Neither the Third Nor the Fourth Age: Viewing Old Age Through the Philosophical Lens of Ambiguity

This paper argues that the philosophy of ambiguity, associated with Maurice Merleau-Ponty and Simone de Beauvoir, provides a helpful framework for understanding the complex and paradoxical nature of old age outside the dominant categories of the "third" and "fourth" ages. Building on philosophical literature in cultural gerontology including that focused on the "art of living" and other approaches that draw on existentialist thought, it suggests "ambiguity" as a theme that has been overlooked in such literature. The advantage of this approach is that it can accommodate contradictory elements and thus underpin an integrated approach to old age. At the same time, in distinguishing between ontological and social dimensions of ambiguity, the conceptual framework offers a new perspective on ageism that can help clarify the distinction between ageism as oppression and the negative aspects of deep old age itself. The paper is structured as follows. After making the case for the value and importance of "ambiguity" as a framework for viewing old age, I set out the key aspects of this philosophy as found in the work of Merleau-Ponty and particularly Beauvoir. I then apply this framework to a discussion of 2 literary memoirs of deep old age, by Diana Athill and Florida Scott-Maxwell, respectively. I argue that the picture of old age that emerges contrasts with the hegemonic discourses enframed by successful aging and frailed old age and offers the possibility not only of a true appreciation of old age but also of a more meaningful life course itself.

Exploring ageism as a structure of consciousness across the female lifecourse through the work of Simone de Beauvoir

Drawing on the work of Simone de Beauvoir, this paper considers ageism as a structure of consciousness, with important convergences with, as well as departures from, those associated with gender. Specifically, it explores the double consciousness through which the self is experienced negatively as old, at two points in a woman’s lifecourse, namely mid-life and ‘old age’. The first kind of ageism works through the double standard of ageing and the gender hierarchy, whereby women can no longer successfully comply with the objectification of the male gaze. This is a moment of intense age consciousness, tainted by a gendered narrative of decline, working jointly from the outside in and from the inside out. The second form of ageism has its source in the social world, in the reactions of other people to old age, resulting in an uneasy dialectic between one’s own sense of an ageless or youthful self and the alien view of self as old. The paper proceeds as follows. After a brief account of Beauvoir’s general philosophical approach, I compare and contrast the doubled consciousness associated with ageing as a woman and with ageing in a more general sense as described in The Second Sex and The Coming of Age respectively. I then flesh out this conceptual framework by drawing on fiction and auto-fiction written by Beauvoir herself. Together, this approach vividly illuminates the important interconnections and intersections between ageism and sexism, the way they work together, as well as separately, across the female lifecourse.

208 First and Second Metacarpal Arthrodesis - Salvage Procedure for Failed Thumb Carpometacarpal Joint Arthritis Surgery

Aim

There are various surgical options for the management of thumb carpometacarpal joint (CMCJ) arthritis. These include first metacarpal osteotomy, trapeziectomy with or without ligament reconstruction, CMCJ arthrodesis and arthroplasty. However, if these operations fail, the options for salvage are limited. The authors aim to offer ‘first and second metacarpal arthrodesis (FSMA)’ as a salvage procedure for failed first CMC joint surgeries. The authors also reviewed the literature on FSMA.

Method

Literature search

Operative Technique

Results

Literature search

Conclusions

FSMA is a good salvage option for failed surgical treatment of thumb CMCJ arthritis. FSMA can also be utilised as a primary procedure for various indications.

