14 492 calls were received during the specified times in the trial year (7308 in the control arm and 7184 in the intervention arm) concerning 10 134 patients (10.4% of the registered population). There were no substantial differences in the age and sex of patients in the intervention and control groups, though male patients were underrepresented overall. Reasons for calling the service were consistent with previous studies. Nurses managed 49.8% of calls during intervention periods without referral to a general practitioner. A 69% reduction in telephone advice from a general practitioner, together with a 38% reduction in patient attendance at primary care centres and a 23% reduction in home visits was observed during intervention periods. Statistical equivalence was observed in the number of deaths within seven days, in the number of emergency hospital admissions, and in the number of attendances at accident and emergency departments. Conclusions Nurse telephone consultation produced substantial changes in call management, reducing overall workload of general practitioners by 50% while allowing callers faster access to health information and advice. It was not associated with an increase in the number of adverse events. This model of out of hours primary care is safe and effective.

The distress of children at the induction of anesthesia (DAI) is unpleasant for all involved and potentially harmful. Many strategies such as premedication or parental presence at induction have been described to minimize it. A preoperative education programme [the 'Saturday Morning Club' or (SMC)] has been in existence in our institution for a number of years and an observational study of children undergoing day case surgery was undertaken to assess the influence of attendance at the SMC on DAI. Ninety-four children aged between 2 and 16 years of age were included in the study; 21 attended the SMC and 73 did not. Patient anxiety using the modified Yale Preoperative Anxiety Scale was measured by blinded observers on the day ward, in the preoperative waiting room and at induction of anesthesia. Parental anxiety at the same locations was self reported using a visual analogue scale. Attendance at the SMC had a favorable effect on patient anxiety levels in all three locations but only reached statistical significance in the waiting room (P = 0.007, Mann-Whitney U-test). At present there is little evidence to support the use of preoperative education programmes in the UK and further studies are required to determine their benefit.

1993-94), 8.2% (1993-94 to 1994-95), and 9.4% (1994-95 to 1995-96).' There has been increasing concern that the needs of many callers may be more appropriately met in ways other than the dispatch of an emergency ambulance with paramedic crew, travelling at high speed with lights and sirens. This paper reviews the literature concerning the appropriateness of use of 999 vehicles.Sources of material For this review, the search strategy used was a search of Medline (1989-97), Healthplan (1983-95), Helmis (1983-95), and BIDS Embase .Keywords entered into these databases of health related references were explode "ambulances/utilisation or ambulance* and (inappropriate* or appropriate* or abuse or misuse)"; "health care and (utilis/zation or delivery or need or planning)"; "emergency and (ambulance or health service or treatment or medicine)", "pre-hospital care", and "out of hours".Further references were followed up from the citations at the end of papers obtained from these initial searches. This review covers all major papers published in English over the last 15 years, as well as some foreign language papers and some work which has not yet been formally published in full.

Practicality and quality of implementationWe carried out this trial in everyday practice. We included thousands of women who might have received the 10 leaflets, but only 70% reported receiving one of them. Studies reported in the systematic review of decision aids were explanatory trials, with the implicit assumption that all patients received the intervention.3 One conclusion might be that the systematic review showed that decision aids can be effective under certain circumstances but that our study showed that they are not necessarily effective in the real world. 7 The pragmatic nature of our design may have affected the outcome, but that outcome represents a true picture of the impact of introducing the leaflets into routine practice.We thank midwives, managers, and administrative staff in the maternity units in Wales (unnamed to ensure confidentiality of participating units), who worked so hard to help us with data collection. We thank the thousands of women who completed our questionnaires at such an important time in their lives.

We recently published the results of a randomised controlled trial of a nurse telephone consultation service in primary care out of hours. 1 The new service, operating at evenings and weekends, significantly reduced general practitioners' workload and was at least as safe as the existing out of hours service. Contacts diminish sharply after about 10 pm, 2 and, anecdotally, a higher proportion of night calls necessitate consultation with a general practitioner. We report here a parallel trial aimed at establishing whether nurse telephone consultation was equally effective in managing workload at night. Subjects, methods, and resultsThis study was an adjunct to a randomised controlled trial in a 55 member general practice cooperative serving 97 000 patients in Wiltshire. The design has been described. 1 The night nurse telephone consultation service ran over two two-week periods (15-28 October 1997 and 12-25 November 1997) from 11.15 pm until 8 am. Outcome measures were as used in the main trial with one addition: the number of patients attending daytime surgery within three days of a call.1 One of us (FT) visited each surgery to extract details of attendances from patient records.In the main study 49.8% of calls were handled by the nurse alone. Specifying = 0.1 (0.05 in a one sided calculation) and = 0.2, we calculated that the night nurse service would need to receive 78 calls to establish equivalence with this figure, with equivalence limits being 40% and 60%.3 A one sided calculation was used as we were interested to establish only whether the night nurse intervention produced worse results (lower numbers of calls handled without referral to a doctor) than the evening and weekend service. For other within-trial outcomes, results are presented as relative risks with 95% confidence intervals, calculated with EpiInfo. This trial was not powered to show within-trial equivalence in numbers of adverse events.During the study 210 callers made 223 calls, 123 in the control group and 100 in the nurse telephone consultation (intervention) group. Follow up was 94% complete: 12 sets of patient records (6%) could not be found, seven in the control group and five in the intervention group. The median age (range) of patients was 34.0 ( 0.01-97.2) years in the control group and 32.5 (0.49-97.0) years in the intervention group. Fifty three patients (43%) in the control group and 44 (44%) in the intervention group were male.The table shows details of call management and outcome. Altogether 59% of calls (95% confidence interval 48.7% to 68.7%) were handled by the nurse alone. As we were interested only in whether the nurse service handled fewer calls at night, this can be interpreted as showing equivalence with the proportion observed in the main trial. The proportions of calls in which callers received advice from a general practitioner and calls ending in a home visit showed clear reductions, with 95% confidence intervals not embracing 1. A lower proportion of calls resulted in a daytime surgery attendance in the intervention ...

Objective-To ascertain general practitioners' views about the future provision of out of hours primary medical care.Design-Self completing postal questionnaire survey.Setting

This patient and public involvement study revealed a number areas that children and young people believe to be important for the future training of children's nurses. Additionally, the factors which children consider inhibit or enhance the experience of hospital admission have been identified.

Professor Alan Glasper discusses the Departments of Health and Education's plans for promoting optimal child health.