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Abstract: Objective: Trauma is the leading cause of death in the first four decades of life in western countries. A national prospective study was conducted in the UK to examine the process and quality of care of severely injured patients. We present a previously unpublished analysis of the severity of injury, place of treatment, quality of care and survival amongst patients with thoracic injuries. Methods: All UK hospitals with an emergency department were asked to provide prespecified clinical and process data on all patients presenting with significant injuries between 1st February and 30th April 2006. All data were stripped of patient, clinician and institutional identifiers before review by expert advisors. Results: Data adequate for analysis were obtained on 1735 of 2203 injured patients reported. An injury severity score (ISS)≥16, the threshold for severe injury, was derived from case records of 795 patients, who comprise the study denominator. Of these, 387 (49%) had a thoracic injury, usually as part of polytrauma. The mortality rate was 8% (of 13) 9% (of 23) 10% (of 175) 14% (of 136) 22% (of 37) and 100% (of 3) for the six ascending grades of severity for the thoracic component of the ISS score. One hundred and seventy-six of the 795 patients (22%) had a thoracic injury sufficient for them to be classified as severely injured regardless of any other injuries. The quality of care as assessed by expert advisors showed an apparent association with overall trauma volume of the 142 treating hospitals. For patients with thoracic injuries where the specialty of the team in charge could be identified (n =284/387) trauma and orthopaedics (T and O) cared for 36%, critical medicine 22%, general surgery 19%, neurosurgery 8% and only 5% were in the care of thoracic surgeons. One or more chest drains were inserted in 203/795 (26%) of patients, few of them by thoracic surgeons. Conclusions: Given that polytrauma patients rarely come under the care of thoracic surgeons and yet frequently have severe thoracic injuries there is a clear need for T and O surgeons and generalists to have a good grounding in thoracic procedures. [Copyright &y& Elsevier]

In the past, British general practitioners (GPs) have referred patients to individual consultants. There is now a trend towards generic referral, whereby the specialist team is consulted via a single point of access. We examined the impact of this innovation on the relationship between GPs and specialists in mental health care. Sixteen groups of randomly selected GPs and mental health professionals (MHPs) in England discussed clinical scenarios involving the use of mental health interventions for patients with functional somatic symptoms. The meetings were audiotaped, transcribed and analysed to the point at which no major new themes were emerging. The final analysis was confined to a purposive sample of six of the sixteen groups, comprising 54 GPs and 15 MHPs. Although the rationale for the single point of access was clear to both GPs and MHPs, the approach erected boundaries because it impeded the establishment of professional relationships and transfer of knowledge. GPs thought the system reduced their capacity to be accountable to their patients and limited the potential for their own professional development. MHPs did not seem to be aware of GPs' concerns. Effective interprofessional management of individual patients depends upon confidence in colleagues' skills and good communication. Factors that hamper these must be addressed in the development of this system of referral.

Background: Clinical guidelines for improving the quality of care are a familiar part of clinical practice. Formal consensus methods such as the nominal group technique are often used as part of guideline development, but little is known about factors that affect the statements produced by nominal groups, and on their consistency with the research evidence., Methods: Cognitive behavioural therapy, behavioural therapy, brief psychodynamic interpersonal therapy, and antidepressants for irritable bowel syndrome, chronic fatigue syndrome, and chronic back pain were selected for study. 16 nominal groups in a factorial design allowed comparison of GP-only with mixed groups of GPs and specialists, provision of a literature review with no provision, and ratings made in the context of realistic or ideal levels of health-care resources. Participants rated appropriateness independently, and again after a facilitated meeting. Audiotapes of four group discussions were analysed., Findings: There was agreement with the research evidence for 51% of 192 scenarios. Agreement was more likely if the group was GP-only, if a literature review was provided, or if the evidence was in accordance with clinicians' beliefs. Assumptions about the level of resources available had no impact. Clinical and social cues had mixed effects, irrespective of the research evidence. Qualitative analysis showed the modifying effect of clinical experience and beliefs about research evidence., Interpretation: Guidelines cannot be based on data alone; judgment is unavoidable. The nominal group technique is a method of eliciting and aggregating judgments in a transparent and structured way. It can provide important information on levels of agreement between experts. However, conclusions can be at odds with the published literature. If they are, reasons need to be explicit.

Objectives: To compare general practitioners' perceptions of chronic fatigue syndrome and irritable bowel syndrome and to consider the implications of their perceptions for treatment., Design: Qualitative analysis of transcripts of group discussions., Participants and Setting: A randomly selected sample of 46 general practitioners in England., Results: The participants tended to stereotype patients with chronic fatigue syndrome as having certain undesirable traits. This stereotyping was due to the lack of a precise bodily location; the reclassification of the syndrome over time; transgression of social roles, with patients seen as failing to conform to the work ethic and "sick role" and conflict between doctor and patient over causes and management. These factors led to difficulties for many general practitioners in managing patients with chronic fatigue syndrome. For both conditions many participants would not consider referral for mental health interventions, even though the doctors recognised social and psychological factors, because they were not familiar with the interventions or thought them unavailable or unnecessary., Conclusions: Barriers to the effective clinical management of patients with irritable bowel syndrome and chronic fatigue syndrome are partly due to doctors' beliefs, which result in negative stereotyping of patients with chronic fatigue syndrome and the use of management strategies for both syndromes that may not take into account the best available evidence.