Waiting like a girl? The temporal constitution of femininity as a factor in gender inequality

This paper explores temporal constituents of the female self in terms of their role in underpinning ongoing gender inequality. Drawing on the work of Simone de Beauvoir and Iris Marion Young, together with sociological approaches to ambivalence, I suggest that these temporal subjectivities are embodied, arise from the split subjectivity associated with woman as simultaneously subject and object, and counterpose the neoliberal emphasis on "choice" and agency with a more traditional gendered "expectation," or "waiting" style. The dialectic between both temporalities, in which neither is hegemonic, results in a chronic state of ambivalence which impedes women's ability to fully project themselves into the future, a skill significant to planning and career ambition and the absence of which suspends women instead in an extended present. The paper aims to do two things in particular. In conceptual terms it aims to explore aspects of the configuration of the gendered self that underlie the stalling and slowing down of the gender revolution and which can be seen to provide a "missing link" between structures, institutions, and micro-cultures. In empirical terms, it suggests a future research agenda, of which this paper constitutes a beginning, through which such gendered temporalities can be explored in greater detail via ethnographies of women's lived experience of time throughout the life course.

On becoming a hag: gender, ageing and abjection

In this article, I explore, through the novels of Elena Ferrante, the role played by the ‘abject’ in mediating ageing in women, focusing on its role in the movement from a disempowered to a more powerful subject position. The article has three sections. The first describes the role of the abject in constituting the feminine, focusing on the place of temporality and ageing in this process. Represented by the symbolic figure of the hag, the old woman is a source of primal fear which forms the foundation of a violently misogynistic gendered (self-)formation. However, following Barbara Creed, there are two representational forms of the hag, that of victim (hag) and that of monster (Hag), which I argue also suggest alternative subjectivities associated with ageing femininity. In the second section, I explore the movement from one form to the other by means of conceptual models drawn from Simone de Beauvoir and Margaret Morganroth Gullette, in which process a battle over the symbolic meaning of abjection is central. Moreover, ageing itself is significant in mediating the shift from an oppressed/fragmented to a powerful/integrated subject position. Whilst the structures of feeling involved in this subjectivity are emergent, fiction and imaginative literature may provide helpful early depictions and in the last section I illustrate the psychosocial domain with material drawn from two early novels by Elena Ferrante.

New horizons in frailty: the contingent, the existential and the clinical

In the past decade, frailty research has focused on refinement of biomedical tools and operationalisations, potentially introducing a reductionist approach. This article suggests that a new horizon in frailty lies in a more holistic approach to health and illness in old age. This would build on approaches that view healthy ageing in terms of functionality, in the sense of intrinsic capacity in interplay with social environment, whilst also emphasising positive attributes. Within this framework, frailty is conceptualised as originating as much in the social as in the biological domain; as co-existing with positive attributes and resilience, and as situated on a continuum with health and illness. Relatedly, social science-based studies involving interviews with, and observations of, frail, older people indicate that the social and biographical context in which frailty arises might be more impactful on the subsequent frailty trajectory than the health crisis which precipitates it. For these reasons, the article suggests that interpretive methodologies, derived from the social sciences and humanities, will be of particular use to the geriatrician in understanding health, illness and frailty from the perspective of the older person. These may be included in a toolkit with the purpose of identifying how biological and social factors jointly underpin the fluctuations of frailty and in designing interventions accordingly. Such an approach will bring clinical approaches closer to the views and experiences of older people who live with frailty, as well as to the holistic traditions of geriatric medicine itself.

Soft governance and attitudes to clinical quality in English general practice

Objectives: English primary care organisations (primary care groups and trusts – PCGs, PCTs) were, and are, responsible for the quality of general practice but lack hierarchical structures and, frequently, contractual relationships through which to influence it. The theory of soft governance describes how managers can influence professional practice by other means. This study examines the hypothesis that PCG/Ts have used 'soft' clinical governance.

Methods: Survey in 2000/01 of general practitioners' (GPs') attitudes, opinions and self-reported activity in six PCGs and six PCTs using a semi-structured mailed questionnaire. To assess how representative respondents were of English GPs generally, four questions from a national sample survey of English GPs were included and the results compared.

Results: Responses were obtained from 437 (52%) GPs. They most often mentioned the technical aspects of clinical governance. Managerial, policy and resourcing implications were next most frequently mentioned, usually in unfavourable terms. Most GPs reported that their clinical practice had changed because of clinical governance activities, although nearly 40% also reported little difference in the quality of care provided. The National Service Framework for coronary heart disease influenced practice independently of PCG/T activities.

