Views of NHS commissioners on commissioning support provision. Evidence from a qualitative study examining the early development of clinical commissioning groups in England

Objective: The 2010 healthcare reform in England introduced primary care-led commissioning in the National Health Service (NHS) by establishing clinical commissioning groups (CCGs). A key factor for the success of the reform is the provision of excellent commissioning support services to CCGs. The Government's aim is to create a vibrant market of competing providers of such services (from both for-profit and not-for-profit sectors). Until this market develops, however, commissioning support units (CSUs) have been created from which CCGs are buying commissioning support functions. This study explored the attitudes of CCGs towards outsourcing commissioning support functions during the initial stage of the reform. Design: The research took place between September 2011 and June 2012. We used a case study research design in eight CCGs, conducting in-depth interviews, observation of meetings and analysis of policy documents. Setting/participants: We conducted 96 interviews and observed 146 meetings (a total of approximately 439 h). Results: Many CCGs were reluctant to outsource core commissioning support functions (such as contracting) for fear of losing local knowledge and trusted relationships. Others were disappointed by the absence of choice and saw CSUs as monopolies and a recreation of the abolished PCTs. Many expressed doubts about the expectation that outsourcing of commissioning support functions will result in lower administrative costs. Conclusions: Given the nature of healthcare commissioning, outsourcing vital commissioning support functions may not be the preferred option of CCGs. Considerations of high transaction costs, and the risk of fragmentation of services and loss of trusted relationships involved in short-term contracting, may lead most CCGs to decide to form long-term partnerships with commissioning support suppliers in the future. This option, however, limits competition by creating ‘network closure’ and calls into question the Government's intention to create a vibrant market of commissioning support provision

PHOENIX: Public Health and Obesity in England – the New Infrastructure eXamined First interim report: the scoping review

The PHOENIX project aims to examine the impact of structural changes to the health and care system in England on the functioning of the public health system, and on the approaches taken to improving the public’s health. The scoping review has now been completed. During this phase we analysed: Department of Health policy documents (2010-2013), as well as responses to those documents from a range of stakeholders; data from 22 semi-structured interviews with key informants; and the oral and written evidence presented at the House of Commons Communities and Local Government Committee on the role of local authorities in health issues. We also gathered data from local authority (LA) and Health and Wellbeing Board (HWB) websites and other sources to start to develop a picture of how the new structures are developing, and to collate demographic and other data on local authorities. A number of important themes were identified and explored during this phase. In summary, some key points related to three themes - governance, relationships and new ways of working - were: The reforms have had a profound effect on leadership within the public health system. Whilst LAs are now the local leaders for public health, in a more fragmented system, leadership for public health appears to be more dispersed amongst a range of organisations and a range of people within the LA. At national level, the leadership role is complex and not yet developed (from a local perspective). Accountability mechanisms have changed dramatically within public health, and many people still seem to be unclear about them. Some performance management mechanisms have disappeared, and much accountability now appears to rely on transparency and the democratic accountability that this would (theoretically) enable. The extent to which ‘system leaders’ within PHE are able to influence local decisions and performance will depend on the strength of relationships principally between the LA and the local Public Health England centre. These relationships will take time to develop. Many people have faced new ways of working, in new settings, and with new relationships to build. Public health teams in LAs have faced the most profound of these changes, having gone from a position of ‘expert voice’ to a position where they must defend their opinions and activities in the context of competing demands and severely restricted resources. Public health staff may require new skills, and may need to seek new ‘allies’ to thrive in the new environment. HWBs could be crucial in bringing together a fragmented system and dispersed leadership. The next phase of data collection will begin in March with the initiation of case study work. National surveys will be conducted in June/July this year (2014), and at the same time the following year. In this work, we will further explore the following themes: relationships, governance, decision making, new ways of working, and opportunities and difficulties

SkillForge: The Future of Learning

SkillForge is a pioneering e-learning platform integrating Augmented Reality (AR) to enhance online education. Users, as learners or mentors, navigate a plethora of courses enriched with AR modules, offering hands-on interactive experiences. The platform tailors learning paths using AI, adjusting content to users\u27 pace and engagement. Features like real-time feedback, and gamification elements elevate the learning journey. Safety and community engagement are paramount, with strong community guidelines and discussion forums. Utilizing technologies like Tkinter, Ollama, Mistral, SQLite, and Sketchfab api. Skill Resolution stands at the forefront of innovative education

Exact Schwarzschild-Like Solution for Yang-Mills Theories

Drawing on the parallel between general relativity and Yang-Mills theory we obtain an exact Schwarzschild-like solution for SU(2) gauge fields coupled to a massless scalar field. Pushing the analogy further we speculate that this classical solution to the Yang-Mills equations shows confinement in the same way that particles become confined once they pass the event horizon of the Schwarzschild solution. Two special cases of the solution are considered.Comment: 11 pages LaTe

BPS Dyon in a Weak Electromagnetic Field: Equations of Motion and Radiation Fields

Dynamics of a BPS dyon in a weak, constant, electromagnetic field is studied through a perturbative analysis of appropriate non-linear field equations. The full Lorentz force law for a BPS dyon is established. Also derived are the radiation fields accompanying the motion.Comment: 14 pages, Seoul National University preprint SNUTP 93-9

