Psychiatric advance decisions – an opportunity missed

After a very long gestation the Mental Capacity Bill was published earlier this year. Among its proposals was the incorporation into statute of advance decisions. These are devices whereby a person, while retaining capacity, can make certain decisions regarding their future treatment for such a time as they have lost capacity and so are unable to make legally binding decisions about their own treatment. As the Bill is phrased, advance decisions only permit a person to refuse treatment. There is no provision for that person to use ADs to express a positive preference for particular forms of treatment. It will be argued this represents a missed opportunity to allow patients and clinicians to engage in a more constructive approach to treatment planning. Experience from the USA demonstrates psychiatric advance directives have a role to play in engaging psychiatric patients and promoting adherence to their treatment plans.This paper will only address the use of AD in relation to mental health treatment, although it is recognised they have an application far wider than this, including decisions regarding life-sustaining treatment

Decentralisation, Decision Space and Directions for Future Research; Comment on “Decentralisation of Health Services in Fiji: A Decision Space Analysis”

Decentralisation continues to re-appear in health system reform across the world. Evaluation of these reforms reveals how research on decentralisation continues to evolve. In this paper, we examine the theoretical foundations and empirical references which underpin current approaches to studying decentralisation in health systems

Research in electrically supported vacuum gyroscope. Volume 3 - ESVG suspension research Final report

Suspension factors analyzed as part of research on Electrically Supported Vacuum Gyroscope /ESVG/ for spacecraf

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

Wearing the Future-Wearables to Empower Users to Take Greater Responsibility for Their Health and Care:Scoping Review

BACKGROUND: Wearables refer to devices that are worn by individuals. In the health care field, wearables may assist with individual monitoring and diagnosis. In fact, the potential for wearable technology to assist with health care has received recognition from health systems around the world, including a place in the strategic Long Term Plan shared by the National Health Service in England. However, wearables are not limited to specialist medical devices used by patients. Leading technology companies, including Apple, have been exploring the capabilities of wearable health technology for health-conscious consumers. Despite advancements in wearable health technology, research is yet to be conducted on wearables and empowerment. OBJECTIVE: This study aimed to identify, summarize, and synthesize knowledge on how wearable health technology can empower individuals to take greater responsibility for their health and care. METHODS: This study was a scoping review with thematic analysis and narrative synthesis. Relevant guidance, such as the Arksey and O’Malley framework, was followed. In addition to searching gray literature, we searched MEDLINE, EMBASE, PsycINFO, HMIC, and Cochrane Library. Studies were included based on the following selection criteria: publication in English, publication in Europe or the United States, focus on wearables, relevance to the research, and the availability of the full text. RESULTS: After identifying 1585 unique records and excluding papers based on the selection criteria, 20 studies were included in the review. On analysis of these 20 studies, 3 main themes emerged: the potential barriers to using wearables, the role of providers and the benefits to providers from promoting the use of wearables, and how wearables can drive behavior change. CONCLUSIONS: Considerable literature findings suggest that wearables can empower individuals by assisting with diagnosis, behavior change, and self-monitoring. However, greater adoption of wearables and engagement with wearable devices depend on various factors, including promotion and support from providers to encourage uptake; increased short-term investment to upskill staff, especially in the area of data analysis; and overcoming the barriers to use, particularly by improving device accuracy. Acting on these suggestions will require investment and constructive input from key stakeholders, namely users, health care professionals, and designers of the technology. As advancements in technology to make wearables viable health care devices have only come about recently, further studies will be important for measuring the effectiveness of wearables in empowering individuals. The investigation of user outcomes through large-scale studies would also be beneficial. Nevertheless, a significant challenge will be in the publication of research to keep pace with rapid developments related to wearable health technology

Decentralisation, centralisation and devolution in publicly funded health services: decentralisation as an organisational model for health-care in England.

This review examines the nature and application of decentralisation as an organisational model for health care in England. The study reviews the relevant theoretical literature from a range of disciplines relating to different public- and private-sector contexts of decentralisation and centralisation. It examines empirical evidence about decentralisation and centralisation in public and private organisations and explores the relationship between decentralisation and different incentive structures, which, in turn affect organisational performance

Every city a food growing city? What food growing Schools London reveals about city strategies for food system sustainability

© 2018 by the authors. Cities have emerged as leaders in food system innovation and transformation, but their potential can be limited by the absence of supportive governance arrangements. This study examined the value of Food Growing Schools London (FGSL) as a programme seeking city-wide change through focusing on one dimension of the food system. Mixed methods case study research sought to identify high-level success factors and challenges. Findings demonstrate FGSL's success in promoting food growing by connecting and amplifying formerly isolated activities. Schools valued the programme's expertise and networking opportunities, whilst strategic engagement facilitated new partnerships linking food growing to other policy priorities. Challenges included food growing's marginality amongst priorities that direct school and borough activity. Progress depended on support from individual local actors so varied across the city. London-wide progress was limited by the absence of policy levers at the city level. Experience from FGSL highlights how city food strategies remain constrained by national policy contexts, but suggests they may gain traction through focusing on well-delineated, straightforward activities that hold public appeal. Sustainability outcomes might then be extended through a staged approach using this as a platform from which to address other food issues