Community care is a vital component of care for older people and the need to evaluate the outcomes of health and social care has become increasingly important. Several studies have looked at the ingredients older people consider important for their overall quality of life. Bowling, for example, compared responses from older and younger age groups in a UK national interview survey. Some have argued against the use of self-administered postal questionnaires in an older population. Others have shown that postal surveys amongst older people can achieve high response rates in certain settings, or where the survey is seen as directly relevant to respondent's interests and concerns. The Royal College of Physicians of London and the British Geriatrics Society recently used the domains for assessment in the elderly recommended by the World Health Organisation to select a set of standardised assessment scales for older people.

With potential budget claw backs of 20% to be found in UK health care in forthcoming years, the question arises as to how these might be achieved.Based on the long-standing economic principle of marginal analysis, a framework for managing such a National Health Service credit crunch is outlined.The framework incorporates not only the natural starting point for cuts through schemes aimed at achieving the same for less cost, such as lean thinking and service redesign, but also the genuine disinvestments, in the form of stopping some services for some people, that might be required.

What is the real aim of this white paper, Equity and Excellence: Liberating the NHS , this mother of all policy interventions? For me its ultimate purpose is almost surreptitiously inserted in just one terse bullet point on page 45, perhaps in the hope that it will pass unnoticed all the way to the statute books. It states, “GP consortia will align clinical decisions in general practice with the financial consequences of those decisions.” These reforms will fail unless GPs are legally obliged to take financial responsibility for practice budgets. There it is: to force doctors, once and for all, to consider the opportunity costs of their day to day clinical decisions. I believe that this has been the unstated aim of every major health policy initiative since the mid-1970s. Why? Because only by getting doctors to acknowledge that NHS resources are scarce, that every clinical decision has an opportunity cost, and that they should take financial responsibility …

Doctors and managers have to make tough decisions about what services to provide from their budgets. Economic approaches can help, but they also need to take into account the practical and ethical challenges faced by healthcare professionals

Purpose: To determine the effectiveness of two dissemination and implementation strategies to implement a national guideline for epilepsy management in primary care settings.Methods: Three-arm cluster-randomized controlled trial. The participants were general practitioners from 68 practices in Tayside, Scotland, and 1, 133 of their patients with self-reported epilepsy treated with antiepileptic medications (AEDs). Practices were randomized blind to a control, intermediate, or intensive intervention. Control: Postal dissemination of a nationally developed clinical guideline. Intermediate intervention: Postal dissemination of the guideline supported by interactive, accredited workshops, and dedicated, structured protocol documents. Intensive intervention: Intermediate intervention plus a nurse specialist who supported and educated practices in the establishment of epilepsy review clinics. The primary outcome was the SF-36 health-related quality-of-life instrument. Secondary measures were a battery of prevalidated epilepsy-specific quality-of-life instruments. These were administered at baseline and after the intervention phase. Process of care was assessed by case-note review on number of review meetings and counseling sessions for epilepsy before and after the interventions.Results: None of the intervention groups showed any change in the primary or secondary outcome measures or process-of-care measures.Conclusions: None of the intervention strategies led to improvements in patient quality of life or quality of epilepsy care. Further research is needed to discover why the interventions failed, to identify barriers to adoption of guidelines, and to develop strategies that might improve implementation and uptake in the future.

Postnatal morbidity is increasingly recognized, but standard assessments may not capture what is most important to the woman with such morbidity in terms of her quality of life. The Mother-Generated Index (MGI) is a proposed postnatal quality-of-life instrument which allows the mother to determine both content and scoring. In this pilot study we found that although a degree of psychological and physical morbidity (including tiredness) is common, and may be very significant, for most women these factors are low-grade, and other aspects of their lives are more important. A quality-of-life approach allows the mother to determine her own postnatal assessment, and encourages practitioners to view her more holistically.

BACKGROUND Although postnatal morbidity has been well documented in recent years, postnatal quality of life has not been addressed. A newly derived subjective measurement of postnatal quality of life (the Mother-Generated Index) combines a quantitative and qualitative evaluation. AIMS This part of our pilot study aimed to compare the aspects of their lives nominated by women with low and high quality of life (Primary Index) scores, and to examine the respective importance of these areas. METHODS The Mother-Generated Index was tested using the Edinburgh Postnatal Depression Scale, Short Form 12, and an established maternal and neonatal physical morbidity index as validators. Four health visitors administered these at 6-8 weeks and 8 months postpartum to 103 women by structured face-to-face interviews between June 2000 and March 2001. Data were entered into Epi-Info, and exported to Microsoft Excel and SPSS for analysis. RESULTS A wide variety of quality of life aspects were reported, including emotional, social and financial concerns. Tiredness was prevalent in all groups, but other physical problems were rare at 8 months. Mothers with low quality of life (Primary Index) scores at 6-8 weeks and 8 months commonly reported having less personal time. Low scoring areas, which health professionals might consider in greatest need of attention, were often not the ones mothers deemed most important. LIMITATIONS The study involved only 103 participants, and did not assess the degree of support experienced by the mothers. CONCLUSIONS The Mother-Generated Index helps mothers to identify the areas of their lives which are of most concern to them. This pilot suggests that mothers with high and low quality of life scores have markedly divergent experiences.

