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The growth and composition of primary and community-based care services. Metrics and evidence from the Italian National Health Service
Organization, structure and delivery of healthcare
Over the past few decades, in OECD countries there has been a general growing trend in the prevalence of out-of-hospital healthcare services, but there is a general lack of data on the use of these services.
We defined a list of 303 indicators related to primary and community healthcare services in collaboration with 13 Italian Local Health Authorities (LHAs). Then, for each LHA, we collected and analyzed these indicators for two different years (2003 and 2007).
Out-of-hospital care absorbs 56% of all costs in our sample of LHAs. Expenditure on outpatients' visits to specialists and on diagnostic examinations accounts for 13% of the costs, while spending on primary care (including prevention and public health) accounts for 9%, and for intermediate structures (including those related to rehabilitation, elderly people, disabled people, and mental health) the figure is 11%. Different Italian LHAs have made different strategic choices with respect to primary and community-based care (PCC).
Two distinct strategic orientations in the adoption of PCC services by LHAs has emerged from our study. The first has been an investment mainly in ambulatory and home-based primary care services in order to increase the number of low-complexity settings. A second strategy has prioritized the allocation of resources to intermediate inpatient structures for specific types of patients, namely elderly and disabled people, post-acute patients in need of rehabilitation and long-term care, and patients in hospices.
Since 1980, in almost every OECD country there has been a trend in the reduction of the use of hospitalization
In OECD countries, this reduction in hospitalization has led to significant resources being directed towards Primary and Community Care (PCC) settings, which now form a fundamental part of most healthcare systems
Primary and Community Care encompasses a network of various and highly diversified services provided in non-hospital and community-oriented settings. The measurement of quantity and cost for PCC services is complex; there are no widely adopted systems for classifying services such as the system of Diagnosis Related Groups (DRG) used in hospital care. Moreover, PCC services are often physically fragmented in a de-integrated network of different services provided by several actors in different locations
The measurement of PCC services is therefore more difficult than the measurement of services delivered in hospital settings. We herein describe a measurement method for PCC services developed in partnership with PCC professionals that classifies services into 15 types covering the entire range of out-of-hospital care provided in Italy. We then report the data for 2007 and the trends in the four previous years for a sample of 13 Italian Local Health Authorities (LHAs).
The conceptual model of measurement described herein was developed by the authors for a collaborative research study promoted by the
The measurement of PCC activity and expenditure
Although several studies have broken down the healthcare expenditure of different countries into its main components, few have analysed the impacts of individual PCC services on overall healthcare expenditure.
Anderson et al. used OECD Health Data from 2005
Orosz and Morgan
Moreover, international institutions such as OECD and WHO defined a list of indicators and annually collected data to compare health expenditure in different countries. OECD collected and analyzed data for total expenditure on health, prevention and public health, expenditure on inpatient care, expenditure on out-patient care, expenditure on home care, pharmaceuticals and other medical non-durables, therapeutic appliances and other medical durables, current health expenditure by provider, along with data on health expenditure by financing agent/scheme. In the 34 OECD countries (2010 data), expenditure on inpatient care represented 53% of overall health expenditure; 16% was spent on outpatient care, 13% on pharmaceuticals and medical non-durables, 7% on medical non durables and 11% on public health and prevention
The WHO presented instead data on government, private, external, social security and out-of-pocket expenditures on health for 193 countries. Data on health financing were generated from national health accounts that collect expenditure information within an internationally recognized framework. In the average of all WHO countries (2010 data), 54% of health expenditure was financed by governmental expenditure, whereas 46% of expenditure was privately funded. Out of pocket expenditure represented in average 11% of overall health expenditure
Other studies were undertaken to analyse the components of spending on healthcare in individual countries. In the United States, researchers at the Centre for Medicare and Medicaid Services (CMS) analysed national healthcare expenditure accounts, with the goal of measuring the total amount spent on the purchase of healthcare goods and services, by type of service delivered (hospital care, physician services, nursing home care, etc.). In 2007, hospital care represented 37% of total personal healthcare spending in the United States, outpatient services represented 40%, drugs and non-durable medical products 14%, and services for the community 9%
Martin et al.
In general, although these studies used different methods of elaboration (function or type of service delivered, source of funding, or programme of care), they were all based on data that were either published officially or collected previously. The researchers were not able to break the expenditure down further into individual services, nor could they analyse the impact of any allocation of resources on clinical outcomes or other performance indicators.
Research goals and contributions
This study has two main goals. First, it aims to define a method of data collection and analysis of PCC healthcare services that can be used to describe the consumption of these services by residents in terms of quantity and cost. It is envisaged that the method developed here for the Italian system could also be used in other national healthcare systems. Second, it aims to report detailed data on expenditure and the main indicators of activity for PCC services in the Italian NHS, in order to compare the strategies of different LHAs within the same national context.
We collected primary data directly from LHAs, instead of using previously published or collected secondary data. In so doing, we obtained a level of detail unavailable to previous studies with respect to out-of-hospital care. WHO data focused on the actors financing healthcare expenditure (government, private, social security, out of pocket expenditure), whereas OECD mainly focused on the type of medical good (pharmaceuticals, medical durables and non durables). Neither WHO nor OECD data, however, provided detailed data for typology of service
Moreover, our methodology involved face-to-face interactions among LHAs' representatives, which permitted a sense-making process to take place that was useful for the proper definition of indicators, to assess the reliability of the data, and to provide benchmarking information for the LHAs.
In summary, the process of primary data collection of both expenditure and activity indicators outlined in this paper and the emphasis on assessing data reliability by means of continuous interactions among researchers and LHAs' professionals make our methodology applicable to all Italian Regions and to OECD countries.
The collaborative research procedure
The study was conducted by collecting quantitative data on the costs and activities of 13 Italian LHAs participating in a collaborative research study on the management of PCC services, organized by the FIASO. The FIASO is the main association of public sector healthcare organizations and has 160 member organizations (either LHAs or public Independent Hospitals [IHs]) out of the 249 public healthcare organizations in Italy. A brief overview of the main characteristics and recent reforms of the Italian NHS is provided in Table
The population covered by the 13 LHAs participating in the research was 5.1 million, which represented 9% of the total population of Italy. The combined yearly budget of the 13 LHAs is equivalent to 8.7 billion euros, almost 9% of the Italian NHS expenditure. The LHAs participating in the study represent 10 of the 20 Italian regions and cover the length and breadth of the country; as in northern regions information systems aimed at collecting and analyzing data are in general more sophisticated than in the southern regions, the sample is opportunistic and some regions (Veneto and Emilia-Romagna) are over-represented, while others in the South are not represented. An overview of the populations and locations of the 13 LHAs is provided in Figure
Figure 1
The population and geographical location of the 13 LHAs
The population and geographical location of the 13 LHAs.
During the preliminary collaborative work, both the authors and some of the general managers of the member LHAs identified the two main goals described above, of collecting data about the healthcare services consumed by residents, and of providing a forum in which to discuss benchmarking and the differences between LHAs.
Each of the participating LHAs designated three managers to be representatives in the collaborative research; a total of 39 managers were involved in the research activity, usually the financial controller, the head of the primary care department, and a representative of the top management. The authors of the present paper were nominated by the FIASO coordinators of the research programme and undertook the role of managing the collection and analysis of the data and of facilitating the collaborative research process. All LHAs gave their approval to the research.
First, we drafted an initial list of indicators that was discussed in the first focus group meeting with representatives of the LHAs. Subsequently, all 39 participants met the authors for four two-day workshops of eight hours per day. These workshops had several aims. The first workshop was used to discuss the draft list of indicators and to define a manual including a short description of each indicator and the rules of data collection. The second and third workshops were used to discuss and verify the reliability of the data collected. The LHA managers discussed the inter-LHA inconsistencies, which could have been caused either by data collection from different sources, or by the misalignment between the definitions of those services provided by the LHAs. Given the complexity of the PCC services and the autonomy enjoyed by the LHAs, indeed, the possibility existed that PCC services that had identical denominations were often not related to the same typology, quantity, and quality of the services offered to citizens
One of the most time-consuming tasks that took place during the workshops was the reduction in the misalignment of the definitions and the contexts of each PCC service in each LHA; it was commonly the case that the representatives of each LHA labelled the same service using different names, and in some cases labelled services that were very different with the same name. This was more evident for those services that were characterized by a lack of national standards, and for which LHAs were allowed a degree of autonomy (such as mother and child health, home care) than for the traditional services of primary care (general practitioners (GPs), prevention, and public health). The final workshop was used to discuss the resulting evidence and to debate the managerial implications for the LHAs.
The collaborative research took more than a year, from the first workshop in May 2007 to when the final results of this study were presented in July 2008. During this period, all the teams from the 13 LHAs were involved in data collection and ongoing interaction with the authors, working an average of 15 days in total over the period of the study.
The representatives of each LHA were asked to collect data on the use of healthcare services by their resident population. This resulted in a list of 303 indicators on quantity, appropriateness, costs, provision setting (hospital, emergency services, home care, etc.), and the nature of the provision (in-house, public or private external providers). The LHAs are all purchasers or providers of their residents' healthcare consumption under the Italian NHS, and they therefore have access to administrative data on every type of healthcare service consumed by their resident population and delivered by any type of provider, with the only exception being private out-of-pocket expenditure, which in Italy accounts for 23% of spending in the entire healthcare sector according to OECD data
The data collection
The method of analysis follows the collection of a set of 303 indicators related to the costs of PCC services and the activities concerned. Cost and activity indicators were computed on the basis of the healthcare services consumed by the residents of the LHAs during the year of the study that were funded by the Italian NHS, and that were provided by any type of provider (directly by the LHA, by IHs, by accredited private providers, or by other LHAs). In some regions LHAs are significantly involved in the provision of healthcare services, whereas in Lombardy Region there is a clear purchaser–provider split, and LHAs only assume the role of purchaser. Despite this difference in the quantity of services provided directly, all the LHAs receive per capita funding by their regional government to provide or to purchase healthcare services for their inhabitants. This guarantees homogeneity when comparing the resources used by the LHAs to finance their healthcare services.
The LHAs extracted data from their different information systems such as management accounting systems and customized in-house systems. One of the requirements of the procedure used for data collection was that the information on aggregate costs drawn from the final balance sheet matched the sum of the costs of the single services obtained from analytical accounting. Where there were differences between the two total costs, the LHAs were asked first to check for possible causes of the mismatch, then to improve the quality of the data used, and then to split the cost differential in each area of activity in proportion to its relative weight in comparison with the total expenditure. Missing data for single indicators related to one or more LHAs are due to the unavailability of data from the respective management information systems.
In order to evaluate the main trends for each indicator, the LHAs were requested to collect data related to two different years, 2007 and 2003, or data related to the closest available year (2004), if data for 2003 were unavailable. By taking this approach, we were able to assess the percentage variation of each indicator within the considered period. To neutralize the effect of inflation on monetary indicators, all the data were scaled to the year 2007 using the appreciation rates provided by the Italian National Statistical Institute
In order to account for differences in the demographic structure of the LHAs, we weighted inhabitants' use of outpatient visits to specialists, and examinations, pharmaceuticals, and hospital admissions, based on age and sex, adopting the same methodology used by the Italian NHS to weight the per capita funding to regional healthcare services in 2007
Additional file 1
Appendix 1 the analytical data of costs and activities collected within the 13 LHAs (2007 data). Appendix 2 the criteria used to weight the inhabitants' consumption of outpatient visits to specialists and examinations, pharmaceuticals, and hospital admissions, based on age and sex.
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LHA expenditure on types of PCC service and trends in the period 2003-2007
The LHAs within the sample spent in year 2007 an average of 1,682 euros per inhabitant; this covers any kind of healthcare service offered to residents by any type of public and private provider within the Italian NHS. This value is measured as full costing for each type of service and, therefore, includes expenditure deficits LHAs may create by having costs higher than their funding. On average deficit of the LHAs within our sample was 2.5% of the overall expenditure
The costs for inpatients, i.e., for both hospital admissions and emergency services, represented 44% of the overall costs, with an average expenditure within the sample of 746 euros per inhabitant (697 euros for hospital admissions and 49 euros for emergency services). The costs for outpatient services and PCC accounted for the remaining 56% of the total budget, with an average expenditure of 936 euros per inhabitant. Specifically, the expenditure on outpatients' drugs and medical goods (including prostheses) represented 16% of the total costs, with the expenditure on outpatients' visits to specialists and on diagnostic examinations being 13%, primary care (including prevention and public health) 9%, and intermediate structures (for rehabilitation, elderly people, disabled people, mental health) 11%.
The LHAs' expenditure is strongly focused on a few types of service: the top five types of service in order of decreasing expenditure per inhabitant (hospital admissions, pharmaceuticals, visits to specialists and for examinations, GPs, admissions of elderly people to residential structures) represented more than 81% of the total expenditure.
The comparison between expenditure data of Italian LHAs and the average of OECD data
The average annual costs increased over the period of analysis (2003–2007) by 3% (Table
The yearly variation in expenditure between 2003 and 2007 was related to a parallel variation in LHAs' indicators of activity concerning both hospital and primary and community care (Table
Variance in expenditure and activity among LHAs
The LHAs within the sample exhibit considerable differences both in terms of their overall health expenditure and in their volume of activity. The variance in expenditure within the sample was measured in terms of the standard deviation and is shown in Table
Next, the variation in the LHAs' activities was assessed using several indicators related to the LHAs' hospital and PCC activities. Average findings are presented in Table
With respect to hospital care, hospitalization rates varied from 142 to 284 admissions per 1,000 inhabitants per year, against a national standard recommended by the Ministry of Health of 180 admissions per 1,000 inhabitants; in average, a resident of the LHA with the highest hospitalization rate is exactly twice as likely to stay in a hospital than a resident of the LHA with the lowest hospitalization rate.
This variability increased while taking into account indicators of appropriateness, in terms of admissions to hospital and emergency services. The number of inappropriate hospital admissions varied within the sample from 5–40 admissions per 1,000 inhabitants, with a standard deviation equal to 67% of the average value of the sample. Rates of inappropriate admissions were calculated for 51 DRGs which are considered by the Ministry of Health to be inappropriate when requiring hospital admission. For example, in the case of cataract surgery, according to the Italian Ministry of Health, a patient should normally be treated in day surgery in hospital or as an outpatient, rather than as an inpatient.
A further indicator of appropriateness in the provision of healthcare services is the number of white codes in emergency departments, which are defined as accesses to emergency services which could be more appropriately treated in non-emergency settings (e.g., General Practitioners' ambulatories or continuity of care services). This indicator varied from 31–228 per 1,000 inhabitants in the LHAs of our sample, with a standard deviation equal to 70% of the average value.
Variation was also higher for indicators of primary and community care services. The average number of accesses to mother and child services varied within the sample from 30 to 432 accesses per 1,000 inhabitants, with a standard deviation equal to 74% of the average value. The number of accesses to mental health services ranged from 28 to 466 within the 13 LHAs, with a standard deviation value of 77% of the average value.
Moreover, variance within the sample was assessed by breaking down PCC expenditure of each LHA into three main groups of services: primary and ambulatory services, intermediate structures involving patient admission and two focused and specialized departments, namely Prevention and Public Health and Mental Healthcare, that are organizationally homogeneous in all the LHAs. Primary and ambulatory services consist of activities or processes that attempt to ensure primary assistance and continuity of care for patients without requiring any institutionalization. They include GPs, paediatricians, home healthcare and nursing home care, ambulatory mother and child services. Intermediate services, instead, are based on the physical presence of residential facilities and include services that aim to assist patients after their discharge from hospital, either in residential facilities for rehabilitation and long-term care or in ambulatory settings, such as structures for elderly people, disabled people, for rehabilitation and long-term care, hospice care. We decided then to keep distinct 'Prevention and Public Health' and 'Mental Healthcare' from the other types of PCC services, as they represent in the Italian context highly institutionalized departments that are traditionally homogeneous within the national sample of Italian LHAs, due to normative pressures separating the boundaries of those organizational departments from other PCC services. Including those departments in the other aggregations of PCC services could therefore risk to bias the comparison among LHAs in our sample.
The data reported in the graph (Figure
Figure 2
Composition of PCC expenditure within the sample (2007 data)
Composition of PCC expenditure within the sample (2007 data).
In addition, Table
The list of the indicators collected by the 13 LHAs during the collaborative research, together with their median and average values, standard deviations, and yearly growth rates, are given in Additional file
LHA expenditure on types of PCC service and trends in the period 2003-2007
Through a detailed analysis of healthcare consumption, which looked both at costs and at services provided by a sample of 13 Italian LHAs, we collected data on health expenditure and outputs related to PCC services. Our results show that the financial resources devoted to PCC are greater than those devoted to hospital inpatient and emergency services, representing on average 56% of the total expenditure of LHAs on their inhabitants' healthcare consumption. Although the expenditure on PCC services exceeds that on hospital care in our sample, the mix of services is highly heterogeneous among the LHAs. Most of the LHAs' expenditure is focused on a few services (hospital admissions, pharmaceuticals and outpatients' services), whereas a number of other services with increasing health and social relevance (e.g., services for elderly people, disabled people, mother and child, and hospice care) receive comparatively few resources. Our findings show that LHAs tend to focus their activity on traditional types of PCC services (e.g., GPs, outpatients' visits to specialists and diagnostic examinations) and allocate only marginal resources to those services that provide care for a growing range of citizens' needs, from disability to hospice care.
Our findings on the annual trends in healthcare expenditure show that there is strong growth in the percentage of outpatient visits to specialists and for diagnostic examinations; this category represents the third service in terms of overall costs (220 euros per inhabitant) and shows a 6% growth rate, which is much higher than those of the other main PCC services. The weakness of many LHAs in managing the level of consumption in this category and integrating it with other services (such as services provided by GP practices and visits to specialists and examinations in hospital) appears to be contributing to the increase in this expenditure, with the risk of clinical path fragmentation, the duplication of costs, and high levels of inappropriate visits
Variance in expenditure and activity among LHAs
There is a high degree of variance in the overall expenditure of LHAs and in their mix of PCC services. Moreover, there is a different mix of expenditure on tiers of care across the LHAs. Specifically, two distinct strategic orientations have emerged with regard to the adoption of PCC services by LHAs: one group of LHAs mainly invested in ambulatory and home-based primary care services (GP networks, community-based services, home and ambulatory care) in order to increase the number of low-complexity settings (with GPs and nurses as case managers), to integrate health and social assistance for chronic patients, and to reduce the inappropriate use of hospital admissions and emergency services. A second group of LHAs prioritized the allocation of resources to focus on intermediate inpatient structures for specific types of patients, namely elderly and disabled people, post-acute patients needing rehabilitation and long-term care, and those in hospices. In this case, the LHAs tended to increase the degree of appropriateness of inpatients with admissions using nursing-based structures.
Evidence of the two strategic orientations within the Italian context arises from the analysis of both Regional and LHAs' strategies. At the Regional level, for example, two of the most populous and wealthy Regions in northern Italy chose different strategic orientations for developing their PCC services. Lombardia Region mainly focused on intermediate, residential structures for older and disabled people, whereas the contiguous Emilia-Romagna Region mainly invested in ambulatory and home-based primary care services. Some few indicators clearly show this difference in strategic orientation. In Lombardia Region there is an endowment of almost 6.5 beds in structures for older people per 1,000 inhabitants, whereas in Emilia-Romagna there are almost 3.2 beds per 1,000 inhabitants. On the contrary, Emilia-Romagna outshines Lombardia for accesses to home care services, with an average value of 454 versus 368 home care visits per 1,000 inhabitants
Those strategic orientations are also evident in the LHAs of our sample. LHA1 is a LHA in Emilia-Romagna Region, with a strong focus on primary and ambulatory services (69% of overall PCC expenditure versus an average of 59% within the sample). Looking at activity indicators, LHA 1 presents a high degree of access to home care services (514 versus an average of 424) and to mother and child services (432 versus an average of 160). Those indicators are related to a limited endowment of intermediate structures for older people (3,241 days in residential structures per 1,000 inhabitants > 65 years versus an average of 5,423 within the sample) and for disabled people (78 days in residential structures for disabled per 1,000 inhabitants versus an average of 115). On the contrary, LHA 11 is a LHA in Lombardia Region and has a strong focus on expenditure in intermediate care structures (28% of overall PCC expenditure versus an average of 21% within the sample). Services for primary and ambulatory services are limited, as it is suggested by the low degree of access to home care services (231 accesses per 1,000 inhabitants versus an average of 424). LHA 11, however, widely invested in intermediate structures for older people (8,652 days in residential structures per 1,000 inhabitants > 65 years versus an average of 5,423) and for disabled people (128 days in residential structures for disabled per 1,000 inhabitants versus an average of 115).
Both strategies have an impact on the local hospital network concerned. In the first case (focus on home and ambulatory care), there is still a need for some local community hospital, in order to provide timely care to patients with acute needs. In the second case (focus on intermediate structures), the opportunity exists for an additional reduction in the local hospital network. Intermediate structures are endowed with medical and nursing personnel and can often also provide appropriate care for some of the chronic and elderly patients' acute phases, thus a further reduction in inpatient hospital assistance is possible
Moreover, the data show that the LHAs in the sample are homogeneously distributed along the entire range of potential PCC strategies, ranging from a focus at one end of the spectrum on home and ambulatory care to a focus at the other end on the use of intermediate structures. During our discussions with LHAs managers, it appeared that these opposing strategies had emerged over time, rather than having been consciously and explicitly planned. For instance, one representative stated: "We have never thought about PCC in this way, we were only concentrating on decreasing the hospital market share and on developing community and primary care".
However, the choices made by the LHAs are often driven by path dependency on previous structural or professional resources rather than by their definition of strategic priorities. Those LHAs that are endowed with former hospital or ambulatory structures tend to have a large number of intermediate care structures. Those LHAs that do not have these structural facilities are instead more suited to investing in ambulatory and home care and to developing GP structures. On the other hand, community-based specialist departments and medical centres, such as departments of Prevention and Public Health and Mental Healthcare, which in Italy are highly regulated by controls that are institutionalized centrally, register much less variability. As shown by our data, they tend to maintain the historical consumption of resources devoted to respect the planned staff, equipment and facilities standards, with limited variation among LHAs.
Path dependency is often related to a weak organizational consciousness and a lack of explicit service portfolio policies
The model of this collaborative research study and the results from the collected data suggest that there are strategic implications for both LHAs and the Italian NHS as a whole, from which many other healthcare systems may draw some lessons. There has been an increasing shift of services and resources from inpatient hospital settings to settings based on outpatient community and primary care. Many LHAs are introducing innovative PCC services and have the scope to develop these further. In this process of transformation, LHAs have the flexibility to identify a suitable mix of PCC services and settings on which to focus their financial and organizational resources. In a context dominated by financial constraints, both the service portfolio and the organizational evolution of PCC services must tackle the emerging needs of elderly and chronic patients and the increasing expectations of the population as a whole
However, whether and to what extent these different balances are driven by the LHAs' strategic choices is unclear. Moreover, these different balances may be the result of emergent, unplanned strategies that depend on the LHA's path dependency on previous structural or organizational resources. As suggested by literature on management, path-dependent resources (e.g., structures, specialist technical expertise, and unique capabilities) are rooted in the history and culture of organizations, and there is a high likelihood that they will be perpetuated within those organizations
We have herein proposed an innovative methodology of data collection for PCC services, which was developed as part of a FIASO collaborative research study, through the analysis of data on health consumption and costs within 13 Italian LHAs. The participants and authors identified a list of more than 300 indicators of PCC services within the Italian NHS. The aim was to tackle the complexity of understanding the consumption of PCC services through an intense interaction with the owners of the data. Whereas previous studies compared and elaborated aggregated and analytical data collected by separate and independent sources
This measurement approach can be applied to LHAs whose management information systems are at different stages of maturity. For example, the costs and activities of LHAs with good management information systems can be compared at an analytical level by using more than 300 indicators; however, it is possible for any LHA to provide a synthetic representation of its healthcare consumption and of key activity indicators by following our approach. Moreover, for the representatives of the LHAs involved, the process of data collection was an important opportunity to identify and compare costs, outputs, and indicators of the quality of the healthcare services they provide to their inhabitants, and to make sense of the data by discussing and interacting with other LHA representatives and the authors.
As shown by the results reported herein, after more than 15 years of progressive resource shifting from hospital to PCC settings
In conclusion, the data reported in this study, the discussion, and concluding suggestions indicate that LHAs' strategies regarding the provision of PCC will play a vital role in the future direction of healthcare organizations and health systems. From this perspective, PCC cannot be considered to be a single service, but to be rather a combination of several services that contribute in variety of ways to the achievement of multiple healthcare goals. We hope that the model proposed in this article can be used as a first step in analysing wider and different contexts, with the aim of ascertaining which combination of PCC services enables LHAs to obtain the best results in terms of effectiveness of care and ability to satisfy the population's diverse healthcare needs.
LHA: Local Health Authority; INHS: Italian National Health Service; PCC: Primary and Community based-care services.
Competing interests
This FIASO collaborative research is supported by an unrestricted grant from
Authors' contribution
Authors' names are listed in alphabetical order. All authors equally contributed to the paper. All authors read and approved the final manuscript.
Authors' information
Francesco Longo is Associate Professor at the Department of Institutional Analysis and Public Management of Bocconi University, Milano
Domenico Salvatore is Assistant Professor at the Parthenope University, and researcher at Istituto SDN Napoli.
Stefano Tasselli is PhD candidate at the Judge Business School of the University of Cambridge and Research Fellow at Cergas-Bocconi.
We would like to thank the Italian Federation of Health Authorities and Hospitals (FIASO) and the participants of the FIASO collaborative research study on the management of non‐hospital care for taking part in this collaborative research and for the data that were used in this article.
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Pre-publication history
The pre-publication history for this paper can be accessed here:


