Integration and Continuity of Primary Care: Polyclinics and Alternatives, a Patient-Centred Analysis of How Organisation Constrains Care Coordination

Background An ageing population, increasingly specialised of clinical services and diverse healthcare provider ownership make the coordination and continuity of complex care increasingly problematic. The way in which the provision of complex healthcare is coordinated produces – or fails to – six forms of continuity of care (cross-sectional, longitudinal, flexible, access, informational, relational). Care coordination is accomplished by a combination of activities by: patients themselves; provider organisations; care networks coordinating the separate provider organisations; and overall health system governance. This research examines how far organisational integration might promote care coordination at the clinical level. Objectives To examine: 1. What differences the organisational integration of primary care makes, compared with network governance, to horizontal and vertical coordination of care. 2. What difference provider ownership (corporate, partnership, public) makes. 3. How much scope either structure allows for managerial discretion and ‘performance’. 4. Differences between networked and hierarchical governance regarding the continuity and integration of primary care. 5. The implications of the above for managerial practice in primary care. Methods Multiple-methods design combining: 1. Assembly of an analytic framework by non-systematic review. 2. Framework analysis of patients’ experiences of the continuities of care. 3. Systematic comparison of organisational case studies made in the same study sites. 4. A cross-country comparison of care coordination mechanisms found in our NHS study sites with those in publicly owned and managed Swedish polyclinics. 5. Analysis and synthesis of data using an ‘inside-out’ analytic strategy. Study sites included professional partnership, corporate and publicly owned and managed primary care providers, and different configurations of organisational integration or separation of community health services, mental health services, social services and acute in-patient care. Results Starting from data about patients' experiences of the coordination or under-coordination of care we identified: 1. Five care coordination mechanisms present in both the integrated organisations and the care networks. 2. Four main obstacles to care coordination within the integrated organisations, of which two were also present in the care networks. 3. Seven main obstacles to care coordination that were specific to the care networks. 4. Nine care coordination mechanisms present in the integrated organisations. Taking everything into consideration, integrated organisations appeared more favourable to producing continuities of care than were care networks. Network structures demonstrated more flexibility in adding services for small care groups temporarily, but the expansion of integrated organisations had advantages when adding new services on a longer term and larger scale. Ownership differences affected the range of services to which patients had direct access; primary care doctors’ managerial responsibilities (relevant to care coordination because of its impact on GP workload); and the scope for doctors to develop special interests. We found little difference between integrated organisations and care networks in terms of managerial discretion and performance. Conclusions On balance, an integrated organisation seems more likely to favour the development of care coordination, and therefore continuities of care, than a system of care networks. At least four different variants of ownership and management of organisationally integrated primary care providers are practicable in NHS-like settings

Phase 2 of the Multiple Provider Employment Zones Qualitative Study, DWP Research Report 399

This report presents the findings of a qualitative study of the operation and impact of the Multiple Provider Employment Zone (MPEZ) initiatives that have operated in four cities (London, Birmingham, Liverpool and Glasgow) since 20041. The study builds on earlier work by Cambridge Policy Consultants (Hirst et al. 2006), which concentrated on issues related to the early establishment of the MPEZ initiative and the initial experiences of Providers, Jobcentre Plus districts and customers. The Phase 2 research took place approximately one year on from the Phase 1 study and focused on tracking developments in the operation of MPEZ as the initiative became more established. The study involved interviews with EZ Providers (managers and Advisers), Jobcentre Plus representatives (managers and Advisers) and customers (young people (aged 18-24) claiming Jobseeker’s Allowance (JSA), who would otherwise have returned to New Deal for Young People (NDYP)2, lone parents receiving Income Support and early entrants – see section 1.6 for full details). In order to gain a wider perspective, researchers also spoke to representatives of organisations that have employed MPEZ participants and a number of stakeholder organisations with a broad interest in local labour market policies and programmes in the MPEZ areas. In total, the research involved interviews or group discussions with over 300 individuals, providing a range and depth of qualitative information that allows a detailed picture to be established of the way that MPEZs developed between mid- 2005 and mid-2006, including the experiences of employers and the labour market destinations of MPEZ participants. A central issue addressed in the research and in this report is the ‘multiple’ element of the initiative and the value that is added through the existence of more than one Provider in each MPEZ area. Questions of allocation, choice, specialisation, competition and innovation are considered from the perspectives of Providers, Jobcentre Plus, customers, employers and stakeholders and the final sections present some conclusions and issues for consideration in relation to these topics

On the use of low-cost computer peripherals for the assessment of motor dysfunction in Parkinson’s disease – Quantification of bradykinesia using target tracking tasks

