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Objective: To investigate whether socioeconomic deprivation is associated with cause specific and all cause survival for colorectal cancer and to what extent this is independent of significant prognostic factors. Design: Prospective cohort. Setting: The former Wessex Health Region, South West England. Participants: All patients resident in Wessex registered with a diagnosis of colorectal cancer over three years (n=5176). Survival analysis was carried out on those patients with compete data for all factors and a positive survival time (n=4419). Outcomes: Death from colorectal cancer and all cause over five year follow up from initial diagnosis. Main results: Deprivation was significantly associated with survival for both outcomes in univariate analysis; the unadjusted hazard ratio for dying from colorectal cancer (most deprived compared with most affluent) was 1.12 (95% CI 1.00 to 1.25) and for all cause was 1.18 (1.07 to 1.30). Significant prognostic factors for both outcomes were age, specialisation of surgeon, Dukes's stage, and emergency compared with elective surgery. Comorbidity and gender were only associated with all cause survival. After adjustment for prognostic factors, the effect of deprivation on both cause specific and all cause mortality was reduced, and it was non-significant for colorectal cancer. However, the most deprived group had consistently worse survival than the most affluent. Conclusions: Factors associated with survival with colorectal cancer depend on the outcome measure. Socioeconomic deprivation is adversely associated with survival in patients with colorectal cancer. This is strongest for non-colorectal cancer death, partly reflecting higher comorbidity, but it is there for colorectal cancer though not statistically significant. Conclusive evidence of the inequalities by socioeconomic status and underlying reasons needs to come from studies using individual based measures of socioeconomic status and more detail on treatment and host related factors.T here is strong evidence that patients from higher socioeconomic groups have better survival across a wide range of cancers, including malignant melanoma, 1 breast cancer, 2 and cancers of the colon, rectum, and cervix. 3 Reduction of such inequalities would contribute to improving cancer survival, yet the reasons underlying them remain poorly understood. Moreover, lessening inequalities in health and promoting equity in access to health care are central to the health policy of the UK government, 4 and a restructuring of cancer services in England and Wales is presently underway, with the aim of reducing regional variations in treatment and outcome for cancer patients. 5Inequalities in colorectal cancer survival have been clearly demonstrated, with a 3%-5% difference in five year survival between the most affluent and deprived quintiles of the population.6 This is of considerable importance as this is the second commonest cause of death from cancer affecting both men (after lung cancer) and women (after breast cancer) in the UK. It accou...

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.