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Belarus president: Subway blasts kills 12
MINSK, Belarus (AP) Belarusian authorities said Tuesday they have identified a suspect of a subway bombing as the death toll rose to 12, with more than 200 wounded. The opposition, meanwhile, voiced fears that the attack may lead to an increased crackdown on dissent.
Belarus' domestic security agency, which still goes under its Soviet-era name KGB, said that had identified the likely perpetrator of Monday's explosion at a busy downtown subway station and was searching for him. It didn't elaborate.
The Interior Ministry said the bomb placed under a bench on the Oktyabrskaya station exploded as people were coming off the trains at an evening peak hour. The station is within 100 meters (yards) of the presidential administration building and the Palace of the Republic, a concert hall often used for government ceremonies.
Belarus' authoritarian President Alexander Lukashenko said at a meeting with officials late Monday that foreign forces could be behind the explosion, but he didn't elaborate.
Authorities said that 204 people have sought medical help and 157 of them have been hospitalized, including 22 in critical condition.
Viktor Sirenko, the chief doctor of the Minsk Emergency Hospital, said that many victims had lost arms or legs.
People streamed to the site of explosion to lay flowers as police tightened security at all subway stations.
"I went through that hell, I saw that pile of disfigured bodies," 37-year old Nina Rusetskaya said as she lit a candle at the explosion site. "I rode a car in the back of the train and only survived by miracle."
Lukashenko, in power for nearly 17 years and dubbed "Europe's last dictator" by the West, was declared the overwhelming winner of December's presidential election which international observers said was rigged. He has run the former Soviet nation of 10 million with an iron fist, retaining Soviet-style controls over the economy and cracking down on opposition and independent media.
Lukashenko took his 6-year-old son to visit the site of the explosion about two hours after the blast. He later ordered the country's feared security forces to "turn everything inside-out" to find the culprits.
Alexander Milinkevich, a prominent opposition leader, voiced fears that the explosion could serve as a pretext for a further crackdown on dissent.
"Forces both inside and outside the country, which are interested in the destabilization of the situation in Belarus, could profit from that terror attack," Milinkevich said in a statement Tuesday. "These forces want to provoke even harsher political repressions."
More than 700 people, including seven presidential candidates, were arrested after massive protests against fraud in December's presidential vote.
The European Union and the United States have responded to the flawed vote with sanctions, leaving Lukashenko to rely exclusively on it main sponsor and ally Russia.
Lukashenko has often launched diatribes at the West, accusing it of trying to destabilize Belarus. But his relations with Russia also have often been strained in the past as he accused the Kremlin of trying to wrest control over Belarus' key economic assets.
Belarus is facing a severe economic crisis with hard currency reserves running critically low and people waiting in day-long lines to exchange rubles as they prepare for devaluation of the national currency.
Alexander Klaskovsky, an independent political analyst, said that Lukashenko would likely use the attack to further tighten control in view of the economic upheavals. "Lukashenko will use it to strengthen his hand ahead of a looming economic catastrophe and social tensions," he told the AP.
Copyright 2011 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.
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SARASOTA COUNTY, Fla. -- It's that time of year again: mosquito time. And it's been highlighted recently with a confirmed case of what is called chikungunya in Charlotte County last week.
Chikungunya is a rare disease spread by mosquitoes. Monday, ABC 7 talked to local experts about what the odds are of more cases appearing and what's being done to combat the pests.
This is the time of year when mosquitoes are becoming more prevalent, and we are told that the most activity in Sarasota County is in the North Port area.
The weather is hot and rainy, so the fact that mosquitoes are here is no real surprise. What is new to many is a disease with a funny name called chikungunya. 18 cases have been reported in the state: one in Lee County and now in Charlotte County.
Sarasota County mosquito manager Matt Smith has been following the spread and says he's really not surprised. "I knew it was just a matter of time before we started seeing cases; definitely in the Caribbean and some imported cases in Florida."
Similar to dengue fever, chikungunya can make you sick like the flu, causing severe joint pain.
"We have not had a locally squired case." State Health Department officials like Michael Drennon say so far there are no cases of someone getting bit by a mosquito in Florida and acquiring the disease. Instead, they are getting bit outside of the country and returning home. "It is important to know they are out there and to do the investigation, but we are not sending out a code red or anything like that."
Right now the odds are pretty low you would catch any type of mosquito-carried disease. However, you can still get bit up.
Smith says they're seeing increases in certain areas. "In the past couple weeks we have seen population increases in the North Port and Venice area. We did put together a couple of flights with our contractor and did some aerial spraying."
They've been going after the salt marsh mosquito. It reproduces quickly in swampy areas.
Last week smith says they sprayed more than 25,000 acres and it appears to be working. "The traps went from the thousands to some in the single digits. It's nice to see. It's a huge response."
In the meantime, they're continuing to monitor for diseases like encephalitis and the west nile virus. Names we've heard before.
They're also asking everyone to get rid of standing water in yards, dress appropriately, and put on some sort repellant. "We can't reach everyone. We can't go to every house. It's really important for people to understand that mosquito management starts with them at their house."


