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This book offers you a warm welcome into the often-complex world of healthcare commissioning. Amanda J. Hughes shares personal insights from her commissioning career and practical guidance that will demystify the commissioning cycle and ease the journey as you strive to achieve good outcomes.
Hypereutrophic Grand Lake St Marys (GLSM) is a large (52 km2), shallow (mean depth ~ 1.5 m) reservoir in an agricultural watershed of western Ohio (USA). GLSM suffers from extensive cyanobacterial harmful algal blooms (cHABs) that persist much of the year, resulting in total microcystin concentrations that are often above safe contact levels. Over two summers (2020 and 2021), two phosphorus (P) binding agents (alum and lanthanum/bentonite clay Phoslock, respectively), in conjunction with a P-binding algaecide (SeClear) in 2021, were applied to a 3.24-ha enclosure to mitigate cHAB activity and create a ‘safe’ recreational space for the public. We evaluated these applications by comparing total phosphorus (TP), total microcystin, total chlorophyll, and phycocyanin concentrations within the enclosure and the adjacent lake. Some evidence for short-term reductions in TP, microcystin, chlorophyll, and phycocyanin concentrations were observed following each P binding treatment, but all parameters rapidly returned to or exceeded pre-application levels within 2–3 weeks after treatment. These results suggest that in-lake chemical treatments to mitigate cHABs are unlikely to provide long-lasting benefits in these semi-enclosed areas of large, shallow, hypereutrophic systems, and resources may be better applied toward reducing external nutrient loads (P and nitrogen) from the watershed.
The relevance of education and outreach (E&O) activities about the Antarctic Treaty has been recognized at the Antarctic Treaty Consultative Meetings (ATCM) and at the Committee for Environmental Protection (CEP). This study examines the key topics and the target audiences detailed in papers submitted to the ATCM on E&O. Since the Antarctic Treaty entered into force in 1961, a total of 216 ATCM papers on E&O have been produced. The number of papers has increased substantially since the mid-1990s. ‘Science’ (76.9%) and ‘Wildlife/Biodiversity/Environment’ (75.5%) were the most addressed topics in these papers, while the ‘Public’ (81.0%) and those attending ‘Schools’ (69.0%) are the main target audiences. ‘Science’ in ATCM papers increased ~120-fold from 1961–1997 to 2015–2023, while ATCM papers discussing engagement with the ‘Public’ increased ~40-fold during the same period. ‘Climate change’ was first mentioned in 2006, and the number of papers per year increased fourfold by 2015–2023. This study shows the increasing interest in E&O through time, addressing key topics to relevant audiences related to the Antarctic region. From an educational perspective, attention should be paid to emerging topics (e.g. equity, diversity and inclusion), and the engagement of early-career professionals and educators should be made a priority.
Leader exemplification involves implicit and explicit claims of high moral values made by a leader. We employed a 2 × 3 experimental design with samples of 265 students in Study 1 and 142 working adults in Study 2 to examine the effects of leader exemplification (exemplification versus no exemplification) and ethical conduct (self-serving, self-sacrificial, and self-other focus) on perceived leader authenticity, trust in leader, and organizational advocacy. In Study 1, we found that exemplification produced elevated levels of perceived authenticity, trust, and advocacy in the form of employment and investment recommendations. We also showed that leader ethical conduct moderated this effect, as ratings were highest following a leader’s self-sacrificial conduct, lowest for self-serving conduct, and moderate for conduct reflecting self-other concerns. In Study 2, we replicated these findings for perceived authenticity and trust, but not organizational advocacy, which yielded mixed results. The leadership implications and future research directions are discussed.
The increased severity and frequency of bushfires accompanying human-induced global warming have dire implications for biodiversity conservation. Here we investigate the response of a cryptic, cool-climate elapid, the mustard-bellied snake Drysdalia rhodogaster, to the extensive Black Summer fires of 2019/2020 in south-eastern Australia. The species is categorized as Least Concern on the IUCN Red List (last assessed in 2017), but because a large part of its range was burnt during the Black Summer and little was known about its ecology, D. rhodogaster was identified as a priority species for post-fire impact assessment. We evaluated three lines of evidence to assess the impact of the Black Summer fires on D. rhodogaster. Habitat suitability modelling indicated that c. 46% of the predicted range of the species was affected by bushfire. Field surveys conducted 9–36 months post-fire and collation of records from public databases submitted 0–24 months post-fire indicated that D. rhodogaster persisted in burnt landscapes. Fire severity and proportion of the landscape that was burnt within a 1,000-m radius of survey sites were poor predictors of site occupancy by D. rhodogaster. Although conclusions regarding the effects of fire on D. rhodogaster are limited because of the lack of baseline data, it is evident that the species has persisted across the landscape in the wake of extensive bushfires. Our work highlights the need for baseline knowledge on cryptic species even when they are categorized as Least Concern, as otherwise assessments of the impacts of catastrophic events will be constrained.
