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This leaflet is part of the pack 28270/National ServiceFramework: A practical aid to implementation in primary care
A practical aid to implementation in primary care
Preventing ill health is a task for everyone, but primary care has aleading role in taking forward prevention action and in supporting localinitiatives led by non health organisations
When prioritising action, consider the evidence base – which areas arelikely to bring the greatest return on effort? Which patients are readyand most able to change their behaviour, and which are at greatest risk?
Use every opportunity to promote healthy lifestyles – advice arounddiet, weight reduction and exercise applies across all the NSFs
Make use of available resources such as those from the Department ofHealth and the HDA to support the implementation of preventionstrategies
Key NSF aims and standards for health improvement and prevention
The NHS and partner agencies should develop, implement and monitor policies
that reduce the prevalence of coronary risk factors in the population, and reduce
inequalities in risks of developing heart disease.Standard two
The NHS and partner agencies should contribute to a reduction in the population
in the prevalence of smoking in the local population.
Health and social services should:
promote mental health for all, working with individuals and communities
combat discrimination against individuals and groups with mental healthproblems and promote social inclusion.
The Cancer Plan
The Cancer Plan sets out aims to:
reduce the risk of cancer through reducing smoking and promoting a healthier diet
raise public awareness with better, more accessible information.
The NHS will develop, implement and monitor strategies to reduce the risk of
developing type 2 diabetes in the population as a whole and to reduce the
inequalities in the risk of developing type 2 diabetes.
As well as older people having access to all of the above, the NSF sets out health
promotion activities which are of specific benefit to older people:
immunisation and management programmes for influenza
requirements for preventing falls and strokes.
Preventing ill-health is a task for everyone in which numerous agencies – public and private,health and non health – have a role to play. Delivering health improvement and achieving thevarious prevention targets requires action by the whole range of local public services, thevoluntary and private sector, and communities themselves. However, the NHS, and primarycare in particular, has a leading role to play in:
offering holistic advice, health promotion and interventions based around the key risk factors
fostering partnerships with local agencies and communities through the local HealthImprovement and Modernisation Plan (HIMP), optimising partners’ capacity to deliveraction on health improvement and inequalities
encouraging and supporting initiatives led by bodies outside the health sector, such asmaking links between HIMPs to local authorities’ Community Strategies and localNeighbourhood Renewal Strategies.
Implementing, in partnership with others, a range of activities designed to promote health andprevent major disease (for example, those focusing on physical activity, nutrition and smokingcessation) will address several targets across the NSFs simultaneously.
What the practice can do
The practice has a key role in delivering the prevention aspects of NSFs and is uniquely placedto act opportunistically in promoting health (95% of the population see their GP over a threeyear period) and to tailor prevention in a culturally appropriate way. In addition, practiceshave a wider role in promoting health than addressing lifestyle factors alone. Strengtheningsocial support, bringing resources into deprived communities and improving the communityinfrastructure can all help to promote health. The practice can contribute by:
developing local health profiles to target those who can benefit most
working with local neighbourhood renewal programmes to support key groups inimproving their health
developing outreach services and community development programmes
developing facilities jointly with social services, advice and benefits services and otherlocal providers – as part of service modernisation.
For many practices, prevention is a relatively new role and good communication with the PCTwill be essential. This will help to ensure awareness of the PCT’s prevention strategy and thecontributions practices are expected to make; it will also facilitate feedback on the progress ofactivities, any support needed in commissioning services and the provision of training.
The following is a selection of interventions which have been shown to be effective and thatmight be considered by practices as part of their prevention activities.
Action to reduce smoking will help to address the objectives of the NHS Plan, NHS CancerPlan and the NSFs for CHD and Older People. It is of crucial importance because:
smoking is the single greatest cause of preventable illness and premature death in the UKand causes 120,000 deaths a year
smoking causes one out of every seven deaths from heart disease
an estimated one in three cancer deaths in the UK is caused by smoking
around 84% of all lung cancer deaths are associated with smoking
treating the illness and disease caused by smoking is estimated to cost the NHS up to£1.7 billion every year.
