LIVERPOOL HEALTH
AUTHORITY

 CIRCULARS RECEIVED 


WEEKS COMMENCING:-
28th September  1998





Further copies of this list and any circulars required, are available
from:-

Library
Hamilton House
24 Pall Mall
Liverpool
L3 6AL

Telephone: 0151 285 2010
Fax: 0151 285 2264

Contact:  Kieran Lamb (0151 285 2356)
Contact: Maureen Horrigan (0151 285 2010)
Contact: Clair Maher (0151 285 2010)
 Obtaining Circulars and Attached Reports Abstracted in this List

The circulars abstracted in this list are all available from the North
West Health Library and Information Service. We are happy to supply
any legitimate user in the North West with copies of public domain
health circulars (letters of guidance from the Department of Health). 
Those outside of the North West Region should make use of their local
Library and Information Services. It should be noted that any attached
reports are only made available to staff of the 16 Health Authorities
across the North West Region and to members of the Merseyside &
Cheshire Health Libraries Group and the North Western Health Services
Librarians Association.  If you are employed by a NHS Trust or in the
Primary Care Services within the North West Region and would like to
obtain a report that was attached to a circular, you must contact this
library via your own library service. If you are uncertain where this
is we will direct you to the relevant library service.  Alternatively
these reports are also available from the NHS Responseline on 0541 555
455. It should be noted that you must be a NHS employee to use the
Responseline.

If an abstract states that an item has been requested from the NHS
Responseline this means it is not held as part of library stock at the
time the abstract was written and is therefore not available for loan
at the that time.  However it will be made available at a later date,
the usual dispatch time for items stocked by the Responseline is 48
hours so pleas allow a fortnight for the item to be received and
catalogued.  If you wish to check on the progress of an item please
call NWHLIS and we will be pleased to inform you. 

If you have no access to these services and are not employed by the
NHS, NWHLIS is available for reference use only by appointment with
the librarian.  The circulars themselves may also be obtained on the
Internet by following the links  to the COIN database from

http://www.open.gov.uk/doh/outlook.htm

in order to use this service you will require a copy of the Adobe
Acrobat Reader programme which can be down loaded at no charge from

http://www.adobe.com/

It should be noted that COIN only contains the circular and not any
attached reports.  Should you require these you should contact the
library of your hospital, educational institution or the public
library service and ask them about Inter-library Loan facilities.

Kieran Lamb
Librarian
NWHLIS 
 Reference No.  	: 	AL(MD)98/4
Title of Circ. 	:    	Pre-interview visiting expenses for Specialist
Registrars amendment to the terms and conditions of service paragraph
313. Accession No.  	: 	0005117 Abstract	:	Amends paragraph 313 of the
'Hospital Medical and Dental Staff Terms and Conditions of Service
Handbook'.  Candidates for Specialist Registrar training placements
may now with prior arrangement with the employing authority be
reimbursed for travelling expenses and subsistence allowance, for
pre-interview, pre-application visits, subject (unless circumstances
warrant exceptional treatment) to the maximum that would have been
payable under sub-paragraph 313 aii or iii as appropriate.

Pre-interview visits should be encourage but should not be seen by the
candidate or committee as part of the selection process.  A doctor not
acting as part of the selection process should act as guide. 
Questions that should be asked at interview should not be asked as
part of this visit.

Reference No.  	: 	AL(PAM/PTA)98/2
Title of Circ. 	:    	Discretionary points - Professions Allied to
Medicine. Accession No.  	: 	0005116 Abstract	:	Details arrangements
for the payment of discretionary points at the top of the Senior II,
Senior I and Superintendent/Head/Chief IV and III grade pay scales
following the 1998 report of the Pay review Body.

This is a national agreement, local procedures for implementation
should be developed and adopted.  Employers should ensure prior to
awarding discretionary points that posts are correctly graded. 
Funding for discretionary points  is a local matter within existing
resources.

Insert for the Handbook at the end of the existing Section III
together with a revised Appendix A and revised Table of Contents are
enclosed with the circular.

