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In 1993 the Conference of Royal Colleges and their Faculties called for its members to develop formalized continuing medical education (CME) programmes. Most colleges have adopted a narrow definition of CME and a mechanistic approach to monitoring participation. The Faculty of Public Health Medicine has responded differently by initiating a broader model of continuing professional development (CPD) which emphasizes the individual nature of continuing education. This paper explores the rationale behind this decision. Recent systematic reviews of the effectiveness of CME have demonstrated the need for relevance in any continuing education activity. This means relevance not only to learning needs but also to current work and the applicability of the knowledge. However, the effectiveness of traditional CME for all doctors and particularly public health physicians remains to be established. Thus the Faculty has moved towards a wider context of learning in the form of CPD incorporating an evaluative approach and aspects of adult learning theory. There remains a need for the links between audit and continuing education to be strengthened.

Background This paper evaluates claims in a recent study that inequalities in small area mortality rates have lessened. We examine the effect of differently estimated populations on time trends in age‐specific mortality rates for Yorkshire and the Humber and East of England. [ABSTRACT FROM PUBLISHER]

Background The continuing identification, assessment and management of risks are key themes for clinical governance. These themes are being integrated into both primary and secondary care practice; however, integration into public health practice appears much slower. This paper describes the recent approach that we have taken in Sheffield, and proposes a model for public health departments to identify, assess and manage risks, which complements other risk management processes and is transferable to other settings. It assumes that public health practice is not a risk‐free activity and holds that the process of identifying, assessing and managing risks is a key component to raising standards. [ABSTRACT FROM PUBLISHER]

This paper discusses the work of Raymond J. Donaldson, who served as Medical Officer of Health (MOH) on Teesside in the North-East of England, 1968-1974, and the professional strategy that he adopted during this period is characterized. It is shown that Donaldson effectively withdrew from areas where the local authority public health department and general practitioners offered the same services, and consciously sought the complete attachment of some grades of staff to general practice. This approach, which was based on the view that in the long term the local authority could not compete successfully with general practitioners, allowed him to develop other activities, notably in the area of action research. 'Progressive realism' will be suggested as a suitable description for Donaldson's professional strategy during his time in Teesside. [ABSTRACT FROM AUTHOR]

Public health practitioners are often faced with the necessity to compare the mortality experience of different geographical areas. Indirect standardization, producing a 'standardized mortality ratio' (SMR) is the most commonly used technique for doing this. However, as we show, indirect standardization is inappropriate for such comparisons, as SMRs for different geographical areas have different denominators. The fact that indirect standardization is usually chosen for this type of comparison is probably based on two beliefs: (1) that direct standardization yields only a rate rather than a more easily interpreted ratio or index; (2) that direct standardization cannot be carried out in many cases because the sub-group specific mortality rates in the groups to be compared are not available or, in at least some age classes, are based upon such small numbers as to be completely unreliable. In this paper we show that a simple index (the comparative mortality figure) can be calculated from the directly standardized rate in most cases. Using a comparison of the overall mortality experience of electoral wards in Sheffield between 1980 and 1987 we demonstrate also that the advantage gained by the smaller standard error of the SMR is outweighed by the bias inherent in its construction. We recommend that the SMR is used only when absolutely necessary, that is, in the rare circumstance when data are not available for the calculation of age- and sex-specific subgroup rates in the study population. [ABSTRACT FROM PUBLISHER]

This paper describes the successful implementation of universal antenatal screening for HIV and hepatitis B in Southampton and South West Hampshire Health Authority. This was achieved through formation of a multi‐disciplinary planning group of clinicians and managers from local trusts. The approach taken in implementing screening is described, key elements of this being the appointment of screening co‐ordinators and consultation with local midwives to ensure their training needs were addressed. Lessons for future work are discussed. [ABSTRACT FROM PUBLISHER]

Background In the United States, an association has been proposed between better access to primary care and lower mortality. This paper reports an ecological analysis that evaluated whether population health was associated with general practitioner (GP) supply in England. [ABSTRACT FROM PUBLISHER]

Background. The aim of the study was to establish the prevalence of urinary symptoms and felt the need in adults. This paper discusses problems with setting thresholds to distinguish cases from non-cases in this field of research. Few studies have provided detailed age- and sex-specific prevalence estimates for felt need in relation to urinary symptoms. [ABSTRACT FROM PUBLISHER]

Background. Recent UK government documents have stated that, within the National Health Service, consumers should be more involved in decision-making. This study considered the technique of discrete choice conjoint analysis (DCCA) for eliciting community views regarding the importance of reducing waiting times. More specifically, the study aimed to establish whether residents living on the Isle of Wight are prepared to travel to the mainland for elective surgery where waiting times are shorter but travel costs may be greater, and, further, if residents are willing to travel, what reduction in waiting time and increase in travel costs would be acceptable. [ABSTRACT FROM PUBLISHER]

Schools are identified as a key setting for health promotion in the UK Government's consultation report on the public health strategy for England. The concept of the 'healthy' or 'health promoting school' provides the basis for a broad settings approach to health promotion in schools. The approach extends beyond the formal health education curriculum to include a consideration of the physical and social environment of schools and their links and partnerships with parents and the wider community, in pursuit of better health. There is growing evidence that the health promoting school approach is effective in influencing outcomes related to health and education. Initiatives in the form of projects and schemes are commonly used by Health Promotion Specialist services and health partnerships, to stimulate and support the adoption of the approach by schools. A national healthy school scheme is to be launched alongside these local initiatives in 1999. The paper reviews research and practice in this area and makes recommendations to inform the future development of schools as health promoting organizations. [ABSTRACT FROM PUBLISHER]

Background: Smoking behaviour is of central concern to enhanced population health and there is a recognized need for detailed information concerning many different aspects of this behaviour. This paper assesses the utility of three large-scale national surveys according to their ability to provide such information. These are the General Household Survey (GHS), the British Household Panel Survey (BHPS) and the Health Survey for England (HSE). [ABSTRACT FROM PUBLISHER]

The article discusses the ineffectivity of population screening on the prevention and control of tuberculosis (TB) in Croydon, England which emphasizes that it should be replaced with early diagnosis. It notes that only one case of TB is diagnosed by TB screening per 951 entrants screened and the three patients diagnosed are non-infectious. It furthers that close links with the agencies which are involved in the management of direct referral to TB nurses must be developed.

Background Data are available on the prevalence of smoking states (never, current and ex). However, data on behaviour change rates (starting – never to current, quitting – current to ex and lapsing – ex to current) are not readily available and cannot be simply derived from or related to prevalence data. [ABSTRACT FROM PUBLISHER]

Background The aim of this study was to determine whether the risk of congenital anomalies in a population resident close to a waste combustion plant located at Byker in the city of Newcastle upon Tyne, United Kingdom, was higher than in a population resident further away. [ABSTRACT FROM PUBLISHER]

Background The aims of this study were to develop ischaemic heart disease (IHD) registers in three primary care groups (PCGs) in SW London; to determine what proportion of patients with IHD were already identified; and to estimate the workload in producing an IHD disease register. [ABSTRACT FROM PUBLISHER]

Until recently, national coding and analysis of routine mortality statistics in most countries included only underlying cause of death. There were changes in the rules for selection and coding of underlying cause in England in 1984 and 1993. We report on trends in mortality rates in an English region from 1979 to 1998, comparing multiple‐cause and underlying‐cause coded rates, for individual diseases that were affected by coding changes. Among many others, these include pneumonia, venous thromboembolism, heart failure, respiratory distress syndrome, tuberculosis, diabetes, dementia, alcohol and drug abuse, epilepsy, multiple sclerosis, stroke, asthma, peptic ulcer, appendicitis, and cancers of the breast, colon and prostate. Comparisons over time of mortality rates based on underlying cause alone will be misleading when the time‐period crosses years in which rules changed for selecting underlying cause. [ABSTRACT FROM PUBLISHER]

Background Over 90 per cent of local housing authorities in England allocate medical priority for rehousing (MPR) to applicants with medical or care needs but very few studies have been undertaken to investigate the health effects of this practice. This longitudinal study compares the change in health status of adult applicants for MPR who were rehoused with applicants who were not rehoused. [ABSTRACT FROM PUBLISHER]

The article reports on the action plan updates of various common communicable diseases in England and Wales from April to June 2002. The Department of Health remarked that the implementation of national sexual health strategy in sexually transmitted infections (STIs) is highly recommended to reduce unintended pregnancy rates. In addition, the prevalence of B streptococcal disease (GBS) is found the leading cause of serious bacterial infection in young infants.