An effective local smoking cessation programme should include:
creating/maintaining readily accessible records on the current smoking status of patients
opportunistic advice to smokers during routine consultations: briefly assess motivation tostop, prescribe NRT or bupropion in appropriate cases, and refer to a cessation service
overseeing provision of services targeted to smokers’ needs, with particular focus onsmokers in manual socio-economic groups and pregnant smokers
intensive behavioural support, usually on a group therapy basis, and one-to-onecounselling in accessible settings such as GP surgeries, pharmacies
accessible services to all smokers, including hospital patients
provision of training to enable health professionals (eg nurses, health visitors, midwives,pharmacists) to act as smoking cessation advisers as part of their professional role.
Action on diet and nutrition will contribute to a reduction in preventable deaths from cancer,CHD and stroke. In particular:
it has been estimated that eating at least five portions of fruit and vegetables a day couldreduce the risk of deaths from heart disease, stroke and cancer by up to 20%
evidence shows that increasing fruit and vegetables consumption is the second mostimportant cancer prevention strategy, after reducing smoking
a 10% reduction in saturated fat intake by the UK population would result in areduction in CHD mortality of between 20 and 30%
along with a physically active lifestyle, a healthy balanced diet can help to achieve andmaintain a healthy body weight, reducing the risk of conditions related to obesity andoverweight such as type 2 diabetes.
Effective interventions to promote healthy eating include:
helping to create an environment that improves access to fruit and vegetables egproviding opportunities to buy and eat more fruit and vegetables locally, at work, and inschool by working with retailers, caterers, voluntary agencies
action to change attitudes and increase awareness via, for example, multiple contacts withtarget groups, working with small groups, tailoring messages and providing personalisedfeedback
use of peer groups, appropriately trained and supervised, to educate, inform and supportcommunity-based interventions
directing education about healthy eating at behavioural change as opposed to just thegaining of information
addressing inequalities in health issues.
Tackling barriers to good nutrition in Birmingham
Set up in August 2000 with Health Improvement monies, the Food Net project aims to workthrough and with local people to promote a cardio-protective diet. The project covers a populationof about 200,000 in some of Birmingham’s most deprived wards. Local people were recruited andtrained to work alongside dieticians as community food workers. Their first job was to go out andmeet people, specifically to contact groups already meeting locally to involve them in a baselineconsultation. After receiving training the project team visited 30 of these groups and, usingparticipatory appraisal techniques, worked to help people to identify barriers to healthy eating. Atthe same time, the Food Net commissioned a survey of food retailers’ opinions from theBirmingham College of Food, Tourism and Creative Studies, and worked with the Public Healthdepartment of Birmingham University to map food price and availability across the project area.
These studies identified a lack of practical skills and family food preference as barriers to healthyeating. The Community Food Workers now run ‘cook and taste’ sessions which are leading toreported changes in family diet. Fruit and vegetable consumption have increased and many arehaving the recommended weekly serving of oily fish. The Food Net is also offering training to thestaff of newly set-up breakfast clubs, to ensure that they are a vehicle for the promotion of nutritionmessages. A Lifestyles Clinic offering weekly support to people at risk of CHD and easy referralinto smoking cessation programmes and exercise on prescription schemes is currently being piloted.
prevents or delays the onset of high blood pressure, and reduces blood pressure in peoplewith hypertension
helps control body weight and, if combined with dietary restriction, leads to greaterweight loss than diet or physical activity alone
can reduce the risk of developing type 2 diabetes by 33-50%
reduces risk of colon cancer by 40-50% and is associated with an overall reduced risk ofdying from cancer
helps to maintain bone density and prevent osteoporosis
can prevent up to 25% of falls among older people
reduces the risk of depression and has positive benefits for mental health includingreduced anxiety, enhanced mood and self-esteem.
The prevalence of inactivity is high, so it is important that primary care professionals adoptpolicies of encouraging and promoting physical activity across the whole practice population.
In parallel, there are specific groups, such as older people at risk of falls or people with type 2diabetes, for whom interventions need to be more tailored. These may require additionalknowledge, be delivered by qualified professionals, be more intensive and include condition-specific advice. The following approaches appear promising:
assessing patients’ activity levels and delivering appropriate interventions based onpredicted risk and the patients’ readiness to change behaviour
counselling and support for behaviour change, by working with patients to identify theirown strategies for becoming more active
exercise referral – into a recognised system with appropriately qualified staff
recommendation to participate in community-based activities such as ‘health walks’.
information about local opportunities for activity/encouragement to use local leisurefacilities
encouraging practice staff to provide positive role models and ensuring practice policies(such as support for cycling and walking) promote an active workforce.
