A genetic chronology for the Indian Subcontinent points to heavily sex-biased dispersals.

BACKGROUND: India is a patchwork of tribal and non-tribal populations that speak many different languages from various language families. Indo-European, spoken across northern and central India, and also in Pakistan and Bangladesh, has been frequently connected to the so-called "Indo-Aryan invasions" from Central Asia ~3.5 ka and the establishment of the caste system, but the extent of immigration at this time remains extremely controversial. South India, on the other hand, is dominated by Dravidian languages. India displays a high level of endogamy due to its strict social boundaries, and high genetic drift as a result of long-term isolation which, together with a very complex history, makes the genetic study of Indian populations challenging. RESULTS: We have combined a detailed, high-resolution mitogenome analysis with summaries of autosomal data and Y-chromosome lineages to establish a settlement chronology for the Indian Subcontinent. Maternal lineages document the earliest settlement ~55-65 ka (thousand years ago), and major population shifts in the later Pleistocene that explain previous dating discrepancies and neutrality violation. Whilst current genome-wide analyses conflate all dispersals from Southwest and Central Asia, we were able to tease out from the mitogenome data distinct dispersal episodes dating from between the Last Glacial Maximum to the Bronze Age. Moreover, we found an extremely marked sex bias by comparing the different genetic systems. CONCLUSIONS: Maternal lineages primarily reflect earlier, pre-Holocene processes, and paternal lineages predominantly episodes within the last 10 ka. In particular, genetic influx from Central Asia in the Bronze Age was strongly male-driven, consistent with the patriarchal, patrilocal and patrilineal social structure attributed to the inferred pastoralist early Indo-European society. This was part of a much wider process of Indo-European expansion, with an ultimate source in the Pontic-Caspian region, which carried closely related Y-chromosome lineages, a smaller fraction of autosomal genome-wide variation and an even smaller fraction of mitogenomes across a vast swathe of Eurasia between 5 and 3.5 ka.

Erratum to: Quantifying the legacy of the Chinese Neolithic on the maternal genetic heritage of Taiwan and Island Southeast Asia.

In the original article, one of the co-authors' (Ken Khong Eng) given name has been published incorrectly. The correct given name should be Ken Khong. The original article has been corrected.

Quantifying the legacy of the Chinese Neolithic on the maternal genetic heritage of Taiwan and Island Southeast Asia.

There has been a long-standing debate concerning the extent to which the spread of Neolithic ceramics and Malay-Polynesian languages in Island Southeast Asia (ISEA) were coupled to an agriculturally driven demic dispersal out of Taiwan 4000 years ago (4 ka). We previously addressed this question using founder analysis of mitochondrial DNA (mtDNA) control-region sequences to identify major lineage clusters most likely to have dispersed from Taiwan into ISEA, proposing that the dispersal had a relatively minor impact on the extant genetic structure of ISEA, and that the role of agriculture in the expansion of the Austronesian languages was therefore likely to have been correspondingly minor. Here we test these conclusions by sequencing whole mtDNAs from across Taiwan and ISEA, using their higher chronological precision to resolve the overall proportion that participated in the "out-of-Taiwan" mid-Holocene dispersal as opposed to earlier, postglacial expansions in the Early Holocene. We show that, in total, about 20% of mtDNA lineages in the modern ISEA pool result from the "out-of-Taiwan" dispersal, with most of the remainder signifying earlier processes, mainly due to sea-level rises after the Last Glacial Maximum. Notably, we show that every one of these founder clusters previously entered Taiwan from China, 6-7 ka, where rice-farming originated, and remained distinct from the indigenous Taiwanese population until after the subsequent dispersal into ISEA.

Policy paradox and political neglect in community health services.