Background Our aim was to describe the epidemiology of cutaneous malignant melanomas (CMMs) in males and females in the south east of England from 1960 to 1998. Birth cohort effects are important when describing the incidence of CMMs because fashions of dress affect whether different body sites are exposed to sunlight. [ABSTRACT FROM PUBLISHER]

In a modern industrialized society it was essential for humankind to be protected by a strong medical presence, to establish a uniform system for public health everywhere in that society, to make public health independent from the welfare system, and to harmonize the relationship between personal hygienic rules and local authority rules. The society in Japan has developed on the basis of those four philosophical principles of public health, and has enabled the people to have the longest life expectancy in the world. However, the public health system in this society is now in a critical situation resulting from the long life expectancy. How can we rebuild the role of public health in this country? A society with a long life expectancy has to face a wide variety of health conditions. However, the health insurance system in Japan does not generally provide any service for a patient without specific symptoms. Consequently, to help people become aware of their own health condition, comprehensive public services such as general health check‐ups, screening for cancers, and health counselling have been established locally by all 3250 municipal authorities. In promoting those services, people must learn how to draw the boundary‐line between ‘public’ and ‘private’ in affairs of health to understand the importance of ‘hygienic rules based on counsels for personal self‐government’, as Simon suggested 100 years ago, and health professionals must develop a public health system which depends not only on regulatory laws but also on scientific findings, as Rumsey advocated 150 years ago. [ABSTRACT FROM PUBLISHER]

Background In the North West of England, data on drug users are routinely collected from a variety of agencies including specialist treatment centres, police and probation services. However, the covert nature of drug use means that alone, these conventional monitoring systems cannot provide the epidemiology required to target and develop drug treatment and prevention initiatives. [ABSTRACT FROM PUBLISHER]

Background The study examines time trends and socio‐demographic aspects of drug poisoning deaths in England and Wales. [ABSTRACT FROM PUBLISHER]

Background NHS Direct was set up in 1998 and now covers all of England. One site in South East London, which went live in April 1999, has been studied to gain an insight into how NHS Direct is used and by whom. [ABSTRACT FROM PUBLISHER]

Background. In the context of contaminated land, assessing risk involves identifying a source, a pathway and a receptor. We describe how this approach worked in practice following the discovery of high lead levels in the soil of an allotment site in a London borough. [ABSTRACT FROM PUBLISHER]

Background. Little is known about the similarities or differences with which Primary Care Group (PCG) Board members view the relative importance of the three functions with which they are charged, or how representative these views are of local primary care teams in general. This project explores the priorities of medical and nursing PCG Board members in relation to those of local General Practitioners (GPs) and practice nurses they represent. [ABSTRACT FROM PUBLISHER]

Background. Excess winter mortality is higher in England and Wales than in other European countries with similar or lower average winter temperatures. It might be expected that excess winter mortality would be higher in areas with greater socio-economic deprivation, and if this were so preventive interventions could be directed at populations in these areas. The association between deprivation and excess winter mortality has not been adequately investigated in the past. The aim of this study was to look at the association between excess winter mortality and socio-economic deprivation, so that policy decisions to reduce this excess mortality could be appropriately directed. [ABSTRACT FROM PUBLISHER]

Background A sulphur dioxide (SO2) episode occurred in the United Kingdom in 1998. The worst affected area was the city of Nottingham. [ABSTRACT FROM PUBLISHER]

The author reflects on the role of general practitioners (GPs) and other public health specialists to render quality of services at the National Health Services in England. The author emphasized the importance of structural and organizational change and establishing strong relationships among the medical personnel. Information regarding the public health policies based on Primary Care Trusts (PCTs) standard is also considered.

