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.

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.

The purpose of this systematic overview was to assess the evidence for the effectiveness of public health nursing interventions when carried out by the strategy of home visiting of clients in the pre- and postnatal period. This is an update of a larger overview first collecting literature to 1993, then updated to the end of 1995, and now updated to 1998. The search of published and unpublished literature related to home visiting resulted in retrieval of a total of 211 articles, including 149 articles relevant to all age groups and including all interventions implemented by various professional and nonprofessional groups, where the intervention was considered to be within the scope of practice of public health nursing in Ontario. When the relevance was limited to interventions where the intervenor was known to be a nurse, and the clients were in the pre- or postnatal period, there were 20 articles with quality ratings of ‘strong’ or ‘moderate’ included in this update for the systematic review, and 8 additional articles in this update. There were no reported negative effects of home visiting in the 12 strong articles. Positive outcomes included improvement in children's mental development, mental health and physical growth, reduction in the mother's depression, improvement in maternal employment, education, nutrition and other health habits, and government cost saving. There is no proven impact on low birth weight, gestational age or neonatal morbidity or mortality, although the studies had inadequate sample sizes to demonstrate a difference in such relatively rare occurrences. As a delivery strategy, nurses visiting pre- and postnatal clients in the home can produce significant benefit, particularly with interventions of high intensity and with clients who are considered to be ‘at risk’ due to factors such as low income and low educational achievement.

This paper is based on a qualitative study that was designed to investigate patients' experiences of day case surgery and its outcomes. The study was a part requirement of a Masters course in Community Care Studies, and was conducted in a Welsh Integrated Trust in 1997. A case-study approach employing semi-structured interviews was used. A total of 16 patients were interviewed (5 females and 11 males). Three of the males and all five females had varicose vein repair, and the other eight males had a hernia repair. The findings of the study were that although patients preferred the option of day care surgery and indicated that they would choose this in future, the information given to them and the postoperative care they received were largely inadequate. The interviews demonstrate that the communication between hospital and home care was often inadequate, and that some patients and carers experienced unforeseen difficulties and distress.