A Systems Approach to Infrastructure Delivery

A review of how systems thinking can be used to improve the delivery of complex infrastructure projects. New or expanded infrastructure services such as mobility and clean energy are delivered via complex projects that bring together physical assets, technology and digital information in the form of a Building Information Model (BIM) or a digital twin. The majority of these assets will need to be integrated into existing networks and services. Asset owners are also seeking a growing range of outcomes from infrastructure including urban regeneration, decarbonisation and wider access to jobs and opportunities. This means that even relatively small construction or refurbishment projects are best seen as interventions into existing complex systems with physical, economic and social characteristics. The rapid evolution of technology adds to the challenge. In areas such as communications or power distribution and storage, the rate of change is far outstripping developments in structural design or construction methods. In parallel, the possibilities opened up by digital twins to improve delivery and operation of infrastructure are also expanding rapidly. This all points to a future in which physical assets form a platform or ‘box’ for the data and technology that will provide the infrastructure services on which millions of people depend. This technology will go through many cycles of development during the lifetime of the physical structures that surround it. The dominant leadership and delivery model for infrastructure projects has not evolved to reflect these profound changes. Delivery remains in the hands of traditionally trained engineers working within organisations using long-established construction industry methods. The consequence of this conservatism is an increasing number of signature projects that are delivered behind schedule, beyond the cost estimate and that fail to meet the public’s expectations. The main output from this review is therefore a new model, a Systems Approach to Infrastructure Delivery (SAID). SAID complements Project 13, also supported by ICE, but has a different focus. Project 13 supports the creation of enterprises, which are long-term commercial arrangements between infrastructure owners and their supply chain. SAID is a model for applying systems thinking to project delivery that has been welcomed enthusiastically by Project 13’s leaders. SAID can be used either in conjunction with or separate from Project 13. SAID is driven by the needs of users. It places the onus on the owners and operators of infrastructure to translate those needs into clear outcomes around which assets and networks can be designed, delivered and operated as whole systems. Systems thinking, systems engineering and systems integration are at the heart of SAID. The review has found that these practices have been extremely effective in other project-based industries such as oil and gas and aerospace. Adopting what works from these sectors can help the infrastructure sector to make rapid progress in the short term. In the medium term, it needs to look at how the technology and software industries have taken advantage of an intense continuous development mindset to help systems adapt to rapidly changing user needs, and the opportunities created by technological change. The SAID model also stresses the importance of committing resource to the front end of projects to minimise delivery risks. In other sectors, this comes under different names including ‘front- end loading’ and ‘left-shift thinking’. Whatever the term, the hard evidence is clear: projects that commit to being shovel worthy before moving into delivery are much more likely to be successful in terms of budget, delivery date and user satisfaction. This front-end work does not eliminate all risk. It does, however, identify the sources of risk and allow leaders to design a project model that manages them more effectively. Data oils projects in the SAID model. High-quality, timely data is sometimes described as the golden thread that should run through projects. In the SAID model, this becomes a golden loop as information generated by the project is integrated back into operating systems and forms the basis for future upgrades to services. Lastly, the model is led by an open, agile leadership style. Evidence submitted to the review made it clear that the heroic leadership style traditionally associated with big infrastructure projects is simply not suitable for complex projects. Borrowing from ideas fostered in the military, SAID requires leaders to be able to define intent, manage the interface with external stakeholders and then step back and let empowered, highly competent teams manage the day-to-day risks to the system. SAID also stresses the importance of diversity within projects and the need for different voices to have prominence at each stage of the lifecycle. The review is now planning a second stage. Industry must lead the charge for change that will work alongside complementary initiatives such as Project 13 and the National Digital Twin Programme to develop and trial aspects of the SAID model with live and recently completed infrastructure projects

Information architecture for a federated health record server

This paper describes the information models that have been used to implement a federated health record server and to deploy it in a live clinical setting. The authors, working at the Centre for Health Informatics and Multiprofessional Education (University College London), have built up over a decade of experience within Europe on the requirements and information models that are needed to underpin comprehensive multi-professional electronic health records. This work has involved collaboration with a wide range of health care and informatics organisations and partners in the healthcare computing industry across Europe though the EU Health Telematics projects GEHR, Synapses, EHCR-SupA, SynEx and Medicate. The resulting architecture models have fed into recent European standardisation work in this area, such as CEN TC/251 ENV 13606. UCL has implemented a federated health record server based on these models which is now running in the Department of Cardiovascular Medicine at the Whittington Hospital in North London. The information models described in this paper reflect a refinement based on this implementation experience

