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

A simple interpretation of quantum mirages

In an interesting new experiment the electronic structure of a magnetic atom adsorbed on the surface of Cu(111), observed by STM, was projected into a remote location on the same surface. The purpose of the present paper is to interpret this experiment with a model Hamiltonian, using ellipses of the size of the experimental ones, containing about 2300 atoms. The charge distribution for the different wavefunctions is analyzed, in particular, for those with energy close to the Fermi energy of copper Ef. Some of them show two symmetric maxima located on the principal axis of the ellipse but not necessarily at the foci. If a Co atom is adsorbed at the site where the wavefunction with energy $E_F$ has a maximum and the interaction is small, the main effect of the adsorbed atom will be to split this particular wavefunction in two. The total charge density will remain the same but the local density of states will present a dip at Ef at any site where the charge density is large enough. We relate the presence of this dip to the observation of quantum mirages. Our interpretation suggests that other sites, apart from the foci of the ellipses, can be used for projecting atomic images and also indicates the conditions for other non magnetic adsorbates to produce mirages.Comment: 3 pages, 3 Fig

Healthcare choice: Discourses, perceptions, experiences and practices

Policy discourse shaped by neoliberal ideology, with its emphasis on marketisation and competition, has highlighted the importance of choice in the context of healthcare and health systems globally. Yet, evidence about how so-called consumers perceive and experience healthcare choice is in short supply and limited to specific healthcare systems, primarily in the Global North. This special issue aims to explore how choice is perceived and utilised in the context of different systems of healthcare throughout the world, where choice, at least in policy and organisational terms, has been embedded for some time. The articles are divided into those emphasising: embodiment and the meaning of choice; social processes associated with choice; the uncertainties, risks and trust involved in making choices; and issues of access and inequality associated with enacting choice. These sociological studies reveal complexities not always captured in policy discourse and suggest that the commodification of healthcare is particularly problematic

MATERNAL PREVALENCE OF TOXOPLASMA ANTIBODY BASED ON ANONYMOUS NEONATAL SEROSURVEY - A GEOGRAPHICAL ANALYSIS

A total of 12902 neonatal samples collected on absorbent paper for routine metabolic screening were tested anonymously for antibodies to toxoplasma. Seroprevalence varied from 19.5% in inner London, to 11.6% in suburban London, and 7.6% in non-metropolitan districts. Much of this variation appeared to be associated with the proportions of livebirths in each district to women born outside the UK. However, additional geographical variation remained and seroprevalence in UK-born women was estimated to be 12.7% in inner London. 7.5% in suburban London, and 5.5% in non-metropolitan areas. These estimates are considerably lower than any previously reported in antenatal sera in the UK. The wide geographical variation highlights a need for further research to determine the relative importance of different routes of transmission

A different appetite for sovereignty? Independence movements in subnational island jurisdictions

Local autonomy in a subnational jurisdiction is more likely to be gained, secured or enhanced where there are palpable movements or political parties agitating for independence in these smaller territories. A closer look at the fortunes, operations and dynamics of independence parties from subnational island jurisdictions can offer some interesting insights on the appetite for sovereignty and independence, but also the lack thereof, in the twenty-first century.peer-reviewe

Geometry of River Networks II: Distributions of Component Size and Number

The structure of a river network may be seen as a discrete set of nested sub-networks built out of individual stream segments. These network components are assigned an integral stream order via a hierarchical and discrete ordering method. Exponential relationships, known as Horton's laws, between stream order and ensemble-averaged quantities pertaining to network components are observed. We extend these observations to incorporate fluctuations and all higher moments by developing functional relationships between distributions. The relationships determined are drawn from a combination of theoretical analysis, analysis of real river networks including the Mississippi, Amazon and Nile, and numerical simulations on a model of directed, random networks. Underlying distributions of stream segment lengths are identified as exponential. Combinations of these distributions form single-humped distributions with exponential tails, the sums of which are in turn shown to give power law distributions of stream lengths. Distributions of basin area and stream segment frequency are also addressed. The calculations identify a single length-scale as a measure of size fluctuations in network components. This article is the second in a series of three addressing the geometry of river networks.Comment: 16 pages, 13 figures, 4 tables, Revtex4, submitted to PR