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'Significant unmet needs' are those needs that patients identify as both important and unsatisfied. In this article we ask whether the overall needs of cancer patients are actually being met. We believe that the range of unmet need, and the kinds of patients who are more likely to claim unmet need, should be carefully identified. The needs responses of a series of 295 cancer patients in a cross-sectional survey were analysed. The majority expressed the opinion that information and good relationships with health care professionals were important, and few expressed dissatisfaction with these aspects of need. Similarly, needs items about support from family and friends were largely rated as important and satisfied. For a sizeable minority of patients, items of significant unmet need cluster around aspects of managing daily life, emotions, and social identity. The distribution of significant unmet needs is not random but is more likely to be experienced by patients who are younger, have a long-standing illness or disability, do not own/have use of a car, and/or have no religious faith. Furthermore, significant unmet needs relate to patients' ability to talk freely to a carer about the cancer, the degree to which the cancer interferes with social activities, and whether financial difficulties are experienced. Most of the significant unmet need is beyond the remit of services primarily designed for the treatment of disease. We consider whether multidisciplinary cancer teams can be expected to deal with all aspects of the cancer experience.

This paper considers the significant unmet psychosocial needs of the informal carers of cancer patients, drawing on data generated in a 3-year UK study (1997-2000) on the psychosocial needs of cancer patients and their main carers. While the needs of the carers of cancer patients are increasingly being recognised in healthcare policy documents, there is relatively little published literature on these needs. A "significant unmet need" is defined here as a need deemed important by the carer, but which has not been met. A descriptive cross-sectional survey of carers was conducted and the responses of 195 carers relating to 48 psychosocial need items were analysed. A subset of these carers (n = 32) were interviewed. Forty-three per cent of carers had significant unmet needs. They were more likely to be those where the relationship to the patient was not that of a partner or spouse, more likely to have other caring responsibilities, and less likely to have friends or relations to call upon for help. Carers with unmet needs were also more likely to be in poor health themselves or to be caring for a patient who had reached the palliation-only phase in their cancer journey. The majority of carers expressed the importance of needs such as having good relationships with healthcare professionals and receiving honest information, but few expressed dissatisfaction with these aspects of need. Items of significant unmet need clustered around aspects of managing daily life, emotions, and also social identity for a sizeable minority of carers. These are the same areas of significant unmet need that concern patients. However, carers have more of these concerns, reflecting their comparative neglect. The paper also considers how these widespread concerns can be addressed.

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The objectives of this study were to identify the prevalence of psychosocial need, and the contributory factors to need, among cancer patients, using a descriptive cross-sectional questionnaire survey of adult cancer patients. The participants were 1,000 patients from four hospitals in the north west of England with the following characteristics: tumour type (breast, colorectal, lymphoma, lung), being 1 month from a 'critical moment' in the cancer journey (i.e. (i) diagnosis, (ii) end of first treatment, (iii) recurrence, (iv) move from active treatment to palliative care), and aged over 18 years. The main outcome measure was a psychosocial needs inventory comprising seven needs categories (48 need items). A sample of 402 was achieved (40% response rate). Psychosocial needs relating to the need categories 'health professionals', 'information' and 'support networks' are commonly expressed and strongly felt by cancer patients. Needs relating to 'identity', 'emotional and spiritual' issues and 'practical' issues are less commonly expressed but are also strongly felt. Particular needs are related to tumour type, illness 'critical moment', age, gender, health status, socioeconomic and other social factors. This information should increase awareness among cancer care professionals about a range of psychosocial needs and may help them target particular patient groups for particular support interventions.

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INTRODUCTIONThis article reviews the characteristics of a range of public sector services suggesting that the delivery of these services sets up special problems for management and results in distinctive practices by managers. It is an attempt to generalize about the findings from a series of research projects in the public sector"] and to connect these with other recent research findings concerning the behaviour of public sector workers. It will be argued that services such as social work (Whittington and Bellaby, 1979; Wilding, 1982) health and psychiatric care (Bellaby and Oribabar, 1980;Haywood and Alaszewski, 1980;Mackay, 1989) and the police (Bradley et al., 1986;Colman and Gorman, 1982;Fielding, 1988;Grimshaw and Jefferson, 1987) have sufficient in common that they may be instructively treated as a relatively homogeneous group.Although the argument presented here is not formalized into an excessively schematic representation, the elements of a model of public sector management will be outlined. It will be suggested that managerial problems encountered in one service are often reproduced in a slightly different form in another: what are managerial issues in, say, the health service or the police, are likely to be found, with some differences of detail, affecting education and the social services. Briefly put, we argue that the relationships between public sector workers and their clients (relations of provision) are quite different from the relationships involved in the provision of services in a market. For this reason the relationships which support and underwrite the provision of public services including managerial roles (relations for provision) take characteristic forms. We suggest that the characteristic managerial stance towards public services is what we designate 'custodial management', because the primary aim of such management is to preserve and perpetuate customary kinds and standards of service provision.We do identify variations of policy or orientation amongst public sector managers. In particular, we distinguish what we call budgetary and policy Addmsjor reprints: