Developing a multi-pollutant conceptual framework for the selection and targeting of interventions in water industry catchment management schemes

In recent years water companies have started to adopt catchment management to reduce diffuse pollution in drinking water supply areas. The heterogeneity of catchments and the range of pollutants that must be removed to meet the EU Drinking Water Directive (98/83/EC) limits make it difficult to prioritise areas of a catchment for intervention. Thus conceptual frameworks are required that can disaggregate the components of pollutant risk and help water companies make decisions about where to target interventions in their catchments to maximum effect. This paper demonstrates the concept of generalising pollutants in the same framework by reviewing key pollutant processes within a source-mobilisation-delivery context. From this, criteria are developed (with input from water industry professionals involved in catchment management) which highlights the need for a new water industry specific conceptual framework. The new CaRPoW (Catchment Risk to Potable Water) framework uses the Source-Mobilisation-Delivery concept as modular components of risk that work at two scales, source and mobilisation at the field scale and delivery at the catchment scale. Disaggregating pollutant processes permits the main components of risk to be ascertained so that appropriate interventions can be selected. The generic structure also allows for the outputs from different pollutants to be compared so that potential multiple benefits can be identified. CaRPow provides a transferable framework that can be used by water companies to cost-effectively target interventions under current conditions or under scenarios of land use or climate change

Ecological influences, observational caries epidemiological trends and associated socioeconomic and geographic dental health inequalities at five-years of age in Scotland, 1993/94-2007/08