Background. Non-occupational exposure to asbestos has been of increasing interest, but residential exposure to asbestos often focuses on a few high-profile asbestos users. This study aimed to identify industrial sites producing asbestos goods in a given area and time period. [ABSTRACT FROM PUBLISHER]

There is increasing provision of welfare benefits advice in primary care (WBAPC). This reflects the present government's recognition of the association between socioeconomic and health inequalities. However, the assumption that increasing an individual's income will improve their health is not based on clear evidence. This paper reviews the relevant evidence, using four categories of pathways from poverty to ill-health: individual material; environmental material; individual psychological; environmental psychological. A description is offered of the scope and limits of WBAPC as a health intervention: one that primarily offers relief from psychological stress for service users, who tend to be middle-aged or older and suffering from chronic disease or disability. WBAPC may also make a small contribution to the physical health of individuals and to the social capital of communities. Thus to define the scope of WBAPC does not diminish its value to its beneficiaries, who carry a significant burden of both poverty and illness, nor does it in any way weaken the ethical argument for public policy to seek to reduce inequalities, and for primary care to play its part in that.

Background: The aim of this paper is to describe an incident where elemental mercury led to widespread contamination and the exposure of 225 individuals and confirmed toxicity in 19 individuals. The paper describes the incident and difficulties found in trying to assess the risk to individuals and to identify and decontaminate the residences involved., Methods: All individuals exposed to elemental mercury in the incident were followed up for 15 months., Results: Thirty-seven individuals were found to be 'at risk' and 13 were symptomatic of mercury poisoning. Five patients required chelation therapy. The incident was closed when the risk of poisoning and re-exposure was minimized., Conclusion: Incident management depends on early effective communication and collaboration between all agencies involved.

Background: The UK government has specified that all health authorities are to develop local health improvement programmes. Birthweight and gestational age are important health determinants, and therefore indicators of the health status of children in a community. They also have important resource implications for health and social services. Data regarding birthweight and its relationship to gestational age are not routinely available. This paper describes the results of the measurement of the birthweights and gestational ages of children born to residents in a UK health district, and their relationship with deprivation., Methods: Routinely collected birthweight and gestational age data for children born to parents resident in the South Tees district during the period 1990-1996 inclusive were downloaded from the community child health department mainframe computer. The data were analysed and compared with national standards., Results: The analysis showed that, despite the high levels of deprivation, birthweights were close to or slightly above average for most gestational ages. However, when compared with the average district in England and Wales, 8 per cent more low-birthweight children, of which 42 per cent were less than 28 weeks gestation, were born in the area. Materially deprived mothers were more likely to give birth to pre-term and light for gestational age infants., Conclusions: This study has shown that it is now possible to use routine sources of information to monitor local trends in birthweight and gestation, and their relationship with deprivation.

Background: Tuberculosis poses a global public health threat, and individuals who fail to comply with treatment risk developing drug-resistant strains, which are a serious public health concern. A number of individuals who have been deemed to pose a 'serious risk of infection' to others have been detained in recent years in England and Wales under the Public Health Act 1984. With the incorporation of the European Convention on Human Rights (ECHR) into British law due to take effect shortly this paper examines the justness of Sections 37 and 38 of the Act, and asks whether the Act stands up to scrutiny under the ECHR., Methods: A critical review, including an examination of recently opened relevant files at the Public Record Office, was carried out on Sections 37 and 38 of the Public Health Act 1984., Results: Sections 37 and 38 of the Public Health Act 1984 fail to provide sufficient safeguards from abuse and fall short of the requirements of the ECHR., Conclusions: Sections 37 and 38 should be replaced. Greater safeguards to protect the rights of those with infectious diseases are needed.

Background: This paper describes primary care consultation rates in a sample of people with learning disability. The study was carried out as part of a wider survey of primary care for this population group in response to concerns over quality of care and debate between general practitioners (GPs) and the local health authority over the need for additional remuneration for caring for people with learning disability. Estimates of consultation rates in the literature to date are conflicting and we sought to provide local data on the number and type of contacts with the primary care teams to inform this debate., Method: A primary care case note review was carried out of 112 people with learning disability aged over 18, identified from an administrative sample of 967 people known to health and social services. Contact rates (with practice nurses or GPs) were calculated and indirectly standardized for age using data from the fourth National Morbidity Survey in General Practice (MSGP4)., Results: Standardized consultation ratio in men was 156 (95 per cent confidence interval (CI) 142-172), in women was 111 (95 per cent CI 102-121) and for both sexes was 127 (95 per cent CI 120-135). Average contact rate was 4.6 per person per year. Eighty per cent of contacts were with GPs. Eighteen per cent (95 per cent CI 11-25 per cent) of subjects consulted, on average, more than once every two months. Limited information on underlying cause of learning disability and severity was available. Consultation rates were independent of age and sex, and were not increased in people with Down's syndrome or epilepsy compared with the rest of the sample population. Consultation rates were highest in people living in staffed group homes (p = 0.01). The presence of special arrangements between practices and residential facilities did not appear to increase service contact, but this finding is prone to measurement bias., Conclusions: Contrary to the findings of previous studies, people with learning disability consult primary care teams more frequently than the general population. However, this should not be taken as supporting calls for additional resources without addressing the effectiveness and appropriateness of health care offered.