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Product Spotlight
Featured Research
Quick Stats
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Publix Store-brand Vanilla Wafers Recalled on Undeclared Ingredient
The product was distributed to Publix stores in Florida, Georgia, South Carolina, Alabama, and Tennessee.
Toufayan Bakery, manufacturer of Publix Vanilla Wafers, said it is recalling a limited number of 12-ounce boxes of the store-brand cookies because they may contain undeclared soy, according to the U.S. Food and Drug Administration.
The product was distributed to Publix stores in Florida, Georgia, South Carolina, Alabama, and Tennessee.
"The recall was initiated after the discovery of gingersnap cookies co-packaged with vanilla wafers. This resulted in the undeclared soy ingredient," said Roy Peterson, Toufayan Bakery general manager, in a news release distributed by the FDA. "As part of the Publix commitment to food safety, they are asking customers to return the product for a full refund or replacement. There have been no reported cases of illness."
People who are allergic to soy may risk a serious or possibly life-threatening allergic reaction if they eat the recalled product.


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years ago (late 1970s) my brother and I ate at an Italian restaurant in Syracuse. I believe that the restaurant was on Erie Blvd, but I am not sure. Anyway, I distinctly remember waiting in the bar for a table to come open. the entire bar was decorated with posters from Frank Sinatra movies, and the juke box only had Frank Sinatra songs on it. If my memory is correct, the cuisine was traditional "red sauce Italian."
does anybody remember this restaurant's name and/or location? is it still in existence? thanks!


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Durban: South African cricket captain Shaun Pollock could be forgiven if it was the trying times of the West Indian tour that caused it, but few people would get on a plane that was heading in the opposite direction to where they were heading and find out about it on the flight.That is exactly what happened early last week. An obviously embarrassed Pollock admitted to the Afrikaans weekly 'Rapport' that he had boarded a plane from Johannesburg to Cape Town while thinking that he was flying to Durban. But Pollock would not say anything more about the incident.Durban is on the eastern coast of South Africa, an hour's flight from Johannesburg, while Cape Town is about two hours away on the west coast.Member of Parliament Cassie Aucamp, a keen cricket fan, told Rapport that he recognised Pollock on the flight and approached him to chat. "We were in the air for about an hour already when I went over and introduced myself. He was very friendly," said Aucamp. "He told me that he had spent the day in Johannesburg playing golf. I told him that I was on my way to Cape Town for the parliamentary session, upon which he said that he would be in Cape Town the next day as well, for a meeting with Sports Minister Ngconde Balfour," Aucamp added."I was very surprised. 'How's that?' I asked him, as this plane is going to Cape Town (tonight). No, he answered, we're on our way to Durban," saidAucamp. Pollock then took out his boarding pass, which reflected Johannesburg-Cape Town."If I had not talked about it, Pollock would probably have arrived in Cape Town before he realised he was not in Durban," Aucamp said. The flight crew made immediate alternative arrangements to help Pollock out of his predicament. They advised his wife and put steps in place to correct the situation.While Pollock might have been confused about the Durban stopover, he certainly arrived well in advance for the meeting with Balfour in Cape Town the next day. No details of the purpose of the meeting were available.IANS
Post your views


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Bankruptcy Law
Bankruptcy Law Questions? Ask a Bankruptcy Lawyer.
Hi JACustomer,
You would have to include the expense check in your income (Schedule I - Current Income), and then include all out-of-pocket expenses in your expenses (Schedule J - Current Expenditures).
In other words, the difference between what you receive and what you spend would end up being a part of your income for a Bankruptcy filing.