BACKGROUND:The extent of postnatal morbidity has become increasingly apparent over the last 15 years, but currently no tool is available that measures postnatal quality of life. This pilot study introduces a subjective tool, the Mother-Generated Index, which assesses the woman's quality of life and identifies those aspects that are of most concern to her.METHODS:The Mother-Generated Index was administered by structured interview to 60 participants at 6 to 8 weeks and to 43 participants at 8 months postpartum. Validation was sought through concurrent use of the Edinburgh Postnatal Depression Scale, the SF12, and two indexes related to maternal and neonatal physical morbidity. The Mother-Generated Index gives a primary index (quality of life) score, which is reported here, and a secondary index, which identifies the areas considered most important by the mother.RESULTS:The primary index was more sensitive at 8 months. The highest and lowest quartile scores were compared. Statistically significant differences in were found in the mothers' Edinburgh Postnatal Depression scores at 6 to 8 weeks, and in their Edinburgh Postnatal Depression and SF12 mental component scores and their physical morbidity index at 8 months. Although physical problems were only a small feature at 8 months, social and psychological issues were prominent in both groups. Age, parity, and mode of delivery had no significant effect on the women's scores or the areas they identified as most important.CONCLUSION:Quality of life of is a complex and personal area, affected by many different aspects of health and well-being. From this pilot study the primary index appears to be a useful step in assessing a mother's quality of life. It identifies which areas of her life are most important to her, and allows her to indicate where she would like to see improvements.

This is the second in a series of three papers reviewing 69 patient-based outcome measures that have been developed specifically for use with older people, or that have been administered to populations that include older people. The first paper described how the measures were identified, and provided a brief description of 17 measures of general health status and quality of life. This paper reviews nine measures of mental status and cognitive function, 10 measures of depression and anxiety, and seven psychological wellbeing measures (see Tables 1-3).

IntroductionThis is the last in a series of three papers reviewing 69 patient-based outcome measures that have been developed specifically for use in older people, or that have been administered to populations that include older people. The previous papers described how the measures were identified, and provided brief descriptions of measures of general health status and quality of life, instruments assessing mental status, measures of depression, and measures of psychological wellbeing. In this paper we describe six pain measures, 12 measures of physical disability and handicap, and eight measures of social health (see Tables 1–3). References in the text which include a copy of the questionnaire are marked with a # sign. Otherwise, a copy can be obtained from the address provided. It is recommended, however, before using any of the questionnaires to contact the authors to obtain permission to use them.

OBJECTIVE:To compare achievement of previously agreed standards for administration of antibiotic prophylaxis for surgical patients in the three acute trusts in Tayside.SETTING:Angus, Dundee Teaching Hospitals and Perth & Kinross Trusts.MAIN OUTCOME MEASURES:Administration of antibiotic prophylaxis and achievement of three general standards of administration.STUDY DESIGN:Prospective case note audit.RESULTS:In total, 341 operations were audited. The range of operations performed in each trust was different and the achievement of standards was sensitive to case mix. For example, prophylaxis was given to 82% of all eligible orthopaedic patients but only 64% of eligible patients in obstetrics & gynaecology. Comparison between trusts was therefore confined to six procedures (166 operations) which were performed regularly in all three. There were significant differences between trusts in the rate of administration to patients undergoing operations for which prophylaxis was indicated (from 84% [95% CI 75-92] to 93% [CI 89-98]) and in the proportion of patients in whom prophylaxis was continued for less than 24 hours (from 78% [CI 68-89] to 97% [CI 93-100]). Administration of prophylaxis within two hours of surgery was achieved following more than 95% of operations in all three trusts. However, second doses were given to only five of 44 (11%) of patients whose operations lasted more than two hours.CONCLUSIONS:Achievement of standards in all three trusts was good in comparison with recently published audits from other UK and European centres but there was still room for improvement, particularly in administration of second doses for prolonged operations. Regular audit of prophylaxis administration and duration should be implemented. Comparisons between trusts or units should be based on a common set of operations.