Reference No.  	: 	CI(98)11
Title of Circ. 	:    	Getting better? Inspection of hospital discharge
arrangements for older people. Accession No.  	: 	0005122
Abstract	:	Details publication of 'Getting better? Inspection of
hospital discharge arrangements for older people' which notes an
improvement in the role of Social Services in facilitating patient
discharge but notes more needs to be done.  Users and carers were
generally shown to be more satisfied and users (less so carers) were
involved in assessment and care planning procedures.  Operationally
staff that were hospital based worked well, responded promptly to
referrals and resolved most cross organisational disagreements before
they became formal complaints.

Distribution of care plans, completion of reviews, and inconsistency
in initial screening continue to cause concern.  Not all Health and
Local Authorities had reached joint continuing care agreements, and
rehabilitation/recovery provision requires improvement.  Performance
and Information monitoring provisions were not robust enough to allow
Social Service managers to chart service development effectively. 
Co-ordination and communication with community based social service or
health service staff remains limited.

Interagency co-operation is required and is a consistent theme running
through recent white and green papers and local authority and health
service circulars.  This report reinforces the need to develop
effective co-operation between agencies.

 Reference No.  	: 	HSC(98)159;LAC(98)22
Title of Circ. 	:    	Modernising Health and Social Services: national
priorities guidance 1999/00-2001/02. Accession No.  	: 	0005118
Abstract	:	First priorities guidance to set out the Government's
national priorities for Health and Social Services (on order from NHS
Responseline, electronic copy is available on request).  The Health
Improvement Guidance will set out practical steps for progressing
these national priorities.

HAs, PCGs, NHS Trusts, Social Services Authorities (SSA's) are require
to action the attached guidance.  HA's and SSA's will need to agree
local targets with NHS Executive Regional Offices and the Social
Services Inspectorate.  

National Priorities are:

Social Services Lead	Shared Lead			NHS Lead

Children's Welfare	Cutting Health Inequalities	WaitingLists/Time

Inter-agency working	Mental health			Primary Care

Regulation		Promoting Independence		Coronary Heart Disease

       Cancer

Reference No.  	: 	HSC(98)161
Title of Circ. 	:    	Nurse consultants.
Accession No.  	: 	0005120
Abstract	:	Circular establishes plans to develop detailed proposals to
establish Nurse Consultant posts as an alternative career path for
senior and experienced nurses.  Guidance will follow in due course. 
Full text of Frank Dobson's speech outlining the proposal is available
on the NHSnet information zone news page or on the internet at;

http://www.number10.gov.uk/public/info/releases/speeches.htm 

Reference No.  	: 	HSC(98)162
Title of Circ. 	:    	Working together: securing a quality workforce
for the NHS: a framework for managing human resources in the NHS.
Accession No.  	: 	0005119 Abstract	:	Identifies the link between 
good quality service delivery and quality management of staff that is
at the heart of good employment practice.  Research evidence from the
NHS shows that:

· poor staff management contributes to factors damaging the delicate
infrastructure and networks delivering patient care, exacerbating
staff turnover, low morale and work based stress and exhaustion. ·
organisations practising progressive HR practices are more productive
and efficient.

Progress will be measured against a range of process and outcome
targets.

Main emphasis will be on progress against priorities for action at a
local level.  Each Health Improvement Programme should be supported by
comprehensive Human Resource and Organisational Development plans and
each PCG/Trust must show preparedness and willingness to sign up to
the aims of the new framework.  Local employers should meet targets in
recruitment, retention, equal opportunities, health and safety, staff
involvement, staff satisfaction and conditions for on call staff.

Performance will be monitored through the  mainstream performance
management arrangements, Regional Offices will follow up failures to
address these priorities  drawing on HR expertise within the Region. 
Guidance document on order from the NHS Responseline.

