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Background Multimorbidity is a major challenge to health and social care systems around the world. There is limited research exploring the wider contextual determinants that are important to improving care for this cohort. In this study, we aimed to elicit and prioritise determinants of improved care in people with multiple conditions. Methods A three-round online Delphi study was conducted in England with health and social care professionals, data scientists, researchers, people living with multimorbidity and their carers. Results Our findings suggest a care system which is still predominantly single condition focused. ‘Person-centred and holistic care’ and ‘coordinated and joined up care’, were highly rated determinants in relation to improved care for multimorbidity. We further identified a range of non-medical determinants that are important to providing holistic care for this cohort. Conclusions Further progress towards a holistic and patient-centred model is needed to ensure that care more effectively addresses the complex range of medical and non-medical needs of people living with multimorbidity. This requires a move from a single condition focused biomedical model to a person-based biopsychosocial approach, which has yet to be achieved.

Fisher-hunter-gatherers built the large earthwork at Poverty Point ca. 3500 cal. B.P. Based on the massive quantities of exotic rock and construction regularities with earlier regional mound complexes, Kenneth Sassaman proposes that builders were a cosmopolitan multiethnic collective with geographically extensive origins. Close examination of Poverty Point's goods fails to support his multiethnic model and suggests that a local communal structure prevailed in Poverty Point's homeland.

Multiple long-term health conditions (multimorbidity) (MLTC-M) are increasingly prevalent and associated with high rates of morbidity, mortality, and health care expenditure. Strategies to address this have primarily focused on the biological aspects of disease, but MLTC-M also result from and are associated with additional psychosocial, economic, and environmental barriers. A shift toward more personalized, holistic, and integrated care could be effective. This could be made more efficient by identifying groups of populations based on their health and social needs. In turn, these will contribute to evidence-based solutions supporting delivery of interventions tailored to address the needs pertinent to each cluster. Evidence is needed on how to generate clusters based on health and social needs and quantify the impact of clusters on long-term health and costs. We intend to develop and validate population clusters that consider determinants of health and social care needs for people with MLTC-M using data-driven machine learning (ML) methods compared to expert-driven approaches within primary care national databases, followed by evaluation of cluster trajectories and their association with health outcomes and costs. The mixed methods program of work with parallel work streams include the following: (1) qualitative semistructured interview studies exploring patient, caregiver, and professional views on clinical and socioeconomic factors influencing experiences of living with or seeking care in MLTC-M; (2) modified Delphi with relevant stakeholders to generate variables on health and social (wider) determinants and to examine the feasibility of including these variables within existing primary care databases; and (3) cohort study with expert-driven segmentation, alongside data-driven algorithms. Outputs will be compared, clusters characterized, and trajectories over time examined to quantify associations with mortality, additional long-term conditions, worsening frailty, disease severity, and 10-year health and social care costs. The study will commence in October 2021 and is expected to be completed by October 2023. By studying MLTC-M clusters, we will assess how more personalized care can be developed, how accurate costs can be provided, and how to better understand the personal and medical profiles and environment of individuals within each cluster. Integrated care that considers \"whole persons\" and their environment is essential in addressing the complex, diverse, and individual needs of people living with MLTC-M. PRR1-10.2196/34405.

Middle Archaic (7400-5100 bp) fisher-hunter-gatherers living alongside the Lower Mississippi River were not fully sedentary but still managed to build mound complexes of impressive dimensions. The Poverty Point earthwork, built rapidly sometime after 3700 bp, was the work of a sedentary fisher-hunter-gatherer people, the Tamaroha. The colossal earthwork, the explosion of material culture, the far-reaching exchange and the swift accommodations to growing population were both cause and consequence of sedentism.

Main study objectives Mixed-methods evaluation. Three linked datasets for 2021/22 (n = 10,135) were analysed for impact of pharmacy size, type (independent, chain, supermarket), location, prescription volume, and region on PQS participation, domains completion and payments. Forty-one qualitative interviews conducted with pharmacists, employers and representative bodies explored views and experiences of PQS implementation and impact. Harrington et al.'s conceptual framework for evaluating community pharmacy pay-for-performance programmes guided qualitative data analysis. Nearly all community pharmacies in England participated in PQS, with differences identified between chains (99% participation) and independents (16.5%), with income via PQS being an important motivator. Interviewees agreed with policy-makers about the purpose of the PQS being patient safety, patient experience, and clinical effectiveness. Beyond these core dimensions, consistency of service provision, sustainability, and wider system integration were considered important. While PQS was largely viewed as positively impacting pharmacy teams, clinical practice, and patient care, interviewees felt that increasing workloads across the sector made it challenging to focus on quality. They felt that there was a lack of feedback, that impacts were not always visible, and indeed frontline pharmacists were often not aware of published evidence of PQS impacts. Multiple sources of guidance lead to duplication and confusion. Particularly independent pharmacies found PQS workload burdensome and complex. The primary incentive for PQS engagement revolved around income stability for employers, with some positive impact achieved, but obstacles concerning resource implications and sustainability persist. Considering concerns about the viability of community pharmacy and the importance of increasing the scope of pharmaceutical services, these implementation challenges should lead policy-makers to question how best to incentivise quality.