Community health services (CHSs) have never had a settled organisational existence but the turmoil has intensified since the publication of Transforming Community Services in 2009. CHSs are now beset by three dilemmas: ongoing organisational fragmentation; the extension of competition law and the spread of privatisation; inadequate workforce development and lack of clarity on the nature of CHS activity. This has left the services in a position of policy and political vulnerability. The solution may be for the service to be part of horizontal integration models such as the accountable care organisation, with a focus on locality and multi-professional teams wrapped around patient pathways.

Large-scale health system transformation in the United Kingdom.

PURPOSE: Following publication of a new vision for the English National Health Service (NHS) in 2014, known as the NHS Five-Year Forward View, a Vanguard programme was introduced by NHS England charged with the task of designing and delivering a range of new care models (NCMs) aimed at tackling deep-seated problems of a type facing all health systems to a greater or lesser degree. Drawing upon recent theoretical developments on the multilevel nature of context, we explore factors shaping the implementation of five NCM initiatives in the North East of England. DESIGN/METHODOLOGY/APPROACH: Data collection was based on semi-structured interviews (66 in total) between December 2016 and May 2017 with key informants at each site and a detailed review of Trusts' internal documents and policies related to the implementation of each NCM. Our analysis explores factors shaping the implementation of five NCM pilot sites as they touched on the multiple levels of context ranging from the macro policy level to the micro-level setting of workforce redesign. FINDINGS: It is far too early to conclude with any confidence that a successful outcome for the NCM programme will be forthcoming although the NHS Long-Term Plan seeks to build on the earlier vision set out in the Five-Year Forward View. Early indications show some signs of promise, especially where there is evidence of the ground having been prepared and changes already being put in place prior to the official launch of NCM initiatives. At the same time our findings demonstrate that all five pilot sites experienced, and were subject to, unrealistic pressure placed upon them to deliver outcomes. ORIGINALITY/VALUE: Our findings demonstrate the need for a deeper understanding of the multilevel nature of context by exploring factors shaping the implementation of five NCMs in the North East of England. Exploring the wider national policy context is desirable as well as understanding the perceptions of front-line staff and service users in order to establish the degree of alignment or, conversely, to identify where policy and practice are at risk of pushing and pulling against each other.

Lessons learnt from the implementation of new care models in the NHS: a qualitative study of the North East Vanguards programme.

OBJECTIVE: To examine lessons learnt from the implementation of five Vanguard initiatives in the North East of England. DESIGN: Data collection comprised semistructured interviews with key informants at each site. SETTING: The study took place across six local authority areas in the North East of England and within six clinical commissioning groups responsible for the delivery of each Vanguard's aims and objectives. PARTICIPANTS: Sixty-six interviewees with participants from five Vanguard initiatives in the North East of England, including senior clinicians, project leads and directors, commissioners, and healthcare managers. RESULTS: While the context for each Vanguard is separate and distinct, there also exists a set of common issues which have a regional dimension. Participants felt that the national programme helped to raise the profile of local change initiatives and also contributed to the wider understanding of regional service integration issues. At the same time our findings demonstrate that all five sites experienced, and were subject to, unrealistic pressure placed on them to deliver outcomes. Of particular concern among all sites was the sheer scale and pace of change occurring at the same time as the National Health Service was being tasked with making significant, if unrealistic, efficiency savings. CONCLUSIONS: It is too early to conclude with any confidence that a successful outcome for the new care models programme will be forthcoming. While early indications show some encouraging signs of promise, the overall context in which the complex and ambitious changes are being implemented remains both fragile and fluid.

Sea change or quick fix? Policy on long-term conditions in England.

Long-term conditions is a policy area that has risen rapidly up the political agenda in England, culminating in the development of the National Health Service and Social Care Model in 2005, which is to be implemented over the following 2 years. The Model draws heavily upon US ideas of case management and proposes the creation of 3000 community matrons to undertake this role with the most vulnerable patients. Although welcomed in principle, the specific proposals in the Model have been subject to some criticism, and these issues are explored in the present paper. The problematic areas include patient identification, the transplanting of US models to England, the role of case management, workforce and funding issues, and the mix of medical and social models. The author concludes that there is a danger of long-term care policy developing an unduly health-focused approach at a time when the thrust of partnership working is towards an inclusive, whole-system model.