Conclusion: English primary care organisations are exercising soft governance (although not by that name) over some but not all aspects of GPs' clinical practice. However, this soft governance is complex, not easy to sustain and appears hard to extend beyond essentially clinical domains.

Frail bodies: geriatric medicine and the constitution of the fourth age

Clinical discourses of frailty are central both to the construction of the social category of the fourth age and to the role and identity of hospital geriatric medicine. However, the influence of such clinical discourses is not just from science to the social sphere and nor do these discourses have their source in a putative truth of the old body but emerge from an interplay between physiological facts, discourses of governmentality, productive processes associated with late modern capitalism and the professional ambitions of geriatric medicine. The article explores this interplay in the two key discourses of frailty that have emerged in the clinical literature during the past 15 years, that of the phenotype and the accumulation of deficits, respectively. Outlining the development of the discourse of senescence from its origins to the more recent emergence of a nosological category of frailty the article explores how these key discourses capture the older body according to particular sets of norms. These norms link physiological understanding with broader discourses of governmentality, including the professional project of geriatric medicine. In particular, metaphorical representations in the discourses of frailty convey key cultural and clinical assumptions concerning both older bodies and old age more generally.

The role of governmentality in the establishment, maintenance and demise of professional jurisdictions: the case of geriatric medicine

This paper examines the professionalising of geriatric medicine in the UK roughly between the 1940s and the 1970s and locates it in terms of the broader context of the relationship between the professions and the state. It looks at how this relationship shaped geriatric medicine's professional jurisdiction, including the discourses of expertise on the one hand and the constituting of the 'subjects' of such expertise on the other. In contrast to other sociological approaches to the professions, which highlight the negative impact of state encroachment on professional territory, this paper contends that without the backing of the Ministry of Health the specialty may never have established itself in the face of prolonged opposition from rival specialists. However, such support was predicated on the specialty's highlighting particular legitimating discourses and practices at the expense of others, and in framing this in terms of specific policy concerns around an ageing population. Whilst this imprinted the profession with the stamp of governmentality, it also contributed to the broader problematising of old age in the twentieth century. The paper concludes by considering the legacy of this context of professionalisation for the profession today.

Impacts of case management for frail elderly people: a qualitative study

OBJECTIVE

To assess the impacts of different forms of case management for people aged over 65 years at risk of unplanned hospital admission, in particular the impacts upon patients, carers and health service organization in English primary care; and, in these respects, compare the Evercare model with alternatives.

METHODS

Multiple qualitative case studies comparing case management in nine English Primary Care Trusts which piloted the Evercare model of case management and four sites which implemented alternative forms of case management between 2003 and 2005. Data were obtained from 231 interviews with patients, carers and other key informants, and from content analysis of documents and observation of meetings.

RESULTS

All the projects established functioning case management services, but none led to major service reorganization or savings elsewhere in the health care system. Many informants reported examples of admissions which case management had prevented, but overall hospital admissions did not significantly change, possibly due to increased case-finding. Patients and carers valued case management for improving access to health care, increasing psychosocial support and improving communication with health professionals.

CONCLUSION

Case management was highly valued by patients and their carers, but there were few major differences in outcomes between Evercare and other models.

Moving specialist care into the community: an initial evaluation

OBJECTIVES

To assess the likely impact on patients and local health economies of shifting specialist care from hospitals to the community in 30 demonstration sites in England.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Patient and carer perceptions of case management for long-term conditions