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Ancient artefacts are artefacts from the Third Age that players can obtain as drops from revenants in the Forinthry Dungeon or the Chaos elemental. According to Mandrith, as the blood of warriors is spilled, as it once was during the God Wars, artefacts of that age feel the call to battle and are drawn into the rays of sun once more.
These can then be traded to Mandrith in Edgeville bank or Nastroth in Lumbridge Castle's courtyard for a sum of cash determined by the type of artefact. Be aware that the noted versions of these artefacts cannot be traded in.
The higher the value of the artefact, the rarer it will be from the revenants. A Saradomin amphora can be easily obtained from high level revenants, but an Ancient statuette will be much rarer from a high level revenant.
Due to the everlasting threat of PKers, it is recommended to bank the artefact straight away unless you are absolutely sure you will not die or if the artefact is much more expensive than one of your standard revenant items (like d'hide, weapons, etc.) Because many players have a risk that usually makes them drop anything below 50k, it is recommended to bank immediately as soon as you get anything that is a Bandos scrimshaw or higher.
Before the return of the Wilderness, these artefacts were obtainable from killing players in a PvP or Bounty Hunter world and only a few were for Free to play players (up to Armadyl statuette). As of 1 February 2011, these artefacts are now exclusively dropped by revenants in the Forinthry Dungeon and the Chaos elemental; all artefacts are Free to Play, making the Ancient statuette the best item a F2P revenant hunter can get, instead of the corrupt dragon battleaxe, which held the record until 1 February 2011.
Image Artefact Value Broken statue headdress 5,000 coins Third age carafe 10,000 coins Bronzed dragon claw 20,000 coins Ancient psaltery bridge 30,000 coins Saradomin amphora 40,000 coins Bandos scrimshaw 50,000 coins Saradomin carving 75,000 coins Zamorak medallion 100,000 coins Armadyl totem 150,000 coins Guthixian brazier 200,000 coins Ruby chalice 250,000 coins Bandos statuette 300,000 coins Saradomin statuette 400,000 coins Zamorak statuette 500,000 coins Armadyl statuette 750,000 coins Seren statuette 1,000,000 coins Ancient statuette
5,000,000 coins
- Some artefacts are placed incorrectly in the tile the drop is usually put in. For example, statuettes of all types, the ruby chalice, Saradomin statuette, Saradomin amphora and Third age carafe are put into one corner of that tile. The Armadyl totem, Guthixian brazier, Zamorak medallion, Bandos scrimshaw, Ancient psaltry bridge, bronzed dragon claw and broken statue headdress are put in the middle of the tile.


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Learn more about SMITH & WALKER (OPTOMETRISTS) LIMITED. Check the company's details for free and view the Companies House information, company documents and list of directors.
Know about every new company document that is added!
Take advantage of our watch this company feature free of charge and have notifications sent directly to your inbox. Whenever a new document appears on this website, or if their particulars change, you will be immediately informed about such changes. To monitor these changes, all you need to do is click on watch this company.
|Tangible Fixed Assets
|£ 98,778
|Current Assets
|£ 167,159
|Tangible Fixed Assets Depreciation
|£ 13,008
|Provisions For Liabilities Charges
|£ 3,686
|£ 44,564
|Shareholder Funds
|£ 111,251
|Profit Loss Account Reserve
|£ 109,502
|Called Up Share Capital
|£ 1,749
|Net Assets Liabilities Including Pension Asset Liability
|£ 111,251
|Total Assets Less Current Liabilities
|£ 124,119
|Net Current Assets Liabilities
|£ 25,341
|Creditors Due Within One Year
|£ 141,818
|Cash Bank In Hand
|£ 44,639
|Stocks Inventory
|£ 77,956
|Share Capital Allotted Called Up Paid
|£ 1,749
|Number Shares Allotted
|£ 1,749
|Tangible Fixed Assets Disposals
|£ 167,835
|Tangible Fixed Assets Additions
|£ 14,713
|Tangible Fixed Assets Cost Or Valuation
|£ 111,251
|Tangible Fixed Assets Depreciation Charged In Period
|£ 5,435
|Tangible Fixed Assets Depreciation Decrease Increase On Disposals
|£ 158,022
|Creditors Due After One Year
|£ 12,868
Information about the Private Limited Company SMITH & WALKER (OPTOMETRISTS) LIMITED has been prepared for information purposes only. It is not intended to be nor does it constitute legal advice. This is public information provided by the official company register.


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Virgin Media has announced a deal with Spotify to offer the music streaming service across its TV, mobile and broadband platforms.
Whichever service you choose – or currently use – you'll be able to add in Spotify at a reduced price and pay it via your monthly Virgin bill.
New and exisiting Virgin customers can get Spotify Unlimited for all-you-can-eat access to Spotify's 13 million track library ad-free on PC, or Spotify Premium, which adds a feature for mobile phone use.
They will also get exclusive features and content likely built from Virgin's long track record of working with the music industry.
Subscribers to Virgin Media TV can use a special app developed by Spotify and Virgin to stream music via TV. Network Three was the first to bundle Spotify at a reduced rate, but Virgin's deal to let you play Spotify on your TV is significant as it places the service at the centre of home entertainment – in addition to its current place in computer and mobile use.
The service will launch in the next few months, with existing customers getting first dibs on signing up. If you already use Spotify, whether on Virgin or not, you can keep your account and still take advantage of the lower monthly rates and special promos.


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3 Important Money Lessons Every Child Should Learn
Entrepreneurship should be a goal for everyone. While we all have to be employed in order to earn money, we must remember that we can't just be working for someone else for the rest of our lives. In one way or another, we must be able to find a way to start our own business that we can develop and grow whether full time or as a side income.
These days, many entrepreneurs are starting their journey when they're already older. As entrepreneurial parents, your children can start their financial education and their journey to the business world as early as possible to increase their chances of success in the future.
The best way to develop business sense in children is to incorporate money lessons and related concepts into play and guided situations. Don't underestimate them because they learn fast through experience, imitation and observation.
Here are 3 lessons you can teach your children at a young age:
1. Budgeting
Most children will often ask parents to buy toys, sweets and other things they see while in shopping centers. If your kids are starting to ask you to stuff like that more frequently, introduce to them the concept that money is limited. Inform them that mom and dad will have to work first to earn money to buy more things.
If your current cash permits, you can tell them that they can only choose one item to buy at the moment. Otherwise, you can inform them of the consequences of buying something they really can't afford, which leads to not having something else that is more important to their daily lives.
"It's not about ideas. It's about making ideas happen." – Scott Belsky
In this way, children will learn how to prioritize and be able to differentiate their needs from wants. Even if you're rich, it's wise for the children to learn this concept so that they won't grow up spoiled.
Activity Idea: Visit a candy shop or a snack bar and give your child a certain amount of money. Let him do his own shopping as he makes sure that he has enough money for the things he wants to buy. Let them figure out what they want and how much they can afford with the budget that was given to them.
2. It pays to shop around
Children generally want to own the first attractive toy they see in the store. This should be a good opportunity for you to teach them about deferring the purchase so you have more time to compare the same products in other stores or find some good alternatives. It's wise to explain why you're not buying what they want yet; otherwise, they would be throwing tantrums in the store.
By shopping around, they will soon realize that a dozen apples in shopping centers may be more expensive than those in the farmer's markets or a generic doll may be much more affordable than the famous branded ones that many girls love.
Activity Idea: Bring your children during "grocery days" — the days when you need to buy important supplies for the home. But before you go, create a shopping list and involve your kids in deciding what the house needs. When shopping, let the children have the list and let them decide which brands you should be buying.
Considering that this involves major purchases, you should have the final say on what should go into the cart but make sure to explain to the kids about product quality, prices and other factors that affect your decisions. The next time you buy groceries with the kids, consider going to another store or better yet, a farmers' market where products have low prices.
3. Time is gold
It may be a cliché, but children will have to understand that they only have 24 hours a day to do productive things or waste away. Just like their summer breaks, they have the freedom to do what they want such as earning money by getting jobs for kids, selling food at their makeshift stalls on the yard, studying for the lessons to be taught in the next semester or just playing around with friends and taking vacations. They should understand that their decisions can affect their future.
"The best time to plant a tree was 20 years ago. The second best time is now." – Chinese proverb
Activity Idea: Let your child list down what she wants to do over the weekend or the school break. Sit down with them and brainstorm the benefits of each activity for their future. The purpose of the activity is to let them understand the concept of time management in terms of self-development, and thus, avoid imposing activities that they should be doing. Let them enjoy the break in ways they know how — with your guidance of course.


