Wace and his Authorities

n/

The Landing of Queen Isadella in 1326

n/

Note on Magna Carta

n/

Patient choice at the point of GP referral: Department of Health

1 The Department of Health has a Public Service Agreement target to ensure that by the end of 2005 every hospital appointment in the National Health Service in England (the NHS) will be booked for the convenience of the patient, making it easier for patients and their General Practitioners (GPs) to choose the hospital and consultant that best meets their need. The Department aims to provide patients with the opportunity to choose between four to five healthcare providers for elective hospital treatment by December 2005. In consultation with their GP, patients should be able to choose, from a menu of NHS and independent sector healthcare providers, their preferred location for treatment. Patients should also be able to book the time and date of their initial outpatient appointment within 24 hours of the decision to refer the patient for treatment. This target will apply to around 9.4 million patients referred for hospital treatment by their GP each year, around four per cent of the total estimated 241 million GP consultations. 2 Choice at referral can contribute to a more patientfocused health service, bringing benefits to both patients and the NHS. But providing such a choice will not happen by accident. There are a number of dependencies and interactions with other policies that need to be managed. Information Technology (IT) systems need to be developed and modified and significant cultural, organisational and behavioural changes will need to be made by patients, NHS organisations and staff. 3 This report examines whether the Department is on track to deliver choice at the point of referral successfully by the target date of December 2005. Our work has found that: a Progress has been made towards delivering choice at referral through establishing the required organisational infrastructure, commissioning new IT systems and modifications to existing ones, and providing support for the NHS organisations that will deliver it. b The engagement of GPs is currently low and is a key risk which the Department must address to deliver choice successfully. The Department plans to address this risk through a campaign to inform and engage GPs during 2005 and it will need to monitor carefully the progress of this campaign. c Choice at referral will be delivered most efficiently and effectively through electronic booking (e-booking, also known as Choose and Book), in which the Electronic Booking Service, commissioned by the Department’s National Programme for IT (NPfIT), is linked to upgraded or new computer systems in hospitals and GPs’ surgeries. However, e-booking will not be universally available by December 2005. Until e-booking is fully adopted choice will have to be provided in other, less efficient, ways. d Parts of the NHS still have much to do if they are to deliver choice. A significant minority of Primary Care Trusts do not yet have adequate plans in place to manage the introduction of choice and some may struggle to manage the required new commissioning arrangements. 4 Our more detailed findings are as follows. Progress has been made towards delivering choice at referral 5 The Department believes that choice is affordable. Additional annual infrastructure and transaction costs are estimated to be £122 million – or 1.4 per cent of the current total expenditure on elective care. The main aim of introducing choice is to improve services for patients, but it should lead to increased efficiencies in primary and secondary care services worth an estimated £71 million, off-setting some of these costs. 6 It is essential that choice is supported by other elements of system reform including e-booking, payment by results, commissioning and appropriate capacity. Modelling exercises have shown that the system reforms should work in harmony with one another. Payment by results should enable the transfer of funding to follow the patient and there should be sufficient capacity across the system to enable choice to be effective. 7 Much of the organisational infrastructure that is required for choice is in place and there is clear accountability for the delivery of the programme. To strengthen detailed national programme management arrangements the Department created, on 22 December 2004, a new post of National Implementation Director for Choose and Book, with effect from 10 January 2005. The new Director will be responsible for overseeing the implementation of choice within the NHS whilst the National Programme for IT Group Programme Director for Choose and Book will continue to be responsible for Choose and Book technology development and deployment, patient access and Choose and Book contract management. 8 The Department has provided different types of support to the NHS – for example, ten pilot schemes have been run to test the policy in practice. It has set up a system for periodically measuring progress and used this to establish the position at the end of October 2004, creating a baseline against which to monitor future progress. 