Nurse-led case management programmes have become increasingly popular over the last 15 years. Countries such as the USA, Canada, Sweden and the Netherlands have long running case management programmes in place for frail elderly people. The Department of Health in England has recently introduced a 'community matron' role to provide case management to patients with highly complex long-term conditions; a group that is predominantly comprised of elderly people. Department of Health policy documents do not define the day-to-day role of community matrons but instead describe the objectives and principles of case management for long-term conditions. The aim of this qualitative study was to describe case management from the perspective of patients and carers in order to develop a clearer understanding of how the model is being delivered for patients with long-term conditions. In-depth interviews were conducted with a purposive sample of 72 patients and 52 carers who had experience of case management. Five categories of case management tasks emerged from the data: clinical care, co-ordination of care, education, advocacy and psychosocial support. Psychosocial support was emphasised by both patients and carers, and was viewed as equally important to clinical care. Patient and carer perceptions of case management appear to contrast with descriptions contained in Department of Health guidance, suggesting an 'implementation surplus' in relation to the policy. This particularly appears to be the case for psychosocial support activities, which are not described in official policy documents. The provision of significant psychosocial support by community matrons also appears to differentiate the model from most other case management programmes for frail elderly people described in the literature. The findings emphasise the importance of seeking patient and carer input when designing new case management programmes.

Impact of case management (Evercare) on frail elderly patients: controlled before and after analysis of quantitative outcome data

OBJECTIVES

To determine the impact on outcomes in patients of the Evercare approach to case management of elderly people.

DESIGN

Practice level before and after analysis of hospital admissions data with control group.

SETTING

Nine primary care trusts in England that, in 2003-5, piloted case management of elderly people selected as being at high risk of emergency admission.

MAIN OUTCOME MEASURES

Rates of emergency admission, emergency bed days, and mortality from April 2001 to March 2005 in 62 Evercare practices and 6960-7695 control practices in England (depending on the analysis being carried out).

RESULTS

The intervention had no significant effect on rates of emergency admission (increase 16.5%, (95% confidence interval -5.7% to 38.7%), emergency bed days (increase 19.0%, -5.3% to 43.2%), and mortality (increase 34.4%, -1.7% to 70.3%) for a high risk population aged >65 with a history of two or more emergency admissions in the preceding 13 months. For the general population aged > or =65 effects on the rates of emergency admission (increase 2.5%, -2.1% to 7.0%), emergency bed days (decrease -4.9%, -10.8% to 1.0%), and mortality (increase 5.5%, -3.5% to 14.5%) were also non-significant.

CONCLUSIONS

Case management of frail elderly people introduced an additional range of services into primary care without an associated reduction in hospital admissions. This may have been because of identification of additional cases. Employment of community matrons is now a key feature of case management policy in the NHS in England. Without more radical system redesign this policy is unlikely to reduce hospital admissions.

Exit, voice, governance and user-responsiveness: The case of English primary care trusts

Hirschman contrasts exit and voice as 'recuperation' mechanisms for making organisations responsive to users. However, the emergence of health-care quasi-markets and of network governance structures since Hirschman necessitate revising his theory, for they complicate the relationships between governance structures and recuperation mechanisms. Using a case study of nine primary care trusts (PCTs), this paper analyses the recuperation mechanisms, governance structures and relations between them in primary care in England. User voice can be exercised through dedicated networks besides hierarchies. As well as the 'user exit' described by Hirschman, two new 'exit' mechanisms now exist in quasi-markets. Commissioner exit occurs when a third-party payer stops using a given provider. Professional proxy exit occurs when a general practitioner (GP) fund-holder (or analogous budget-holder) behaves similarly. Neither exit mechanism requires the existence of mechanisms for user exit from healthcare purchasers, provided strong voice mechanisms exist instead to make commissioners responsive to users' demands. Establishing such voice mechanisms is not straightforward, however, as the experience of English PCTs illustrates.

Relationship between biological and self-reported measures of stress among informal caregivers of patients with prostate cancer