The potential of computer games peripherals to measure the motor dysfunction in Parkinson’s diseases is assessed. Of particular interest is the quantification of bradykinesia. Previous studies used modified or custom haptic interfaces, here an unmodified force feedback joystick and steering wheel are used with a laptop. During testing an on screen cursor moves in response to movements of the peripheral, the user has to track a continuously moving target (pursuit tracking), or move to a predetermined target (step tracking). All tasks use movement in the horizontal axis, allowing use of joystick or steering wheel. Two pursuit tracking tasks are evaluated, pseudo random movement, and a swept frequency task. Two step tracking tasks are evaluated, movement between two or between two of five fixed targets. Thirteen patients and five controls took part on a weekly basis. Patients were assessed for bradykinesia at each session using standard clinical measures. A range of quantitative measures was developed to allow comparison between and within patients and controls using ANOVA. Both peripherals are capable of discriminating between controls and patients, and between patients with different levels of bradykinesia. Recommendations for test procedures and peripherals are given

Induced QCD and Hidden Local ZN Symmetry

We show that a lattice model for induced lattice QCD which was recently proposed by Kazakov and Migdal has a $Z_N$ gauge symmetry which, in the strong coupling phase, results in a local confinement where only color singlets are allowed to propagate along links and all Wilson loops for non-singlets average to zero. We argue that, if this model is to give QCD in its continuum limit, it must have a phase transition. We give arguments to support presence of such a phase transition

A Study of the N=2N=2 Kazakov-Migdal Model

We study numerically the SU(2) Kazakov-Migdal model of `induced QCD'. In contrast to our earlier work on the subject we have chosen here {\it not} to integrate out the gauge fields but to keep them in the Monte Carlo simulation. This allows us to measure observables associated with the gauge fields and thereby address the problem of the local $Z_2$ symmetry present in the model. We confirm our previous result that the model has a line of first order phase transitions terminating in a critical point. The adjoint plaquette has a clear discontinuity across the phase transition, whereas the plaquette in the fundamental representation is always zero in accordance with Elitzur's theorem. The density of small $Z_2$ monopoles shows very little variation and is always large. We also find that the model has extra local U(1) symmetries which do not exist in the case of the standard adjoint theory. As a result, we are able to show that two of the angles parameterizing the gauge field completely decouple from the theory and the continuum limit defined around the critical point can therefore not be `QCD'.Comment: 11 pages, UTHEP-24

Exact 1/N and Optimized Perturbative Evaluation of mu_c for Homogeneous Interacting Bose Gases

In the framework of the O(N) three-dimensional effective scalar field model for homogeneous dilute weakly interacting Bose gases we use the 1/N expansion to evaluate, within the large N limit, the parameter r_c which is directly related to the critical chemical potential mu_c. This quantity enters the order-a^2 n^{2/3} coefficient contributing to the critical temperature shift Delta T_c where a represents the s-wave scattering length and n represents the density. Compared to the recent precise numerical lattice simulation results, our calculation suggests that the large N approximation performs rather well even for the physical case N=2. We then calculate the same quantity but using different forms of the optimized perturbative (variational) method, showing that these produce excellent results both for the finite N and large-N cases.Comment: 12 pages, 2 figures. We have performed a refined and extended numerical analysis to take into account the very recent results of Ref. [15

Integrating serological and genetic data to quantify cross-species transmission: brucellosis as a case study

Epidemiological data are often fragmented, partial, and/or ambiguous and unable to yield the desired level of understanding of infectious disease dynamics to adequately inform control measures. Here, we show how the information contained in widely available serology data can be enhanced by integration with less common type-specific data, to improve the understanding of the transmission dynamics of complex multi-species pathogens and host communities. Using brucellosis in Northern Tanzania as a case-study, we developed a latent process model based on serology data obtained from the field, to reconstruct Brucella transmission dynamics. We were able to identify sheep and goats as a more likely source of human and animal infection than cattle; however, the highly cross-reactive nature of Brucella spp. meant that it was not possible to determine which Brucella species (B. abortus or B. melitensis) is responsible for human infection. We extended our model to integrate simulated serology and typing data, and show that although serology alone can identify the host source of human infection under certain restrictive conditions, the integration of even small amounts (5%) of typing data can improve understanding of complex epidemiological dynamics. We show that data integration will often be essential when more than one pathogen is present and when the distinction between exposed and infectious individuals is not clear from serology data. With increasing epidemiological complexity, serology data become less informative. However, we show how this weakness can be mitigated by integrating such data with typing data, thereby enhancing the inference from these data and improving understanding of the underlying dynamics