Overcoming silos in health care systems through meso-level organisations - a case study of health reforms in New South Wales, Australia.

Fragmented care delivery is a barrier to improving health system performance worldwide. Investment in meso-level organisations is a potential strategy to improve health system integration, however, its effectiveness remains unclear. In this paper, we provide an overview of key international and Australian integrated care policies. We then describe Collaborative Commissioning - a novel health reform policy to integrate primary and hospital care sectors in New South Wales (NSW), Australia and provide a case study of a model focussed on older person's care. The policy is theorised to achieve greater integration through improved governance (local stakeholders identifying as part of one health system), service delivery (communities perceive new services as preferable to status quo) and incentives (efficiency gains are reinvested locally with progressively higher value care achieved). If effectively implemented at scale, Collaborative Commissioning has potential to improve health system performance in Australia and will be of relevance to similar reform initiatives in other countries.

Impacts of chain and head lengths of nonionic alkyl ethoxylate surfactants on cytotoxicity to human corneal and skin cells in agri-spraying processes.

HYPOTHESIS: Nonionic surfactants are widely used as co-formulants in agrochemical sprays. During spraying, they may come into direct contact with humans and animals, causing irritation in different tissues. However, how the molecular structures of these surfactants affect their toxicity towards human eye and skin at the cellular level has not been well characterised. EXPERIMENT: In this study, the cytotoxicities of two sets of nonionic surfactants (alkyl ethoxylate, CnEm) against human corneal and skin cell lines were examined, with one set composed of varied surfactant head length but fixed tail length (C12E4-23) and the other set oppositely composed (C10-16E6). The cell viability and morphology against different nonionic surfactants for varied exposure times were studied, followed by characterisation of their membrane-lytic ability. FINDING: Nonionic surfactants with intermediate amphiphilicity killed cells rapidly due to their strong membrane-lytic power. Those with weak or strong hydrophobicity exhibited low cytotoxicity but had different modes of action depending on their hydrophobicity. Hydrophobic surfactants were found to adsorb on to cell membranes with no observed structural damage for 2 hr. Hydrophilic surfactants were also found to adsorb on to cell membranes but did cause mild structural changes. While the changes were not sufficient to elicit large cytoplasmic leakage over short periods of time, membrane associations did cause cell shrinkage which eventually resulted in cell death over longer exposure periods. These results revealed that the specific amphiphilic nature of nonionic surfactants played a crucial role in determining their cytotoxicity. This work provided a useful basis for the assessment of amphiphilicity of the nonionic surfactants used in agrochemical sprays by balancing their efficiency, toxicity and environmental impact.