Within the context of the creation of the internal market for health care, the paper examines the role of clinical directors, that is doctors who have retained their professional clinical positions whilst at the same time assumed roles as managers within increasingly well-defined corporate organizations providing health care. This represents considerable change from previous contexts in which doctors could always contract out of difficult managerial decisions. The role of clinical director is examined in terms of its own directorate and its involvement in contracting, co-operation and competition both within its own corporate organization and within the wider market place for health. Key issues are raised for the individuals and organization by these changes, they are discussed in terms of time, succession, managing colleagues, financial and human resources, market behaviour , support and terms of reference. These changes occasion wider discussion in terms of the challenge of coping with future demands for innovation, changes in the distribution of power within an emerging market for health care and the relationship among health care organizations, professionals and lay clients.The National Health Service (NHS) has entered a period of far reaching change since the publication of the White Paper Working for Patients (DHSS, 1989) and the creation of the internal market in April 1991. Change is not new to those who work in the health service. The difference between this and previous creations, however, is that rather than concentrating attention on specifying how operating institutions are to be restructured -these reforms have concentrated attention on the creation of an environment in which health care is to be provided. That environment is the internal market in which purchasers (district health authorities, general practitioner (GP) fund holders) now receive money from the state in proportion to their population figures, weighted for certain indices of disadvantage. Their remit is to assess local needs, determine the acute, community and priority services required and accordingly place annual contracts for an expected level of activity at an agreed price with selected providers. There are procedures for handling emergency requirements falling outside these contractual arrangements.The focus of this paper is on the position of medical doctors in NHS trusts who have become engaged in management, usually on a part-time basis. The context is described in terms of an evolving relationship between medicine and management and the emergence of a 'doctor cum manager' role. The paper is in three parts. The first deals with the context of change. The second looks at the implications of the changes for the role of doctors cum managers within NHS trusts. It pays particular attention to those who are now known as clinical directors and examines their increasing involvement in management and competition. The final section identifies issues for discussion and places this case of doctors in management within a wider context.

The UK government's 2015 temporary class drug order on ethylphenidate was effective in reducing infections among people who inject drugs during an outbreak situation in Lothian, Scotland.

Liaison between emergency departments, clinical toxicology services and community based drug addiction services is important to identify drug misusers at high risk. A hospital-based specialist nurse-led liaison service may be able to fulfil this role.

This paper reports on a postal questionnaire survey of district nurses' work with HIV positive patients. Each nurse was asked to provide information about their contact with HIV positive patients and the level of training they had received in HIV/AIDS care. The nature of nursing activities carried out for these patients was established along with levels of confidence the nurses had in being able to provide a high standard of care. Where the nurses indicated less than full confidence they were asked to indicate what factors predisposed their response. Questionnaires were completed by 101 district nurses. On average, each nurse made 1.25 visits to HIV-infected patients in the two weeks preceding the study. The nursing activities most commonly carried out for these patients were providing advice/counselling, carer support, general nursing care and specialist treatments. The activities least commonly carried out were technical procedures, tests and assessments. Nurses were most confident in providing a high standard in relation to general nursing care and least confident that high standards were being achieved in providing specialist treatments. The most frequently encountered explanations offered by the district nurses for their lack of confidence in achieving a high standard were a lack of specialist training and a lack of experience with HIV-infected patients.

Aims To ascertain the characteristics of patients whose death was associated with methadone intoxication during the period 1997-9 in the Lothian region of Scotland. Design Patients were identified from death certificates. General practitioner records relating to methadone-associate d deaths were reviewed in association with autopsy, toxicology and police reports. Deprivation categories (DepCat) were derived from the postal code of residence and the Carstairs index. Findings There were 77 methadoneassociated deaths in the Lothian Health Board area. GP records were obtained for 60 patients registered with a general practitioner. The majority of methadoneassociated deaths (73%) occurred in persons who were not prescribed methadone at the time of their death. Thirty-eight persons were prescribed medication other than methadone or dihydrocodeine at the time of death. Thirty (79%) of those being prescribed for were receiving benzodiazepines . Fortyseven per cent had a history of excessive alcohol consumption. Fifty per cent had a reported psychiatric history. Sixty per cent had previously attended Accident and Emergency through deliberate self-harm or accidental overdose. Low socioeconomic status was found to be associated with the highest rate of methadone-related deaths. Conclusions Given the variety of characteristics outlined it is likely that reducing drug-related deaths is a longer term aim, not amenable to one particular solution.