Patient choice at the point of GP referral: Department of Health

1 The Department of Health has a Public Service Agreement target to ensure that by the end of 2005 every hospital appointment in the National Health Service in England (the NHS) will be booked for the convenience of the patient, making it easier for patients and their General Practitioners (GPs) to choose the hospital and consultant that best meets their need. The Department aims to provide patients with the opportunity to choose between four to five healthcare providers for elective hospital treatment by December 2005. In consultation with their GP, patients should be able to choose, from a menu of NHS and independent sector healthcare providers, their preferred location for treatment. Patients should also be able to book the time and date of their initial outpatient appointment within 24 hours of the decision to refer the patient for treatment. This target will apply to around 9.4 million patients referred for hospital treatment by their GP each year, around four per cent of the total estimated 241 million GP consultations. 2 Choice at referral can contribute to a more patientfocused health service, bringing benefits to both patients and the NHS. But providing such a choice will not happen by accident. There are a number of dependencies and interactions with other policies that need to be managed. Information Technology (IT) systems need to be developed and modified and significant cultural, organisational and behavioural changes will need to be made by patients, NHS organisations and staff. 3 This report examines whether the Department is on track to deliver choice at the point of referral successfully by the target date of December 2005. Our work has found that: a Progress has been made towards delivering choice at referral through establishing the required organisational infrastructure, commissioning new IT systems and modifications to existing ones, and providing support for the NHS organisations that will deliver it. b The engagement of GPs is currently low and is a key risk which the Department must address to deliver choice successfully. The Department plans to address this risk through a campaign to inform and engage GPs during 2005 and it will need to monitor carefully the progress of this campaign. c Choice at referral will be delivered most efficiently and effectively through electronic booking (e-booking, also known as Choose and Book), in which the Electronic Booking Service, commissioned by the Department’s National Programme for IT (NPfIT), is linked to upgraded or new computer systems in hospitals and GPs’ surgeries. However, e-booking will not be universally available by December 2005. Until e-booking is fully adopted choice will have to be provided in other, less efficient, ways. d Parts of the NHS still have much to do if they are to deliver choice. A significant minority of Primary Care Trusts do not yet have adequate plans in place to manage the introduction of choice and some may struggle to manage the required new commissioning arrangements. 4 Our more detailed findings are as follows. Progress has been made towards delivering choice at referral 5 The Department believes that choice is affordable. Additional annual infrastructure and transaction costs are estimated to be £122 million – or 1.4 per cent of the current total expenditure on elective care. The main aim of introducing choice is to improve services for patients, but it should lead to increased efficiencies in primary and secondary care services worth an estimated £71 million, off-setting some of these costs. 6 It is essential that choice is supported by other elements of system reform including e-booking, payment by results, commissioning and appropriate capacity. Modelling exercises have shown that the system reforms should work in harmony with one another. Payment by results should enable the transfer of funding to follow the patient and there should be sufficient capacity across the system to enable choice to be effective. 7 Much of the organisational infrastructure that is required for choice is in place and there is clear accountability for the delivery of the programme. To strengthen detailed national programme management arrangements the Department created, on 22 December 2004, a new post of National Implementation Director for Choose and Book, with effect from 10 January 2005. The new Director will be responsible for overseeing the implementation of choice within the NHS whilst the National Programme for IT Group Programme Director for Choose and Book will continue to be responsible for Choose and Book technology development and deployment, patient access and Choose and Book contract management. 8 The Department has provided different types of support to the NHS – for example, ten pilot schemes have been run to test the policy in practice. It has set up a system for periodically measuring progress and used this to establish the position at the end of October 2004, creating a baseline against which to monitor future progress. 