We discuss some of the issues that have arisen during the development and introduction into practice of information materials for health professionals and patients that aim to promote clinical effectiveness and informed patient participation in clinical decision making.

Objectives: To determine the use and costs of the principal out of hours health services in Buckinghamshire. Design: Prospective cross sectional survey and cost description of patient contacts with out of hours services. Setting: Buckinghamshire during March and April 1995. Subjects: General practices, accident and emergency departments, ambulance services, and community nursing services. Main outcome measure: Contacts with patients and cost of out of hours services. Results: 438 patient contacts/1000 population/year were recorded at an annual incremental cost of between £4.6m and £7.2m (depending on the costing of general practitioner services), for a population of 660 000. Of these contacts, 21 649 (45%) were with general practitioners. Night time contacts with all services diminished sharply after 10 pm. General practitioners considered that 40% of contacts were unnecessary or could have waited until morning. Over 70% of contacts were for upper respiratory tract infections, earache, gastroenteritis, and other minor ailments. Nursing care was predominantly for elderly people, and 33% of nursing contacts were to supervise medication. Accident and emergency care was predominately for young adults, especially men, and 41% of attendances were for medical conditions. Conclusions: New models such as multidisciplinary primary care centres with telephone advice lines and triaging are required to ensure high quality, cost effective care that is responsive to the needs of both consumers and professionals.

Aims-To assess test-retest reliability and validity of the "TyPE" patient self assessed visual function questionnaire, as part of a study in two hospitals measuring the eVectiveness of cataract surgery. The American TyPE questionnaire had minor adaptations made for use in Britain. Methods-Test-retest reliability was assessed on 63 out of 378 adult cataract surgery patients in the study, using Spearman correlation coeYcients and kappa coeYcients of agreement. "Construct" validity was evaluated by comparing the association between changes in visual function questionnaire scores after surgery, with patients' perception of change in visual function obtained by independent interview of 24 patients. Results-The TyPE questionnaire items showed very good test-retest reliability. Average Spearman and kappa coeYcients for 39 patients from hospital 1 were 0.93 and 0.84 respectively. Spearman and kappa coeYcients of 0.9 and 0.81 were obtained for those nine patients in hospital 2 where both the test and retest questionnaires were filled in by the same people. However, for the 15 patients from hospital 2, where the questionnaire was filled in by diVerent people in the retest, reliability was less good: the Spearman coeYcients were still high, average 0.72, but the kappa coeYcients were poor, 0.27. Good construct validity was exhibited, with a correlation of 0.79 between change in distance vision score from the questionnaires and the independent interview. Conclusions-The adapted TyPE questionnaire is both very reliable and has good construct validity. The kappa coefficient should be used wherever possible to evaluate reliability. The test-retest reliability and validity and practicability of other visual function questionnaires have not been assessed adequately, and further development should be carried out of all such questionnaires, so that they may be introduced into routine clinical care. (Br J Ophthalmol 1999;83:66-70)

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