An overall response of 94% (1052/1123) was achieved. Factors influencing the average respondent's choice of appointment, in order of importance, were: seeing a doctor of choice; booking at a convenient time of day; seeing any available doctor; and having an appointment sooner rather than later (acute, low worry condition). This finding was the same for an ongoing, high worry condition but in addition the duration of the appointment was also of (small) value. Patients traded off speed of access for more convenient appointment times (a willingness to wait an extra 2.5–3 days longer to get a convenient time slot for an acute low worry/ongoing, high worry condition, respectively). However, contrary to expectation, patients were willing to trade off speed of access for continuity of care (e.g. willingness to wait five days longer to see the doctor of their choice for an acute, low worry condition). Preferences varied by a person's gender, work and carer status.

Patients hold strong preferences for the way general practice appointment systems are managed. Contrary to current policy on improving access to primary care patients value a more complex mix of factors than fast access at all costs. It is important that policy-makers and practices take note of these preferences.

A qualitative study which focuses on the controversial downsizing of Kidderminster Hospital, a highly publicized landmark case of district general hospital closure. Rhetorical strategies are analysed to examine how legitimacy was constructed by stakeholder groups and how these strategies were used to support or resist change.

Stakeholders promoting change legitimized re-organization pragmatically and morally arguing the need for centralization as a rational necessity. Stakeholders resisting change argued for cognitive and moral legitimacy in current service arrangements, contrasting local versus regionalized aspects of safety and provision. Groups managed to talk past each other, failing to establish a dialogue, which led to significant conflict and political upheaval.

Stakeholders value hospitals in different ways and argue for diverse accounts of legitimacy. Broader discourses of medical science and democratic participation were drawn into rhetorical texts concerning regionalization to render them more powerful.

Qualitative research with people who had recently used the system: 47 people in eight focus groups and 13 individual interviews.

Recurrent themes included characteristics of the system which are rarely addressed in service-specific questionnaires, in particular, confusion over the most appropriate service to use for particular health problems, coordination between services and informational continuity across services. Other characteristics were identified which, although commonly included in service-specific questionnaires, could have system-level consequences. These included communication between health professionals and patients, and ease of access to services. For example, patients' perception of poor communication with one service could increase their subsequent use of other services in the system. Proactive behaviour from health professionals was an important system characteristic because it could allay patient anxiety by making patients feel that their concerns were being taken seriously and that staff could sort out problems such as feeling ‘stuck in’ or ‘bounced around’ the system. ‘Candidacy’, whereby eligibility for health care is jointly negotiated between the user and the service provider, was evident as an issue for patients across the social spectrum when seeking help urgently.

Questionnaires designed to assess patients' views and experiences of emergency and urgent care should address system-level as well as service-specific issues in order to address the full range of patient concerns.

Data were gathered from Welsh Assembly Government concerning project set-up and borrowing rates. Mailed questionnaires were completed by 21/22 (95.4%) Local Health Boards and 44/64 (68.8%) Community Mental Health Teams. In addition, 327 out of 497 (66%) primary care practices were surveyed by telephone, 20 prescribers took part in in-depth telephone interviews and three focus groups were conducted with library staff.

From July 2005–March 2006, books were borrowed 15,236 times. There was a 10-fold variation in borrowing rates across local authorities (1.07 to 10.18 loans/1000 people). The priority which Local Health Board staff reported giving to the scheme varied. Uptake among prescribers was mixed: in 35% of general practices (n = 116) no-one participated. Prescribers reported different ways of using the bibliotherapy scheme. Library staff reported issues of patchy uptake.

Variation in usage of bibliotherapy raises questions about equity; it is unlikely to reflect the distribution of people who could potentially benefit. Factors influencing variation existed all along the implementation chain. It is not always possibly to separate demand-side and supply-side factors when considering equity and service innovation in health care.

Mixed methods, including secondary analysis of quantitative data, qualitative research and a large self-completion survey of all British-registered pharmacists with an overseas address.

Almost 11% of British-registered pharmacists reside overseas. Nearly three-quarters are British-trained and most are UK nationals. The US, Canada and Australia are the main destinations. The majority work as pharmacists in health services, but sizeable proportions are either retired, not working for other reasons or work in industry. Those who emigrate include those returning home, moving for career opportunities, for lifestyle reasons or as a ‘spouse trailer’. For many the move abroad is a permanent one.

Great Britain is both a source and destination country for migrating pharmacists. Emigration currently exceeds immigration. Pharmacists are not migrating to developing countries, so the profession may want to consider ways of contributing to the health care systems in developing countries which are the source of some of the immigrant pharmacists to Great Britain.

Secondary analysis of a high quality clinical database from a national clinical audit using data from 385,429 admissions to174 ICUs in England and Wales between December 1995 and July 2005, of which 4219 (1.1%) had alcoholic liver disease. The extrapolated total number of admissions with alcoholic liver disease and total number of ICU bed-days occupied were calculated. Changes over time in the case mix (age, sex and APACHE II and ICNARC risk prediction models), mortality at ultimate discharge from acute hospital, and length of stay in ICU and in hospital were explored.

The percentage of ICU admissions with alcoholic liver disease increased from 0.65% in 1996 to 1.35% in 2005, but the case mix remained similar. Mortality decreased and length of stay increased over this period. The extrapolated total number of admissions to all 229 adult, general critical care units in England and Wales increased from 550 in 1996 to 1513 in 2005, and the extrapolated total number of bed-days occupied by these admissions increased from around 3100 to over 10,000.

Admissions to ICUs in England and Wales with alcoholic liver disease tripled over the 10-year period from 1996 to 2005. The continuing increase in alcohol consumption means that this trend is likely to continue.

Two annual surveys conducted with the same cohort of pharmacy students in 2005 and 2006. The questionnaires sought to clarify influences on respondents' career intentions and their early career plans.

Only two-thirds of respondents intended going straight into British pharmacy practice after training, with fewer white men (57%) than ethnic minority men (71%) intending to go straight into practice. Preferences for early careers reflected existing occupational segregation, with 41% of white females hoping to work in hospital pharmacy and a similar proportion of ethnic minority men (40%) hoping to work for a large multiple community pharmacy after training.

A sizeable proportion of pharmacy students do not intend entering the profession for which they have trained, a proportion which is much larger than estimated by other studies. This has significant implications for workforce planning. Existing gender and ethnic segregation in the profession may have occurred as a result of personal choice rather than being a function of constraints operating within the pharmacy labour market.

In December 2005, all UK obstetric maternity units were contacted and asked to provide a copy of their protocol on preventing GBS disease. Information was extracted on the protocol's recommendations, its development date and the evidence cited. The protocol's recommendations were then compared against the recommendations in the Royal College of Obstetricians and Gynaecologists (RCOG) guideline.

Protocols were obtained for 171 of the 227 units (75%), of which 120 were developed after the guideline has been published. There were 134 protocols (78%) that followed the RCOG prevention strategy, recommending a risk-based approach to selecting women for intrapartum antibiotic prophylaxis (IAP). However, the sets of risk factors named as indications for IAP differed between the protocols and only 34 of these 134 protocols were entirely consistent with the guideline. The 37 protocols (22%) that did not follow the RCOG prevention strategy recommended IAP for some risk factors but only if a bacteriological test was also GBS positive.

There are considerable differences in the GBS protocols used in maternity units in the UK despite the availability of a national guideline. Consequently, some high-risk women may not receive IAP while some women without risk factors are treated needlessly. While local adaptation may be for legitimate reasons, the processes used in some units seem to require improvement.