Clinical management. Where medicine meets management. Random factors

Care is required when applying the findings from randomised controlled trials, systematic reviews of RCTs or national 'evidence-based' guidelines to the broad groups of patients in primary care. N-of-1 trials offer a useful approach to tailor medication and improve the quality of a treatment decision in an individual patient. The length of the relationship with patients makes follow-up important.     

Clinical management. Where medicine meets management. Remote control

Remote disease monitoring uses IT to link a patient at home with medical staff and systems. The potential is to improve chronic disease management and cut costs in the long term. Despite a tough government take-up target for 2007, there is little activity in the UK.     

Clinical management. Where medicine meets management. On reflection

There is an urgent need for validated, feasible tools to assess doctors' performance. A peer-rating tool mapped to good medical practice (SPRAT) is feasible, valid and reliable. SPRAT is ideal for revalidation purposes and performs particularly well in areas that are traditionally difficult to assess. It can also inform personal development planning.     

Clinical management. Where medicine meets management. Destination unknown

A south-east London GP co-operative has expanded beyond provision of out-of-hours care. Skill mixing is to be introduced to free up GPs' time. Pilots in north-east London are working on continuity of care.     

Clinical management. Where medicine meets management. Growing pains

Commissioning arrangements are not working for tertiary paediatric sub-specialties, such as paediatric nephrology. Staff shortages are leaving nephrology centres vulnerable to total breakdown. More trained nephrologists are becoming available, but trusts do not have the funding to take them on.     

Clinical management. Where medicine meets management. Reduced circumstances

The development of effective clinical teams is vital to the delivery of quality clinical care and reducing clinical errors. Implementation of the European working-time directive will disrupt team dynamics and reduce the training opportunities for junior doctors. Funding is needed to increase further the number of doctors if the directive is not to be at the expense of patient care.     

Clinical management. Where medicine meets management. Assistants required

The use of US-trained physician assistants is addressing a GP shortage in the West Midlands and is being extended to emergency care. PAs are trained in general and first-contact medicine and undergo rigorous, regular re-certification. Birmingham University is evaluating the scheme with a view to UK-based training and accreditation.     

Clinical management. Where medicine meets management. Senior moments

Most general hospital users are older people. Standard 4 of the national service framework for older people aims to transform the whole hospital experience for this group. Trusts have yet to grasp the fundamentals of this approach, despite the fact that it will help them achieve improvements such as access targets. Investment in staff training and education is needed to achieve the necessary cultural change.     

Clinical management. Where medicine meets management. Faith healers

An inner London mental health trust wanted to improve services for Muslim patients. Staff at the trust attended workshops on the religion and a cross-cultural nurse was appointed. Inpatient service users are feeling increasingly able to discuss their beliefs.     

Clinical management. Where medicine meets management. Acute accent

There is urgent need for reform in the care of acutely ill medical patients. Problems are being compounded by rising admissions, the reduction in junior doctors' hours and changes in training. Care should be delivered in acute medical or assessment units by dedicated teams specialising in acute care, according to a new report by the Royal College of Physicians.     

Clinical management. Where medicine meets management. Pumping iron

Non-haemodialysis renal patients requiring intravenous iron therapy are increasing the pressure on renal units. A new form of iron therapy can dramatically reduce patient visits, but takes longer to administer. Sunday provision of nurse-led clinics has enabled a switch to this new therapy. Cost savings have more than offset the additional nurse-led sessions and eliminated waiting lists for this group.     

Clinical management. Where medicine meets management. Muscle power

Physiotherapy-led services can dramatically cut orthopaedic waiting times, improve patient choice and reduce GP workload. Waiting times are cut by reducing the number of unnecessary referrals. Providing more direct access to physiotherapy services is key.     

Clinical management. Where medicine meets management. Uneasy riders

The NHS needs to form new alliances to address the public health challenges posed by the second Wanless report and the government's consultation paper on public health. Public health physicians need to return to clinical practice if they are to play a credible leadership role. 'Policy partnerships' could promote issues such as health inequalities.     

Clinical management. Where medicine meets management. Kidney complaint

The renal NSF sets a 10-year modernization plan for dialysis and transplantation. The shortage of haemodialysis facilities are blamed for UK end-stage renal failure death rates being 36 per cent higher than in other European countries. Critics have targeted the NSF's lack of hard-hitting targets.     

Clinical management. Where medicine meets management. Crib notes

This is a year of change for children's services, with reports, proposals and new clinical guidelines. Some primary care trusts have been accused of using the focus on the core programme as a way of cutting services. A royal college report may clash with the imminent national service framework.     

Clinical management. Where medicine meets management. Can of worms

There have been massive increases in the incidence of liver diseases in the UK, reaching epidemic levels. The development of liver services has been haphazard and there is no national service framework for liver disease, endangering patients. Specialist groups have formulated a national plan setting standards and guidelines.     

Clinical management. Where medicine meets management. Sink or swim

A Nottingham GP is working with local government colleagues to secure funding for well-being initiatives. Trust in one's GP has been identified as a key factor in social cohesion, and primary care can play a significant role in healing fragmented communities. Several PCTs are using the GMS contract to bring practices together and provide a wider and more integrated service.     

Clinical management. Where medicine meets management. Let us play

There is evidence that hospital play hastens children's recovery, increases compliance and reduces the need for general anaesthesia. The children's national service framework recommends that all children in hospital have daily access to a play specialist. A survey showed an 11 per cent rise in the number of play specialists in the past two years, but more are needed.     

Clinical management. Where medicine meets management. Heart to heart

The James Cook University Hospital appointed a cardiology pathways co-ordinator to reduce waits for those with acute coronary syndromes. The approach, in line with the coronary heart disease national service framework, has reduced error, duplication and delay.