Reference No.  	: 	HSC(98)168
Title of Circ. 	:    	Information for health: an information strategy
for the modern NHS. Accession No.  	: 	0005121 Abstract	:	Requires
HA's to establish a project team with appropriate membership to begin
preparatory work on a Local Implementation Strategy for information
management and technology.  The IM & T strategy will deliver over
time;

· lifelong electronic health records for everyone in Britain
· 24 hour access to patient records and support to best clinical
practice · National Electronic Library for Health enabling clinical
staff access to latest clinical research and best practice at time
they need it · integrated care for patients through shared information
between GPs, Hospitals and Community Services · fast convenient public
access to NHS resources through online information services and
telemedicine · more effective use of NHS Resources by providing
required information to planners and managers.

£1 billion of modernisation funding is being made available during the
lifetime of the strategy.  £70 million is to be made available in
1999/00 with progressive increases in subsequent years.

This strategy shifts the emphasis on information and information
technology from management information to supporting clinical services
and improving population health.

NHS Executive will start implementing the new strategy by;

· connecting all GP computerised practices to NHS net
· enabling anyone to contact NHS Direct
· establishing beacon sites to pioneer electronic patient records ·
ensuring HAs, NHS Trusts and PCGs have the right support at both
National and Regional levels to buy the best services, systems and
avoid unnecessary duplication.

 In the meanwhile HAs should;

· establish a project team to represent organisations involved in the
Local Implementation Strategy. · complete initial stocktake of local
baseline position in relation to targets in the strategy · complete
baseline stocktake of IM &T/Informatics skill base to support local
implementation · agree mechanisms to produce local IM & T
implementation strategy. · establish local pooling approach to IM
&T/Informatics skills · consider mechanisms required for effective
clinical input to support strategy

Interagency co-operation with partner agencies with whom sharing of
information for service planning and other purposes should be
considered fully.

of the £70 million allocated from the modernisation fund to support
implementation costs in 1999/00

· £20 million should support the information needs of Primary Care
Groups · £40 million should centrally fund the cost of connecting GPs
to NHSnet · £10 million should fund some expansion of local Health
Informatics provision.

Full text of the IM & T strategy is available within LHA at:

http://nww.liverpool-ha.nwest.nhs.uk/lha/document.htm (intranet)

or

G:\IMT98STGY\IMT.PDF  (Adobe Acrobat Format)

or

G:\ IMT98STGY\IMT.DOC  (Word Format)

Reference No.  	: 	MISC977
Title of Circ. 	:    	Stimulant needs assessment project.
Accession No.  	: 	0005126
Abstract	:	Surveys of drug prevalence suggest that amphetamines are
the most commonly used drug after cannabis and seizure data indicate
wide availability of cocaine numbers of stimulant users in treatment
remain small.  It is unclear whether this is related to the
unattractiveness of existing services to stimulant users or that
stimulant use patterns in the UK result in a less significant number
of users requiring help than is the case in the USA.  A sample of 541
cocaine and amphetamine users were interviewed of which 491 were not
in contact with treatment services.  The group was recruited in
London, Bristol, Kent, and Liverpool.  61% were male, 39% female. 
Mean age was 29 (age range 16-52).  A further 50 interviews with
London treatment attendees were conducted to provide a comparison
group.  Understanding the range of problems faced by stimulant users
is a necessary prerequisite to targeting  and developing effective
interventions.

All 491 respondents had used at least one type of stimulant drug in
the month prior to interview with 1 in 3  having used more than one
stimulant.  24% had used crack cocaine, 40% cocaine powder, 67%
amphetamine sulphate.  Routes of administration figures are detailed
on a chart.  Frequency of use varied across the sample with crack
cocaine smokers the most common daily users (27%).  Polydrug use was a
noticeable problem as was alcohol abuse amongst participants.

The Severity of Dependence Scale was used as a measure of dependence,
most users did not appear on this scale to be dependent but dependence
did appear to be related to route of administration with injection and
smoking of crack cocaine associated with the highest dependence
scores.

40% of users reported a problem with their stimulant use in the year
prior to interview.  15% reported severe problems, this was
significantly associated with smoking crack cocaine, injecting
stimulants and use of other drugs such as heroin and a high score on
the dependence scale.

25% did not feel in control of their drug use and 28% would like to
stop stimulant use.  20% reported a need for help in controlling their
use.  Crack users were most likely to perceive a need for help and one
third expressed a desire for help.