18506

Background: Informal caregivers of prostate cancer patients often experience chronic psychological stress that may adversely impact their physical and mental health, and their ability to care for their families and the patient. This study aims to determine the association between perceived and biological stress among informal caregivers of prostate cancer patients. Methods: A total of 24 informal caregivers of prostate cancer patients were recruited from both the Jesse Brown VA Center (Lakeside and Westside, Chicago) and the Robert H. Lurie Comprehensive Cancer Center at Northwestern University. Caregivers completed self-reported measures of stress, somatization, life events, burden, health status (SF-36) and mental health. Capillary blood spot samples from caregivers were used to examine two measures of biological stress, Epstein-Barr virus antibody titer and C-reactive protein. Results: Informal caregivers had a mean age of 63 years and were mostly female and spouses of patients with prostate cancer. Many had preexisting co-morbidities, including 45.8% with hypertension, 45.8% with arthritis, and 33.3% with diabetes. Nearly 30% had been hospitalized in the last 12 months. 33.3% of caregivers experienced at least one major life event in the last year and 62.5% had symptoms of somatization illness. Caregivers with symptoms of somatization illness had higher mean Epstein-Barr antibody titers as compared with those without symptoms (Mean EBV antibody titer: 198.3 versus 141.8, respectively (p < 0.05)). Caregiver-reported measures were not correlated with C-reactive protein levels. Caregivers with higher levels of strain perceived more stress in their lives (p < 0.05), but showed relatively high self-esteem (mean = 30.6, SD = 2.8, on a 7–35 scale). Conclusions: These preliminary findings suggest that informal caregivers who report symptoms of somatization illness exhibit signs of relative suppression of the cell-mediated immune processes as a result of the reactivation of the Epstein-Barr virus. Final analyses will be conducted that control for potential confounders and will further elucidate if caregiver stress is associated with suppression of the immune system.

No significant financial relationships to disclose.

A subtle governance: 'soft' medical leadership in English primary care

In many countries governments are recruiting the medical profession into a more active, transparent regulation of clinical practice. Consequently the medical profession adapts the ways it regulates itself and its relationship to health system managers changes. This paper uses empirical research in English Primary Care Groups (PCGs) and Primary Care Trusts (PCTs) to assess the value of Courpasson's concept of soft bureaucracy as a conceptualisation of these changes. Clinical governance in PCGs and PCTs displays important parallels with governance in soft bureaucracies, but the concept of soft bureaucracy requires modification to make it more applicable to general practice. In English primary care, governance over rank-and-file doctors is exercised by local professional leaders rather than general managers, harnessing their colleagues' perception of threats to professional autonomy and self-regulation rather than fears of competition as the means of 'soft coercion'.

User involvement in clinical governance

OBJECTIVES

To investigate the involvement of users in clinical governance activities within Primary Care Groups (PCGs) and Trusts (PCTs). Drawing on policy and guidance published since 1997, the paper sets out a framework for how users are involved in this agenda, evaluates practice against this standard and suggests why current practice for user involvement in clinical governance is flawed and why this reflects a flaw in the policy design as much as its implementation.

DESIGN

Qualitative data comprising semi-structured interviews, reviews of documentary evidence and relevant literature.

SETTING

Twelve PCGs/PCTs in England purposively selected to provide variation in size, rurality and group or trust status.

PARTICIPANTS

Key stakeholders including Lay Board members (n = 12), Chief Executives (CEs) (n = 12), Clinical Governance Leads (CG leads) (n = 14), Mental Health Leads (MH leads) (n = 9), Board Chairs (n = 2) and one Executive Committee Lead.

RESULTS

Despite an acknowledgement of an organizational commitment to lay involvement, in practice very little has occurred. The role of lay Board members in setting priorities and implementing and monitoring clinical governance remains low. Beyond Board level, involvement of users, patients of GP practices and the general public is patchy and superficial. The PCGs/PCTs continue to rely heavily on Community Health Councils (CHCs) as a conduit or substitute for user involvement; although their abolition is planned, their role to be fulfilled by new organizations called Voices, which will have an expanded remit in addition to replacing CHCs.

CONCLUSIONS

Clarity is required about the role of lay members in the committees and subcommittees of PCGs and PCTs. Involvement of the wider public should spring naturally from the questions under consideration, rather than be regarded as an end in itself.

A qualitative study of the cultural changes in primary care organisations needed to implement clinical governance

BACKGROUND

It is commony claimed that changing the culture of health organisations is a fundamental prerequisite for improving the National Health Service (NHS). Little is currently known about the nature or importance of culture and cultural change in primary care groups and trusts (PCG/Ts) or their constituent general practices.