An Oxfordshire practice pioneered the idea of ‘health walks’, in conjunction with theCountryside Agency. Based not only on evidence for the positive health benefits of regularexercise, but also on the belief that the local environment has a major impact on an individual’swell-being, Health Walks takes health promotion a step further by promoting well-being. Theproject provides:
daily organised walks, led by volunteers
When the scheme was evaluated, it was found that 85% of people had committed to more thana year’s involvement, 75% of patients reported a positive impact on their health and 20%reported a reduction in weight. For more details, contact Sonning Common Health Centre,Wood Lane, Sonning Common, Reading.
Action on obesity will help to address the requirements of the NHS Plan and the NSFs forCHD and diabetes, as well as supporting the implementation of the NICE guidance on the useof the anti-obesity drugs Orlistat and Sibutramine in the primary care setting. Prevention hasbeen shown to be a more effective strategy than treatment, and is important because:
about one-fifth of the population is obese. It has been estimated that around 30,000deaths were attributable to obesity in 1998
it has been estimated that around 5% of all cancers might be prevented if no individualwere overweight or obese
a modest reduction in body weight (eg 10kg) could lead to a 20% reduction in overallmortality, a 40% reduction in obesity related cancer deaths, and a 30% reduction indeaths from diabetes.
Effective interventions to reduce obesity include:
a combination of diet, physical activity and behavioural therapy. Diets restricted inenergy (1000 – 1500 Kcals/day) and fat (less than 30% energy from fat) are effective
individualised risk assessment and advice, with regular follow-up contact delivered viagroup sessions and tailored to the needs of particular groups eg minority ethnic groups,older people or disabled groups
specialist weight loss clinics within the GP practice – this has achieved up to a 10%weight reduction in a third of participants with a weight loss of 6% maintained at oneyear through regular follow-up. Partnerships with commercial clubs which aim to deliverappropriate weight loss programmes could be explored
promoting physical activity as an integral part of a weight loss programme, throughencouraging physical activity in daily life and through involving family, friends or agroup ‘buddy’ in undertaking activity
frequent contact over the long term, particularly through face-to-face contact orcorrespondence course
in obese children, a reduction in sedentary behaviour and the use of family therapy, theunderlying strategy being to help children grow into their weight or to slow the rate ofweight increase relative to growth
brief training sessions for GPs and practice nurses, which have been shown to improvethe management of obesity
the use of the drugs Orlistat and Sibutramine alongside diet, physical activity andbehavioural strategies in appropriate cases. Certain criteria must be met, however, includingsome previous weight loss through diet and physical activity (see www.nice.org.uk).
Action on alcohol will help to address the requirements of the NHS Cancer Plan and the NSFsfor CHD and Older People. Tackling prevention and reduction of alcohol misuse is importantfor the following reasons:
alcohol misuse is considered to be a major cause in about 3% of all cancers in Englandand is highlighted as an area of preventive activity in the NHS Cancer Plan
epidemiological studies have demonstrated that alcohol is causally related to cancers ofthe oral cavity and pharynx, larynx, oesophagus and liver, while there is suggestive butinconclusive data for a causal relationship in rectal and breast cancer
heavy drinking has been shown to be a severe risk for cardiovascular disease, while lowlevels of consumption have a protective effect against CHD mortality
15-25% of suicides and 65% of suicide attempts are related to alcoholism
medication and alcohol contribute to falls in older people.
Opportunistic brief interventions can be effective in reducing alcohol consumption: a briefintervention can reduce alcohol consumption by around 20% in excessive drinkers.
Action on mental health will help to address the requirements of the NSFs for Mental Health,CHD and for Older People, as well as the NHS Plan and the social inclusion agenda whichinforms HIMPs.
WHO suggests that mental health problems are the commonest cause of premature deathand years of life lived with disability.
Reported stress levels have risen steeply since 1995 but now appear to be stabilising. (Seethe 1998 Health Education Monitoring Survey for further statistics).
In 1998, 24% of men and 29% of women reported having suffered ‘a large amount ofstress’ in the past 12 months.
In the 1993 Survey of Psychiatric Morbidity, one in six adults reported some sort ofneurotic disorder in the week prior to interview. Most common were: anxiety/depression, alcohol dependence, drug dependence, the four most common symptomsbeing fatigue (27%), sleep problems (25%), irritability (22%) and worry (20%).