20% of interviewees had sought help in the past of which half had
sought help for heroin use.  The remaining half had sought help for
joint opiate and stimulant problems .  81% of those seeking help with
opiate problems had received help as opposed to 34% seeking help with
stimulant problems.

Most interviewees believed themselves well informed about local drug
services, 50% reported they would not seek help from local drug
agencies and only 20% would seek help form a GP.  Most respondents
wanted harm reduction advice, residential services, counsellors who
were ex users and support and advice for family members were also
deemed to be important.  those who had previously sought help were 
significantly more likely to rate a prescribed substitute as an
important element of treatment.

Of the 50 users currently in treatment the key to their seeking help
was lack of control over use, had emotional or relationship
difficulties or severe physical health problems.

Concludes that route of administration  is an important predictor of
problems.  Poly substance use  was also notable and may complicate
treatment.  Many behavioural and personal problems reported by users
were not attributed by them to there stimulant use.  It was
significantly harder to get support for stimulant problems as opposed
to opiate problems.  Awareness of  drug treatment options was high but
many respondents could not envisage a need for formal treatment
provision.  Advice and harm minimisation information were particularly
valued.

Reference No.  	: 	MISC978
Title of Circ. 	:    	Amphetamine use and treatment.
Accession No.  	: 	0005125
Abstract	:	Longitudinal study commissioned by the DOH which details
the need to treat amphetamine users and considers the effectiveness of
current drug services ability to provide such a service.  Amphetamine
use is second in popularity to cannabis, the number of users utilising
needle exchange schemes suggest there are many requiring treatment who
are deterred from seeking help.

Heavy use can cause enhanced perceptual sensitivity and acuity to turn
to paranoid delusions and hallucination.  The mixture of confidence
and paranoia may lead to aggressive behaviour and in more severe cases
amphetamine psychosis.  Heavy users may also utilise 'downers' (both
legal and illegal) to reduce the impact of withdrawal or to reduce the
hyperactivity caused by amphetamines.  Users therefore run the same
health risks as any other polydrug user.

Orientation of treatment services towards opiate users may be a
contributory factor in the low number of amphetamine users in
treatment.  Treatment only be sought when secondary use of
benzodiazepines and heroin qualifies them for the classification of
polydrug users.

Research utilised a matched-case control design in which clients
presenting to drug services in the North West were matched with
controls such as age, gender, drug use and partner variables.  Four
semi-structured interviews were carried out, the first three at
intervals of one month the last following an interval of four months,
they were designed to detail the following outcomes;

· use of street drugs
· change in mode of administration
· health (physical/psychological)
· injecting risk behaviour
· social integration (partners/friends/family)
· criminal activity

Clients were daily or frequent users using a median number of two
drugs, with a range of one to ten. Average age was 28.6 with the range
from 17 to 44.  11 (19%) were women.  59% were injecting and the
average daily dose was 3.8 grams by all methods of use.  Half of the
clients were self-referred, there was a preference to use GPs first
prior to drug agencies and there was dissatisfaction with regard to
health workers knowledge of amphetamine use.  Clients wanted to avoid
mixing and being identified with heroin users.  43% were prescribed
dexamphetamine (PDA's) and these tended to be older and had presented
for treatment before.

Significant differences between clients and controls were evident with
most outcome categories positive for those undergoing treatment.  

· use of street drugs - clients were found to have reduced use, and
this was most pronounced within the first month of treatment.  This
was largely a result of reduced use of street drugs by PDA's and there
was no reduction of frequency of use for PDA's or non-PDA's (NPDA's) .
Use of all drugs apart from cigarettes and legitimately prescribed
drugs was evident.  Controls reduced the amount used of street
amphetamine as a result of research intervention drawing attention to
use levels.