AIMS

To investigate the importance of culture and cultural change for the implementation of clinical governance in general practice by PCG/Ts, to identify perceived desirable and undesirable cultural attributes of general practice, and to describe potential facilitators and barriers to changing culture.

DESIGN

Qualitative: case studies using data derived from semi-structured interviews and review of documentary evidence.

SETTING

Fifty senior non-clinical and clinical managers from 12 purposely sampled PCGs or trusts in England.

RESULTS

Senior primary care managers regard culture and cultural change as fundamental aspects of clinical governance. The most important desirable cultural traits were the value placed on a commitment to public accountability by the practices, their willingness to work together and learn from each other, and the ability to be self-critical and learn from mistakes. The main barriers to cultural change were the high level of autonomy of practices and the perceived pressure to deliver rapid measurable changes in general practice.

CONCLUSIONS

The culture of general practice is perceived to be an important component of health system reform and quality improvement. This study develops our understanding of a changing organisational culture in primary care; however, further work is required to determine whether culture is a useful practical lever for initiating or managing improvement.

Comparing and contrasting the role of family carers and nurses in the domestic health care of frail older people

Care in the community has been constructed on the basis of professional support for carers who, as a result of community care policy that has released highly dependant people from residential care and long-stay wards, are carrying out a wide range of tasks, including complex health care activities. The present paper examines the health care activities currently undertaken by family carers and the way in which they work with, and are supported by, professional nurses in the home. It compares and contrasts the approaches of both groups to care-giving for this client group. The authors conclude by making some suggestions for improving the way in which family carers and nurses work together in the home.

Implementing clinical governance in English primary care groups/trusts: reconciling quality improvement and quality assurance

OBJECTIVES

To investigate the concept of clinical governance being advocated by primary care groups/trusts (PCG/Ts), approaches being used to implement clinical governance, and potential barriers to its successful implementation in primary care.

DESIGN

Qualitative case studies using semi-structured interviews and documentation review.

SETTING

Twelve purposively sampled PCG/Ts in England.

PARTICIPANTS

Fifty senior staff including chief executives, clinical governance leads, mental health leads, and lay board members.

MAIN OUTCOME MEASURES

Participants' perceptions of the role of clinical governance in PCG/Ts.

RESULTS

PCG/Ts recognise that the successful implementation of clinical governance in general practice will require cultural as well as organisational changes, and the support of practices. They are focusing their energies on supporting practices and getting them involved in quality improvement activities. These activities include, but move beyond, conventional approaches to quality assessment (audit, incentives) to incorporate approaches which emphasise corporate and shared learning. PCG/Ts are also engaged in setting up systems for monitoring quality and for dealing with poor performance. Barriers include structural barriers (weak contractual levers to influence general practices), resource barriers (perceived lack of staff or money), and cultural barriers (suspicion by practice staff or problems overcoming the perceived blame culture associated with quality assessment).

CONCLUSION

PCG/Ts are focusing on setting up systems for implementing clinical governance which seek to emphasise developmental and supportive approaches which will engage health professionals. Progress is intentionally incremental but formidable challenges lie ahead, not least reconciling the dual role of supporting practices while monitoring (and dealing with poor) performance.

Caring for a relative with dementia: The perceptions of carers and CPNs

Older people with dementia living in the community are most likely to be cared for by other older people, predominantly spouses, who will be at increased risk of stress‐related health problems themselves. Appropriate support of such carers is crucial if carer breakdown and consequent care‐receiver admission to residential homes is to be avoided. This paper examines the experience of older carers of frail older people with dementia and examines the kind of support that is provided to such carers. In practice, the sole source of professional support received by older people in this study was from community psychiatric nurses (CPNs). CPNs' role did not comprise hands‐on care‐giving and family carers carried out most personal/physical and healthcare tasks themselves, aided in some cases by care workers. The paper concludes by suggesting that lack of support for carers in these activities requires redress.