9 Research has identified what information patients will want to base their choices on, and the Department is seeking to provide this. While it is unlikely that full information will be available for December 2005, the majority of those aspects identified by patients as being the most important, such as waiting times and basic access information, will be in place. The Department plans to increase the information available over time. The key risk to the delivery of choice is the engagement of GPs 10 Choice cannot be delivered without support from GPs but our survey of GPs found that around half of GPs know very little about it and 61 per cent feel either very negative or a little negative. GPs’ concerns include practice capacity, workload, consultation length and fears that existing health inequalities will be exacerbated. The Department has deliberately held back its main effort to inform and engage GPs about choice until it has had a working e-booking system to show GPs, but it intends to mount a campaign to inform and engage GPs during 2005. Until e-booking is fully adopted choice will be supported by other mechanisms 11 The Department has commissioned Atos Origin to develop a national system for e-booking, which will be linked to upgraded or new Patient Administration Systems in hospitals and IT systems in GPs’ surgeries to provide an overall service known as e-booking. The National Programme for IT has planned the roll out of e-booking on an incremental basis to minimise risk, and to link it by the end of 2005 to some 60 to 70 per cent of hospital systems and GP practices. 12 E-booking is the most effective and efficient way of delivering the Department’s plans for choice, and alternative booking mechanisms offer poorer value for money. Atos Origin has delivered a functioning system and the first booking using e-booking was made in July 2004. However the roll-out of e-booking has been slower than planned and at the end of December 2004 only 63 bookings had been made. Problems have included the reluctance of users to work with an unreliable end-to-end system, limited progress in linking to GP and hospital systems, and the limited number of GPs willing to use the system. 13 The Department believes that new releases of software have addressed the reliability of the whole end-to-end system and that having a fully operational system will encourage GPs to engage with e-booking. The roll-out of changes to hospital systems to allow them to link to e-booking is gathering pace and four types of GP systems can now link to e-booking, although the largest supplier has not yet agreed an implementation plan. A combined team of Departmental and NHS personnel are working with the three main existing GP system suppliers to agree a national deployment schedule. This work should be completed by February 2005, along with a nationally negotiated commercial arrangement. The Department is also developing and trialling contingency plans against further delays, as well as alternatives to the fully integrated Choose and Book solution. Parts of the NHS still have much to do 14 Programme management arrangements in the NHS are incomplete. While most Primary Care Trusts expect to be able to deliver the choice target, there is variability in their overall performance. As many as a quarter of Primary Care Trusts currently forecast that they will not deliver the choice targets. In addition, some Primary Care Trusts may struggle to manage the new commissioning arrangements and two-thirds have yet to commission the required number of providers. The department is developing a framework of support to assist trusts to overcome these obstacles. 15 The Department needs urgently to address the low level of GP support for their plans for implementing choice at referral, and should: I Press on urgently with its plans for informing GPs about the implementation of choice at referral and its impact on GPs and patients. II Monitor the views of GPs, for example by a regular survey, repeating key questions from our own survey, to assess the rate of progress being achieved towards the level of support needed to meet its target of full implementation by December 2005. III Consider whether further action is needed to secure the required level of GP support, once GPs are fully informed on what choice at referral involves. 16 The Department should also: IV Complete its planned benefits realisation plan for choice at referral by the summer of 2005, along with a monitoring mechanism and quantified targets. V Keep under regular and close review the progress of its planned implementation of choice through implementing e-booking and consider the scope for accelerating the roll-out of e-booking to make it available everywhere by December 2005. VI If it becomes clear that it is not possible to deliver e-booking everywhere by December 2005, the Department should: a monitor closely the development of the interim solutions to ensure that they meet their delivery dates; and b ensure that the implementation of interim solutions does not detract from the priority of bringing in fully integrated e-booking systems as soon as possible. VII Establish an evaluation framework for Primary Care Trust commissioning to assist Strategic Health Authorities in assessing the capacity and skills of Primary Care Trusts in this area and securing improvements in capacity and skills where necessary

