In the rapidly progressing field of telemedicine, there is a multitude of evidence assessing the effectiveness and financial costs of telemedicine projects; however, there is very little assessing the environmental impact despite the increasing threat of the climate emergency. This report provides a systematic review of the evidence on the carbon footprint of telemedicine. The identified papers unanimously report that telemedicine does reduce the carbon footprint of healthcare, primarily by reduction in transport-associated emissions. The carbon footprint savings range between 0.70-372 kg CO 2 e per consultation. However, these values are highly context specific. The carbon emissions produced from the use of the telemedicine systems themselves were found to be very low in comparison to emissions saved from travel reductions. This could have wide implications in reducing the carbon footprint of healthcare services globally. In order for telemedicine services to be successfully implemented, further research is necessary to determine context-specific considerations and potential rebound effects.

Objectives To compare patients' enablement and satisfaction after teaching and non-teaching consultations. To explore patients' views about the possible impact that increased community based teaching of student doctors in their practice may have on the delivery of service and their attitudes towards direct involvement with students.

There is anecdotal evidence that general practitioners are being flooded with guidelines. We set out to quantify this by conducting a survey of all guidelines retained in general practices in the Cambridge and Huntingdon Health Authority. Methods and resultsFP visited 22 urban and rural general practices, a sample of the 65 practices in the authority, and asked them to produce copies of all guidelines retained for use. Guidelines were defined as any written material used by a doctor or nurse in primary care to assist decision making in relation to health care, 1 excluding medical textbooks and electronic databases.We found 855 different guidelines-a pile 68 cm high weighing 28 kg (see fig). There were 243 single page and 195 two page guidelines. There were, however, 160 guidelines that were more than 10 pages long, including 25 presented as booklets or large folders. About 60% of the guidelines had been produced locally, of which 50% had been produced by local trusts and 30% by general practitioners. The remaining 40% were produced nationally. The pharmaceutical industry and the local health authority produced only 31 (4%) and 32 (4%) of the guidelines respectively.We found that 38% of all the guidelines collected were undated. The dated guidelines suggest an exponential rise in guideline production since 1989: eight guidelines were published in 1990, compared with 73 in 1995 and 138 in 1996. We identified 57 guidelines produced in the first third of 1997 alone.Guidelines on clinical or disease management accounted for 75% of the total. Half of the remaining guidelines related to referral pathways. Guidelines produced in general practice were almost exclusively clinical, whereas nearly half of those produced by trusts described referral pathways.

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GPRs have mixed perceptions about their palliative care education. Future educational packages should ensure that GPRs receive planned systematic training in bereavement care and some practical experience in the use of syringe drivers. Both Postgraduate General Practice Education departments and specialist palliative care providers should explore ways of working more closely together to provide GPRs with more expertize in palliative care.

This paper describes the Cascade Communication Skills Teaching Project, which is a programme of facilitator training enabling communication skills teaching in the consultation to general practitioners to be cascaded throughout the former East Anglia Deanery. The paper also explores the project's educational and organizational effectiveness. The programme is based on an ongoing training programme for a cohort of around 30 district-based communication skills facilitators, and was set up in the autumn of 1995. These facilitators are now able to act as a resource to cascade high-quality communication skills teaching into vocational training schemes, trainer education and the continuing professional development of established general practitioners throughout each district in the region. The project has now been extended into medical student teaching, specialist teaching at junior and senior level, and multi-disciplinary teaching.

The team of fellows gained personal understanding of the reality of the impact of social determinants on health experiences and outcomes. The CA offers the health systems and services a way to engage hard to reach communities with issues that they know to be important and are then able to prioritise. Clinicians who are taught in the evidence based style need to reframe their understanding of community needs if they are to be effective in their work. Working in this way can challenge their own values and beliefs. With planned support this can be a powerful developmental process and the CA is a set of principles that can be used to facilitate the empowerment of communities, the service planners and providers.

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