‘So people know I'm a Sikh’: Narratives of Sikh masculinities in contemporary Britain

This article examines British-born Sikh men's identification to Sikhism. In particular, it focuses on the appropriation and use of Sikh symbols amongst men who define themselves as Sikh. This article suggests that whilst there are multiple ways of ‘being’ a Sikh man in contemporary post-colonial Britain, and marking belonging to the Sikh faith, there is also a collectively understood idea of what an ‘ideal’ Sikh man should be. Drawing upon Connell and Messerschmidt's discussion of locally specific hegemonic masculinities (2005. “Hegemonic Masculinity: Rethinking the Concept.” Gender and Society 19 (6): 829–859), it is suggested that an ideal Sikh masculine identity is partly informed by a Khalsa discourse, which informs a particular performance of Sikh male identity, whilst also encouraging the surveillance of young men's activities both by themselves and by others. These Sikh masculinities are complex and multiple, rotating to reaffirm, challenge and redefine contextualised notions of hegemonic masculinity within the Sikh diaspora in post-colonial Britain. Such localised Sikh masculinities may both assert male privilege and reap patriarchal dividends (Connell, W. 1995. Masculinities. Cambridge: Polity Press), resulting in particular British Sikh hegemonic masculinities which seek to shape the performance of masculinity, yet in another context these very same performances of masculinity may also signify a more marginalised masculinity vis-à-vis other dominant hegemonic forms

Towards an interoperable healthcare information infrastructure - working from the bottom up

Historically, the healthcare system has not made effective use of information technology. On the face of things, it would seem to provide a natural and richly varied domain in which to target benefit from IT solutions. But history shows that it is one of the most difficult domains in which to bring them to fruition. This paper provides an overview of the changing context and information requirements of healthcare that help to explain these characteristics.First and foremost, the disciplines and professions that healthcare encompasses have immense complexity and diversity to deal with, in structuring knowledge about what medicine and healthcare are, how they function, and what differentiates good practice and good performance. The need to maintain macro-economic stability of the health service, faced with this and many other uncertainties, means that management bottom lines predominate over choices and decisions that have to be made within everyday individual patient services. Individual practice and care, the bedrock of healthcare, is, for this and other reasons, more and more subject to professional and managerial control and regulation.One characteristic of organisations shown to be good at making effective use of IT is their capacity to devolve decisions within the organisation to where they can be best made, for the purpose of meeting their customers' needs. IT should, in this context, contribute as an enabler and not as an enforcer of good information services. The information infrastructure must work effectively, both top down and bottom up, to accommodate these countervailing pressures. This issue is explored in the context of infrastructure to support electronic health records.Because of the diverse and changing requirements of the huge healthcare sector, and the need to sustain health records over many decades, standardised systems must concentrate on doing the easier things well and as simply as possible, while accommodating immense diversity of requirements and practice. The manner in which the healthcare information infrastructure can be formulated and implemented to meet useful practical goals is explored, in the context of two case studies of research in CHIME at UCL and their user communities.Healthcare has severe problems both as a provider of information and as a purchaser of information systems. This has an impact on both its customer and its supplier relationships. Healthcare needs to become a better purchaser, more aware and realistic about what technology can and cannot do and where research is needed. Industry needs a greater awareness of the complexity of the healthcare domain, and the subtle ways in which information is part of the basic contract between healthcare professionals and patients, and the trust and understanding that must exist between them. It is an ideal domain for deeper collaboration between academic institutions and industry

Characterising (and closing?) the accountability-capability gap in complex procurement