Effective interventions to promote good mental health include:
advising patients to take more exercise, which has been shown to prevent clinicaldepression and is as effective in treatment as other psychotherapeutic interventions
facilitation between primary care and the voluntary sector, which improves outcomes egreferral from primary care to a liaison organisation.
For all risk factors, it is worth reiterating the NSF clinical targets:
maintain blood pressure below 140/85 mm/Hg (CHD†, diabetes, Older People)
aim to lower cholesterol to either less than 5 mmol/l or by 30% whichever is the greater(15% for hypertensive patients) (CHD).
What PCTs can do
PCTs are able to contribute to disease prevention and health improvement through their owndirect action, and by supporting the work of primary care practices and other partners in avariety of ways. These include:
Grateful thanks to Mentality for contributing to this section. Their website is www.mentality.org.uk.
Both people with diagnosed CHD and those without diagnosed CHD, or other occlusive arterial disease, with a CHD risk greaterthan 30% over ten years.
leading on the development of HIMPs, and developing networks across the PCT area tobring together primary care, senior clinicians and commissioners
commissioning smoking cessation services, or commissioning training for practice staff inscreening for alcohol misuse
supporting local authorities in undertaking health impact assessments (see furtherinformation), including access to retail services, transport provision or housingdevelopments
contributing to programmes to create safe environments for walking, cycling and safeplay; also linking with employers, schools and the leisure industry to reduce exposure toenvironmental tobacco smoke.
encouraging high quality, face-to-face server training for alcohol programmes which areaccompanied by strong and active management
urging local further education institutions to provide tailored learning opportunities formental health service users
bringing together frontline staff who deliver preventive programmes with strategic leadsin public health
developing specific local strategies/programmes for disease prevention and healthimprovement. This requires PCTs to establish a vision and agreed objectives inconjunction with partners, as well as supporting activities such as equity profiling, andreviewing workforce capacity. (See the HDA’s tool to support work in this area, whichcan be found at: www.hda-online.org.uk/html/resources/ publications_a-q.html). Healthneeds assessment is an essential starting point for strategy development, and the HealthDevelopment Agency has produced a workbook for health needs assessment that can befound at http://www.hda-online.org.uk/downloads/pdfs/HNA.pdf)
The process of developing a strategy involves the following elements:
agreeing a vision and setting aims and objectives
identifying the potential partners for planning
identifying key settings and target audiences
auditing current practice: mapping existing initiatives and resources
mapping of the workforce and other resources
identifying key stakeholders – consultation and gaining commitment
selecting effective interventions to support the strategy
building in evaluation: setting targets and establishing indicators of progress.
More details can be found in the HDA’s Coronary Heart Disease: Guidance for theimplementation of the preventive aspects of the National Service Framework and Cancer prevention:a resource to support local action in delivering the NHS Cancer Plan.
Tackling CHD in the South Asian community: Project Dil
Project Dil is a Leicester-wide primary care and health promotion programme. It aims toincrease understanding of CHD and improve primary and secondary prevention of CHDamongst the South Asian community via interventions at appropriate general practices. Fourkey approaches were used to raise community awareness:
developing a baseline for the current level of understanding amongst the target group
developing health promotion materials
using relevant media to target heart health messages at the Asian community
introduction of an accredited Peer Education Heart Health Programme.
Health promotion activities were supported by action to ensure effective secondary prevention.
This included training for primary health care teams and a clinical audit of secondaryprevention, followed up with agreed action plans with individual practices.
More information is available at
The most effective interventions are those that tackle risk factors at an individual level or withsmall groups of people; with organisations; and at an environmental level. In selecting theinterventions that will make up a strategy, it is important to consider the following points:
whether the intervention is likely to contribute to the aims of the overall strategy
whether the interventions will act at different levels (as outlined above)
whether it will contribute to reducing inequalities
the needs of the whole population and of identified target groups
the potential for differential impact among different groups
the resources needed (human, physical and financial) to implement differentinterventions
the practicality and feasibility of implementing different interventions
the evidence of effectiveness of different interventions.
Key reference documents for PCTs are available at: www.doh.gov.uk/tobacco; www.ash.org.uk;or www.thoraxjnl.com. These include:
DH guidance on NHS smoking cessation services
The case for commissioning smoking cessation services (see ASH website)
Evidence based guidelines e.g. Thorax, 1998 & 2000
There are resources to support the implementation of prevention strategies – see ‘Furtherinformation.’