Ecological influences, observational caries epidemiological trends and associated socioeconomic and geographic dental health inequalities at five years of age in Scotland, 1993/94-2007/08. Introduction: In recent years many national Governments have called for health improvements at the population level and at the same time reductions in health inequalities. To date, dental epidemiology has concentrated mainly on tracking trends in dental health. Methodologies relating to dental health inequalities are, however, not well established. Within Scotland, over the past decade, children’s oral health improvement programmes have been established at national level. Preceding and concurrent with these developments, similar initiatives have been implemented within Greater Glasgow NHS Board. This is Scotland's largest NHS Board with the highest proportion of Scotland’s socio-economic status (SES) deprived population. Recent reports from the National Dental Inspection Programme (NDIP) for five-year-olds show improvements in dental health. The above conditions provide the opportunity to explore dental trends in more detail at geographic level within Scotland and to investigate dental health inequality methodologies within the context of health improvement programmes and overall improvements in dental health. Aim: To examine caries epidemiology data and apply and appraise a range of tests of health inequality to data from Primary 1 (P1) five-year-old children in Scotland during the period 1993/94-2007/08, against a background of health improvement programmes. Furthermore, to apply the selected inequalities tests to the caries data for a) Scotland as a whole and b) the geographic subgroups: 1] Glasgow (GGHB) and 2] the remainder of Scotland, outwith Glasgow (Not-Glasgow). Methods: Secondary analyses were performed on eight successive cross-sectional NDIP five-year-olds' caries datasets, 1993/94 to 2007/08. These permitted both SES and geographic trends in mean d3mft and % dmft=0 to be plotted for the areas: Scotland, GGHB and Not-Glasgow. The metrics selected to model dental health inequalities were: the Significant Caries Index (SIC) and modified SIC10, the Receiver Operator Curve (ROC), the Gini coefficient, the Concentration Curve (CC), Koolman and Doorslaer's transformed Concentration Index (CI), the Slope Index of Inequality (SII), the Relative Index of Inequality (RII) and the Population Attributable Risk (PAR). Odds Ratios and Meta-analyses using Generalised Linear Modelling assessed statistical-inference for dental health and inequality trends. Results: Overall, usable data was retrieved for 68,398 five-year-old subjects (n=18,174 from GGHB; n=50,224 from Not-Glasgow). In Scotland as a whole, marked SES gradients in caries prevalence and caries burden were related to the DepCat score of children’s home postcode. Between the start and endpoints of the study, the simple absolute SES inequality in mean d3mft between the most affluent and most deprived groups decreased (p0 in Scotland decreased (p<0.0001) to 0.43 (95%CI, 0.40-0.46). Although Scotland's simple absolute SES related dental health inequality (DHI) decreased for mean d3mft (p<0.02), there were no improvements in simple relative SES DHIs over this time period. Simple absolute and simple relative geographic inequalities in weighted %d3mft=0 and mean d3mft were seen when GGHB was compared with Not-Glasgow data. These geographic inequalities metrics tended to increase from 1993/94 until 1999/00. However, by 2007/08 reductions in simple absolute geographic inequality were observed, with marginal improvements in simple relative geographic inequality compared to baseline. Additionally, simple absolute and relative geographic inequality in SIC scores decreased overall against a background of SIC improvements in both GGHB & Not-Glasgow (Meta-analysis, p<0.01, respectively). By 2007/08, relative to 1993/94, Odds Ratios for d3mft>0 in the geographic subgroups GGHB and Not-Glasgow decreased, respectively (p<0.0001), to 0.31 (95%CI, 0.26-0.38) and 0.46 (95%CI, 0.43-0.50). There was evidence of a 'Glasgow (dental health) Effect', whereby GGHB children’s dental health was poorer than in Not-Glasgow during the period 1993 to 1999, after controlling for confounding factors (p<0.01). This ‘Glasgow Effect’ was no longer evident by 2007. Modelling caries data using the complex inequality metrics has given further insights into different dimensions of geographic and SES-related dental health inequalities. For example, in each area from 1993/94-2007/08, the full SIC10 distributions showed respective decreases in complex absolute DHI in affected individuals in population deciles (irrespective of SES). Simultaneously, Scotland's SII indicated that complex absolute SES inequalities decreased (p<0.02). Furthermore, in Glasgow the %PAR decreased by 24 percentage points, itself impacting on Scotland's decreased PAR. However, the RII and transformed CI indicated that complex relative SES DHI increased in each area over the period of study. The ROC, CC & RII plots were comparatively stable over time for Scotland, compared to trends in the GGHB subgroup. There was evidence of some variation in DHI, and the Gini-coefficient (for individual DHI) was counter-intuitive. Discussion: Analysis and interpretation of simple and complex absolute and relative DHI outcomes are not straightforward against a background of population dental health improvements across the SES spectrum. If equivalent absolute dental health improvements are achieved in the best and poorest d3mft groups, as %d3mft>0 and mean d3mft diminish in the denominator group it is increasingly difficult to achieve improvement in relative inequalities. Nonetheless, tests suggest that simple absolute geographic DHI in Scotland's P1's weighted %d3mft=0 and mean d3mft have improved, while simple relative geographic inequality has not deteriorated over the interval 1993-2007. Further insights were obtained from examination of the cross-sectional distributions of SIC10. These showed improvements in complex absolute individual inequality across all population deciles with d3mft>0, over time, at each geographic level. Moreover, comparison of the geographic SIC10 scores for the worst affected deciles demonstrated reductions in simple absolute and relative geographic DHI in five-year-olds' d3mft morbidity for those with the poorest dental health outcomes in 2007 vs. 1993. Furthermore, Scotland's complex absolute SES-related DHI has decreased over time when assessed by SII. Improvements in complex absolute SES-related DHI have occurred more readily than improvements in complex relative SES-related DHI. Conclusions: For the first time, these multiple tests of inequality have been applied to Scotland’s and Glasgow’s child caries datasets. Generally, caries epidemiology trends occurred slowly and smoothly, however, DHI trends from this same data tended to fluctuate (especially in the geographic subgroups). The apparent lack of consonance of the various inequalities metrics demonstrates that measurement, understanding and interpretation of population DHI trends are complicated and require knowledge of the underlying epidemiology trends. Nonetheless, with the exception of the Gini, all results provided useful information which aid understanding of DHI. The complex measures such as the SII and RII had the advantage of using all the available d3mft information within the DepCat domains and weighting results for SES within the denominator populations. Furthermore, in Scotland as a whole, the SIC10 distribution, SII and RII appear to exhibit stable DHI trends, against the background populations' dental health improvements. The results suggest that in addition to the simple measures, the SIC10 distribution, SII and RII appear the most useful tests when describing dental health inequality with caries epidemiology data of this type. Recommendations for future research include modelling other large caries databases and future Scottish P1 & P7 datasets with the selected DHI tests

Improving oral healthcare in Scotland with special reference to sustainability and caries prevention