To maximize its value, the design, development and implementation of structural health monitoring (SHM) should focus on its role in facilitating decision support. In this position paper, we offer perspectives on the synergy between SHM and decision-making. We propose a classification of SHM use cases aligning with various dimensions that are closely linked to the respective decision contexts. The types of decisions that have to be supported by the SHM system within these settings are discussed along with the corresponding challenges. We provide an overview of different classes of models that are required for integrating SHM in the decision-making process to support the operation and maintenance of structures and infrastructure systems. Fundamental decision-theoretic principles and state-of-the-art methods for optimizing maintenance and operational decision-making under uncertainty are briefly discussed. Finally, we offer a viewpoint on the appropriate course of action for quantifying, validating, and maximizing the added value generated by SHM. This work aspires to synthesize the different perspectives of the SHM, Prognostic Health Management, and reliability communities, and provide directions to researchers and practitioners working towards more pervasive monitoring-based decision-support.
Understanding the generation of large-scale magnetic fields and flows in magnetohydro-dynamical (MHD) turbulence remains one of the most challenging problems in astrophysical fluid dynamics. Although much work has been done on the kinematic generation of large-scale magnetic fields by turbulence, relatively little attention has been paid to the much more difficult problem in which fields and flows interact on an equal footing. The aim is to find conditions for long-wavelength instabilities of stationary MHD states. Here, we first revisit the formal exposition of the long-wavelength linear instability theory, showing how long-wavelength perturbations are governed by four mean field tensors; we then show how these tensors may be calculated explicitly under the ‘short-sudden’ approximation for the turbulence. For MHD states with relatively little disorder, the linear theory works well: average quantities can be readily calculated, and stability to long-wavelength perturbations determined. However, for disordered basic states, linear perturbations can grow without bound and the purely linear theory, as formulated, cannot be applied. We then address the question of whether there is a linear response for sufficiently weak mean fields and flows in a dynamical (nonlinear) evolution, where perturbations are guaranteed to be bounded. As a preliminary study, we first address the nature of the response in a series of one-dimensional maps. For the full MHD problem, we show that in certain circumstances, there is a clear linear response; however, in others, mean quantities – and hence the nature of the response – can be difficult to calculate.
Accelerating COVID-19 Treatment Interventions and Vaccines (ACTIV) was initiated by the US government to rapidly develop and test vaccines and therapeutics against COVID-19 in 2020. The ACTIV Therapeutics-Clinical Working Group selected ACTIV trial teams and clinical networks to expeditiously develop and launch master protocols based on therapeutic targets and patient populations. The suite of clinical trials was designed to collectively inform therapeutic care for COVID-19 outpatient, inpatient, and intensive care populations globally. In this report, we highlight challenges, strategies, and solutions around clinical protocol development and regulatory approval to document our experience and propose plans for future similar healthcare emergencies.
The Accelerating COVID-19 Therapeutic Interventions and Vaccines (ACTIV) Cross-Trial Statistics Group gathered lessons learned from statisticians responsible for the design and analysis of the 11 ACTIV therapeutic master protocols to inform contemporary trial design as well as preparation for a future pandemic. The ACTIV master protocols were designed to rapidly assess what treatments might save lives, keep people out of the hospital, and help them feel better faster. Study teams initially worked without knowledge of the natural history of disease and thus without key information for design decisions. Moreover, the science of platform trial design was in its infancy. Here, we discuss the statistical design choices made and the adaptations forced by the changing pandemic context. Lessons around critical aspects of trial design are summarized, and recommendations are made for the organization of master protocols in the future.
The Accelerating COVID-19 Therapeutic Interventions and Vaccines Therapeutic-Clinical Working Group members gathered critical recommendations in follow-up to lessons learned manuscripts released earlier in the COVID-19 pandemic. Lessons around agent prioritization, preclinical therapeutics testing, master protocol design and implementation, drug manufacturing and supply, data sharing, and public–private partnership value are shared to inform responses to future pandemics.