Common themes – physical activity and healthy eating
Among the features of effective interventions for promoting physical activity and healthyeating, there are some common themes which may be of use to PCTs in planning theirstrategy. In summary, effective interventions:
have clear goals and include behavioural change not just the provision of information
are developed with community involvement and focus on identifying and addressing thebarriers to behavioural change
incorporate multiple strategies designed to address a range of barriers to change
promote changes to the local environment to help facilitate change eg promotion ofaccess to good quality, affordable fruit and vegetables via food co-operatives
are culturally appropriate to the needs of the target group eg the provision of single sexswimming/ activity sessions in leisure centres
aim to overcome perceived lack of need to change by promoting clear, simple messagesabout, for example, eating at least five portions of fruit and vegetables each day, takinghalf an hour’s exercise a day, or the health consequences of smoking
aim to overcome practical barriers by, for example, developing cooking skills to encouragepeople to eat more vegetables
provide training and support to those involved in delivering the intervention, forexample, primary care teams, local people, community workers, school staff
take a ‘whole organisation’ approach in working with institutions such as schools andworkplaces.
The effectiveness of individual interventions such as cooking skills classes, exercise referral
Healthy Living Project – Sheffield
schemes are discussed in detail in resources developed by the Health Development Agency andby Mentality to support the implementation of the NSFs. (See Further Information)
A range of initiatives to promote better health has been put in place in South East Sheffield.
One of these is a Food Co-op, organised by a community worker and group of volunteers on ahousing estate where access to fruit and vegetables was limited. The range is decided by thegroup, bought from wholesalers, bagged and sold to the community at cost price. A ‘drop-in’coffee morning is run alongside the co-op, encouraging residents to stay and interact with others.
Several volunteers have accessed a certificated, basic food hygiene course, increasing theirconfidence and self-esteem.
The Healthy Living Project also provides:•
a subsidised aerobics class in local community centre
a kids Saturday morning activities club – including working with the British HeartFoundation Cookbook to introduce children to healthy eating
an Active in Later Life Group, which brings together residents who feel isolated or anxiousabout going out. A community worker provides leaflets and a signposting service to otheragencies.
For more information, contact
email@example.com or SeanFenalon at
Department of Health funded support
NHS Smoking Cessation Services established in all areas. These helped over 79,000people to successfully give up smoking at four week follow up between April andDecember 2001.
Public education campaigns run to highlight the harm associated with smoking,particularly targeting young people, pregnant women and Asian groups.
The NHS Smoking Helpline provides a free information, advice and referral service tosmokers, their families and health professionals.
A comprehensive network of local tobacco alliances established.
The Tobacco Advertising and Promotion Bill to ban advertising and sponsorship bytobacco products taken forward.
A Five-a-day Programme established to improve access to, and availability of, fruit andvegetables. The Five-a-day Programme includes:
National School Fruit Scheme aimed at giving four to six year olds a free piece offruit each school day, as part of a national campaign to improve the diet ofchildren. The Scheme has been piloted, and expansion is taking place region byregion
work with industry (including producers and retailers) to increase provision andaccess to fruit and vegetables with local initiatives, where necessary
local Five-a-day initiatives to increase access to, and availability of, fruit andvegetables within disadvantaged communities. The New Opportunities Fund hasmade £10m available to support the establishment of 66 new initiatives, led byPCTs. Guidance on delivering evidence-based interventions has been developed
a communications programme to ensure that consumers receive consistentmessages and advice, supported by the production of information materials
evaluation and monitoring to underpin programme development.
Initiatives with the food industry to improve the overall balance of diet including salt,fat and sugar in food, working with the Food Standards Agency.
A new £2.5 million programme of community physical activity pilots will test outdifferent community approaches to increasing physical activity. The results will informand lead action on physical activity across all PCTs.
A National Quality Assurance Framework on Exercise Referral Systems offers guidance toprimary care and fitness professionals, who work together to offer tailored exercise andphysical activity programmes to patients whose health would benefit from increasedexercise.
NICE guidance on the use of the anti-obesity drugs, Orlistat and Sibutramine.
HDA is reviewing all systematic reviews, and meta-analyses on the prevention andtreatment of obesity and weight maintenance.