9 Research has identified what information patients will want to base their choices on, and the Department is seeking to provide this. While it is unlikely that full information will be available for December 2005, the majority of those aspects identified by patients as being the most important, such as waiting times and basic access information, will be in place. The Department plans to increase the information available over time. The key risk to the delivery of choice is the engagement of GPs 10 Choice cannot be delivered without support from GPs but our survey of GPs found that around half of GPs know very little about it and 61 per cent feel either very negative or a little negative. GPs’ concerns include practice capacity, workload, consultation length and fears that existing health inequalities will be exacerbated. The Department has deliberately held back its main effort to inform and engage GPs about choice until it has had a working e-booking system to show GPs, but it intends to mount a campaign to inform and engage GPs during 2005. Until e-booking is fully adopted choice will be supported by other mechanisms 11 The Department has commissioned Atos Origin to develop a national system for e-booking, which will be linked to upgraded or new Patient Administration Systems in hospitals and IT systems in GPs’ surgeries to provide an overall service known as e-booking. The National Programme for IT has planned the roll out of e-booking on an incremental basis to minimise risk, and to link it by the end of 2005 to some 60 to 70 per cent of hospital systems and GP practices. 12 E-booking is the most effective and efficient way of delivering the Department’s plans for choice, and alternative booking mechanisms offer poorer value for money. Atos Origin has delivered a functioning system and the first booking using e-booking was made in July 2004. However the roll-out of e-booking has been slower than planned and at the end of December 2004 only 63 bookings had been made. Problems have included the reluctance of users to work with an unreliable end-to-end system, limited progress in linking to GP and hospital systems, and the limited number of GPs willing to use the system. 13 The Department believes that new releases of software have addressed the reliability of the whole end-to-end system and that having a fully operational system will encourage GPs to engage with e-booking. The roll-out of changes to hospital systems to allow them to link to e-booking is gathering pace and four types of GP systems can now link to e-booking, although the largest supplier has not yet agreed an implementation plan. A combined team of Departmental and NHS personnel are working with the three main existing GP system suppliers to agree a national deployment schedule. This work should be completed by February 2005, along with a nationally negotiated commercial arrangement. The Department is also developing and trialling contingency plans against further delays, as well as alternatives to the fully integrated Choose and Book solution. Parts of the NHS still have much to do 14 Programme management arrangements in the NHS are incomplete. While most Primary Care Trusts expect to be able to deliver the choice target, there is variability in their overall performance. As many as a quarter of Primary Care Trusts currently forecast that they will not deliver the choice targets. In addition, some Primary Care Trusts may struggle to manage the new commissioning arrangements and two-thirds have yet to commission the required number of providers. The department is developing a framework of support to assist trusts to overcome these obstacles. 15 The Department needs urgently to address the low level of GP support for their plans for implementing choice at referral, and should: I Press on urgently with its plans for informing GPs about the implementation of choice at referral and its impact on GPs and patients. II Monitor the views of GPs, for example by a regular survey, repeating key questions from our own survey, to assess the rate of progress being achieved towards the level of support needed to meet its target of full implementation by December 2005. III Consider whether further action is needed to secure the required level of GP support, once GPs are fully informed on what choice at referral involves. 16 The Department should also: IV Complete its planned benefits realisation plan for choice at referral by the summer of 2005, along with a monitoring mechanism and quantified targets. V Keep under regular and close review the progress of its planned implementation of choice through implementing e-booking and consider the scope for accelerating the roll-out of e-booking to make it available everywhere by December 2005. VI If it becomes clear that it is not possible to deliver e-booking everywhere by December 2005, the Department should: a monitor closely the development of the interim solutions to ensure that they meet their delivery dates; and b ensure that the implementation of interim solutions does not detract from the priority of bringing in fully integrated e-booking systems as soon as possible. VII Establish an evaluation framework for Primary Care Trust commissioning to assist Strategic Health Authorities in assessing the capacity and skills of Primary Care Trusts in this area and securing improvements in capacity and skills where necessary

