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

Rules of the Laboratory of the Maine State College of Agriculture and the Mechanic Arts

A scan of the published rules for the scientific laboratory on the campus of Maine State College in 1871

Are fluoride levels in drinking water associated with hypothyroidism prevalence in England? A large observational study of GP practice data and fluoride levels in drinking water

Background While previous research has suggested that there is an association between fluoride ingestion and the incidence of hypothyroidism, few population level studies have been undertaken. In England, approximately 10% of the population live in areas with community fluoridation schemes and hypothyroidism prevalence can be assessed from general practice data. This observational study examines the association between levels of fluoride in water supplies with practice level hypothyroidism prevalence. Methods We used a cross-sectional study design using secondary data to develop binary logistic regression models of predictive factors for hypothyroidism prevalence at practice level using 2012 data on fluoride levels in drinking water, 2012/2013 Quality and Outcomes Framework (QOF) diagnosed hypothyroidism prevalence data, 2013 General Practitioner registered patient numbers and 2012 practice level Index of Multiple Deprivation scores. Findings We found that higher levels of fluoride in drinking water provide a useful contribution for predicting prevalence of hypothyroidism. We found that practices located in the West Midlands (a wholly fluoridated area) are nearly twice as likely to report high hypothyroidism prevalence in comparison to Greater Manchester (non-fluoridated area). Interpretation In many areas of the world, hypothyroidism is a major health concern and in addition to other factors—such as iodine deficiency—fluoride exposure should be considered as a contributing factor. The findings of the study raise particular concerns about the validity of community fluoridation as a safe public health measure

Surveillance of neonatal herpes in the British Isles 2004-2006

BACKGROUND: Neonatal herpes simplex virus (HSV) infection is rare but potentially devastating and can result in neonatal death or serious disability. National incidence was estimated at 1.65/100,000 live births in an earlier British Paediatric Surveillance Unit (BPSU) study of births 1986-1991. METHODS:A second surveillance study of neonatal HSV was undertaken through the BPSU 2004-2006, with follow-up information collected on surviving children in early childhood. RESULTS: Over the three-year period, 85 infants were reported with confirmed neonatal HSV, an estimated incidence of 3.58/100,000 live births (95% CI 2.86-4.42), about double that reported almost two decades earlier. Over 40% of infants were pre-term compared with 25% in the earlier period. Just over 70% had central nervous system (CNS) or disseminated infection, and among these 54% had no skin, eye or mouth lesions noted. Almost all received antivirals, but 22 (26%) neonates died, all with disseminated or CNS infection. All but six infections were typed, of which 57% involved HSV-2; the increased risk of adverse outcomes associated with HSV-2 in the earlier study was confirmed and strengthened, with twice as many deaths or long term disability in infants with HSV-2 than HSV-1. As before, a reported history or diagnosis of maternal HSV infection was rare prior to infant diagnosis. Likely timing of infant exposure to HSV could only be assigned in 43% of cases, of which just over half were probable postnatal transmissions. CONCLUSIONS: Neonatal HSV infection remains rare although incidence doubled in the British Isles between the late 1990s and the mid-2000s. These findings suggest that future research should explore the relationship between pre-term delivery and infant susceptibility, and also the role of postnatal acquisition of infection. Healthcare professionals and new parents must continue to be aware of this rare condition in order to enable prompt investigation and instigation of treatment

Common Skin Lesions in Baby Pigs

Greasy pig disease and parakeratosis focused considerable attention on the skin of the pig and pointed out how critical cutaneous disease can be. The importance of other skin lesions in baby pigs is often overlooked and considerable mortality may occur before their significance is recognized

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

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