Brett Duane Improving oral healthcare in Scotland with special reference to sustainability and caries prevention University of Turku, Faculty of Medicine, Institute of Dentistry, Community Dentistry, Finnish Doctoral Program in Oral Sciences (FINDOS-Turku), Turku, Finland Annales Universitatis Turkuensis, Sarja- Ser. D, Medica-Odontologica. Painosalama Oy, Turku, Finland, 2015. Dentistry must provide sustainable, evidence-based, and prevention-focused care. In Scotland oral health prevention is delivered through the Childsmile programme, with an increasing use of high concentration fluoride toothpaste (HCFT). Compared with other countries there is little knowledge of xylitol prevention. The UK government has set strict carbon emission limits with which all national health services (NHS) must comply. The purpose of these studies was firstly to describe the Scottish national oral health prevention programme Childsmile (CS), to determine if the additional maternal use of xylitol (CS+X) was more effective at affecting the early colonisation of mutans streptococci (MS) than this programme alone; secondly to analyse trends in the prescribing and management of HCFT by dentists; and thirdly to analyse data from a dental service in order to improve its sustainability. In all, 182 mother/child pairs were selected on the basis of high maternal MS levels. Motherswere randomly allocated to a CS or CS+X group, with both groups receiving Childsmile. Theintervention group consumed xylitol three times a day, from when the child was 3 months until 24 months. Children were examined at age two to assess MS levels. In order to understand patterns of HCFT prescribing, a retrospective secondary data analysis of routine prescribing data for the years 2006-2012 was performed. To understand the sustainability of dental services, carbon accounting combined a top-down approach and a process analysis approach, followed by the use of Pollard’s decision model (used in other healthcare areas) to analyse and support sustainable service reconfiguration. Of the CS children, 17% were colonised with MS, compared with 5% of the CS+X group. This difference was not statistically significant (P=0.1744). The cost of HCFT prescribing increased fourteen-fold over five years, with 4% of dentists prescribing 70% of the total product. Travel (45%), procurement (36%) and building energy (18%) all contributed to the 1800 tonnes of carbon emissions produced by the service, around 4% of total NHS emissions. Using the analytical model, clinic utilisation rates improved by 56% and patient travel halved significantly reducing carbon emissions. It can be concluded that the Childsmile programme was effective in reducing the risk for MS transmission. HCFT is increasing in Scotland and needs to be managed. Dentistry has similar carbon emissions proportionally as the overall NHS, and the use of an analytic tool can be useful in helping identify these emissions. Key words: Sustainability, carbon emissions, xylitol, mutans streptococci, fluoride toothpaste, caries prevention.Brett Duane Suuterveyden edistäminen kestävän kehityksen ja kariesprevention kannalta Turun yliopisto, Lääketieteellinen tiedekunta, Hammaslääketieteen laitos, Sosiaalihammaslää- ketiede. Suun terveystieteiden tohtoriohjelma (FINDOS-Turku), Turku, Suomi Annales Universitatis Turkuensis, Sarja- Ser. D, Medica-Odontologica. Painosalama Oy, Turku, Finland, 2015. Hammaslääketieteen pitää tuottaa kestävää sekä näyttöön ja ennaltaehkäisyyn perustuvaa hoitoa. Skotlannissa suuterveyden ennaltaehkäisyä hoidetaan Childsmile-ohjelmalla, jossa hyödynnetään yhä enemmän korkeapitoisia fluorihammastahnoja (HCFT). Verrattuna muihin maihin Skotlannissa tiedetään hyvin vähän ksylitolipreventiosta. Englannin hallitus on asettanut tiukat päästörajoitukset, joita kaikkien valtakunnallisten terveydenhuoltopalvelujen (NHS) on noudatettava. Tutkimuksen tarkoituksena oli 1) kuvailla Skotlannin suuterveyden ennaltaehkäisyohjelmaa Childsmilea (CS) ja selvittää vähentäisikö äitien käyttämä ksylitoli (CS+X) tehokkaammin lasten varhaista mutans streptokokki (MS) -kolonisaatiota verrattuna perusohjelmaan, 2) tutkia HCFT-tuotteiden reseptimääräyksiä ja käyttöä, 3) sekä suorittaa todennäköisyyslaskelmia hammaslääkärien vastaanotoilta saaduista tiedoista niiden kestävän kehityksen parantamiseksi. Satakahdeksankymmentäkaksi äiti-lapsi-paria valittiin tutkimukseen korkeiden MS-tasojen perusteella. Äidit satunnaistettiin CS- ja CS+X-ryhmiin, ja kumpikin ryhmä osallistui Childsmile-ohjelmaan. CS+X-ryhmä käytti ksylitolia kolme kertaa päivässä lapsen ollessa 3–24 kk. Lapset tutkittiin kahden vuoden iässä MS-tasojen määrittämiseksi. Korkeapitoisten fluorihammastahnojen reseptikäytäntöjen tutkimiseksi analysoitiin vuosina 2006–2012 vallinneita käytäntöjä. Hammaslääkärivastaanottojen kestävän kehityksen arvioimiseksi hiilikirjanpidossa käytettiin ylhäältä alaspäin- ja prosessianalyysi-lähestymistapojen yhdistelmää, ja sovellettiin lopuksi Pollardin mallia (käytössä muilla terveyspalvelun alueilla) kestävän palvelun uudelleenjärjestelyn analysoimiseksi ja tukemiseksi. Vain 17 % CS-ryhmän lapsista oli kolonisoitunut mutans streptokokeilla, ja vastaava luku CS+X-ryhmässä oli jopa 5 %. Ero ei kuitenkaan ollut tilastollisesti merkitsevä (P=0.1744). Viidessä vuodessa korkeapitoisten reseptihammastahnojen kustannukset 14-kertaistuivat, ja 4 % hammaslääkäreistä kirjoitti 70 % resepteistä. Matkat (45 %), hankinnat (36 %) ja rakennusten lämmityskustannukset (18 %) tuottivat vastaanotoille yhteensä 1800 tonnin hiilipäästöt, 4 % NHS:n kokonaispäästöistä. Käytettäessä analyysimallia vastaanottojen käyttöaste parani 56 %:lla ja potilaiden matkakustannukset puolittuivat, mikä vähensi hiilipäästöjä merkitsevästi. Päätelmänä voidaan sanoa, että Childsmile-ohjelma tehokkaasti vähensi MS-transmissiota. Korkeapitoisten fluorihammastahnojen määrääminen on lisääntynyt Skotlannissa, mikä vaatii sääntelyä. Hammaslääkärien hiilipäästöt ovat samaa luokkaa kuin NHS:llä yleensä ja analyysi- malli voi olla käyttökelpoinen päästöjen vähentämisessä. Avainsanat: Ksylitoli, mutans streptokokit, fluorihammastahna, kariespreventio, kestävä kehitys, hiilipäästöt.Siirretty Doriast