Contact tracing for COVID-19 in England operated from May 2020 to February 2022. The clinical, demographic and exposure information collected on cases and their contacts offered a unique opportunity to study secondary transmission. We aimed to quantify the relative impact of host factors and exposure settings on secondary COVID-19 transmission risk using 550,000 sampled transmission links between cases and their contacts. Links, or ‘contact episodes’, were established where a contact subsequently became a case, using an algorithm accounting for incubation period, setting, and contact date. A mixed-effects logistic regression model was used to estimate adjusted odds of transmission. Of sampled episodes, 8.7% resulted in secondary cases. Living with a case (71% episodes) was the most significant risk factor (aOR = 2.6, CI = 1.9–3.6). Other risk factors included unvaccinated status (aOR = 1.2, CI = 1.2–1.3), symptoms, and older age (66–79 years; aOR = 1.4, CI = 1.4–1.5). Whilst global COVID-19 strategies emphasized protection outside the home, including education, travel, and gathering restrictions, this study evidences the relative importance of household transmission. There is a need to reconsider the contribution of household transmission to future control strategies and the requirement for effective infection control within households.
This chapter demystifies the new NHS England funding models, improving understanding of how they work and why they are an aid to today's commissioning aims. This includes the blended payment approach but also other payment alternatives to support commissioning for outcomes. Limited funding or complicated finance arrangements are often regarded as one of the biggest barriers for commissioning and service redesign. This is because financial sustainability is a major risk and affordability is nearly always a factor. Because of this, the chapter also covers alternative funding approaches and ways to find the money.
History of NHS tariff schemes
Figure 7.1 shows the key changes in NHS funding approaches from 2003/ 04 to 2023/ 24. The NHS Payment Scheme was introduced in 2023/ 24 but aspects of the scheme had been slowly rolled out prior to this.
With a very brief look at NHS payment history, the tariff schemes – Payment by Results (2003/ 04 onwards) and the National Tariff (2014/ 15 to the introduction of the NHS Payment Scheme) – were used to set the rules and prices that commissioners needed to pay providers. These schemes were predominantly used for acute hospital care, and payment made from these schemes made up approximately 60 per cent of a hospital's income (NHS England and NHS Improvement, 2022a). Other service providers, such as community and mental health providers, remained largely on block arrangements, with no or few individual prices for units of activity. A block arrangement provides a set monetary value based on anticipated activity volumes and costs. This is usually then split into 12 monthly payments.
The tariff schemes were based on units of activity, to which a code and a price was applied. For example, a first outpatient appointment with a diabetes consultant would have a treatment function code 307 and attract a price of £137. This coding arrangement was applied for consultations, procedures, units of care, and investigations. It also reflected patient complexity – that is, how many conditions a person had, their age, how long they stayed in hospital, what professionals they saw, and so on. A single episode of care could have many codes. Coded activity translated into a price which commissioners were obliged to pay. Therefore, it was financially beneficial as a provider to get your coding completed thoroughly.
We have come on a long journey through the stages of commissioning and the key ingredients that make any commissioning practice a greater success regarding good outcomes and experiences for people and their communities. In this concluding chapter, I bring together the priority aspects in a model for good commissioning. Although all the individual model components require in- depth understanding and practical knowledge, I would suggest the model can act as a simple memory aid when considering new commissioning projects or programmes – commissioners can ask: have all the aspects of the model been considered adequately and employed appropriately?
This model is more effectively applied to larger commissioning projects. A proportional approach will be needed for smaller commissioning projects.
The aim is to strive towards outcomes- based commissioning. I suggest that today, compared with ten years ago, what constitutes good commissioning has significantly changed. It is now a difficult balance between achieving quality outcomes for people and achieving sustainability in a resource- challenged environment. This means embracing change and innovation to tailor solutions for improving local outcomes. What this will look like will be quite different from area to area, but the focus for commissioners is to achieve good or improved outcomes for the population through defining, planning, and contracting health and care services.
The model
The model (shown in Figure 12.1) includes three output pillars. These pillars are essential – each one must be in place to support the aim of outcomes- based commissioning. The foundation for these pillars is provided by enabling bricks. You could remove a few of the enabling bricks, but the model would be less ‘stable’ and potentially less likely to succeed or to stand the test of time.
The output pillars
The output pillars of outcomes- based commissioning are Access, Quality, and Sustainability.
Access
The Access output pillar ensures that services, care, and support are accessible to those who need it. Here, commissioners are looking to ensure that services are provided at the right time, in the right place, and for the right people. Access as an output seeks to reduce avoidable health and care inequalities.