Children's trusts. New kid on the block.

The proposal to establish children's trusts follows years of poor co-ordination of services. The establishment of these trusts will involve structural integration with other organisations and may not appeal to everyone in the NHS. The government seems prepared to consider almost any form for these trusts. Partnerships, not restructuring, would seem to be the way forward.

Delayed discharges. Another fine mess.

A simulation exercise on charging for delayed discharges revealed significant potential for conflict between organisations, and no benefit for service users. Participants thought the charging system would work against the development of community services. They favoured joint NHS/local authority approaches to the development of an effective system for preventing delayed discharges.

Ten years of jointly commissioning health and social care in England.

INTRODUCTION: Over the past two decades, the service delivery landscape across health and social care in England has been reshaped in order to separate the commissioning of services from their delivery. POLICY/PRACTICE: The market ethic that underpinned this move has depicted the previously roles as unresponsive to the needs of service users and dominated by provider interests. As well as seeming to offer commissioners the chance to change the nature of provision and type of provider, this policy model also created a further new opportunity-for joint commissioning across organisational boundaries. The logic here is that if two or more commissioners can jointly shape their programmes then they will be better able to secure integrated provision across a range of separate agencies and professions. CONCLUSION: This article reviews the experience of joint commissioning across health and social care over the past decade in England. It contrasts the proliferation of policies against the paucity of achievements, seeks explanations for this situation, and offers pointers for future development.

Pessimism and optimism in inter-professional working: the Sedgefield Integrated Team.

The literature on inter-professional working tends to be dominated by explanations for lack of progress rather than accounts of achievements. This paper develops two models, termed the optimistic and pessimistic models respectively, to understand the factors that may underpin different rates of interprofessional achievement. A case study of the Sedgefield Integrated Team in County Durham, UK is used to test out aspects of the models. It is concluded that the grounds for pessimism have been overstated and that the scope for professional integration is greater than tends to be assumed.

Policy change and policy dilemmas: interpreting the community services White Paper in England.

CONTEXT: In 2006 the Labour Government in England published its long awaited White Paper on 'community services', following on from the 2005 Green Paper on the future of social care. The policy envisages an unprecedented shift of activity and resources from acute care to community settings, along with a much stronger focus on preventive care. Several mechanisms are to be put in place to ensure this shift takes place, most notably practice-based commissioning, payments-by-results and enhanced partnership working. PURPOSE: This article outlines the intended changes and assesses the extent to which they add up to a coherent strategy. CONCLUSION: It is argued that although there is widespread support for the overall vision, the strategy contains some difficult policy tensions that are common to other welfare systems. These will have to be addressed if the vision is to be a reality.

Information sharing and children's services reform in England: can legislation change practice?

The Laming Report into the death of Victoria Climbie reiterated the long-standing critique of inadequate communication and coordination amongst the key professions and agencies. It led directly to the Green Paper, Every Child Matters in 2003 and the subsequent Children Act 2004. Amongst other things the Act proposes the establishment of a database on every child, which would be accessible to a range of practitioners - a measure that has been hotly contested. This article examines the reasons for this contestation and explores the extent to which a compromise might be judged to have dislodged a key policy objective.

Social services and Primary Care Groups: a window of collaborative opportunity?

This paper reports on the findings of two investigations into the relationship between social services and Primary Care Groups (PCGs): a national postal questionnaire and a series of regional seminars. The key findings of both explorations are summarised and placed in the context of other available evidence on the development of PCGs. Issues covered include: the background and status of social services representatives; preparation and support for the board role; feedback and accountability, and early contributions. It is concluded that progress is being made in bringing together the agendas and activities of PCGs and social services, and to a lesser extent the wider local authority, but that important obstacles remain in place. The enduring significance of the resource dependency model needs to be a key factor in emerging partnerships.