Algebraic logoi

We introduce normal cores, as well as the more general action cores, in the context of a semi-abelian category, and further generalise those to split extension cores in the context of a homological category. We prove that, if the category is moreover well-powered with (small) joins, then the existence of split extension cores is equivalent to the condition that the change-of-base functors in the fibration of points are geometric. We call a finitely complete category that satisfies this condition an algebraic logos. We give examples of such categories, compare them with algebraically coherent ones, and study equivalent conditions as well as stability under common categorical operations.Comment: Revision with changes throughout the text; new final section; 22 page

Galois theory and commutators

We prove that the relative commutator with respect to a subvariety of a variety of Omega-groups introduced by the first author can be described in terms of categorical Galois theory. This extends the known correspondence between the Froehlich-Lue and the Janelidze-Kelly notions of central extension. As an example outside the context of Omega-groups we study the reflection of the category of loops to the category of groups where we obtain an interpretation of the associator as a relative commutator.Comment: 14 page

Global citizens: Who are they?

A growing desire to instigate global citizenship programmes in Higher Education (HE) has led to the development of optional structured opportunities for students to engage in prosocial activities. One of the challenges facing such programmes is to demonstrate and plan for the personal growth of those students. This paper reports the dispositional, prosocial and attitudinal characteristics; knowledge and skills; and perceptions of social justice that students who undertake these activities bring to their initial participation. The findings indicate, that in comparison to a control group, the students differ significantly in a number of important ways (e.g. conscientiousness, extraversion, openness; Machiavellianism, prosocial behaviour; self-esteem; skills relating to social action and tolerance and understanding and their concern regarding social problems). However, consideration should be given to the ways in which those students can be developed within a framework for social justice. Further, recruitment procedures for citizenship programmes in general should encourage the participation of a more diverse group of students than currently appears to be the case

The effectiveness of protected areas in the conservation of species with changing geographical ranges

A cornerstone of conservation is the designation and management of protected areas (PAs): locations often under conservation management containing species of conservation concern, where some development and other detrimental influences are prevented or mitigated. However, the value of PAs for conserving biodiversity in the long term has been questioned given that species are changing their distributions in response to climatic change. There is a concern that PAs may become climatically unsuitable for those species that they were designated to protect, and may not be located appropriately to receive newly-colonizing species for which the climate is improving. In the present study, we analyze fine-scale distribution data from detailed resurveys of seven butterfly and 11 bird species in Great Britain aiming to examine any effect of PA designation in preventing extinctions and promoting colonizations. We found a positive effect of PA designation on species' persistence at trailing-edge warm range margins, although with a decreased magnitude at higher latitudes and altitudes. In addition, colonizations by range expanding species were more likely to occur on PAs even after altitude and latitude were taken into account. PAs will therefore remain an important strategy for conservation. The potential for PA management to mitigate the effects of climatic change for retracting species deserves further investigation

Can agricultural cultivation methods influence the healthfulness of crops for foods

The aim of the current study was to investigate if there are any health effects of long-term consumption of organically grown crops using a rat model. Crops were retrieved over two years from along-term field trial at three different locations in Denmark, using three different cultivation systems(OA, organic based on livestock manure; OB, organic based on green manure; and C, conventional with mineral fertilizers and pesticides)with two field replicates. The cultivation system had an impact on the nutritional quality, affecting γ-tocopherol, some amino acids, and fatty acid composition. Additionally, the nutritional quality was affected by harvest year and location. However, harvest year and location rather than cultivation system affected the measured health biomarkers. In conclusion, the differences in dietary treatments composed of ingredients from different cultivation systems did not lead to significant differences in the measured health biomarkers, except for a significant difference in plasma IgGl evels

Opinions of citizen scientists on open access to UK butterfly and moth occurrence data

Citizen science plays an increasingly important role in biodiversity research and conservation, enabling large volumes of data to be gathered across extensive spatial scales in a cost-effective manner. Open access increases the utility of such data, informing land-use decisions that may affect species persistence, enhancing transparency and encouraging proliferation of research applications. However, open access provision of recent, fine-scale spatial information on the locations of species may also prompt legitimate concerns among contributors regarding possible unintended negative conservation impacts, violations of privacy and commercial exploitation of volunteer-gathered data. Here we canvas the attitudes towards open access of contributors (104 regional co-ordinators and 510 recorders) of species occurrence records to two of the largest citizen science biodiversity recording schemes, the UK’s Butterflies for the New Millennium project and National Moth Recording Scheme. We find that while the majority of participants expressed support for open access in principle, most were more cautious in practice, preferring to limit the spatial resolution of records, particularly of threatened species, and restrict commercial reuse of data. In addition, citizen scientists’ opinions differed between UK countries, taxonomic groups and the level of involvement volunteers had in the schemes. In order to maintain successful and democratic citizen science schemes, organisers, funders and data users must understand and respect participants’ expectations and aspirations regarding open data while seeking to optimise data use for scientific and societal benefits