Background: Fallout containing asbestos from a factory fire at Tranmere, Wirral, England, landed on a highly populated urban area with an estimated 16000 people living in the area worst affected, which included a shipbuilding community. There was considerable public concern over the health impact of the acute environmental incident, and great media interest., Methods: A descriptive study was carried out of the acute environmental incident and its management, and the difficulties encountered., Results: Practical lessons learnt include need for: increased fire-fighter awareness of potential adverse health effects from asbestos in the structure of buildings; early involvement of both Local Authority environmental health and National Health Service public health departments; creation of a systematic local database of potential environmental health hazards in the structure of buildings as well as their contents; 24 hour on-call arrangements with laboratories expert in analyses of fire fallout; rapid quantitative analyses of multiple environmental samples; district written policy on handling asbestos incidents; systematic assessment of fright and media factors in public impact of an incident; dedicated public help-lines open long hours; consistent evidence-based public messages from all those communicating with the public; measurement of asbestos levels in the street and homes for public reassurance; local and health authorities' subscription to an environmental incident support service; formation of an acute environmental incident team to jointly manage and publicly report on airborne acute environmental incidents; clear government definition of responsibilities of different agencies., Conclusions: This paper provides a description of important lessons learnt during an acute environmental incident with asbestos-containing fallout. It will be helpful to those involved in the practical planning for and management of future incidents.

Background: Ischaemic heart disease is the commonest cause of mortality in the United Kingdom. The objective of this study was to assess the management of patients with ischaemic heart disease in primary care, focusing particularly on the management of hypercholesterolaemia., Methods: A cross-sectional survey was carried out of the clinical records of patients aged 25-74 years with confirmed ischaemic heart disease in six general practices (total list size 56 600)., Results: Recording of risk factors varied from 97 per cent for blood pressure to 73 per cent for cholesterol measurement. Seventy-two per cent of the patients had adequate blood pressure control, based on their last recorded blood pressure. Sixty-one per cent (267) were known to be taking aspirin daily and 29 per cent (125) had undergone revascularization treatment. Sixty-eight per cent (296) of the patients had pre-treatment cholesterol levels of 5.5 mmol/l or greater and 34 per cent (147) were currently taking lipid lowering drugs. Statins were the most commonly used cholesterol lowering agents and were being taken by 30 per cent (131) of the patients. Patients who had undergone revascularization treatment had levels of recording of risk factors similar to other patients with ischaemic heart disease but were more likely to be taking daily aspirin (71 per cent versus 57 per cent, relative risk 1.24, 95 per cent confidence intervals (CI) 1.07-1.44). The mean pre-treatment cholesterol was 6.49mmol/l and the mean post-treatment cholesterol 5.80 mmol/l (difference 0.69 mmol/l, 95 per cent CI 0.55-0.84 mmol/l)., Conclusions: Systematic searches of computerized and paper medical records can identify subgroups of patients who will benefit from continuing follow-up in primary care. The results of this study suggest that ischaemic heart disease remains an area where there is scope to improve the management of patients in primary care. Considerable effort will be required from the members of the primary health care team to achieve this objective, particularly in the areas of computerized data collection and in the identification and recall of patients.

This paper describes the approach of one total purchasing project (TPP) to health needs assessment (HNA) and identifies issues that require consideration when undertaking HNA in primary care. It discusses the advantages of adopting a Health Authority (HA) HNA strategy and the development of a decision-making process for implementing this and other strategies to address possible areas of identified need. The prerequisites, advantages and potential difficulties of this approach are highlighted and related to the needs of primary care groups (PCGs) for addressing health needs and population health.