The possible antinociceptive effect of hemispheric‐synchronised sounds, classical music and blank tape were investigated in patients undergoing surgery under general anaesthesia. The study was performed on 76 patients, ASA 1 or 2, aged 18–75 years using a double‐blind randomised design. Each of the three tapes was allocated to the patients according to a computer‐generated random number table. General anaesthesia was standardised and consisted of propofol, nitrous oxide 66%/oxygen 33%, isoflurane and fentanyl. Patients breathed spontaneously through a laryngeal mask and the end‐tidal isoflurane concentration was maintained near to its minimum alveolar concentration value of 1.2%. Fentanyl was given intravenously sufficient to keep the intra‐operative heart rate and arterial blood pressure within 20% of pre‐operative baseline values and the fentanyl requirements were used as a measure of nociception control. Patients to whom hemispheric‐synchronised sounds were played under general anaesthesia required significantly less fentanyl compared with patients listening to classical music or blank tape (mean values: 28 μg, 124 μg and 126 μg, respectively) (p < 0.001). This difference remained significant when regression analysis was used to control for the effects of age and sex.

AIMS:To quantify the increased risk of non-fatal injury when children travel unrestrained in a car, and to identify other preventable risk factors.METHODS:Case-control study of 78 children presenting to an accident and emergency (A&E) department having sustained an injury while travelling in a car, and 97 children attending an A&E outpatient clinic with conditions unrelated to road traffic accidents.RESULTS:Seat restraint was associated with a 93% lower risk of child accident injury. A driver with points on the licence was over five times more likely to have had an accident resulting in child injury than a driver without points. Child accident injury was also associated with the driver's accident history.CONCLUSIONS:These data allow the effect of achieving new target levels of seat restraint use to be estimated. Strategies aimed at reducing the risk of further accident among drivers with a history of accident may have a beneficial impact on childhood accident injuries.

The EuroQol (EQ-5D) generic health index comprises a five-part questionnaire and a visual analogue self-rating scale. The questionnaire may be used as a health index to calculate a 'utility' value or as a health profile. The validity, reliability and responsiveness of EQ-5D were tested in 233 patients with rheumatoid arthritis stratified by functional class. EQ-5D demonstrated moderate to high correlations with measures of impairment and high correlations with disability measures. Stepwise regression models showed that EQ-5D utility values and visual analogue scores were explained best as a function of pain, disability, disease activity and mood (R2 approximately 70%), although other variables (side-effects, years of education) were required to explain the visual analogue scores. The EQ-5D health index and visual analogue scale are more responsive than any of the other measures, except pain and doctor-assessed disease activity. The reliability of the EQ-5D index and EQ-5D visual analogue scale is as good or better than that of all other instruments except the Health Assessment Questionnaire. Some patients with severe long-standing disease had health states which attracted utility values below zero, i.e. from a societal perspective they were regarded as being in states 'worse than death'. The practical and ethical implications of these utility valuations are discussed, and at present the utility values should be used and interpreted with caution. With this caveat, EQ-5D is simple to use, valid, responsive to change and sufficiently reliable for group comparisons. It is of potential use as an outcome measure in clinical trials, audit and health economic studies, but further work is required on its performance in other clinical contexts and on the interpretation of the utility values.

EDITOR,—Charlotte Paterson should be commended for piloting her patient generated outcome measure in a primary care setting.1 The “measure yourself medical outcome profile” (MYMOP) has potential for routine use, not least because it is simple to use. Also, the authors' tests of validity and responsiveness indicate that it correlates with health status and perceived improvements in health. Three important questions remain unanswered, however. Firstly, does the MYMOP really measure outcomes that matter to patients—that is, that have meaning and …

OBJECTIVE--To assess the feasibility of monitoring health outcomes in a routine hospital setting and the value of feedback of outcomes data to clinicians by using the SF 36 health survey questionnaire. DESIGN--Administration of the questionnaire at baseline and three months, with analysis and interpretation of health status data after adjustments for sociodemographic variables and in conjunction with clinical data. Exploration of usefulness of outcomes data to clinicians through feedback discussion sessions and by an evaluation questionnaire. SETTING--One gastroenterology outpatient department in Aberdeen Royal Hospitals Trust, Scotland. PATIENTS--All (573) patients attending the department during one month (April 1993). MAIN MEASURES--Ability to obtain patient based outcomes data and requisite clinical information and feed it back to the clinicians in a useful and accessible form. RESULTS--Questionnaires were completed by 542 (95%) patients at baseline and 450 (87%) patients at follow up. Baseline health status data and health outcomes data for the eight different aspects of health were analysed for individual patients, key groups of patients, and the total recruited patient population. Significant differences were shown between patients and the general population and between different groups of patients, and in health status over time. After adjustment for differences in sociodemography and main diagnosis patients with particularly poor scores were identified and discussed. Clinicians judged that this type of assessment could be useful for individual patients if the results were available at the time of consultation or for a well defined group of patients if used as part of a clinical trial. CONCLUSIONS--Monitoring routine outcomes is feasible and instruments to achieve this, such as the SF 36 questionnaire, have potential value in an outpatient setting. IMPLICATIONS--If data on outcomes are to provide a basis for clinical and managerial decision making, information systems will be required to collect, analyse, interpret, and feed it back regularly and in good time.