MutLα heterodimers modify the molecular phenotype of Friedreich ataxia

This article has been made available through the Brunel Open Access Publishing Fund.Background: Friedreich ataxia (FRDA), the most common autosomal recessive ataxia disorder, is caused by a dynamic GAA repeat expansion mutation within intron 1 of FXN gene, resulting in down-regulation of frataxin expression. Studies of cell and mouse models have revealed a role for the mismatch repair (MMR) MutS-heterodimer complexes and the PMS2 component of the MutLα complex in the dynamics of intergenerational and somatic GAA repeat expansions: MSH2, MSH3 and MSH6 promote GAA repeat expansions, while PMS2 inhibits GAA repeat expansions. Methodology/Principal Findings: To determine the potential role of the other component of the MutLα complex, MLH1, in GAA repeat instability in FRDA, we have analyzed intergenerational and somatic GAA repeat expansions from FXN transgenic mice that have been crossed with Mlh1 deficient mice. We find that loss of Mlh1 activity reduces both intergenerational and somatic GAA repeat expansions. However, we also find that loss of either Mlh1 or Pms2 reduces FXN transcription, suggesting different mechanisms of action for Mlh1 and Pms2 on GAA repeat expansion dynamics and regulation of FXN transcription. Conclusions/Significance: Both MutLα components, PMS2 and MLH1, have now been shown to modify the molecular phenotype of FRDA. We propose that upregulation of MLH1 or PMS2 could be potential FRDA therapeutic approaches to increase FXN transcription. © 2014 Ezzatizadeh et al.This article has been made available through the Brunel Open Access Publishing Fund

Generation and characterisation of Friedreich ataxia YG8R mouse fibroblast and neural stem cell models

This article has been made available through the Brunel Open Access Publishing Fund.Background: Friedreich ataxia (FRDA) is an autosomal recessive neurodegenerative disease caused by GAA repeat expansion in the first intron of the FXN gene, which encodes frataxin, an essential mitochondrial protein. To further characterise the molecular abnormalities associated with FRDA pathogenesis and to hasten drug screening, the development and use of animal and cellular models is considered essential. Studies of lower organisms have already contributed to understanding FRDA disease pathology, but mammalian cells are more related to FRDA patient cells in physiological terms. Methodology/Principal Findings: We have generated fibroblast cells and neural stem cells (NSCs) from control Y47R mice (9 GAA repeats) and GAA repeat expansion YG8R mice (190+120 GAA repeats). We then differentiated the NSCs in to neurons, oligodendrocytes and astrocytes as confirmed by immunocytochemical analysis of cell specific markers. The three YG8R mouse cell types (fibroblasts, NSCs and differentiated NSCs) exhibit GAA repeat stability, together with reduced expression of frataxin and reduced aconitase activity compared to control Y47R cells. Furthermore, YG8R cells also show increased sensitivity to oxidative stress and downregulation of Pgc-1α and antioxidant gene expression levels, especially Sod2. We also analysed various DNA mismatch repair (MMR) gene expression levels and found that YG8R cells displayed significant reduction in expression of several MMR genes, which may contribute to the GAA repeat stability. Conclusions/Significance: We describe the first fibroblast and NSC models from YG8R FRDA mice and we confirm that the NSCs can be differentiated into neurons and glia. These novel FRDA mouse cell models, which exhibit a FRDA-like cellular and molecular phenotype, will be valuable resources to further study FRDA molecular pathogenesis. They will also provide very useful tools for preclinical testing of frataxin-increasing compounds for FRDA drug therapy, for gene therapy, and as a source of cells for cell therapy testing in FRDA mice. © 2014 Sandi et al

Agrotóxicos e saúde: realidade e desafios para mudança de práticas na agricultura.

Este artigo apresenta os resultados de uma pesquisa que teve como objetivo principal caracterizar o contexto e as práticas relacionadas ao uso de agrotóxicos entre agricultores residentes na Serrinha do Mendanha, comunidade agrícola situada em Campo Grande, município do Rio de Janeiro. A proposta metodológica teve uma abordagem qualitativa, sendo a principal fonte de dados a aplicação de questionário semiestruturado. Participaram da pesquisa 38 agricultores familiares. O perfil socioeconômico mostra uma realidade de idosos no trabalho agrícola, percentuais expressivos de analfabetismo e baixa renda. O uso de agrotóxicos é uma rotina para essas famílias. Apesar de existir uma naturalização do uso, a maioria dos informantes acredita que agrotóxicos podem afetar sua saúde, apresenta preocupação com o consumidor e gostaria de conhecer formas alternativas de cultivo. Tais achados apontam para a possibilidade de busca de mudança de práticas. Não se trata de repasse de conhecimento, pois este tipo de informação de alguma forma eles já possuem. Trata–se de desenvolver estratégias objetivando a minimização dos riscos ou mesmo o desuso de agrotóxicos na lavoura