Randomised cluster trial to support informed parental decision-making for the MMR vaccine.

BACKGROUND: In the UK public concern about the safety of the combined measles, mumps and rubella [MMR] vaccine continues to impact on MMR coverage. Whilst the sharp decline in uptake has begun to level out, first and second dose uptake rates remain short of that required for population immunity. Furthermore, international research consistently shows that some parents lack confidence in making a decision about MMR vaccination for their children. Together, this work suggests that effective interventions are required to support parents to make informed decisions about MMR. This trial assessed the impact of a parent-centred, multi-component intervention (balanced information, group discussion, coaching exercise) on informed parental decision-making for MMR. METHODS: This was a two arm, cluster randomised trial. One hundred and forty two UK parents of children eligible for MMR vaccination were recruited from six primary healthcare centres and six childcare organisations. The intervention arm received an MMR information leaflet and participated in the intervention (parent meeting). The control arm received the leaflet only. The primary outcome was decisional conflict. Secondary outcomes were actual and intended MMR choice, knowledge, attitude, concern and necessity beliefs about MMR and anxiety. RESULTS: Decisional conflict decreased for both arms to a level where an 'effective' MMR decision could be made one-week (effect estimate = -0.54, p < 0.001) and three-months (effect estimate = -0.60, p < 0.001) post-intervention. There was no significant difference between arms (effect estimate = 0.07, p = 0.215). Heightened decisional conflict was evident for parents making the MMR decision for their first child (effect estimate = -0.25, p = 0.003), who were concerned (effect estimate = 0.07, p < 0.001), had less positive attitudes (effect estimate = -0.20, p < 0.001) yet stronger intentions (effect estimate = 0.09, p = 0.006). Significantly more parents in the intervention arm reported vaccinating their child (93% versus 73%, p = 0.04). CONCLUSIONS: Whilst both the leaflet and the parent meeting reduced parents' decisional conflict, the parent meeting appeared to enable parents to act upon their decision leading to vaccination uptake.

Retaining older nurses in primary care and the community.

AIM: This paper is a report of a study conducted to examine issues associated with the impact of age on the retention of female primary and community care nurses in the National Health Service in England. BACKGROUND: Little is known about why older nurses in the primary and community care workforce leave and what might encourage them to stay. METHODS: A cross-sectional survey using a semi-structured postal questionnaire was carried out during 2005. Responses were received from 485 (61%) district nurses, health visitors, school nurses and practice nurses in five primary care trusts in England. Data were analysed to test for associations. RESULTS: Older nurses were more likely than younger ones to report that their role had lived up to expectations (P = 0.001). Issues important for older nurses were feeling valued and being consulted when change was implemented. Important factors encouraging nurses to stay were pension considerations, reduced working hours near retirement, and reduced workload. For those with degree-level qualifications, enhanced pay was a factor encouraging retention (P = 0.044). Nurses might leave in response to high administrative workloads, problems in combining work and family commitments (P < or = 0.001), and lack of workplace support (P = 0.029). Retirement and pensions advice was not widely available. CONCLUSION: Since two-thirds of nurses were generally happy in their role, it is important that the conditions necessary to maintain this level of satisfaction are continued throughout a nurse's working life. Nurses may all too easily consider leaving prematurely unless policy makers and managers ensure that their working environment reflects the issues nurses consider to be conducive to retention.

Retention of nurses in the primary and community care workforce after the age of 50 years: database analysis and literature review.

AIM: This paper is a report of a study conducted to explore strategies for retaining nurses and their implications for the primary and community care nursing workforce. BACKGROUND: An ageing nursing workforce has forced the need for recruitment and retention of nurses to be an important feature of workforce planning in many countries. However, whilst there is a growing awareness of the factors that influence the retention of nurses within secondary care services, little is known about those that influence retention of nurses in primary and community care. Little is known about the age profile of such nurses or the impact of the ageing nursing workforce on individual nursing specialities in the England. METHODS: Nursing databases were analysed to explore the impact of age on nursing specialities in primary and community care. The nurse retention literature was reviewed from 1995 to 2006. FINDINGS: Workforce statistics reveal that primary and community care nurses have a higher age profile than the National Health Service nursing workforce as a whole. However, there are important gaps in the literature in relation to the factors influencing retention of older primary and community care nurses. Specific factors exist for older nurses within primary care that are unique. Implications for their retention are suggested. CONCLUSION: Particular attention needs to be paid to factors influencing retention of older nurses in primary and community care. These factors need to be incorporated into local and national policy planning and development.