Predicting geogenic groundwater fluoride: Malawi as a case study

Geogenic fluoride contamination of groundwater causes the health condition fluorosis and is a global water degredation issue affecting an estimated 200 million people. It has been identified as a priority chemical contaminant of concern by the United Nations and will be a focus in many fluoride-vulnerable developing countries towards Sustainable Development Goal 6 (SDG 6) related to water quality. Predicting groundwater vulnerability to geogenic fluoride will be key to sustainably managing groundwater assets for SDG 6, however some developing nations may not have the resources or data available to develop a solution. Malawi has only sparse knowledge of issues with fluoride and fluorosis and it does not have access to comprehensive national groundwater fluoride data which is a hinderance to the development of a complex risk model. This thesis sought to fill the knowledge gap with a national data collation and a synthesis of geological, hydrogeological and hydro-geochemical analyses of fluoride occurrence, to develop an innovative prediction method to screen for groundwater fluoride contamination which can be applied nationally. National groundwater fluoride occurrence was documented for the first time in Malawi providing a master data set of groundwater fluoride spanning 50 years. Fluoride was found to occur from two distinct source types (lithological, hydrothermal), each of which was designated a fluoride risk factor using fluoride-lithology statistics from existing data and extrapolating where data were absent. The method was developed to be dynamic with prediction accuracy increasing as new data is acquired, and can be easily applied at any scale in any country for little expense. The prediction method developed will allow the Government of Malawi to manage its groundwater infrastructure assets for fluoride contamination in a targeted manner, boost their attainment potential for SDG 6, redefine their groundwater policy to include geogenic fluoride contamination and bring their groundwater fluoride standard in line with observed health risks.Geogenic fluoride contamination of groundwater causes the health condition fluorosis and is a global water degredation issue affecting an estimated 200 million people. It has been identified as a priority chemical contaminant of concern by the United Nations and will be a focus in many fluoride-vulnerable developing countries towards Sustainable Development Goal 6 (SDG 6) related to water quality. Predicting groundwater vulnerability to geogenic fluoride will be key to sustainably managing groundwater assets for SDG 6, however some developing nations may not have the resources or data available to develop a solution. Malawi has only sparse knowledge of issues with fluoride and fluorosis and it does not have access to comprehensive national groundwater fluoride data which is a hinderance to the development of a complex risk model. This thesis sought to fill the knowledge gap with a national data collation and a synthesis of geological, hydrogeological and hydro-geochemical analyses of fluoride occurrence, to develop an innovative prediction method to screen for groundwater fluoride contamination which can be applied nationally. National groundwater fluoride occurrence was documented for the first time in Malawi providing a master data set of groundwater fluoride spanning 50 years. Fluoride was found to occur from two distinct source types (lithological, hydrothermal), each of which was designated a fluoride risk factor using fluoride-lithology statistics from existing data and extrapolating where data were absent. The method was developed to be dynamic with prediction accuracy increasing as new data is acquired, and can be easily applied at any scale in any country for little expense. The prediction method developed will allow the Government of Malawi to manage its groundwater infrastructure assets for fluoride contamination in a targeted manner, boost their attainment potential for SDG 6, redefine their groundwater policy to include geogenic fluoride contamination and bring their groundwater fluoride standard in line with observed health risks