Main study objectives Mixed-methods evaluation. Three linked datasets for 2021/22 (n = 10,135) were analysed for impact of pharmacy size, type (independent, chain, supermarket), location, prescription volume, and region on PQS participation, domains completion and payments. Forty-one qualitative interviews conducted with pharmacists, employers and representative bodies explored views and experiences of PQS implementation and impact. Harrington et al.'s conceptual framework for evaluating community pharmacy pay-for-performance programmes guided qualitative data analysis. Nearly all community pharmacies in England participated in PQS, with differences identified between chains (99% participation) and independents (16.5%), with income via PQS being an important motivator. Interviewees agreed with policy-makers about the purpose of the PQS being patient safety, patient experience, and clinical effectiveness. Beyond these core dimensions, consistency of service provision, sustainability, and wider system integration were considered important. While PQS was largely viewed as positively impacting pharmacy teams, clinical practice, and patient care, interviewees felt that increasing workloads across the sector made it challenging to focus on quality. They felt that there was a lack of feedback, that impacts were not always visible, and indeed frontline pharmacists were often not aware of published evidence of PQS impacts. Multiple sources of guidance lead to duplication and confusion. Particularly independent pharmacies found PQS workload burdensome and complex. The primary incentive for PQS engagement revolved around income stability for employers, with some positive impact achieved, but obstacles concerning resource implications and sustainability persist. Considering concerns about the viability of community pharmacy and the importance of increasing the scope of pharmaceutical services, these implementation challenges should lead policy-makers to question how best to incentivise quality.

To evaluate implementation and impact (at pharmacy and system level) of the pharmacy quality scheme (PQS), a pay-for-performance quality incentive scheme in community pharmacies in England since 2017. Mixed-methods evaluation. Three linked datasets for 2021/22 (n = 10,135) were analysed for impact of pharmacy size, type (independent, chain, supermarket), location, prescription volume, and region on PQS participation, domains completion and payments. Forty-one qualitative interviews conducted with pharmacists, employers and representative bodies explored views and experiences of PQS implementation and impact. Harrington et al.'s conceptual framework for evaluating community pharmacy pay-for-performance programmes guided qualitative data analysis. Nearly all community pharmacies in England participated in PQS, with differences identified between chains (99% participation) and independents (16.5%), with income via PQS being an important motivator. Interviewees agreed with policy-makers about the purpose of the PQS being patient safety, patient experience, and clinical effectiveness. Beyond these core dimensions, consistency of service provision, sustainability, and wider system integration were considered important. While PQS was largely viewed as positively impacting pharmacy teams, clinical practice, and patient care, interviewees felt that increasing workloads across the sector made it challenging to focus on quality. They felt that there was a lack of feedback, that impacts were not always visible, and indeed frontline pharmacists were often not aware of published evidence of PQS impacts. Multiple sources of guidance lead to duplication and confusion. Particularly independent pharmacies found PQS workload burdensome and complex. The primary incentive for PQS engagement revolved around income stability for employers, with some positive impact achieved, but obstacles concerning resource implications and sustainability persist. Considering concerns about the viability of community pharmacy and the importance of increasing the scope of pharmaceutical services, these implementation challenges should lead policy-makers to question how best to incentivise quality.

Traces the sources of power and large-scale organization of prehistoric peoples among Archaic societies. By focusing on the first instances of mound building, pottery making, fancy polished stone and bone, as well as specialized chipped stone, artifacts, and their widespread exchange, this book explores the sources of power and organization among Archaic societies. It investigates the origins of these technologies and their effects on long-term (evolutionary) and short-term (historical) change. The characteristics of first origins in social complexity belong to 5,000- to 6,000-year-old Archaic groups who inhabited the southeastern United States. In Signs of Power , regional specialists identify the conditions, causes, and consequences that define organization and social complexity in societies. Often termed "big mound power," these considerations include the role of demography, kinship, and ecology in sociocultural change; the meaning of geometry and design in sacred groupings; the degree of advancement in stone tool technologies; and differentials in shell ring sizes that reflect social inequality.

ObjectivesTo examine the extent, and nature, of impact on junior doctors' career decisions, of a proposed new contract and the uncertainty surrounding it.DesignMixed methods. Online survey exploring: doctors' future training intentions; their preferred specialty training (ST) programmes; whether they intended to proceed immediately to ST; and other plans. Linked qualitative interviews to explore more fully how and why decisions were affected.SettingDoctors (F2s) in second year of Foundation School (FS) Programmes in England.ParticipantsInvitations sent by FSs. Open to all F2s November 2015–February 2016. All FSs represented. Survey completed by 816 F2s. Sample characteristics broadly similar to national F2 cohort.Main outcome measuresProportions of doctors intending to proceed to ST posts in the UK, to defer or to exit UK medicine. Proportion of doctors indicating changes in training and career plans as a result of the contract and/or resulting uncertainty. Distribution of changes across training programmes. Explanations of these intentions from interviews and free text comments.ResultsAmong the responding junior doctors, 20% indicated that issues related to the contract had prompted them to switch specialty and a further 20% had become uncertain about switching specialty. Switching specialty choice was more prevalent among those now choosing a community-based, rather than hospital-based specialty. 30% selecting general practice had switched choice because of the new contract. Interview data suggests that doctors felt they had become less valued or appreciated in the National Health Service and in society more broadly.ConclusionsDoctors reported that contract-related issues have affected their career plans. The most notable effect is a move away from acute to community-based specialities, with the former perceived as more negatively affected by the proposed changes. It is concerning that young doctors feel undervalued, and this requires further investigation.