· change in mode of administration - 28 pairs of injectors were
studied, half were PDA's compared with 33% on non-injectors, clients
either stopped injecting (9 in month 1, 13 by month 3) or reduced
injecting over time.

 health (physical/psychological) - first months were stressful with no
 immediate improvement in physical health,  Injectors reported fewer
 physical health problems than non-injectors in the first month. 
 Psychologically depression and anxiety was poor in the first month
 (34% suicidal ideation compared to 16% in controls) and remained poor
 for some.  Clients that received counselling reported better
 psychological health by the end of the study.

· social integration (partners/friends/family) - 55% of clients had
regular sexual partners and these played a key role in encouraging
them to seek treatment.  Relationships were volatile during treatment
and by the end of treatment 39% of clients were still with partners
compared to 69% of controls.  Relationships with parents (particularly
mothers) improved.

· criminal activity - Prior to treatment 67% of clients had been
involved in property crime compared with 93% of the controls.  51% of
the controls said they enjoyed it compared with 21% of clients.  505
of clients and 43% clients reported violent crime.  Treatment reduced
crime, after two months 18% of clients compared with 53% of controls
reported a criminal act.  PDA's were less likely to persist in
criminal activities.

Key issues for services are a change of image to attract users. 
Treatment should be started quickly and support to address crises in
clients lives are vital in retaining clients.  Staff should be
educated and trained so that they understand the motives and lifestyle
of clients.  Appropriate models of care should be adopted, substitute
prescribing should be examined closely, while successful at reducing
injecting and crime quickly it was less appreciated by clients than
support and counselling.  Family relationships should receive a high
priority.

Concludes that demand for treatment should not be taken as an
indication of level of amphetamine use or lack of need.  Treatment was
shown to reduce crime, injecting, use of other street drugs.  Social
relationships are a key factor in success of treatment.

Reference No.  	: 	MISC979
Title of Circ. 	:    	Medical Devices Agency: Evaluation Number 368:
ECG recorders, UK market product review July 1998: an assessment of 24
products and the results from 13 brief assessments. Accession No.  	:
	0005124 Abstract	:	Reviews 24 ECG recorders fully and briefly
assesses a further 13.

Reference No.  	: 	MISC980
Title of Circ. 	:    	Sainsbury Centre for Mental Health: Keys to
engagement: review of care for people with severe mental illness who
are hard to engage with services: Briefing 1. Accession No.  	:
	0005123 Abstract	:	Details the contents of a review (not held by the
library)  focusing on the needs and aspirations of people not engaging
with services.  It identifies that users need;

· engagement
· range of treatments and care including crises intervention
· identified person responsible 24 hours a day
· risk management approach offering safety for both client and public
· attention to social as well as mental and medical problems ·
supported access to mainstream services · daytime activity giving
occupation, opportunity and purpose · help with finance and benefits ·
suitable accommodation

   The review concludes that assertive outreach through teams of
   health professionals and
outreach workers is required to ensure the right mix of day-to-day
engagement with active healthcare and rehabilitation services. 
Outreach must meet clients on their terms and provide access to a
range of services and agencies as appropriate.  The six key findings
of the review are;

1. There must be a strategic approach to the needs of the client group
both nationally and locally (Each HA should establish an interagency
strategy group to plan and monitor service provision).

2. Assertive outreach is required of mental health services (HAs with
a sufficient client base (100-150) should create one or more assertive
outreach teams, where the client base is too small alternative
arrangements should be made)

3. A human resource plan is required to enable the implementation of
assertive outreach (lead agencies should  set core criteria for staff
selection with a range of expertise and develop training strategies
for the team).

4. Teams should be effectively managed  (with managers visible to
staff and accountable for service delivery and team members should
have protected caseloads)

5. Teams  must developing working styles matching the needs of clients
(maintaining contact with clients families, suitable arrangements for
24 hour cover, and strategies and service delivery must reflect the
ethnic make up of the client group).

6. Range of provision for teams to draw upon must be available across
the relevant agencies (local service level agreements with partner
agencies should be negotiated including; sufficient supply of suitable
supported accommodation, range of daytime activities including
employment opportunities are required in each planning area.  Clear
arrangements for 24 hour care including in-patient care are vital. 
Mechanisms for liaison with local child and adolescent mental health
services to allow early intervention are also required).




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