Background: The concept of deprivation refers to the conditions experienced by people who are poor, whereas the concept of poverty relates to the lack of income and other resources that make these conditions difficult to break away from. The usual Census-based deprivation indices are often based on equally weighted (and highly correlated) variables. This is in spite of the fact that different social groups have been shown in numerous studies to have differing probabilities of suffering from deprivation. A weighted deprivation index based on individual level data and Census data produces a more accurate and more easily understandable method of estimating deprivation within an area, as it reflects the differences between social groups. This paper will describe how a technique used by Gordon (J Epidemiol Commun Hlth 1995; 49(Suppl. 2): S39-S44) can be applied to smaller areas to give estimates of the number of deprived living within them, producing a weighted index., Methods: Breadline Greenwich data together with Census data were used to estimate the percentage of poor households in Greenwich wards using similar methods to those of Gordon., Results: The results produced were very similar to the numbers estimated using the Breadline Britain weightings but there were differences in individual weightings for some of the variables., Conclusion: Gordon's approach can be applied to smaller areas to give estimates of the number of deprived using the nationally derived weightings. More accurate local estimates, subject to the different local conditions, can be easily derived if a similar survey to the Breadline Britain survey is conducted locally.

Background: Body mass index is used to measure obesity in individuals and to monitor trends in population obesity. Some observers use self-reported height and weight to assess body mass index; others use measured parameters. This paper reports on a study to compare body mass index when calculated from self-reported and measured heights and weights., Methods: A randomized postal questionnaire survey and follow-up clinical measurement study were carried out in a geographically defined population in the rural South West of England; subjects were 6000 residents of Somerset health district aged 16-64 years selected from the Family Health Services Authority register., Results: The response rate for the postal questionnaire was 57.6 per cent. A total of 73.3 per cent of responders agreed to clinical measurements; 84 per cent of measured volunteers had over-reported their height and 74 per cent under-reported their weight. The difference between body mass indices based on self-reported and measured values of height and weight is highly statistically significant for the whole population and for most age-sex and body mass groups., Conclusions: Self-reported heights and weights are unreliable and if used for monitoring health targets should be treated with caution.

Background: Over the last 25 years clinical trials have reported improvement in the management of leukaemia leading to improved survival. In this paper we present the population-based survival patterns of leukaemia over the last two decades from East Anglia., Methods: Data on leukaemia from the East Anglian cancer registry were analysed to study survival based on age and time period at diagnosis. Kaplan-Meier survival was calculated for children (ages 0-14) and for adults (ages 15+) separately, for the main leukaemia sub-types., Results: A total of 2044 males and 1524 females with leukaemia were registered between 1971 and 1990, of whom 158 (7.7 per cent) and 123 (8.1 per cent) were aged less than 15 years at diagnosis. In children, five-year survival was significantly better for females for all leukaemias (p = 0.02) and for acute lymphoid leukaemia (ALL) (p < 0.01). Infants and older children had the worst prognosis as compared with children aged 2-9 years. Analysis by quinquennium of diagnosis showed a highly significant improvement in survival (p < 0.00001) for children with ALL in the later decade (1981-1990). In adults, patients with lymphoid leukaemia survived better as compared with the myeloid subtypes (p < 0.0001). Analysis by year of diagnosis in five-year calendar period showed a significant improvement in survival for acute myeloid leukaemia (p < 0.01), chronic myeloid leukaemia (p < 0.05), chronic lymphoid leukaemia (p < 0.05) and for the four types together (p < 0.001). Survival decreased with age for each subtype., Conclusions: Age is an important predictor of survival. There was a significant improvement in survival with time for all subtypes except ALL in adults.