A 'Third Way' for lay involvement: what evidence so far?

AIMS AND OBJECTIVES

This article considers evidence regarding lay involvement in the NHS, following the White Paper's commitment to rebuild public confidence in an NHS 'accountable to patients and open to the public and shaped by their views'. It looks at two aspects of lay involvement: the lay board member's involvement in primary care group (PCG) decision-making and the engagement of the PCG with the wider public.

METHODS

The paper analyses data from the first sweep of the annual Tracker Survey of a sample of PCGs in England, led by the National Primary Care Research and Development Centre in collaboration with the King's Fund between September and December 1999. It draws specifically from the postal questionnaires sent to lay members. Firstly, however, it contextualizes this data by reviewing the history of lay involvement before 1997 in the NHS and particularly in primary care.

CONCLUSIONS

The paper concludes that, during the first 6 months of their operation, the lay voice was faintly heard in PCGs. The lay member's role in decision-making at board-level was peripheral. The majority rated their involvement in key aspects of decision-making as low and their influence on decision-making below that of other board members including the Chief Officer, the chair and the GP board members. Beyond the arena of the board, what little contact there was with the lay voice has taken the shape of informing rather than consulting. Mitigating factors include the early stage at which the survey was completed and the lack of precedents for lay involvement in primary care in a broad sense on which PCGs can draw.

Fitting contraceptive diaphragms: can laywomen provide quality training for doctors?

OBJECTIVE

To test the feasibility of training laywomen as professional patients to teach doctors to fit the contraceptive diaphragm.

DESIGN

Semi-structured interviews with instructing doctors and questionnaires to DFFP trainees. These documented current teaching practice and the acceptability of professional patients. The Delphi technique was used to establish a curriculum for the professional patients' training programme.

RESULTS

The results show that there is currently a lack of standardisation in teaching methods and content with respect to diaphragm fitting. All instructing doctors and DFFP trainees involved had experienced difficulties in recruiting women for training, and the majority would be happy to work with professional patients. After three rounds of the Delphi procedure, consensus was reached and a curriculum developed. Five women were recruited on to a training programme, and four successfully completed it.

CONCLUSION

Lack of standardisation and difficulty recruiting patients are current problems when training doctors to fit diaphragms. Our study shows that the use of professional patients would be acceptable to both DFFP trainees and instructing doctors, and that it is possible to recruit and train women for this purpose.

Decreased health care use among patients with silent myocardial ischemia: support for a generalized rather than cardiac-specific silence

OBJECTIVE

The absence of angina among patients with silent myocardial ischemia (SMI) may be a cardiac phenomenon or may reflect a generalized lack of bodily awareness and symptom reporting. We tested the hypothesis that the silence is generalized, and, therefore, that patients with SMI would make fewer health care visits for noncardiac/chest-pain problems than patients with symptomatic ischemia.

METHODS

We counted all out-patient visits to our medical system for the prior 18 months for 95 patients who demonstrated ischemia during treadmill exercise testing and subsequent nuclear scanning: 62 of the patients had SMI during exercise, and 33 of the patients had symptomatic ischemia.

RESULTS

Patients with SMI made were significantly less likely to have sought emergency care or primary care and had significantly fewer primary care visits than patients with symptomatic ischemia. Group differences remained after controlling for demographics and health status variables. The two groups did not differ on utilization of specialty care.

CONCLUSION

The reduced use of emergency and primary care among patients with SMI suggests that they have a generalized rather than cardiac-specific reduction in somatic awareness and/or symptom reporting.

Primary care groups and NHS rationing: implications of the Child B Case

Implementing The new NHS and the 1997 NHS (Primary Care) Act will gradually extend cash-limiting into primary health care, especially general practice. UK policy-makers have avoided providing clear, unambivalent direction about how to 'ration' NHS resources. The 'Child B' case became an epitome of public debate about NHS rationing. Among many other decision-making processes which occurred, Cambridge and Huntingdon Health Authority applied an ethical code to this rationing decision. Using new data this paper analyses the rationing criteria NHS managers and clinicians used at local level in the Child B case; and the organisational structures which confronted them with such decisions. Primary Care Groups are likely to confront similar rationing decisions in respect of 'gate-kept' NHS services. However, such rationing processes are not so easily transposed to open-access services such as general practice. NHS rationing decisions, especially in PCGs, will require a much more specific ethical code than hitherto used.

