Making sense of joint commissioning: three discourses of prevention, empowerment and efficiency

Background: In recent years joint commissioning has assumed an important place in the policy and practice of English health and social care. Yet, despite much being claimed for this way of working there is a lack of evidence to demonstrate the outcomes of joint commissioning. This paper examines the types of impacts that have been claimed for joint commissioning within the literature. Method: The paper reviews the extant literature concerning joint commissioning employing an interpretive schema to examine the different meanings afforded to this concept. The paper reviews over 100 documents that discuss joint commissioning, adopting an interpretive approach which sought to identify a series of discourses, each of which view the processes and outcomes of joint commissioning differently. Results: This paper finds that although much has been written about joint commissioning there is little evidence to link it to changes in outcomes. Much of the evidence base focuses on the processes of joint commissioning and few studies have systematically studied the outcomes of this way of working. Further, there does not appear to be one single definition of joint commissioning and it is used in a variety of different ways across health and social care. The paper identifies three dominant discourses of joint commissioning – prevention, empowerment and efficiency. Each of these offers a different way of seeing joint commissioning and suggests that it should achieve different aims. Conclusions: There is a lack of clarity not only in terms of what joint commissioning has been demonstrated to achieve but even in terms of what it should achieve. Joint commissioning is far from a clear concept with a number of different potential meanings. Although this ambiguity can be helpful in some ways in the sense that it can bring together disparate groups, for example, if joint commissioning is to be delivered at a local level then more specificity may be required in terms of what they are being asked to deliver

Wholeness and holiness — synergy or tension? Medicine, disease and the purity laws of Ancient Israel

The Book of Leviticus has been described as the ‘first hygiene text’ based upon the observation that Leviticus contains a great deal of matter relating to two conditions. The first is צרעת translated in the Septuagint as λέπρα and confused in English translations with modern leprosy. The second, זוב was misused as a generic term for a whole spectrum of genital discharges. Apart from these, Leviticus contains nothing of a ‘medical’ nature. The question arises, as to whether these terms implied any sort of medical context or whether their only significance was as markers of ritual impurity to the priesthood. In Chapter 1 this question is developed and an hypothesis arrived at. A hermeneutic and methodology for the study are introduced and discussed. Chapter 2 is a review of the state of developing ‘medical practice’ in the Ancient Near East. Chapter 3 is concerned with the ideology of the levitical priesthood and their worldview in particular in respect of the establishment and operation of practice of ritual. Chapter 4 treats on the Levitical notion of impurity considered from both taxonomical and sociological standpoints and these approaches are discussed in the context of the present study. Chapters 5 and 6 each contain a detailed ‘medical exegesis’ of chapters 13 and 15 of Leviticus dealing with צרעת and .זוב Chapter 7 contains a similar treatment of the biblical notion of blemish and addresses the question of whether this was a mark of impurity like צרעת and .זוב In Chapter 8 embodies idea of contagion in the context of the ‘hygienic’ theme in Leviticus and the priests’ concern with what might imperil sacred objects. Chapter 9 employs context logometrical analysis in a detailed study of the word צרעת and whether there was, in Ancient Israel, any relationship, adverse or synergic between the activities of the priests in preserving purity, and early healthcare practice. Chapter 10 is a discussion of how צרעת has been seen from a theological perspective. While the exact nature of צרעת remains unknown, its biblical context — levitical and non levitical — is considered in relation to modern theories of the relationship of the impurity laws, sin and the wholeness↔ healthcare dynamic. Chapter 11 is a presentation of the conclusions that may be drawn from this study in respect of the wholeness↔ holiness paradigm posited in the hypothesis. It is concluded that there is no clear evidence to suggest that the priesthood saw צרעת and זוב in any terms commensurate with modern pathology and clinical medicine. Consequently it would be wrong to suppose, as many authors have, that in the levitical context, countermeasures to these conditions, though diagnostic, were hygienic in the modern, medical, — they were not, nor were they ever envisaged to be. That some of these measures subsequently found a significant place in preventive medicine appears to have been both fortuitous and fortunate

On finite pp-groups whose automorphisms are all central

An automorphism $\alpha$ of a group $G$ is said to be central if $\alpha$ commutes with every inner automorphism of $G$. We construct a family of non-special finite $p$-groups having abelian automorphism groups. These groups provide counter examples to a conjecture of A. Mahalanobis [Israel J. Math., {\bf 165} (2008), 161 - 187]. We also construct a family of finite $p$-groups having non-abelian automorphism groups and all automorphisms central. This solves a problem of I. Malinowska [Advances in group theory, Aracne Editrice, Rome 2002, 111-127].Comment: 11 pages, Counter examples to a conjecture from [Israel J. Math., {\bf 165} (2008), 161 - 187]; This paper will appear in Israel J. Math. in 201

Demonstration of microwave multiplexed readout of DC-biased superconducting nanowire detectors

Superconducting nanowires are widely used as sensitive single photon detectors with wide spectral coverage and high timing resolution. We describe a demonstration of an array of dc-biased superconducting nanowire single photon detectors read out with a microwave multiplexing circuit. In this design, each individual nanowire is part of a resonant LC circuit where the inductance is dominated by the kinetic inductance of the nanowire. The circuit also contains two parallel plate capacitors, one of them is in parallel with the inductor and the other is coupled to a microwave transmission line that carries the signals to a cryogenic low-noise amplifier. All of the nanowires are connected via resistors to a single dc bias line that enables the nanowires to be current biased close to their critical current. When a photon hits a nanowire, it creates a normal hotspot that produces a voltage pulse across the LC circuit. This pulse rings down at the resonant frequency of the LC circuit over a time period that is fixed by the quality factor. We present measurements of an array of these devices and an evaluation of their performance in terms of frequency and time response