Retaining primary and community nurses over the age of 50 years: the views of managers.

AIM: To investigate employment policies in England to encourage retention of primary and community nurses over the age of 50 years. BACKGROUND: Little is known about why older nurses in the primary and community workforce leave or what might encourage them to stay. METHODS: Fifteen telephone interviews with staff with responsibility for the nursing workforce in five primary care trusts (PCTs) and associated Workforce Development Confederations and Strategic Health Authorities. RESULTS: When older nurses left, there was concern about the loss of skills, experience and intelligence about local communities. Strategies such as flexible working, support for returners and carers, and career breaks had been introduced. Concern about pensions was a key influence on nurses' decisions to stay or leave nursing. CONCLUSIONS: Efforts were being made to introduce employment strategies to improve the working lives and experiences of all nurses. Some policies designed more specifically for younger nurses requiring childcare were also being taken up by older nurses with caring responsibilities. There were numerous strategies in place or being set up to improve recruitment and retention, indicating a desire amongst managers to retain their pool of nurses. IMPLICATIONS FOR NURSING MANAGEMENT: Managers should continue to develop policies to retain older nurses and learn from others with successful strategies.

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.

Stage, survival and delays in lung, colorectal, prostate and ovarian cancer: comparison between diagnostic routes.

BACKGROUND: Very few studies have reported cancer outcomes of patients referred through different routes, despite the prominence of current UK cancer urgent referral guidance. AIM: This study aimed to compare outcomes of cancer patients referred through the urgent referral guidance with those who were not, with respect to stage at diagnosis, survival, and delays in diagnosis. DESIGN OF STUDY: Analysis of hospital records. SETTING: One hospital trust in England. METHOD: The records of 889 patients diagnosed in 2000-2001 with one of four types of cancer were analysed: 409 with lung cancer; 239 with colorectal cancer; 146 with prostate cancer; and 95 with ovarian cancer. Outcome measures were diagnostic stage, survival, referral and secondary care delays. RESULTS: For lung cancer, urgent referrals had more advanced TNM (tumor, node, metastasis) stage than patients diagnosed through other routes (P = 0.035) and poorer survival (P = 0.020). There was no difference in stage or survival for the other cancers. For each cancer, a higher proportion of urgent referrals was seen within 2 weeks. Secondary care delays for lung and colorectal cancer were shorter for inter-specialty referrals. CONCLUSION: For patients with lung cancer, the guidance appears to be prioritising those in the more advanced stages of disease. This was not the case for the other three cancers. Referral delays were shorter for patients urgently referred, as is the intention of the guidance. The avoidance of delays in outpatient diagnostics probably accounts for shorter secondary care delays for inter-specialty referrals.

How do receptionists view continuity of care and access in general practice?

BACKGROUND: Continuity of care is widely regarded as an important feature of general practice, but the role of receptionists in influencing continuity has been the subject of little research. OBJECTIVE: To explore how receptionists might influence access and continuity of care in general practice. METHODS: A questionnaire survey of receptionists in practices in Leeds, UK, was conducted. All 119 practices in Leeds were contacted to recruit receptionists via practice managers. A total of 148 receptionists responded from 50 practices. RESULTS: The majority of receptionists (140, 94%) perceived continuity as team continuity. Most (139, 93%) felt it was important for the patient to be seen on the same day by any doctor, rather than the usual doctor. They were less willing to ask patients for more details of a routine problem than an urgent one. The majority (113, 76%) thought that non-attendance was more related to patient issues than to their own behaviour. Organizational factors affected how receptionists offered appointments. Advanced access could impede longitudinal continuity and, indirectly, relational continuity. Having a policy to deal with urgent appointments or routine appointments could facilitate such continuity. CONCLUSION: The majority of receptionists perceived continuity as a team response rather than longitudinal. However, if relational continuity is to survive in UK and European general practice, educational and training measures would need to be taken to promote these values to receptionists.