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I've been joining The Noise FM on stage the last several months, helping out with guitar, synth and background vox. Here are some…
Category Archives: Featured
Ken Arlen's Entourage
Half Moon Run
Tom Fuller Band
I had the opportunity to track five songs last week with Tom Fuller and his band at Waterdog Studios. Tom is a killer songwriter with a truckload of raw character [Continued…]
Tom Cloud
Spent several weeks this past month working in the studio with Tom Cloud. Tom is an incredible singer-songwriter with a rich, deep, classic voice. Christian Cullen is producing this one, with Grant Tye on guitar, Klem Hayes on bass and [Continued…]
Playing Bass with Cathy Richardson
The Van Goghs
In the studio this week with singular Chicago-based artist Surachai, bridging multiple genres from experimental electronic to black metal. Guest musicians include my old friend Alessandro Cortini (Nine Inch Nails, Muse), mind-blowing experimental electronic artist Richard Devine, and Charlie Werber on drums. [Continued…]
Joey Hatcher
In the studio this week with Nashville-based singer-songwriter Joey Hatcher. My old friend Rick Chudacoff is producing this one, with a star cast of musicians including Christian Cullen (keys and bass), Grant Tye (guitar) and Michael Caskey (drums). [Continued…]


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JRS Consultancy
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Required Md Orhto Having Rich Experience in Arthroscopic and Joint Placental for a Reputed Hospital.
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We have Urgent Need of Cardiologist.
Key Skills : heart specialist,cardiologist,cardiology,heart surgeon,interventional cardiologist,cardiology consultant,cardiac surgeon,cardiovascular specialist
Urgent Requirement for General Surgeons..!! ( Fresher)
Hi Impact Consultants
North Delhi, South Delhi, Delhi,Haryana,Uttar Pradesh
This is regarding the position of General Surgeon in the leading Medical College & Hospitals of multiple locations Locations -DELHI/NCR -Haryana -Uttar Pradesh Post- Senior Resident Qualification- MS/DNB Salary- As per norms and Nego...
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Key Skills : veterinary doctor,doctor,medical officer,animal doctor,veterinary drug formulation,veterinary surgeon,animal health,icu...
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RS 1,25,000 To 4,00,000 North Delhi, Delhi, Mayur vihar phase 1
As a Full Time Consultant At the Dental Clinic (from 10-2pm and 4-7 Pm). Urgently Required a Dentist Graduated from Government Dental College Who Can Work in Mayur Vihar Phase 1 ( Near Metro Station).
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Marketing Executive ( 1 - 3 yrs)
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We are Looking for cardiologist for Location Delhi, U.P, Bihar, Rajasthan, MBBS, MD, DNM, PGDC.
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Plumbing Repair Service, Boca Raton and surrounding area
Leak Detection Service – Palm Beach Fl Plumbers
Hardenburgh Plumbing offers plumbing repair service, leak detection, drain cleaning and water restoration services that include new installations and 24 hour emergency repair services. We handle everything from installing a new faucet, toilet, fixture, or water heater to fixing repairs or finding and handling leaks. We now also handle water restoration for those pesky leaks that have gone too far and caused you damage before you noticed there was a problem.
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We are dedicated to handling the needs of residential plumbing repair service and commercial plumbing services in West Palm Beach, Wellington Fl, Boca Raton, Greenacres, Lake Worth, Royal Palm Beach, Palm Beach Gardens, Lantana and surrounding Palm Beach area.
Call Hardenburgh Plumbing to ask about our plumbing repair service, talk about a plumbing problem you are having or a plumbing installation you need to be done. Schedule an appointment for us to come take a look at your home or business.
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Call: 561-968-0000 Today!
Since 1989, Hardenburgh Plumbing has been providing plumbing installation, emergency plumbing services, maintenance, drain cleaning services, air conditioning services and repair, sump pump repair, and pool pump repair services in South Florida. We provide both residential and commercial services to those in West Palm Beach, Wellington, Boca Raton, Greenacres, Lake Worth and beyond.


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Disclaimer: I do not own any of these characters. *Sobs* Joss Whedon does. *Cries in corner*
Authors Note: This is probably a one-shot story, but I could continue it . . . IF you review. Please? :)
Summary: It was a dark and stormy night . . .
After the fight, and they picked up all of the disgusting body parts, they stood outside the mall parking lot. Cordelia rolled her eyes in disgust when Buffy told them she hadn't killed Angel. Great, the psycho-vamp was still up and running. Just what they needed.
Giles turned to Buffy. "I'll drive you home, Buffy." Buffy nodded, looking distracted.
Cordelia watched them leave. Fantastic, she was going to have to hitch a ride with Xander. Oz was driving Willow home and she doubted he'd want her there. Cordelia flipped her hair and turned around. Xander was nowhere to be seen, his mom's car was gone. Oz's van started to pull out.
She ran after it, desperately, "No wait! Guys, I don't have my car!" She swung her arms wildly, trying to catch their attention.
The van disappeared around the corner. Great! She was stuck in the middle of the night, sixteen miles from her house, with no cell phone.
She kicked a can out of her way, angrily and headed over to the she fished in her purse and pulled out her wallet. She had nine pennies! Cordelia Chase, who was always prepared, didn't have enough money to make one fricking phone call! Cordelia mentally kicked herself as she remembered where all her change had gone. She'd lent Xander all of her change because he'd wanted some chocolate. And the guy re-payed her by leaving her in an abandoned parking lot.
She jumped when someone tapped her shoulder. A hand held out a dime. She turned to the owner gratefully,"Oh thank you! You are a life- Angel!"
Angel was leaning against the booth, nonchalantly, smiling at her. Cordelia jumped backwards and shut the pay-phone's door. She recoiled at his inviting, casual smile. Buffy was right, he was someone else entirely.
His smile widened at her discomfort and he said breezily "It's interesting."
Cordelia's eyes narrowed and after a moment she asked suspicously "What is?"
"That the people who you help kill monsters every fricking day, could just leave you here. At night. In the middle of nowhere. With an evil vampire on the loose. Not the best thank-you." Angel said.
Cordelia felt annoyed that the vampire had nailed it so well.
"It's not like they did it on purpose or anything." If they had, she'd have been all for Angel eating them.
"How's that feel, Cordy? That you; Cordelia Chase, could be so easily forgotten? I'm betting not very nice."
"Pssh, easily. There's just been a lot going on . . ."
"You sure bout that Cordelia? Even your boy-toy left you here. He made sure Buffy got home safely. And Willow. Don't tell me that doesn't bother you. That he cares more about Buffy and Willow then the girl he's groping in the janitor's closet?!"
"How do you even . . . Nobody knows that we . . ." Cordelia stuttered, trying to regain her senses.
" Please. His scent is all over that wonderfully sculpted body. I notice a lot more then you'd think."
Angel's eyes roamed. Cordelia shifted uncomfortably. Her hand fingered the cross she wore around her neck, similar to the one Buffy had.
Angel straightened up. That tiny movement made Cordelia regain her senses. He was an evil vampire who'd tried to kill Willow and here she was chit-chatting with him. Angel noticed the change in Cordelia's features.
"I never told you, but you have an intoxicating scent. A special flavor, if you will. And mixed with all this fear . . .Yummy!" He banged the door loudly and she let out a quiet gasp.
"I was gonna kill Willow, but you'll do too." He added inspecting her.
Cordelia's pulse quickened. She backed up and pressed against the wall, mind racing frantically.
"It won't inspire any of that deep sorrow I was going for. You may not even be missed. But hey! A life's a life." He said, spreading his arms wide. "Maybe I'll leave you outside of Harris's house. Or maybe your car?" He mused.
Cordelia barely heard him. She let out an incoherent whimper. She was going to die.
"I wonder how many people will show up at your funeral. Do you think your parents will bother to go?"
The fear pulsing through Cordelia was replaced with anger. She was Cordelia Chase dammit! She wasn't going to cower in a corner while some vampire with over-gelled hair taunted her. She straightened and grabbed the handle of the door. Angel tugged on it and it took all of her strength to hold it shut. She breathed deeply. They played tug of war for a few minutes and then Angel relinquished the handle.
Cordelia couldn't resist a satisfied smirk in his direction. Which was probably a bad idea. Angel gave a shrug and then turned around. Cordelia let out a deep breathe, and then screamed when he swung back around and punched the glass.
"You really think you're stronger then a vampire?" He asked grinning.
Cordelia dug in her purse quickly. She pulled out a vial of holy water. Uncapping it shakily, she pointed it at him.
"D-don't come any c-closer!" She warned.
He gave a crazed laugh. "Very scary."
"I mean it." Cordelia choked out.
He strutted towards the door and pulled on it again. Cordelia scrambled to grab it, the vial of holy water crashing to the floor and shattering into a million pieces. He pulled the door open easily, jerking her released the handle and Angel swung the door towards her. The door hit her and she fell backwards, banging her head against one of the glass walls.
Cordelia leaned against the glass, head spinning, and eyes blurry. Angel walked forwards.
She tried to kick him. He dodged it easily.
"Tsk, tsk, tsk." He shook a finger disaprovingly. "Play nice, Cordy."
Her jaw clenched angrily and her hand shot out. It connected with his jaw with as much force as she could muster. She swore when her hand felt like she'd slammed it against a wall.
Angel worked his jaw back and forth and then chuckled. "Wow, Cordy. Didn't think you had it in you."
Ignoring his comment, she kneed him in the groin and then bolted around him. She'd pushed the door open when he grabbed her and slammed her against the glass again. Cordelia slid to the floor and looked up at him fearfully.
Her life wasn't flashing before her eyes like it was supposed too. She was stuck in the cold, harsh here and now. Tremors were running up and down her body, fear pulsating through every vein.
Angel was grinning widely again. He tossed something silver in the air and caught it. Still grinning, he dropped it onto the ground next to her. It was a dime.
"See ya around Cordy." He said with a tip of his head. Then he turned and strode away, humming to himself.
Cordelia stared at the dime for several long seconds, breathing deeply. Then she collected herself, fixed her hair, and picked up the small circular dime.