Comparing the Invasibility of Experimental “Reefs” with Field Observations of Natural Reefs and Artificial Structures

Natural systems are increasingly being modified by the addition of artificial habitats which may facilitate invasion. Where invaders are able to disperse from artificial habitats, their impact may spread to surrounding natural communities and therefore it is important to investigate potential factors that reduce or enhance invasibility. We surveyed the distribution of non-indigenous and native invertebrates and algae between artificial habitats and natural reefs in a marine subtidal system. We also deployed sandstone plates as experimental ‘reefs’ and manipulated the orientation, starting assemblage and degree of shading. Invertebrates (non-indigenous and native) appeared to be responding to similar environmental factors (e.g. orientation) and occupied most space on artificial structures and to a lesser extent reef walls. Non-indigenous invertebrates are less successful than native invertebrates on horizontal reefs despite functional similarities. Manipulative experiments revealed that even when non-indigenous invertebrates invade vertical “reefs”, they are unlikely to gain a foothold and never exceed covers of native invertebrates (regardless of space availability). Community ecology suggests that invertebrates will dominate reef walls and algae horizontal reefs due to functional differences, however our surveys revealed that native algae dominate both vertical and horizontal reefs in shallow estuarine systems. Few non-indigenous algae were sampled in the study, however where invasive algal species are present in a system, they may present a threat to reef communities. Our findings suggest that non-indigenous species are less successful at occupying space on reef compared to artificial structures, and manipulations of biotic and abiotic conditions (primarily orientation and to a lesser extent biotic resistance) on experimental “reefs” explained a large portion of this variation, however they could not fully explain the magnitude of differences

'Localism and intimacy, and horizontal ellipsis other rather imponderable reasons of that sort': A qualitative study of patient experience of community hospitals in England

Debates over the value and contribution of community hospitals are hampered by a lack of empirical assessment of the experience of patients using these services. This paper presents findings from a study which included a focus on patient and family-carer experiences of community hospitals in England. We adopted a qualitative design involving nine case study hospitals. Data collection included interviews with patients (n = 60), carers (n = 28) and staff (n = 89). Through patients and carers highlighting the value of community hospitals feeling ‘close to home’, providing holistic and personalised care and supporting them through difficult transitions, the study confirms the importance of functional and interpersonal aspects of care, while also highlighting the importance of social and psychological aspects. These included having family, friends and the community close, maintaining social connections during periods of hospital treatment, and feeling less anonymous and anxious when attending the hospital due to the high levels of familiarity and connectedness. Although the experiences uncovered in this study were not uniformly positive, patients and carers placed a high overall value on the care provided by community hospitals, often arguing that these were distinctive when compared to their experiences of using other health and care services. The study suggests the need to weigh the full range of these dimensions of patient experience—functional, interpersonal, social and psychological—when assessing the role and contribution of community hospitals

The ethos of physical activity delivery in mental health: a narrative study of service user experiences.

Our research into the physical activity experiences of people with severe mental illness has led us to take seriously the social and cultural environment in which physical activity is delivered. In this study, through narrative methodology, we examine service user accounts of physical activity to illuminate the characteristics of physical activity groups that are experienced as positive, helpful, or beneficial. We present several qualities and show how effective leadership and coaching is central to these qualities being present. We conclude that it is not so much what activity is delivered, but how it is delivered that is critical for sustained participation and positive outcomes

Modifiable risk-factors for keratinocyte cancers in Australia: a case-control study

Keratinocyte cancer is the most common malignancy in Caucasians. The aim of this study was to investigate risk-factors responsible for development of keratinocyte cancer in Australia. A case-control study was conducted, including 112 cases of squamous cell carcinoma (SCC), 95 cases of basal cell carcinoma (BCC) and 122 controls. Freckling during adolescence (SCC: odds ratio (OR) 1.04, p < 0.01; BCC: OR 1.05, p < 0.01), propensity to sunburn (SCC: OR 2.75, p = 0.01, BCC: OR 2.68 p = 0.01) and high cumulative sun-exposure (SCC: OR 2.43, p = 0.04; BCC: OR 2.36 p = 0.04) were independent risk-factors for both SCC and BCC. This study provides further evidence that a sun-sensitive phenotype and excessive sun-exposure during adulthood contribute to the risk of developing keratinocyte cancer. Wearing a hat, long-sleeved shirts, and sunscreen did not significantly reduce the risk of keratinocyte cancer in this study

Writing projective representations over subfields

Let G=〈X〉be an absolutely irreducible subgroup of GL(d, K), and let F be a proper subfield of the finite field K. We present a practical algorithm to decide constructively whether or not G is conjugate to a subgroup of GL(d, F).K×, where K× denotes the centre of GL(d, K). If the derived group of G also acts absolutely irreducibly, then the algorithm is Las Vegas and costs O(|X|d3+d2log|F|) arithmetic operations in K. This work forms part of a recognition project based on Aschbacher’s classification of maximal subgroups of GL(d, K)