Career intentions and preferences of GP registrars in Yorkshire.

With a shortage of GPs in England, there is a need to consider the career development for new GPs to ensure that they remain in post. This study examines, by means of a postal questionnaire survey, the views of GP registrars (GPRs) about their future careers in Yorkshire, England. The response rate was 59%. One hundred and eighteen (60%) responders were female, of whom 80 (39%) were planning to work part time. One hundred and fifty-six (76%) GPRs planned to take up a specific job in primary care; 81 (40%) in a general practice rather than a primary care trust setting. One hundred and seven (52%) had sought a different medical career prior to general practice and 113 (55%) did not feel well prepared to find a suitable practice. Interest in teaching was expressed by 167 (82%) and in sub-specialisation by 170 (83%). One hundred and seventeen (57%) GPRs said that their job choice was affected by domestic commitments. More males than females intended to become a principal. Primary care trusts should consider the profile and aspirations of the workforce and a more structured approach to career guidance is required.

Patients' experiences of continuity in the care of type 2 diabetes: a focus group study in primary care.

BACKGROUND: Continuity of care is fundamental to general practice and type 2 diabetes is a common chronic disease with major health and social impacts. Nevertheless continuity, as experienced by patients with type 2 diabetes, remains a neglected area. AIM: To explore perceptions and experiences of continuity of care in general practice from the perspectives of patients with type 2 diabetes, focusing on the advantages and disadvantages of different types of continuity. DESIGN OF STUDY: Focus groups with patients. SETTING: Seven practices with different organisational structures in Leeds, UK. METHOD: Seventy-nine patients with type 2 diabetes were recruited. Focus group interviews were conducted with 79 patients with type 2 diabetes from seven practices in Leeds, UK. RESULTS: Patients experienced three different types of continuity: relational (or longitudinal) continuity, cross-boundary (or team) continuity, and continuity of information. Patients' perceptions of continuity were influenced by several factors including a personal relationship between themselves and their healthcare professional, their own beliefs and behaviours, presence of diabetes, and the systems and structures of general practices. Patients identified the advantages and disadvantages of two types of continuity. Relational or longitudinal continuity was important in providing psychosocial care, but with a risk of misdiagnosis. The advantages of cross-boundary or team continuity were to provide physical care, whereas the main disadvantages were the absence of personal care and patient confusion. CONCLUSION: Perceptions of continuity by patients with type 2 diabetes were influenced by several factors; they perceived several advantages and disadvantages associated with different types of continuity. Patients might expect certain healthcare benefits by following certain types of continuity.

Urgent GP referrals for suspected lung, colorectal, prostate and ovarian cancer.

BACKGROUND: The UK urgent cancer referral guidance was introduced between 1999-2000. There is a dearth of literature relating to the effectiveness in detecting cancer of urgent suspected cancer referrals and general practitioners' compliance with the guidance. AIMS: This paper aims to determine the diagnostic yield from urgent referrals for suspected colorectal, lung, ovarian and prostate cancer, and the proportion of patients with cancer who were urgently referred. Secondary aims are to determine the association of these findings with age, ethnicity, sex and marital status, and to determine the proportions of patients who fulfilled the urgent referral criteria. DESIGN: Detailed notes analysis of all urgent referrals and all cancer diagnoses. SETTING: One hospital trust in England. METHOD: Data regarding all urgent referrals and all cancer diagnoses were obtained from one hospital trust over a 2-year period. Data analysis was undertaken to determine, diagnostic yields and their association with sociodemographic factors, trends over time and fulfilment of the guidance. RESULTS: The percentages of urgent referrals diagnosed with cancer were colorectal 11%, lung 42%, ovarian 20%, and prostate 50%. The percentages of patients with cancer referred urgently were colorectal 21%, lung 23%, ovarian 24%, and prostate 32%. Patients who were urgently referred without cancer were younger than those with cancer for all but prostate. There were no significant differences by sex, marital status or ethnicity. For patients with cancer there were no differences for any sociodemographic factors in whether or not they were referred urgently. CONCLUSIONS: The predictive power of the referral guidance as a marker for cancer is low, resulting in significant numbers of patients being urgently referred without cancer. A large majority of patients not diagnosed with cancer through the urgent referral route did fulfil the criteria for urgent referral, suggesting that with more widespread use of the guidance the diagnostic yields will be higher. This has implications for patients, on hospital diagnostic systems, and for patients presenting through other pathways.