Re-examining Larson's Scaling Relationships in Galactic Molecular Clouds

The properties of Galactic molecular clouds tabulated by Solomon etal (1987) (SRBY) are re-examined using the Boston University-FCRAO Galactic Ring Survey of 13CO J=1-0 emission. These new data provide a lower opacity tracer of molecular clouds and improved angular and spectral resolution than previous surveys of molecular line emission along the Galactic Plane. We calculate GMC masses within the SRBY cloud boundaries assuming LTE conditions throughout the cloud and a constant H2 to 13CO abundance, while accounting for the variation of the 12C/13C with Galacto-centric radius. The LTE derived masses are typically five times smaller than the SRBY virial masses. The corresponding median mass surface density of molecular hydrogen for this sample is 42 Msun/pc^2, which is significantly lower than the value derived by SRBY (median 206 Msun/pc^2) that has been widely adopted by most models of cloud evolution and star formation. This discrepancy arises from both the extrapolation by SRBY of velocity dispersion, size, and CO luminosity to the 1K antenna temperature isophote that likely overestimates the GMC masses and our assumption of constant 13CO abundance over the projected area of each cloud. Owing to the uncertainty of molecular abundances in the envelopes of clouds, the mass surface density of giant molecular clouds could be larger than the values derived from our 13CO measurements. From velocity dispersions derived from the 13CO data, we find that the coefficient of the cloud structure functions, vo=sigma_v/R^{1/2}, is not constant, as required to satisfy Larson's scaling relationships, but rather systematically varies with the surface density of the cloud as Sigma^{0.5} as expected for clouds in self-gravitational equlibrium.Comment: Accepted by ApJ. Newest version includes modifications from the refere

Dualisation of the General Scalar Coset in Supergravity Theories

The dualised formulation of the symmetric space sigma model is peformed for a general scalar coset G/K where G is a maximally non-compact group and K is it's maximal compact subgroup.By using the twisted self-duality condition the general form of the first-order equations are obtained.The results are applied to the example of SL(2,R)/SO(2) scalar manifold of the IIB supergravity.Comment: 22 page

Exploring the role of pain as an early predictor of category 2 pressure ulcers: a prospective cohort study

Objective To explore pressure area related pain as a predictor of category ≥2 pressure ulcer (PU) development. Design Multicentre prospective cohort study. Setting UK hospital and community settings. Participants inclusion Consenting acutely ill patients aged ≥18 years, defined as high risk (Braden bedfast/chairfast AND completely immobile/very limited mobility; pressure area related pain or; category 1 PU). Exclusion Patients too unwell, unable to report pain, 2 or more category ≥2 PUs. Follow-up Twice weekly for 30 days. Primary and secondary outcome measures Development and time to development of one or more category ≥2 PUs. Results Of 3819 screened, 1266 were eligible, 634 patients were recruited, 32 lost to follow-up, providing a 602 analysis population. 152 (25.2%) developed one or more category ≥2 PUs. 464 (77.1%) patients reported pressure area related pain on a healthy, altered or category 1 skin site of whom 130 (28.0%) developed a category ≥2 PU compared with 22 (15.9%) of those without pain. Full stepwise variable selection was used throughout the analyses. (1) Multivariable logistic regression model to assess 9 a priori factors: presence of category 1 PU (OR=3.25, 95% CI (2.17 to 4.86), p<0.0001), alterations to intact skin (OR=1.98, 95% CI (1.30 to 3.00), p=0.0014), pressure area related pain (OR=1.56, 95% CI (0.93 to 2.63), p=0.0931). (2) Multivariable logistic regression model to account for overdispersion: presence of category 1 PU (OR=3.20, 95% CI (2.11 to 4.85), p<0.0001), alterations to intact skin (OR=1.90, 95% CI (1.24 to 2.91), p=0.0032), pressure area related pain (OR=1.85, 95% CI (1.07 to 3.20), p=0.0271), pre-existing category 2 PU (OR=2.09, 95% CI (1.35 to 3.23), p=0.0009), presence of chronic wound (OR=1.66, 95% CI (1.06 to 2.62), p=0.0277), Braden activity (p=0.0476). (3) Accelerated failure time model: presence of category 1 PU (AF=2.32, 95% CI (1.73 to 3.12), p<0.0001), pressure area related pain (AF=2.28, 95% CI (1.59 to 3.27), p<0.0001). (4) 2-level random-intercept logistic regression model: skin status which comprised 2 levels (versus healthy skin); alterations to intact skin (OR=4.65, 95% CI (3.01 to 7.18), p<0.0001), presence of category 1 PU (OR=17.30, 95% CI (11.09 to 27.00), p<0.0001) and pressure area related pain (OR=2.25, 95% CI (1.53 to 3.29), p<0.0001). Conclusions This is the first study to assess pain as a predictor of category ≥2 PU development. In all 4 models, pain emerged as a risk factor associated with an increased probability of category ≥2 PU development

Introduction to S-Duality in N=2 Supersymmetric Gauge Theory. (A pedagogical review of the work of Seiberg and Witten)

In these notes we attempt to give a pedagogical introduction to the work of Seiberg and Witten on S-duality and the exact results of N=2 supersymmetric gauge theories with and without matter. The first half is devoted to a review of monopoles in gauge theories and the construction of supersymmetric gauge theories. In the second half, we describe the work of Seiberg and Witten.Comment: Latex file with seven eps figures. 81 page