Background: This paper describes the relationship between social deprivation and incidence of, and survival from, breast, lung, and colorectal cancers among residents of the South Thames regions. We analysed 23,505 cases of breast cancer, 29,903 cases of lung cancer and 21,905 cases of colorectal cancer, aged 40-99 inclusive at diagnosis and diagnosed between 1 January 1987 and 31 December 1992., Methods: Using the 1991 Census in conjunction with the Townsend index on social deprivation, we derived proxy indicators of deprivation based on patients' home postal codes. Cumulative relative five-year survival rates (per cent) were calculated for each cancer. We then compared our results with the relevant standardized incidence and mortality ratios by deprivation status., Results: A clear trend was observed in standardized mortality rates across deprivation tenths for the three tumour sites: mortality increased with deprivation. A strong positive correlation was found between deprivation and the incidence of lung cancers (p < 0.0001), but no association was found between deprivation and incidence of breast and colorectal cancers. Significantly lower five-year relative survival rates were found for breast and colorectal cancer patients in the most deprived Townsend tenths. Breast cancer patients resident in the most affluent tenth of enumeration districts had a 70 per cent relative survival ratio compared with 57 per cent in the most deprived tenth. The corresponding figures for colorectal cancer patients were 40 per cent and 32 per cent, respectively., Conclusions: Survival differences by deprivation status exist in South Thames among patients suffering from breast or colorectal cancers and are not explained by differences in the incidences of these diseases. For lung cancer, incidence and mortality were positively correlated with deprivation, but no socio-economic gradient was found for survival.

Between 8 December 1995 and 16 January 1996 seven laboratory confirmed cases of septicaemia owing to infection with Neisseria meningitidis serogroup C strains and one highly probable case of meningococcal septicaemia occurred in three electoral wards in south Rotherham and the Retford area of north Nottinghamshire. All cases occurred among children aged 1-17 years. One patient died. The public health response to this outbreak was the largest community prophylactic antibiotic and immunization programme against meningococcal infection, to date, in the United Kingdom. The target group for each Health Authority was 8900 for Rotherham Health Authorities and 8000 for North Nottinghamshire Health. Local logistical factors led to differences in the implementation of the programme by each Health Authority. At the completion of each programme, 8320 doses of vaccine had been administered (92.5 per cent coverage) during the Rotherham Health Authorities programme and 7660 (95.7 per cent coverage) during the North Nottinghamshire Health programme. The additional financial cost of the exercise amounted to approximately Pounds 125000 for each Health Authority. This paper describes the evolution of the outbreak, the decision-making process resulting in the immunization programme in each Health Authority, the implementation of each programme, problems identified and lessons learned.

Background: In a bid to increase consumer satisfaction, recent government reports have encouraged maternity services providers to offer women more choice about their care. At the same time, there has been considerable pressure on hospital managers and clinicians to drive down health service costs. Women need information about the likely effects of different service patterns on their wellbeing, and service providers about the implications of allowing women choice., Methods: This paper reports on a descriptive study in six districts in the Yorkshire Region and focuses on the implications of variation in length of stay. The aim of the study was to describe variation in the care process and to explore associations between care process variables, consumer satisfaction and maternal psychological wellbeing. One hundred and twenty randomly selected women in each district delivering in a specified four-week period were asked to complete postal survey questionnaires in the postnatal period., Results: There were significant differences between districts in terms of the length of postnatal hospital stay for women experiencing normal deliveries. Those women who thought that their postnatal length of stay was too short had significantly higher depression scores., Conclusions: Variation in length of postnatal hospital stay may have implications for consumer satisfaction, maternal psychological outcomes and resource use.

Background: The research described in this paper arose out of the need to address the growing waiting list for orthodontic treatment in Northamptonshire. Although the prevalence of dento-facial anomalies is the same across time, sex, race and socio-economic class, studies in the United States and this country suggest that certain groups are over-represented among patients who receive orthodontic treatment. The introduction of valid and reliable indices of therapeutic need such as the index of Orthodontic Treatment Need (IOTN) will allow improved focusing of services. The aim of the study was to determine the variables affecting access to orthodontic care, and the extent to which services were delivered according to objective measures of need., Methods: Analyses were undertaken for speed, appropriateness, timing of referral, duration and complexity of the pathway for new referrals to specialist orthodontic care. possible explanations for the length of pathway were examined, including socio-demographic factors, location of residence and the IOTN., Results: A total of 405 patients were approached, of whom 400 (99 per cent) agreed to participate. There was an over-representation among socio-economic groups I and V among patients referred to orthodontic treatment. By contrast, those of male sex and from socio-economic class IV were under-represented. This appeared to be the case irrespective of treatment setting. There was also a wide range of waiting times to treatment and complexity of pathway. Over a quarter of the sample had been inappropriately referred, and objective need as measured by the IOTN was not a determinant in the speed of access to specialist treatment. Adult patients waited longer for treatment., Conclusions: These results suggest that the delivery of care is neither based on objective need nor equitably distributed. More appropriate directing of resources is required, using the IOTN and agreed protocols, so that referrals are made to the most suitable provider.