text: The Work Bench is the home improvement store where Sam works with Sock, Andi and Ben. Ted was their boss. Andi was recently promoted to manager. The outside of the Work Bench resembles Hechinger's which went out of business. Retrieved from "http://reaper-cw.wikia.com/wiki/The_Work_Bench?oldid=4206" Ad blocker interference detected! Wikia is a free-to-use site that makes money from advertising. We have a modified experience for viewers using ad blockers Wikia is not accessible if you've made further modifications. Remove the custom ad blocker rule(s) and the page will load as expected. Categories: Locations Add category Cancel Save


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Thin Lizzy - Thunder and Lightning - Live (HQ) MP3
We Were Promised Jetpacks - It's Thunder and It's Lightning (Live on KEXP) MP3
We Were Promised Jetpacks perform "It's Thunder and It's Lightning" live at the Doug Fir in Portland during KEXP's broadcast during Musicfest NW.
30min of Real Lightning Storm, Rain and...THUNDER MP3
(English-Español) After nearly a week of hot summer days (about 100F/ 37C) the thunderstorm finally arrived. Heavy clouds, countless lightnings, a continuous ...
EXTREME Close Lightning in HD compilation! Loud thunder! MP3
A collection of close lightning strikes and loud thunder captured in 1080i HD! **** The audio in these clips is real and unedited, straight from the camera with no ...
Motörhead - "Thunder & Lightning" - Fan Video MP3
"Thunder & Lightning" by Motörhead Publishing: Dust and Glass Publishing GmbH Management: Singerman Entertainment Motörheads featured in the video: ...
Thin Lizzy Thunder and Lightning Tour - The Last Filmed Performance MP3
Thin Lizzy was an Irish heavy rock band, formed in 1969. Thin Lizzy's most famous lineup included singer and bassist Phil Lynott, Brian Downey on drums and ...
We Were Promised Jetpacks - It's Thunder And It's Lightning (Live in London) | Moshcam MP3
Start the We Were Promised Jetpacks concert playlist: ...
Thunder And Lightning (Full), Lacrimosa, Unterwelt Tour 2015, Live 4K, Minsk, Belarus MP3
Thin Lizzy - Thunder & Lightning (Live) 1/10 MP3
Thin Lizzy - Thunder & Lightning (Live) From Life Live's Disc 1 Thin Lizzy's farewell tour in 1983 Enjoy!
Phil Collins - Thunder and Lightning LIVE MP3
My video including wonderful Phil's performance, in Merriville 12/02/1982.
THIN LIZZY LIVE "Thunder and Lightning" MP3
Setlist 1) Thunder And Lightning 2) Baby Please Don't Go 3) Angel Of Death 4) Are You Ready 5) Cold Sweat 6) The Sun Goes Down 7) Emerald 8) Still In Love ...
THIN LIZZY - Thunder And Lightning Tour (Full Live 1983) MP3
Facebook - New Wave Of British Heavy Metal (NWOBHM) BULGARIA.
CHI COLTRANE - "Thunder and Lightning" live in Dortmund 12. April 2011 (5) MP3
"Thunder and Lightning", her first and biggest hit from her self titled 1972 debut album. This is my last video from this show.
Live - Lightning Crashes MP3
Music video by Live performing Lightning Crashes. (C) 2004 Radioactive Records J.V..
Lightning Crashes
LiveLightning crashes, a new mother cries Her placenta falls to the floor The angel opens her eyes The confusion sets in Before the doctor can even close the door Lightning crashes, [...]
lacrimosa thunder and lightning circo volador 2015 MP3
lacrimosa circo volador.
Lacrimosa Unterwelt Thunder and Lightning Live MP3
Lacrimosa Unterwelt Thunder and Lightning en vivo en Monterrey 2015 Café Iguana.
Brown Bird - "Thunder And Lightning" MP3
Indie rock duo Brown Bird perform "Thunder and Lightning" during an interview with Radio Boston Host Meghna Chakrabarti at the WBUR studios September 19 ...
We Were Promised Jetpacks - It's Thunder And It's Lightning / THEY SHOOT MUSIC MP3
We Were Promised Jetpacks performing It's Thunder And It's Lightning, live in Vienna Subscribe to They Shoot Music: http://bit.ly/TheyShootMusic ...
Live - Lightning Crashes With Lyrics MP3
Enjoy! Over 340000 views! ~~~~~~~~~~~~~~~~ No copyright intended!
Thin Lizzy "Thunder and Lightning tour 1983" MP3
Phil Lynott, John Skykes, Brian Downey, Scott Gorham and Darren Wharton - one of their best line ups!!!!!!!!!


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White Knight PhotoPhotographer Male Marysville, Washington, US
My MM URL: http://www.modelmayhem.com/whiteknightphotography
Mayhem # 515560
About Me
I'm an exclusive photographer for iStockphoto/Getty Images and been shooting for iStock for 8 years, a Staff photographer for Westco Athletics for 3, and an avid air show photographer at shows up and down the west coast from Canada to San Diego for the past 7 years.
I have a full mobile studio so I can shot at any location using natural light, speed lights or strobes.
I have some of my models photos here, but to see my full work either see my iStock portfolio or my website for other things I shoot.
I am a professional and if we work together I will expect the same of you, that would mean that you show up on time and are ready to shoot. I will almost always be early and will make sure my equipment is set up and ready to go. I know that your time is valuable as is mine.
If you have questions you can message me here, from my website or text me as I'm text friendly. Just give me an idea of what you are looking for in a shoot or if you like we can meet to discuss your project.
Have an amazing day and I hope to work with you soon.
iStockphoto site: http://www.istockphoto.com/user_view.php?id=2133135
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text: Flowers I saw during my trekkings here at my country. Enjoy the colours! Friends who have some picture of flowers here in Brazil, fell free to add your own! ImagesThe gorgeous, the unique...Like fire at hand...Orchid near the summit area. Nymphaea Rubra. Gorgeous water flower.Donald the Duck or just an Orchid?Nymphaea Rubra. Gorgeous water flower.Gorgeous pink flowerBeauty on the way up.Oh yeah!Nymphaea Rubra. Gorgeous water flower.Regular garden small flowerYellow fever!Another beautyNymphaea Odorata. Gorgeous water flower.Nymphaea Rubra. Gorgeous water flower. With perfect reflection on the lake.[ View Gallery - 11 More Images ]