South Asian participation in clinical trials: the views of lay people and health professionals.

There is little UK-based empirical research on South Asian participation in clinical trials. The predominantly US literature rarely engages with mainstream debates about ethnicity, diversity and difference. This study was prompted by a lack of knowledge about how South Asian people perceive trial involvement and the risks and benefits involved. Face to face interviews were conducted with 25 health professionals (consultants, GPs, nursing staff, academics, non-medically trained trial co-ordinators, LREC and MREC members) and 60 South Asian lay people (20 Indians, 20 Pakistanis and 20 Bangladeshis) who had not taken part in a trial. The study took place in the Leeds and Bradford areas of England. It was found that lay South Asian attitudes towards clinical trial participation focused on similarities rather than differences with the general UK population, suggesting that the relevance of ethnicity should be kept in perspective. There was no evidence of antipathy amongst South Asians to the concept of clinical trials, and awareness was a correlate of social class, education and younger age. Lay factors that might affect South Asian participation in clinical trials included: age; language, social class; feeling of not belonging/mistrust; culture and religion. Approachable patients (of the same gender, social class and fluent in English) tended to be 'cherry picked' to clinical trials. This practice was justified because of a lack of time, resources and inadequate support. South Asian patients might be systematically excluded from trials due to the increased cost and time associated with their inclusion, particularly in relation to the language barrier. Under-representation might also be due to passive exclusion associated with cultural stereotypes. The paper concludes by applying the theoretical framework of institutional racism as a means of making sense of policy and practice. At the same time, caution is advocated against using ethnicity as the only form of discrimination facing minority ethnic populations.

New opportunities for nurses and other healthcare professionals? A review of the potential impact of the new GMS contract on the primary care workforce.

PURPOSE: The paper seeks to show that the new General Medical Services (GMS) contract will provide opportunities for NHS staff to enhance their roles, so it is important that adequate training assessment and quality control systems are set in place. This paper assesses the implications for NHS staff in primary care. DESIGN/METHODOLOGY/APPROACH: In this paper a review of policy documents was undertaken. FINDINGS: The paper finds that enhanced services set out in the new GMS contract may be provided by primary care organisations and healthcare professionals other than those located in general practitioner (GP) practices. As nurses and other healthcare professionals take on tasks previously conducted by GPs, so GPs will take on more consultant tasks previously confined to secondary care. Personal Medical Services (PMS) and GMS are converging in their contractual obligations and the opportunities offered to staff. As well as General Practitioners with Special Interests (GPwSIs), Practitioners with Special Interests (PwSIs) are important developments, which could promote recruitment and retention in the nursing and allied health professional workforce. Nurses and other healthcare professionals will be the main source of staffing for services shifted from secondary care. PRACTICAL IMPLICATIONS: The paper shows that it will be important to identify whether these professionals can substitute for GPs, the boundaries to that substitution, and whether recruitment and retention are enhanced. Training for GPwSIs and PwSIs will be introduced or expanded but also needs accreditation and validation. ORIGINALITY/VALUE: The paper provides an overview of the implications of the new GMS contract for nurses and other NHS professionals.

Developing cancer services strategy in primary care in England: primary care trust managers' views of the primary care cancer leads initiative.