The Healthy Communities Collaborative in one of a number of initiatives aimed atimproving health and tackling inequalities. Currently in its early stages, it willconcentrate on a particular topic where significant improved outcomes have beenachieved in at least one geographical area. Topic selection is being undertaken with keystakeholders. The programme will trial the ‘Breakthrough Collaborative’ method ofimprovement in a particular aspect of community health in pilot locations. Moreinformation on this and other collaboratives in available at www.npdt.org andwww.modernnhs.uk
Leaflets, posters and other materials on sensible drinking and the risks of alcohol misuse
National, free and confidential helpline for people with alcohol problems and theirfriends and relatives. (The Drinkline number is 0800 917 8282 and lines are openMon-Fri 9am - 11pm, Sat-Sun 6pm -11pm.)
Training course for GPs and practice nurses (at pilot stage) to identify patients who aremisusing alcohol and to offer advice and support in cutting down on their drinking.
Coronary heart disease: guidance for the implementation of the preventive aspects of the NationalService Framework.
Health Development Agency, 2001. See http://www.hda-online.org.uk/downloads/pdfs/chdframework.pdf or email firstname.lastname@example.org
Improving quality in primary care: a practical guide to the National Service Framework for mentalhealth.
National Primary Care Research and Development Centre, 2000, University ofManchester. See http://www.npcrdc.man.ac.uk
Making it happen – a guide to delivering mental health promotion.
Seewww.doh.gov.uk/mentalhealth/makingithappen.htm. Department of Health,2001.
An executive briefing on standard one of the National Service Framework for mental health.
Mentality (2001), Published by Sainsbury Centre for Mental Health.
Introducing health impact assessment (HIA): Informing the decision making process.
HealthDevelopment Agency (2002). See prototype website at www.hiagateway.org.uk
Health needs assessment workbook.
Health Development Agency (2002). See http://www.hda-online.org.uk/downloads/pdfs/HNA.pdf
Bull, J., and Hamer, L., (2001). Closing the gap: setting local targets to reduce health inequalities.
London: Health Development Agency
Community strategies and health improvement: a review of policy and practice
HealthDevelopment Agency (2002).
Planning across the LSP: case studies of integrating community strategies and health improvement.
Health Development Agency (2002).
Physical activity toolkit: A training pack for primary health care teams
. British Heart Foundation.
Prevention and reduction of alcohol misuse
, Health Development Agency (2002). London: HDA.
The balance of good health
(1994). Health Education Authority, Ministry of Agriculture, Fisheriesand Food, and Department of Health. London. Available from Food Standards Agency.
Cancer prevention: a resource to support local action in delivering the NHS Cancer Plan.
Forthcoming publication from the Health Development Agency.
A Resource to support the implementation of Standard 8 of the NSF for Older People –
Forthcoming publication from the Health Development Agency.
The working partnership: an assessment and capacity building resource
. Forthcoming publicationfrom the Health Development Agency.
National Primary and Care Trust Development Team http://www.natpact.nhs.uk/
Local Government Association http://www.lga.gov.uk/ and http://www.idea.gov.uk forexamples of local authority work.
Health Development Agency www.hda-online.org.uk
Health Action Zones website http://www.haznet.org.uk/
Public Health Electronic Library prototype website http://www.nelph.net/
National Institute for Clinical Excellence www.nice.org.uk
Five-a-day programme www.doh.gov.uk/fiveaday
A guide to evaluation of Healthy Living Centres is available at http://www.hda-online.org.uk/downloads/pdfs/evhlc.pdf
Royal College of Psychiatrists’ site for the ‘Changing Minds Campaign’, an anti-stigma anddiscrimination initiative www.changingminds.co.uk
Mental health promotion project within the DH www.doh.gsi.gov.uk/mentalhealth
Primary Care Mental Health and Education www.primhe.org
MEDICAL HISTORY Patient Name__________________________________________________________________________________________________ Date of Birth _____________________ Age _________ Weight _______________________ Height ___________________________ EMERGENCY INFORMATION Physician ____________________________________________________________ Relative Name _______________________________________
§11 . Excerpts from class, October 21 [notes by PMR] Don opened class with the good news that Mary-Claire van Leunen has agreed to helpread the term papers and drafts thereof, despite the fact that her name was incorrectlycapitalized in last week’s notes. Returning to the subject of “Literate Programming,” Don said that it takes a whileto ﬁnd a new style to suit a new system li