Paradoxes of GP fundholding: contracting for community health services in the British National Health Service

The expansion of GP fundholding (GPFH) is central to the British government's attempt to maintain the revolution under way in the National Health Service (NHS). Evaluations of the NHS reforms have portrayed GPFH as an important mechanism for competition, and GPFH's bargaining power is reported to have secured significant changes in health service provision. However, these developments have been acknowledged to be less applicable in relation to community health services (CHS) than acute hospital services. On the basis of case studies of the process of contracting for CHS, GPFHs are shown to display ambivalent and sometimes contradictory views which have to be related to broader policy developments in general practice and primary care. Although this paper focuses on the British situation, many of the issues raised by reforms in primary and community health services have implications for developments in other Western health care systems.

A cooperative effort to pass tobacco control ordinances in Wichita, Kansas

In October 1993, the Tobacco-Free Wichita Coalition proposed ordinances to the Wichita City Council that would tightly control access of minors to tobacco and prohibit smoking in public places. The subsequent successful change in local health policy required the collaborative efforts of local and state organizations and health agencies. A simple random telephone survey commissioned and financed by the coalition demonstrated that 76 percent (95 percent CI = 72 percent to 80 percent) of adult Wichita-Sedgwick County residents favored enforced penalties for merchants selling tobacco to minors, and 62 percent (95 percent CI = 58 percent to 66 percent) favored a ban on tobacco vending machines. Fifty-four percent (95 percent CI = 50 percent to 58 percent) favored a smoking ban in all public places.

Langerhans' cell depletion by staphylococcal superantigens

Superantigens were examined for effects on the distribution of Langerhans' cells (LC) in mouse skin. This was accomplished by analysing the expression of LC-specific markers, ATPase and IA among the epidermal portion of cultured sections of mouse skin following treatment with staphylococcal enterotoxins. In this study, treatment of skin sections with staphylococcal enterotoxin A or exfoliative toxin but not toxic shock syndrome toxin led to significant depletion of LC. This depletion was inhibited by agents which specifically block the action of GTP binding proteins or their associated kinases (cholera and pertussis toxins and H-8) as well as those which block protein or RNA synthesis. Therefore, signals which lead to LC depletion in response to staphylococcal enterotoxins appear to involve a cholera and pertussis toxin-sensitive GTP-binding protein and protein synthesis. These requirements are identical to those observed previously for LC depletion following exposure of skin to ultraviolet radiation.

Requirements for Langerhans' cell depletion following in vitro exposure of murine skin to ultraviolet-B

Langerhans' cells found within the skin and mucous membranes are critical regulators of antimicrobial and allergic responses. Therefore, the depletion of these cells following exposure of skin to solar ultraviolet radiation (UV) has direct functional consequences on immunity within this tissue. In order to understand how Langerhans' cell depletion is regulated following exposure of skin to medium-wave UV (UVB), the role of second messengers in these responses was investigated using a novel in vitro system. This was accomplished by analysing the expression of a specific marker associated with Langerhans' cells (ATPase) among the epidermal portion of cultured sections of mouse skin following treatment with inhibitors specific for second messenger components and subsequent exposure to UVB. In this study, inhibitors of guanosine triphosphate (GTP) binding proteins, H-8, pertussis toxin and cholera toxin as well as inhibitors of RNA and protein synthesis were all capable of blocking Langerhans' cell depletion in response to UVB treatment. In contrast, an inhibitor of protein kinase C (H-7) was incapable of specifically blocking depletion following treatment with this physical agent. These results suggest that Langerhans' cell depletion mediated by UVB may involve a pertussis and cholera toxin-sensitive G protein as well as de novo protein synthesis.