Towards evidence-based, GIS-driven national spatial health information infrastructure and surveillance services in the United Kingdom

The term "Geographic Information Systems" (GIS) has been added to MeSH in 2003, a step reflecting the importance and growing use of GIS in health and healthcare research and practices. GIS have much more to offer than the obvious digital cartography (map) functions. From a community health perspective, GIS could potentially act as powerful evidence-based practice tools for early problem detection and solving. When properly used, GIS can: inform and educate (professionals and the public); empower decision-making at all levels; help in planning and tweaking clinically and cost-effective actions, in predicting outcomes before making any financial commitments and ascribing priorities in a climate of finite resources; change practices; and continually monitor and analyse changes, as well as sentinel events. Yet despite all these potentials for GIS, they remain under-utilised in the UK National Health Service (NHS). This paper has the following objectives: (1) to illustrate with practical, real-world scenarios and examples from the literature the different GIS methods and uses to improve community health and healthcare practices, e.g., for improving hospital bed availability, in community health and bioterrorism surveillance services, and in the latest SARS outbreak; (2) to discuss challenges and problems currently hindering the wide-scale adoption of GIS across the NHS; and (3) to identify the most important requirements and ingredients for addressing these challenges, and realising GIS potential within the NHS, guided by related initiatives worldwide. The ultimate goal is to illuminate the road towards implementing a comprehensive national, multi-agency spatio-temporal health information infrastructure functioning proactively in real time. The concepts and principles presented in this paper can be also applied in other countries, and on regional (e.g., European Union) and global levels

Intensity of COVID-19 in care homes following Hospital Discharge in the early stages of the UK epidemic

BackgroundA defining feature of the COVID-19 pandemic in many countries was the tragic extent to which care home residents were affected, and the difficulty preventing introduction and subsequent spread of infection. Management of risk in care homes requires good evidence on the most important transmission pathways. One hypothesised route at the start of the pandemic, prior to widespread testing, was transfer of patients from hospitals, which were experiencing high levels of nosocomial events.MethodsWe tested the hypothesis that hospital discharge events increased the intensity of care home cases using a national individually linked health record cohort in Wales, UK. We monitored 186,772 hospital discharge events over the period March to July 2020, tracking individuals to 923 care homes and recording the daily case rate in the homes populated by 15,772 residents. We estimated the risk of an increase in cases rates following exposure to a hospital discharge using multi-level hierarchical logistic regression, and a novel stochastic Hawkes process outbreak model.FindingsIn regression analysis, after adjusting for care home size, we found no significant association between hospital discharge and subsequent increases in care home case numbers (odds ratio: 0.99, 95% CI 0.82, 1.90). Risk factors for increased cases included care home size, care home resident density, and provision of nursing care. Using our outbreak model, we found a significant effect of hospital discharge on the subsequent intensity of cases. However, the effect was small, and considerably less than the effect of care home size, suggesting the highest risk of introduction came from interaction with the community. We estimated approximately 1.8% of hospital discharged patients may have been infected.InterpretationThere is growing evidence in the UK that the risk of transfer of COVID-19 from the high-risk hospital setting to the high-risk care home setting during the early stages of the pandemic was relatively small. Although access to testing was limited to initial symptomatic cases in each care home at this time, our results suggest that reduced numbers of discharges, selection of patients, and action taken within care homes following transfer all may have contributed to mitigation. The precise key transmission routes from the community remain to be quantified