PURPOSE: Primary care cancer lead clinicians (PCCLs) act strategically in primary care trusts (PCTs) in England to improve communication and understanding of cancer across primary and secondary care and provide a link between Cancer Networks and primary care. The aim is to evaluate the first three years of the initiative. DESIGN/METHODOLOGY/APPROACH: A postal questionnaire was sent to all PCT chief executives in all PCTs in England and some were passed on to other PCT managers for completion. The response rate was 61 per cent. PCT directors of public health were the largest group of respondents (29 per cent). Most (74 per cent) PCCLs were GPs and 22 per cent were nurses. FINDINGS: PCCLs were most likely to focus on palliative care and preventive services. Key achievements were identified as raising awareness of cancer, developing relationships and promoting primary care. The personal skills of the PCCLs were important as was support of colleagues at all levels. Lack of time was a major barrier to achievement, as was a lack of understanding of the role from others. Links with the Cancer Networks were being developed. About 85 per cent of managers wanted the role to continue. ORIGINALITY/VALUE: The paper illustrates that PCCLs are at the forefront of improving cancer services in primary care. They are particularly important in view of the priority of reducing premature deaths and promotion of healthy lifestyles.

Measuring health status: information for primary care decision making.

Primary Care Trusts (PCTs), charged with improving the health of their population, need to measure the extent to which patients actually benefit from the health care that is provided for them. One way of achieving this is to measure health status of patients over time. The study described here reports on the feasibility of administering the EQ-5D in general practitioner (GP) surgeries and identifies how the results might be used by practices and PCTs to improve the health of their populations. The study took place in an opportunistic sample of 1942 patients attending GP surgeries. One year later, patients who had provided contact details were sent another EQ-5D together with a request for additional information about their use of health care services in the intervening time period. A total of 770 patients completed this follow-up questionnaire. There were significant age effects associated with variation in self-reported health status and also associated with top-level Read diagnostic codes in some groups of patients. The results showed that EQ-5D could be used by individual GP practices to identify patients with specific health problems. This knowledge can also be used by PCTs and other primary care organisations, to better target scarce health resources.

Researchers' responses to research management and governance for primary care research in England: persistent and escalating problems over time.

PURPOSE: Research Governance has been introduced to regulate research involving National Health Service (NHS) patients and staff but the process is lengthy and bureaucratic and has improved little since its introduction. The paper seeks to investigate changes over time. DESIGN/METHODOLOGY/APPROACH: A comparison between two studies, one in 2003-2004 and the second in 2004-2005, provided the opportunity of observing the process of Research Governance as it was developing. Both studies included postal questionnaire surveys and interviews with study participants. FINDINGS: In order to achieve Research Governance approval, application forms have to be completed, reviews undertaken, sponsors and indemnity information identified and honorary contracts from individual PCTs applied for. Honorary contracts can require references and health and Criminal Records Bureau checks. The process reduces the time available for research and employs large numbers of people, yet is still inefficient. Some of the requirements reduce the quality of the research and researchers' rights are marginalised. RESEARCH LIMITATIONS/IMPLICATIONS: The studies took place in a rapidly changing research environment. Further studies should continue to assess the situation and report any progress in making Research Governance less onerous for researchers. PRACTICAL IMPLICATIONS: There is an urgent requirement to investigate how procedures can be simplified and made less bureaucratic and costly, and to protect the rights of researchers. Without this, primary care research will be seriously disadvantaged and may become impossible to pursue. ORIGINALITY/VALUE: The study compares process over time and shows that achieving Research Governance approval is seriously limiting research in primary care.

The role of UK general practitioners with special clinical interests: implications for policy and service delivery.

The development of specialist clinical interests by general practitioners (GPs) is currently receiving considerable attention in the United Kingdom. Although GPs have long been able to pursue such interests, it is only in recent years that they have taken on within primary care what were previously secondary care tasks, provided such services for patients outside their own practices, and received payment for them. The expansion of such services has been highlighted as a target in the NHS plan for England. Managerial and professional guidance is becoming available that seeks to clarify the role and nature of specialisation within general practice, to learn from the experiences of individuals who have embarked on specialist practice, and suggests procedures for future developments. Drawing on a range of sources, this paper builds on that burgeoning knowledge by setting the development of GPs with special interests in a broader policy context, highlighting the implications for the way that healthcare services are organised and delivered, and discussing their actual and potential impact of professional roles and practice.

Salaried contracts in UK general practice: a study of job satisfaction and stress.