The National Health Service Act 1946 transferred responsibility for the non-voluntary hospitals and certain clinical services from the public health departments of counties and county boroughs to new regional hospital boards, thereby substantially reducing the functions of their medical officers of health and creating a separate cadre of doctors concerned with the planning and management of hospital and specialist services. At around the same time there was pressure to develop in each medical school a department of social and preventive medicine with full-time staff involved in research work. Reviewing the situation 20 years later, the Royal Commission on Medical Education recommended that doctors in public health, medical administration or related teaching and research should form a single professional body concerned with the assessment of specialist training for and standards of practice in 'community medicine'. Immediately after the publication of the Commission's Report in 1968, J. N. Morris invited leaders in the three strands of activities to meet and discuss the proposal. A series of informal meetings led to the setting up, in 1969, of a Working Party (chairman, J. N. Morris) which negotiated with the Royal Colleges of Physicians of Edinburgh, Glasgow and London for them to create a faculty of community medicine. In November 1970 the Colleges set up a Provisional Council (chairman, W. G. Harding), later Board, and the Faculty formally came into existence on 15 March 1972. The key decisions and some of the complications and hitches encountered in achieving this radical outcome are described in this paper.

Background: In England and Wales, surveillance of communicable disease is carried out and co-ordinated by the Public Health Laboratory Service (PHLS). The surveillance of HIV infection and AIDS is undertaken by the PHLS AIDS Centre at the Communicable Disease Surveillance Centre (CDSC). Epidemiological data derived from surveillance are not, however, a free good: they are a resource with an associated opportunity cost and should therefore be open to economic appraisal alongside other users of health care resources such as medical interventions. This paper assembles information on the current surveillance of HIV and AIDS in England and Wales, and explores methods for performing an economic evaluation of such activities., Methods: An examination of the cost and effectiveness of the PHLS AIDS Centre's epidemiological surveillance mechanisms for HIV and AIDS in England and Wales was undertaken. The total costs of each component of surveillance of HIV and AIDS in England and Wales were calculated. Two categories of cost were estimated: peripheral costs incurred by reporters in reporting AIDS cases or HIV infections or by laboratories in collecting samples; and central costs incurred by the PHLS AIDS Centre in processing and analysing incoming data. Using these cost data and information from a cost-effectiveness register, the additional health gains that would have to be obtained from surveillance to make the programme broadly cost-effective in comparison with other accepted uses of health service resources were then estimated., Results: In the financial year 1993-1994 the total costs of surveillance were estimated to be 1.4 million pounds. To avoid being considered relatively cost-ineffective at least 3.5 infections per annum need to be averted. To be considered favourably cost-effective, approximately 9.5 infections per annum need to be averted., Conclusions: In 1993-1994, expenditure on surveillance of HIV and AIDS accounted for less than 1 per cent of the total allocation of resources to the National Health Service for all HIV and AIDS activities. Given these cost estimates, the number of infections which surveillance would have to contribute towards preventing in order to be considered cost-effective is low.

Background: Following the introduction of Helicopter Emergency Ambulance Services (HEAS) in the United Kingdom in the last ten years this paper examines the costs and benefits of three contrasting services in Cornwall, London and Sussex., Methods: Pre-hospital processes of care were compared between helicopter attended patients and land ambulance patients in all three studies, and health outcomes were compared between helicopter and land ambulance patients in the Cornwall and London studies. A review of the literature on the benefits of HEAS has also been undertaken., Results: There were no improvements in response times and the time on scene was longer for helicopter attended patients. Survival of trauma or cardiac patients attended by helicopter was not improved. In London there was some evidence of worse residual disability in helicopter attended survivors, but in Cornwall residual disability was better in helicopter attended patients. There was no improvement in general health status or aspects of daily living in the helicopter attended patients. The overall total operational costs for these services were [symbol: see text] 55 000 p.a. in Sussex, [symbol: see text] 600 000 in Cornwall and [symbol: see text] 1.2 million in London., Conclusion: The analysis suggests that Helicopter Emergency Ambulance Services are costly, the health benefits are small, and there are limited circumstances in which the pre-hospital performance of an ambulance service in England and Wales can be improved.