Decentralisation, centralisation and devolution in publicly funded health services: decentralisation as an organisational model for health-care in England.

This review examines the nature and application of decentralisation as an organisational model for health care in England. The study reviews the relevant theoretical literature from a range of disciplines relating to different public- and private-sector contexts of decentralisation and centralisation. It examines empirical evidence about decentralisation and centralisation in public and private organisations and explores the relationship between decentralisation and different incentive structures, which, in turn affect organisational performance

Decentralisation and performance: Autonomy and incentives in Local Health Economies

This project will examine the inter-relationship between governance mechanisms, autonomy and incentives in local health economies (LHEs). This interaction shapes decentralisation policies in the NHS and is thought to shape LHE performance. Recently, English health policy has been implementing new forms of decentralisation (eg. earned autonomy, Foundation Trusts) by altering the mix of governance mechanisms (command, collaboration and competition) and making explicit use of autonomy and incentives, thereby aiming to improve NHS performance. Local contextual factors might also shape performance outcomes. The project involves a synergy between the multi-disciplinary teams involved in 2 previous NCC-SDO funded studies. The aim is to investigate the inter-relationship between decentralisation and performance in LHEs. The project has 5 objectives: a. To examine the impact of decentralisation upon performance through analysis of selected 'tracers (as examples of current priorities) in 3 case-studies; b. To describe the local interaction of governance mechanisms; c. To evaluate the degree of autonomy available to local health-care organisations; d. To assess the (financial and non-financial) incentives associated with different policy initiatives; e. To provide lessons for policy-makers and managers at all levels in implementing decentralisation, managing the implications of autonomy and incentives, and addressing performance management through incentives. The study will use mixed methods. First, analysis of policy and performance data will generate the broad pattern of decentralisation and performance across England. Analysis of these data will aid selection of case-studies and 'tracers (examples within case-studies). Second, three case-studies will be selected which represent a maximum variety of pre-defined criteria. Longitudinal, comparative case-study methods include (a) 'mapping LHE performance and organisational characteristics (using local performance and activity data, and published reports); (b) a survey of senior staff in 3 LHEs (n=c.180) to provide their perceptions of current LHE issues and constraints (especially relating to tracer examples); (c) interviews with a sample of stakeholders (n=c.120) will identify the strengths and effects of organisational relationships across the LHE (such as the impact of service developments in the tracer examples); (d) observation of local planning meetings. Parts (a) and (b) will be conducted in year 1, parts (c) and (d) in years 2 and 3. Quantitative analysis will provide descriptive statistics of broad patterns and association. Qualitative analysis will provide thematic comparisons by LHE, organisational type and tracer example. Analysis will identify the pathways by which governance, autonomy and incentives can facilitate improved performance and also the conditions under which the optimal balance of these may be achieved in different contexts. The study will also consider conceptual frameworks (including 'decision space , resource dependency and principal-agent) to improve understanding of the inter-relationships within LHE and the intersection of national/vertical and local/horizontal pressures affecting performance. The study will engage decision-makers at all stages (via data collection, formative and summative feedback and as members of an Advisory Group). Formative feedback to LHEs (and NCC-SDO) will help validate emergent findings and sharpen subsequent fieldwork. Final dissemination will include such (oral and written) feedback, NCC-SDO report, presentations and publications to practitioner and research communities

Geiger Mode Ge-on-Si Single-Photon Avalanche Diode Detectors

Ge-on-Si single-photon avalanche diode (SPAD) detectors have demonstrated a high single-photon detection efficiency of 38% at a wavelength of 1310 nm when operated at a temperature of 125 K. These devices exhibit reduced afterpulsing compared to InGaAs/InP SPADs under nominally identical operating conditions

Geiger Mode Ge-on-Si Single-Photon Avalanche Diode Detectors

High efficiency single photon avalanche detectors (SPADs) based on the Ge-on-Si material system are a promising emerging technology for high sensitivity optical detection in the short-wave infrared region. Here we demonstrate record single photon detection efficiencies of 38% at 1310nm with an operating temperature of 125K. This was achieved using a novel planar geometry which allowed us to achieve an NEPs of 3×10 −16 WHz −1/2 and reduced afterpulsing when compared to InGaAs/InP based SPADs operated in nominally identical conditions

Programmable Deuteration of Indoles via Reverse Deuterium Exchange

Methods for selective deuterium incorporation into drug-like molecules have become extremely valuable due to the commercial, mechanistic, and biological importance of deuterated compounds. Herein, we report a programmable labeling platform that allows access to C2, C3, or C2- and C3-deuterated indoles under mild, user-friendly conditions. The C2-deuterated indoles are accessed using a reverse hydrogen isotope exchange strategy which represents the first non-directed C2-deuteration of indoles

Services just for men? Insights from a national study of the well men services pilots.

Men continue to have a lower life expectancy in most countries compared to women. Explanations of this gendered health inequality tend to focus on male risk taking, unhealthy lifestyle choices and resistance to seeking help from health services. In the period 2005-2008 the Scottish Government funded a nationwide community health promotion programme aimed at improving men's health, called Well Men Service Pilots (henceforth WMS)

Ultralow-light-level color image reconstruction using high-efficiency plasmonic metasurface mosaic filters