Electroluminescence from single nanowires by tunnel injection: an experimental study

We present a hybrid light-emitting diode structure composed of an n-type gallium nitride nanowire on a p-type silicon substrate in which current is injected along the length of the nanowire. The device emits ultraviolet light under both bias polarities. Tunnel-injection of holes from the p-type substrate (under forward bias) and from the metal (under reverse bias) through thin native oxide barriers consistently explains the observed electroluminescence behaviour. This work shows that the standard p-n junction model is generally not applicable to this kind of device structure.Comment: 6 pages, 6 figure

Diatoms and acid lakes. Proceedings of a workshop of the 8th International Diatom Symposium, Paris, September 1984

Diatom analysis of lake sedimentshasbecome one of the most important techniques used in the contemporary debate on lake acidification. In recent years the relationship between diatom assemblages and pH has been quantified allowing the pH history of individual lakes to be reconstructed. Much reliance is placed on these reconstructions yet we have little understanding of the causal mechanisms that underlie the impressive statistics. There has been little research on the ecology and physiology of diatom taxa in acid and acidifying waters and we have little information on the role of either planktonic or non-planktonic diatoms in acid lake ecosystems. This Workshop, hence, was not only devoted to the exchange of information on current research projects but also to a discussion of some of the ecological questions that require resolution to improve our understanding of the diatom:pH relationship

Relativity principles in 1+1 dimensions and differential aging reversal

We study the behavior of clocks in 1+1 spacetime assuming the relativity principle, the principle of constancy of the speed of light and the clock hypothesis. These requirements are satisfied by a class of Finslerian theories parametrized by a real coefficient $\beta$, special relativity being recovered for $\beta=0$. The effect of differential aging is studied for the different values of $\beta$. Below the critical values $|\beta| =1/c$ the differential aging has the usual direction - after a round trip the accelerated observer returns younger than the twin at rest in the inertial frame - while above the critical values the differential aging changes sign. The non-relativistic case is treated by introducing a formal analogy with thermodynamics.Comment: 12 pages, no figures. Previous title "Parity violating terms in clocks' behavior and differential aging reversal". v2: shortened introduction, some sections removed, pointed out the relation with Finsler metrics. Submitted to Found. Phys. Let

A new cell primo-culture method for freshwater benthic diatom communities

A new cell primo-culture method was developed for the benthic diatom community isolated from biofilm sampled in rivers. The approach comprised three steps: (1) scraping biofilm from river pebbles, (2) diatom isolation from biofilm, and (3) diatom community culture. With a view to designing a method able to stimulate the growth of diatoms, to limit the development of other microorganisms, and to maintain in culture a community similar to the original natural one, different factors were tested in step 3: cell culture medium (Chu No 10 vs Freshwater “WC” medium modified), cell culture vessel, and time of culture. The results showed that using Chu No 10 medium in an Erlenmeyer flask for cell culture was the optimal method, producing enough biomass for ecotoxicological tests as well as minimising development of other microorganisms. After 96 h of culture, communities differed from the original communities sampled in the two rivers studied. Species tolerant of eutrophic or saprobic conditions were favoured during culture. This method of diatom community culture affords the opportunity to assess, in vitro, the effects of different chemicals or effluents (water samples andindustrial effluents) on diatom communities, as well as on diatom cells, from a wide range of perspectives

Human helminth therapy to treat inflammatory disorders - where do we stand?

Parasitic helminths have evolved together with the mammalian immune system over many millennia and as such they have become remarkably efficient modulators in order to promote their own survival. Their ability to alter and/or suppress immune responses could be beneficial to the host by helping control excessive inflammatory responses and animal models and pre-clinical trials have all suggested a beneficial effect of helminth infections on inflammatory bowel conditions, MS, asthma and atopy. Thus, helminth therapy has been suggested as a possible treatment method for autoimmune and other inflammatory disorders in humans

Moderating Readers and Reading Online

Despite the proliferation of online forums for the discussion of literary texts, very little has been written to date on the management of these spaces and how this helps frame the kinds of discussion and interpretative work that take place. This article draws on a series of interviews with moderators of online book-related sites, alongside close analysis of online interactions between moderators and users to consider issues of authority, hierarchy, power and control, asking how these act to structure or facilitate acts of interpretation taking place online. We begin by outlining the moderator's role before conducting a brief review of existing scholarship on offline reading groups and online communities, to identify how social infrastructures are established and negotiated. The main body of the article draws upon interviews with moderators of two online literary forums – The Republic of Pemberley and The Guardian’s online Reading Group – to explore the ways in which each of the respective moderators frames his or her role. This is accompanied by an in-depth exploration of how the forms of interpretation we find on the two sites are shaped and directed by the moderators. The article concludes by reflecting upon some of the issues raised by this study and its methodology, particularly with regards to digital dualism and the blurring of the boundaries between the public and the private in online spaces