The SPHERE Study: Secondary prevention of heart disease in general practice: protocol of a randomised controlled trial of tailored practice and patient care plans with parallel qualitative, economic and policy analyses. [ISRCTN24081411]

Background: The aim of the SPHERE study is to design, implement and evaluate tailored practice and personal care plans to improve the process of care and objective clinical outcomes for patients with established coronary heart disease (CHD) in general practice across two different health systems on the island of Ireland.CHD is a common cause of death and a significant cause of morbidity in Ireland. Secondary prevention has been recommended as a key strategy for reducing levels of CHD mortality and general practice has been highlighted as an ideal setting for secondary prevention initiatives. Current indications suggest that there is considerable room for improvement in the provision of secondary prevention for patients with established heart disease on the island of Ireland. The review literature recommends structured programmes with continued support and follow-up of patients; the provision of training, tailored to practice needs of access to evidence of effectiveness of secondary prevention; structured recall programmes that also take account of individual practice needs; and patient-centred consultations accompanied by attention to disease management guidelines.

Methods: SPHERE is a cluster randomised controlled trial, with practice-level randomisation to intervention and control groups, recruiting 960 patients from 48 practices in three study centres (Belfast, Dublin and Galway). Primary outcomes are blood pressure, total cholesterol, physical and mental health status (SF-12) and hospital re-admissions. The intervention takes place over two years and data is collected at baseline, one-year and two-year follow-up. Data is obtained from medical charts, consultations with practitioners, and patient postal questionnaires. The SPHERE intervention involves the implementation of a structured systematic programme of care for patients with CHD attending general practice. It is a multi-faceted intervention that has been developed to respond to barriers and solutions to optimal secondary prevention identified in preliminary qualitative research with practitioners and patients. General practitioners and practice nurses attend training sessions in facilitating behaviour change and medication prescribing guidelines for secondary prevention of CHD. Patients are invited to attend regular four-monthly consultations over two years, during which targets and goals for secondary prevention are set and reviewed. The analysis will be strengthened by economic, policy and qualitative components.

Devolving Housing Policy and Practice in Northern Ireland 1998 - 2002

This paper reviews the effect of devolution on housing policy and practice in Northern Ireland. It outlines the history and context of devolution and housing policy in Northern Ireland, including the legacy and persistence of intense social conflict. Current devolution arrangements are reviewed, including the implications of enforced coalition for policy governance. The paper focuses on three dimensions of housing and housing-related policy development and implementation: social housing, especially the distinctive history and changing organisation of social housing provision; policies affecting the housing market, including the changing regime for spatial planning; and, regeneration and tenant participation. The paper argues that housing policy has tended to converge with policies in England, rather than moving towards a distinctively local agenda. Local political agendas remain dominated by disagreements over constitutional status, thus policy formulation is determined more by officials than by elected politicians.

Safeguarding and promoting children in maternity services- implications for policy and practice

The article debates the issues involved in safeguarding and protecting children in maternity services and offers implications for professional practice. Midwives and other staff who work as members of the maternity team have a safeguarding role to play in the identification of babies and children who have been abused, or at risk of abuse, and in subsequent intervention and protection services. The study highlights how domestic violence increases during pregnancy and the postpartum period, and is significantly related to all types of child maltreatment up to the child's fifth year, and children under one being at the highest risk of injury, or death. Close inter-agency liaison is required with midwives who are accountable and not afraid to challeneg hiostorical working practices.