A place-based approach to payments for ecosystem services

Payment for Ecosystem Services (PES) schemes are proliferating but are challenged by insufficient attention to spatial and temporal inter-dependencies, interactions between different ecosystems and their services, and the need for multi-level governance. To address these challenges, this paper develops a place-based approach to the development and implementation of PES schemes that incorporates multi-level governance, bundling or layering of services across multiple scales, and shared values for ecosystem services. The approach is evaluated and illustrated using case study research to develop an explicitly place-based PES scheme, the Peatland Code, owned and managed by the International Union for the Conservation of Nature’s UK Peatland Programme and designed to pay for restoration of peatland habitats. Buyers preferred bundled schemes with premium pricing of a primary service, contrasting with sellers’ preferences for quantifying and marketing services separately in a layered scheme. There was limited awareness among key business sectors of dependencies on ecosystem services, or the risks and opportunities arising from their management. Companies with financial links to peatlands or a strong environmental sustainability focus were interested in the scheme, particularly in relation to climate regulation, water quality, biodiversity and flood risk mitigation benefits. Visitors were most interested in donating to projects that benefited wildlife and were willing to donate around £2 on-site during a visit. Sellers agreed a deliberated fair price per tonne of CO2 equivalent from £11.18 to £15.65 across four sites in Scotland, with this range primarily driven by spatial variation in habitat degradation. In the Peak District, perceived declines in sheep and grouse productivity arising from ditch blocking led to substantially higher prices, but in other regions ditch blocking was viewed more positively. The Peatland Code was developed in close collaboration with stakeholders at catchment, landscape and national scales, enabling multi-level governance of the management and delivery of ecosystem services across these scales. Place-based PES schemes can mitigate negative trade-offs between ecosystem services, more effectively include cultural ecosystem services and engage with and empower diverse stakeholders in scheme design and governance

Visual literacy, student employability and the role of librarians

In the UK we live in a society that tacitly equates information with the written word. Clues to the precedence accorded to text-based data over visual information surround us. The most recent Higher Education Academy Employability paper (HEA, 2007) makes no mention of the need for visual literacy skills. By neglecting visual literacy, we run the risk of sending our students into the job market, and into society, ill equipped to consciously decode the images streaming towards them, and conversely, unable to create and encode visual data, whether it be for business graphs or to commission a website etc. Since 2004, the library at the University of Northampton has run a successful undergraduate Information Management module, which is available to all first years and has an annual cohort of around 80 students. In 2007, a strand dedicated to visual literacy was developed by the University’s arts library team and added to the module programme. From the favourable student response, the content awakened something within the students, and proved stimulating and timely. We now have a growing research interest in understanding the role librarians have to play in developing and delivering visual literacy programmes and the impact of visual literacy on student employability. The “Learning Dialogues” conference will enable us to share our research project whilst it is in progress in particular: the methods we are employing to understand the need for visual literacy to enhance employability (dialogue with students), how we are bench marking other UK institutions (through visiting these institutions) and comparing our role with that of information professionals in the USA and Australia (through interactive dialogue). Rees, C., Forbes P., and B. Kubler (2007) Student Employability Profiles: A Guide for Higher Education Practitioners [online]. York: Higher Education Academy. Available from http://www.heacademy.ac.uk/assets/York/documents/ourwork/tla/employability_enterprise/student_employability_profiles_apr07.pdf [Accessed on 26, November 2009

Integrated Design, Design Management and the Delivery of Major Hospitals

There is a failure to fully achieve client expectations and to deliver integrated hospital building solutions that function to all spatial and equipment requirements. Often this is because the construction of hospitals is based on designs established several years before the start on site. A retrospective abductive, auto-ethnographic case study approach has been taken in the examination of four major hospital projects over a period of 30 years. The level of design integration and effect of design management and coordination issues relating to stakeholder engagement, roles and responsibilities, static and dynamic briefing and the integration of major medical equipment has been explored at a project level, then contextualised within a wider delivery model to understand the impacts of these on integrated delivery and systems integration. Five temporal periods were observed, four of them relating to the retrospective case studies these were: (1) prescriptive integration – where traditional procurement with Design, Bid, Build delivery was combined with standards and guidance; (2) dysfunctional integration – where the adoption of Private Finance Initiative (PFI) with Design and Build delivery transferred traditional roles and reduced standardisation; (3 and 4) adaptive integration 1 and 2 – which saw both a gradual deregulation of standards; and, an understanding for standards, and (5) the fifth temporal disintegration period – where guidance from the wider delivery model ceased to be updated due to top down policy reorganisation and lack of centralised control and includes a current case study. Throughout these temporal periods, it was found that the national delivery models have had a significant influence on hospital project delivery and particularly systems of systems integration. A new model based on layering principles that shows the impact of wider delivery models on systems integration is proposed to improve the provision of ‘state of the art’ facilities at project completio