Integration and continuity of primary care: polyclinics and alternatives - a patient-centred analysis of how organisation constrains care co-ordination

Background An ageing population, the increasing specialisation of clinical services and diverse health-care provider ownership make the co-ordination and continuity of complex care increasingly problematic. The way in which the provision of complex health care is co-ordinated produces – or fails to produce – six forms of continuity of care (cross-sectional, longitudinal, flexible, access, informational and relational). Care co-ordination is accomplished by a combination of activities by patients themselves; provider organisations; care networks co-ordinating the separate provider organisations; and overall health-system governance. This research examines how far organisational integration might promote care co-ordination 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 co-ordination 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; and (5) the implications of the above for managerial practice in primary care. Methods Multiple-methods design combining (1) the assembly of an analytic framework by non-systematic review; (2) a framework analysis of patients’ experiences of the continuities of care; (3) a systematic comparison of organisational case studies made in the same study sites; (4) a cross-country comparison of care co-ordination mechanisms found in our NHS study sites with those in publicly owned and managed Swedish polyclinics; and (5) the 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 inpatient care. Results Starting from data about patients’ experiences of the co-ordination or under-co-ordination of care, we identified five care co-ordination mechanisms present in both the integrated organisations and the care networks; four main obstacles to care co-ordination within the integrated organisations, of which two were also present in the care networks; seven main obstacles to care co-ordination that were specific to the care networks; and nine care co-ordination mechanisms present in the integrated organisations. Taking everything into consideration, integrated organisations appeared more favourable to producing continuities of care than did 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 a larger scale. Ownership differences affected the range of services to which patients had direct access; primary care doctors’ managerial responsibilities (relevant to care co-ordination because of their impact on general practitioner 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 co-ordination 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. Future research is therefore required, above all to evaluate comparatively the different techniques for coordinating patient discharge across the triple interface between hospitals, general practices and community health services; and to discover what effects increasing the scale and scope of general practice activities will have on continuity of care

The cost effectiveness of NHS physiotherapy support for occupational health (OH) services

Background: Musculoskeletal pain is detrimental to quality of life (QOL) and disruptive to activities of daily living. It also places a major economic burden on healthcare systems and wider society. In 2006, the Welsh Assembly Government (WAG) established a three tiered self-referral Occupational Health Physiotherapy Pilot Project (OHPPP) comprising: 1.) telephone advice and triage, 2.) face-to-face physiotherapy assessment and treatment if required, and 3.) workplace assessment and a return-to-work facilitation package as appropriate. This study aimed to evaluate the feasibility and cost-effectiveness of the pilot service. Methods: A pragmatic cohort study was undertaken, with all OHPPP service users between September 2008 and February 2009 being invited to participate. Participants were assessed on clinical status, yellow flags, sickness absence and work performance at baseline, after treatment and at 3 month follow up. Cost-effectiveness was evaluated from both top-down and bottom-up perspectives and cost per Quality Adjusted Life Year (cost/QALY) was calculated. The cost-effectiveness analysis assessed the increase in service cost that would be necessary before the cost-effectiveness of the service was compromised. Results A total of 515 patients completed questionnaires at baseline. Of these, 486 were referred for face to face assessment with a physiotherapist and were included in the analysis for the current study. 264 (54.3%) and 199 (40.9%) were retained at end of treatment and 3 month follow up respectively. An improvement was observed at follow up in all the clinical outcomes assessed, as well as a reduction in healthcare resource usage and sickness absence, and improvement in self-reported work performance. Multivariate regression indicated that baseline and current physical health were associated with work-related outcomes at follow up. The costs of the service were £194-£360 per service user depending on the method used, and the health gains contributed to a cost/QALY of £1386-£7760, which would represent value for money according to current UK thresholds. Sensitivity analyses demonstrated that the service would remain cost effective until the service costs were increased to 160% per user. Conclusions: This pragmatic evaluation of the OHPPP indicated that it was likely to be feasible in terms of service usage and could potentially be cost effective in terms of QALYs. Further, the study confirmed that improving physical health status for musculoskeletal pain patients is important in reducing problems with work capacity and related costs. This study suggests that this type of service could be potentially be useful in reducing the burden of pain and should be further investigated, ideally via randomised controlled trials assessing effectiveness and cost-effectiveness

Prospects for domestic biofuels for transport in Sweden 2030 based on current production and future plans

Currently, Sweden has the largest share of renewable fuels for transport in the EU. The ambition of the Swedish Government for 2030 is for a vehicle fleet independent of fossil fuels. This paper assesses the potential future contribution of domestically produced biofuels for transport in Sweden to 2030, based on a mapping of the prospects from the actual and potential Swedish biofuel producers. There are plans for cellulose-based ethanol, methanol, DME, methane, and the biodiesel option HVO. Continued domestic production of biofuels at current levels, and the realization of all the ongoing mapped plans for additional biofuels production, results in a potential domestic biofuels production of 18 TWhfuel in 2023. When assuming a continued expansion of biofuels production capacity, the potential domestic biofuels production reaches about 26 TWh(fuel) in 2030. If the realization of the mapped biofuels plans is delayed by 5 years and the pace of continued implementation of additional biofuel capacity is also reduced, the potential domestic biofuels production is reduced to about 8 TWh(fuel) and 20 TWh(fuel) biofuels in 2020 and 2030, respectively. These two scenarios correspond to a share of biofuels of the total future energy demand for road transport in Sweden at about 10-30% in 2020 and 26-79% in 2030, depending on which official energy demand scenario is used. The actual contribution of biofuels for road transport will depend on, e.g., policies, the global development for fossil fuels and biofuels, the competition for biomass and biofuels, and future energy demand in the road transport sector

Balancing data protection and privacy : The case of information security sensor systems

This article analyses government deployment of information security sensor systems from primarily a European human rights perspective. Sensor systems are designed to detect attacks against information networks by analysing network traffic and comparing this traffic to known attack-vectors, suspicious traffic profiles or content, while also recording attacks and providing information for the prevention of future attacks. The article examines how these sensor systems may be one way of ensuring the necessary protection of personal data stored in government IT-systems, helping governments fulfil positive obligations with regards to data protection under the European Convention on Human Rights (ECHR), the EU Charter of Fundamental Rights (The Charter), as well as data protection and IT-security requirements established in EU-secondary law. It concludes that the implementation of sensor systems illustrates the need to balance data protection against the negative privacy obligations of the state under the ECHR and the Charter and the accompanying need to ensure that surveillance of communications and associated metadata reach established principles of legality and proportionality. The article highlights the difficulty in balancing these positive and negative obligations, makes recommendations on the scope of such sensor systems and the legal safeguards surrounding them to ensure compliance with European human rights law and concludes that there is a risk of privatised policymaking in this field barring further guidance in EU-secondary law or case law