As single-photon imaging becomes progressively more commonplace in sensing applications such as low-light-level imaging, three-dimensional profiling, and fluorescence imaging, there exist a number of fields where multispectral information can also be exploited, e.g., in environmental monitoring and target identification. We have fabricated a high-transmittance mosaic filter array, where each optical filter was composed of a plasmonic metasurface fabricated in a single lithographic step. This plasmonic metasurface design utilized an array of elliptical and circular nanoholes, which produced enhanced optical coupling between multiple plasmonic interactions. The resulting metasurfaces produced narrow bandpass filters for blue, green, and red light with peak transmission efficiencies of 79%, 75%, and 68%, respectively. After the three metasurface filter designs were arranged in a 64×64 format random mosaic pattern, this mosaic filter was directly integrated onto a CMOS single-photon avalanche diode detector array. Color images were then reconstructed at light levels as low as approximately 5 photons per pixel, on average, via the simultaneous acquisition of low-photon multispectral data using both three-color active laser illumination and a broadband white-light illumination source

Adjunctive liraglutide treatment in patients with persistent or recurrent type 2 diabetes after metabolic surgery (GRAVITAS): a randomised, double-blind, placebo-controlled trial

Background Many patients with type 2 diabetes do not achieve sustained diabetes remission after metabolic (bariatric) surgery for the treatment of obesity. Liraglutide, a glucagon-like peptide-1 analogue, improves glycaemic control and reduces bodyweight in patients with type 2 diabetes. Our aim was to assess the safety and efficacy of liraglutide 1·8 mg in patients with persistent or recurrent type 2 diabetes after metabolic surgery. Methods In the GRAVITAS randomised double-blind, placebo-controlled trial, we enrolled adults who had undergone Roux-en-Y gastric bypass or vertical sleeve gastrectomy and had persistent or recurrent type 2 diabetes with HbA1c levels higher than 48 mmol/mol (6·5%) at least 1 year after surgery from five hospitals in London, UK. Participants were randomly assigned (2:1) via a computer-generated sequence to either subcutaneous liraglutide 1·8 mg once daily or placebo, both given together with a reduced-calorie diet, aiming for a 500 kcal per day deficit from baseline energy intake, and increased physical activity. The primary outcome was the change in HbA1c from baseline to the end of the study period at 26 weeks, assessed in patients who completed the trial. Safety was assessed in the safety analysis population, consisting of all participants who received either liraglutide or placebo. This trial is registered with EudraCT, number 2014-003923-23, and the ISRCTN registry, number ISRCTN13643081. Findings Between Jan 29, 2016, and May 2, 2018, we assigned 80 patients to receive either liraglutide (n=53) or placebo (n=27). 71 (89%) participants completed the study and were included in the principal complete-cases analysis. In a multivariable linear regression analysis, with baseline HbA1c levels and surgery type as covariates, liraglutide treatment was associated with a difference of −13·3 mmol/mol (−1·22%, 95% CI −19·7 to −7·0; p=0·0001) in HbA1c change from baseline to 26 weeks, compared with placebo. Type of surgery had no significant effect on the outcome. 24 (45%) of 53 patients assigned to liraglutide and 11 (41%) of 27 assigned to placebo reported adverse effects: these were mainly gastrointestinal and in line with previous experience with liraglutide. There was one death during the study in a patient assigned to the placebo group, which was considered unrelated to study treatment. Interpretation These findings support the use of adjunctive liraglutide treatment in patients with persistent or recurrent type 2 diabetes after metabolic surgery

3D LIDAR imaging using Ge-on-Si single–photon avalanche diode detectors

We present a scanning light detection and ranging (LIDAR) system incorporating an individual Ge-on-Si single-photon avalanche diode (SPAD) detector for depth and intensity imaging in the short-wavelength infrared region. The time-correlated single-photon counting technique was used to determine the return photon time-of-flight for target depth information. In laboratory demonstrations, depth and intensity reconstructions were made of targets at short range, using advanced image processing algorithms tailored for the analysis of single–photon time-of-flight data. These laboratory measurements were used to predict the performance of the single-photon LIDAR system at longer ranges, providing estimations that sub-milliwatt average power levels would be required for kilometer range depth measurements

New insights into risk factors for transplant-associated thrombotic microangiopathy in pediatric HSCT

This study aimed to identify a risk profile for development of transplant-associated thrombotic microangiopathy (TA-TMA) in children undergoing hematopoietic stem cell transplantation (HSCT). Between 2013 and 2016, 439 children underwent 474 HSCTs at 2 supraregional United Kingdom centers. At a median of 153 days post-HSCT, TA-TMA occurred among 25 of 441 evaluable cases (5.6%) with no evidence of center variation. Sex, underlying disease, intensity of the conditioning, total body irradiation–based conditioning, the use of calcineurin inhibitors, venoocclusive disease, and viral reactivation did not influence the development of TA-TMA. Donor type: matched sibling donor/matched family donor vs matched unrelated donor vs mismatched unrelated donor/haplo-HSCT, showed a trend toward the development of TA-TMA in 1.8% vs 6.1% vs 8.3%, respectively. Presence of active comorbidity was associated with an increased risk for TA-TMA; 13% vs 3.7% in the absence of comorbidity. The risk of TA-TMA was threefold higher among patients who received >1 transplant. TA-TMA rates were significantly higher among patients with acute graft-versus-host disease (aGVHD) grades III to IV vs aGVHD grade 0 to II. On multivariate analysis, the presence of active comorbidity, >1 transplant, aGVHD grade III to IV were risk factors for TA-TMA (odds ratio [OR]: 5.1, 5.2, and 26.9; respectively), whereas the use of cyclosporine A/tacrolimus-based GVHD prophylaxis was not a risk factor for TA-TMA (OR: 0.3). Active comorbidity, subsequent transplant, and aGVHD grades III to IV were significant risk factors for TA-TMA. TA-TMA might represent a form of a vascular GVHD, and therefore, continuing control of aGVHD is important to prevent worsening of TA-TMA associated with GVHD