The role of procurement in the Grenfell fire can be explored in a variety of ways. First, the outsourcing of complex work is increasingly common in private and public-sector procurement. Although the primary strategic rationale for the ‘make-or-buy’ decision remains efficiency maximization, a range of factors, including core competencies and greater technological complexity have shifted the scale and scope of outsourcing. Given the knowledge asymmetries and asset specificities inherent in complex procurement, it seems certain that Grenfell’s procurement professionals found themselves facing the complexity of 'buying more than they knew’, which has demonstrated insufficient procurement capability. Furthermore, replacing internal production by outsourcing (for example, outsourcing auditing to fire services) without considering the loss of internal knowledge, further exacerbated the issue of Grenfell’s lack of capability to buy and monitor complex work. Goal incongruency is also clearly an issue - i.e. the buyer focused on achieving high quality, while the contractors’ goal was to minimise the costs incurred. Well-established behavioural insights indicate that the goal incongruity can, especially if not aligned to an explicit/formal governance system, leads to dysfunctional outcomes. The paper also proposes some ways in which the procurement accountability and capability gap could be addressed. First, adoption of long(er)-term, relational contracts might go some way to resolving the goal congruency issue and incentivise contractors to provide high quality service while reducing monitoring costs. Second, and more fundamentally, public sector contracting organisations need to think much more carefully about outsourcing decisions and consider hybrid mechanisms that both leverage external specialised competencies and limit the loss of control and monitoring capability. Finally, such sophistication likely requires greater professionalisation in the public/construction procurement space with greater emphasis on ethical conduct. Although not without its own challenges, greater professionalisation may be useful for upholding explicit (for example, ethical) and implicit norms

The Pyramid of Transgender Health Therapeutics

Transgender care needs a multidisciplinary team approach. The awareness about transgender health has increased over the past few years in India. The pyramid of transgender health helps to demystify the care of transgender individuals. The 7 S\u27s of lifestyle modification need to be followed in the routine clinical care of transgender individuals. The individuals also need psychological care and support, metabolic and medical care, endocrine management, and later surgery in some cases. The policy makers can use the pyramid to decide about financial help to the community for their holistic care. The physicians involved in the care of transgender individuals can also take guidance about comprehensive care and management of transgender and gender diverse individuals

A model-driven privacy compliance decision support for medical data sharing in Europe

Objectives: Clinical practitioners and medical researchers often have to share health data with other colleagues across Europe. Privacy compliance in this context is very important but challenging. Automated privacy guidelines are a practical way of increasing users' awareness of privacy obligations and help eliminating unintentional breaches of privacy. In this paper we present an ontology-plus-rules based approach to privacy decision support for the sharing of patient data across European platforms. Methods: We use ontologies to model the required domain and context information about data sharing and privacy requirements. In addition, we use a set of Semantic Web Rule Language rules to reason about legal privacy requirements that are applicable to a specific context of data disclosure. We make the complete set invocable through the use of a semantic web application acting as an interactive privacy guideline system can then invoke the full model in order to provide decision support. Results: When asked, the system will generate privacy reports applicable to a specific case of data disclosure described by the user. Also reports showing guidelines per Member State may be obtained. Conclusion: The advantage of this approach lies in the expressiveness and extensibility of the modelling and inference languages adopted and the ability they confer to reason with complex requirements interpreted from high level regulations. However, the system cannot at this stage fully simulate the role of an ethics committee or review board. © Schattauer 2011

Dapagliflozin in the Landscape of Type 2 Diabetes Management

As per current statistics, India accounts for more than 74 million individuals living with diabetes. Many of these individualshave associated cardiovascular disease (CVD) and chronic kidney disease (CKD) comorbidities. Optimal glycemic managementis important because uncontrolled glycemia may accelerate the macrovascular and microvascular complications, furtheraggravating the comorbid conditions. Metformin is used as the first-line therapy in most persons. However, there are somewho do not tolerate metformin, are unable to achieve required glycemic targets or require greater efforts for cardiovascular(CV) risk reduction. These patients require an alternative hypoglycemic agent to be used as either monotherapy or ascombination treatment with metformin, respectively. Sodium-glucose cotransporter-2 (SGLT2) inhibitors are one such novelclass of drugs that can be used as either monotherapy or as part of two drug (dual) or three drug (triple) combinations withother oral hypoglycemic agents or insulin. Dapagliflozin is a promising option for managing type 2 diabetes with CV andrenal benefits, weight and blood pressure reducing properties. A low risk of hypoglycemia and drug-drug interactions are theadded advantages. In this article, the authors have reviewed the existing clinical evidences on dapagliflozin and highlightedits place in the diabetes management landscape