OBJECTIVES: To compare job satisfaction and stress levels of general practitioners (GPs) employed on salaried contracts with GPs on a 'standard' performance-related contract paid by fee-for-service and capitation. METHODS: Job satisfaction and stress levels were assessed using data from two postal surveys of GPs: a national survey of 'standard' contract GPs carried out in 1998; and a survey of salaried GPs and their non-salaried GP employers in 1999. Differences in satisfaction and stress scores were assessed by t-tests; regression analysis was used to control for confounding factors and possible selection bias. RESULTS: We achieved a response rate of 77% in the 1999 survey of salaried and non-salaried GPs; 48% of 'standard' contract GPs responded in the 1998 survey. We found that salaried GPs were as satisfied overall as both non-salaried GP employers and GPs on the 'standard' contract, even after controlling for confounding factors and selection bias. Salaried GPs were more satisfied with their remuneration, working hours and the recognition they got for their work. They experienced more stress with two factors but less stress with 19 factors compared with the 'standard' contract GPs. CONCLUSIONS: Overall job satisfaction levels among salaried doctors were similar to those of doctors on contracts paid by mixed fee-for-service and capitation. Future studies of job satisfaction levels under different doctor payment systems need to take account of the extent to which doctors have preferences for different types of contract if they are to derive unbiased results.

Paying doctors by salary: a controlled study of general practitioner behaviour in England.

The study aim was to evaluate the impact of the experimental introduction of salaried contracts in England on general practitioner (GP) behaviour and the quality of care. A controlled before-and-after design was implemented involving ten practices of standard contract GPs, paid largely by capitation and fee-for-service, and ten salaried GP practices. Diaries and routinely available data were used to assess GP workload, and patient assessments of the quality of care were obtained by postal questionnaire. GPs in salaried practices spent less time on practice administration but more working out-of-hours and in direct patient care, allowing more patients to be seen. Total list sizes were smaller in salaried compared with standard contract practices, but lists per GP were higher because of staffing policies. Salaried GPs tended to provide shorter consultations compared with standard contract GPs, prescribe in fewer consultations, but referral rates were similar. Quality was rated as higher for seven out of thirteen aspects of care examined in salaried practices and two in standard contract practices. However, none of these differences were statistically significant. To conclude, salaried contracts did not adversely affect GP productivity and had little impact on other aspects of GP behaviour or the quality of care provided.

Why ethnic minority groups are under-represented in clinical trials: a review of the literature.

Randomised controlled trials (RCTs) are considered to be the gold standard in evaluating medical interventions; however, people from ethnic minorities are frequently under-represented in such studies. The present paper addresses a previously neglected debate about the tensions which inform clinical trial participation amongst people from ethnic minorities, in particular, South Asians, the largest ethnic minority group in the UK. In a narrative review of the available literature, based mainly on US studies, the present authors aim to make sense of the issues around under-representation by providing a theoretical reconciliation. In addition, they identify a number of potential barriers to ethnic minority participation in clinical trials. In so doing, the authors recognise that the recent history of eugenic racism, and more general views on clinical trials as a form of experimentation, means that clinical trial participation among people from ethnic minorities becomes more problematic. Lack of participation and the importance of representational sampling are also considered, and the authors argue that health professionals need to be better informed about the issues. The paper concludes by offering a number of strategies for improving ethnic minority accrual rates in clinical trials, together with priorities for future research.

Impact on health authorities of the introduction of primary care groups and trusts.

The National Tracker Survey of Primary Care Groups (PCGs) and Trusts (PCTs) in the UK has provided evidence about how PCGs and Health Authorities managed the transition to PCTs. This was a major challenge for both organizations. Devolution of responsibilities was dependent on the capacity and readiness of PCGs to take on their new roles. The development of good working relationships between the principal parties was critical to this process. Health Authorities started to let go and all put in place basic mechanisms for holding PCGs to account in their first year. However, a number of PCGs regarded their Health Authority as authoritarian. Most Health Authorities were found to have started to provide information to support PCGs in their core functions, but resources were frequently problematic. It will be important for Health Authorities and PCG/Ts to negotiate a shared view of their respective roles and responsibilities. The future role of Health Authorities in providing strategic leadership for their local health economies was not sufficiently well defined or understood.