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"everything has gone well and we are very happy with our new carbonated water cooler"...... WS, Ria Smith, 14th March 2013
"Thanks Glyn and thank you for the great service as usual!"...... Hat, Sescia 211th March 2013
"We are very happy with the service - the engineer is polite and professional. We were happy with the current service in Chiswick - that's why we used you again."...... Naomi, Koma 24th January 2013
"Many thanks to Lawrie for his hard work on the installation"...... Films, 8th January 2013
"Can I say as well thanks to your company for such good service! Moving premises you deal with a lot of facilities companies and The Water Cooler Company are yet again perfect in every way."......Bolt. Alison, 17th September 2012
"WOW, not only is the machine lovely looking the water is hotter and colder"...... Property Group, 1st March 2012
"I would just like to say that i am chuffed to bits the new water cooler! Looks great in my kitchen. Also thanks for making it a smooth and speedy sale/installation, will definitely recommend you. " Mike ...... , 29th February 2012
"Many thanks for all your help in resolving our water system problem which your man Kevin has sorted. Please put me on your 6 month list for filter renewal." Chris ...... , 10th January 2012
"Many thanks for your email, your technician was really helpful so please appraise him for his excellent customer service. I will purchase the cooler on a rental basis in January " S.Lyle ...... Properties, 16th December 2011
"Just a thanks for the service and the installation of the new unit. Both of your guys just get on with the job and are excellent ambassadors for your company requiring the minimum of supervision. R.Meek , ........... School, 25th August 2011
"Yes it's a plumbed in cooler we wanted. Thank you for taking the time to ask, very impressed with the care your company has towards its shoppers. Do you have a delivery date?" Julie ........, Window ....., 4th July 2011
"Yes Julian turned up the minute I put the phone down to your office. Thanks a lot, great customer service!" Beth, ..... Information Security,7th March 2011
"Just thought I'd drop you a note regarding our recent installation. Although I haven't even seen the machines yet (the flooring was being installed in the tea prep area last time I was across), the Site Project Manager commented on how efficient your guys were and said I'd made an excellent selection of Contractor. It's good to receive positive feedback for a change!" Lorraine, ..... Fac, 3th June 2010
"We have our fountain installed now. I wanted to take this opportunity to thank you for the meticulous and professional manner in which your engineer carried out the installation. Merry Christmas and Happy New Year." Edgeware ................., 23rd December 2009
"Robert: Hi there Visitor: Hi there, we work in a high school with wall mounted stainless steel drinking fountains. The pupils have commented that they can not fit their drinking bottles in the basin to fill them up. Is it possible to change the tap to a higher one? Visitor: PS this is a great service, congrats to the person who came up with the idea of a chat service. Robert: Hi there. Thank you. If you drop me your email I'll get a colleague to send some info over right away. " From our online chat facility, 17th June 2009
"Thanks – Lawrie just left. He is a darling isn't he!?" Eci, Hayley Tower, 11th March 2009
"Much appreciated!. Do like your service ;0)" Nomi Mobile, 5th February 2009
"Thank you for organising that, your customer service is impeccable a real pleasure to deal with." Caroline Edwards, Marketing Manager, 30th January 2009
"Just to let you know that the filter/chiller is working beautifully" Denise Cadore, 19th November
"Well the machine, to me, looks great and is not in the way at all. Also I must say that the engineer – Peter was really professional and polite and even hovered up after himself. We have a busy office and I was really impressed with his attitude and causing the minimum amount of fuss and I'd certainly recommend him." 28th August 2008
"The Water Cooler company are fantastic to deal with, their service and prices were unrivaled in a competitive marketplace.
" Parktown Capital, September 2008
"Thanks for the service and also give a big thanks to the engineer who attended. He was very helpful and professional." Kwong, Raycon, September 2008
After speaking to several suppliers of water coolers, it was refreshing to find a company such as 'The Water Cooler Company' who offered a professional and friendly service. 'The Water Cooler Company' met all our requirements by finding the perfect solution to our needs. There was no hard sell or demands to sign for a service contract compared with other companies in the field. Our Account Manager was a pleasure to deal with and also offered an excellent after sales service to ensure we were happy with the goods supplied. They also offered a friendly and knowledgeable service explaining installation and future service of units available to be carried out by ourselves along with an option of installation and service by 'The Water Cooler Company'." Patrick Wright, Heatcraft, September 2008
"We used the Water Cooler Company on a few occasions. The level of customer service and service provided was exemplary. Most importantly, the aftersales support provided to us by Sarah was commendable. I would not shop around for cheaper prices after receiving the excellent level of service provided by the Watercooler Company and Sarah. I strongly recommend the Water Cooler Company to anyone who needs their service. Well done." Milennium Cleaning, August 2008
"The Water Cooler Company delivered precisely what we needed - a quick and reasonable quote, an accurate delivery date and a helpful installer. Simple and easy solutions are not always that easy to find!" Rowan McCarthy, Catalyst, August 2008
" The move went extremely well and we are all settled now. The coolers are working fine and everyone seems to like the facility. The service from you has been very good to date – the ordering process went smoothly and the installation procedure was fine. From the administrative side i.e. you, I can not fault you. The communication has been excellent and you have kept me informed every step of the way. Roll on phase 2! We commence the fit-out of the second phase on 22nd September so we should be ready to install our remaining water cooler towards the end of October." Audrey Butler, Operations Manager
"We have been using this service for over a year and we are really impressed with their commitment to customer service. Being a service company ourselves, supplying services to various charities and organisations in our building, we have enjoyed our relationship. May it
continue…" ..................... Mission
"They have gone out of their way to provide us with an extremely efficient service. The delivery drivers are always polite and friendly, nothing is too much trouble."
..................... Productions
"The Water cooler Company have been efficient and extremely helpful since we began using them. We would recommend them to all businesses who require a professional water service!" Winkworth
"The water cooler company are reliable and efficient" Wisden cricket info
"Dedicated service and always a friendly face. We would definitely recommend The Water cooler Company." ........................Prasad LLP
"Great personal and reliable service. Knocks the socks off the rest of our suppliers!"W2 ............................
"We have been using The Water cooler Company for almost a year now, we are very happy with the service they provide. Always reliable, always on time, a pleasure to deal with" Zodiac .........................................
"Thanks for a great service for the past couple of years. I'd say your company's is one of the best examples of customer service that I have seen in the past 6 years living in London." Peter Vermette - Domestic rental customer
"Just wanted to thank your on your fast and impressive delivery, everything has arrived this morning and has been set up very professionally, I am now sorting out the payment for you and it should be with you shortly." Roehampton University .........................
"In return, may I thank you for the great service that you have always extended to us. You will always be my first recommendation if the subject of water coolers arises!" ......................... Digital Motion
"Thank you very much, This is the type of excellent service we were looking for when we left the devil that is pow wow! We have been very happy with The Water Cooler company and will continue to recommend you." Ominor ..................
"Thanks Robert, the installation was perfect - friendly staff, no fuss and the coolers look great! Very impressed, thanks." SThree
"I would also just like to say how pleased we are with the friendly and reliable service that you and your staff provide us." Eden .........................
"I just wanted to let you know how happy we are with your company. They have been on time, efficient, friendly and over all just a pleasure to work with. I believe that this is the level of customer service that we need from a company and they have completely exceeded my expectations. If you are looking for a new water delivery company for any new contracts I highly recommend them!" Thistle - .............................


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Discussion in 'XenForo Development Discussions' started by Dan Allen, Dec 21, 2015.
When the login form is submitted to xenforo/, where is the form handler?
That can be found in the helper_login_form template.
I look forward to understanding this.
Look in library/Xenforo/ControllerPublic/Login.php for actionLogin() That is the login form submit action.
Erik, thank you for taking time to help me get my bearings.
It's kind of funny how this is going. I have done a fair amount over the years on oop/mvc systems, but I guess there are gaps in what I know and I need to get into xf at a new depth. I think I have what I need to get this rolling now, as soon as I can put a few hours into it. I will find out if that is the case pretty soon here.
Separate names with a comma.


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Apples aren't just high in fibre, they're also packed full of Vitamin B6, essential for a healthy immune system and for cell repair. Cinnamon reportedly contains antioxidants and there's some evidence too that it can help to reduce inflammation and balance blood sugar levels.
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>General Running>Murphy's Law & Running
Princess Cancer Pants
• Chemo
• Chemo-Radiation
• Surgery
• Return to kicking my own ass by 2018
She was not strong. She was valiant. Radiant. Brave and broken. The beauty she discovered in the aftermath was unparalleled to anything she had known before, because it had come at such a cost.
~ Unknown
Runners run.
I saw a dead rabbit as I was walking down my hill before my run this morning. Looked like he got squashed by a car, so just about everything went wrong for him.
My run went fine. I could go for a Murphy's stout right about now, though.
Modified to add: BTW has anyone seen the pace bunny lately?
Your toughness is made up of equal parts persistence and experience. You don't so much outrun your opponents as outlast and outsmart them, and the toughest opponent of all is the one inside your head." - Joe Henderson
Ya he was chasing a snake into a tree on another thread.


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Fisher Scientific accumet Glass Body Standard Size Combination Electrodes - Mercury-Free
For routine pH and titration measurements with small samples and small vessels, where separate half-cell electrodes may be impractical
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Vogue's Basic Design 2236; ca. 1979; Skirt pattern with 5 variations. Length 5" below mid-knee or evening length. Views A B C & E have a center front inverted box hemline pleat. B & C have a center front hemline slit in pleat. View D has side inverted box hemline pleats and side hemline slits. View E has side front hemline seams and side front hemline pleats.
Links to reviews/blog postsEdit
- QuiltCitySueWaist 25
- Vintagepatterns4sale.com
Add a photo to the gallery by clicking the "modify" button below. {C}
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The hotel was renovated in 2006 and is a unique beach resort with 36 rooms on 2 floors. The hotel is ideal for couples as well as for those travelling alone and for families. Amongst the facilities are a foyer with 24-hour reception desk, a safe and a currency exchange desk. In addition, there is a restaurant, a bar and car parking is also available. Room service is also on hand.
The beach hotel is located around 500 metres from centre of Negril. The famous Rick's Caf� is around 2 km from the hotel. Negril lighthouse is just 3 km from the hotel and Donald Sangster international airport is located roughly 90 km away.
Each room includes either a balcony or terrace enjoying views of the garden. They all come with an en suite bathroom with hairdryer, satellite/ cable TV, an iron and ironing board, a double bed and individually adjustable air conditioning or a ceiling fan (on lower floors). Only studios have a kitchenette.
The hotel features a garden where a swimming pool with a poolside snack bar maybe found.
Breakfast is available to guests each morning. At lunchtime and in the evenings, guests may select dishes from an � la carte menu. It is also possible to book a half-board, bed and breakfast or full board stay.
American Express, MasterCard and VISA are all accepted in the hotel.
After leaving the airport on Norman Manley Boulevard or Beach Road drive in the direction of Negril. It is the third to last hotel on the southerly approach to the town centre.
Room Facilities:
Satellite cable TV
Iron and board
Double bed
Individual airconditioned
Wheelchair accessible


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Client: Axis Animation
Director: Ben Hibon
Alien: Isolation 'Improvise' Trailer concepts.
I worked together with talented director Ben Hibon and producers at Axis Animation. I was provided with rough storyboard for the entire animation and my task was to bring those sketches into keyframe quality images that would be then used as lighting and VFX reference.
Several keyframes eventually didn't make it to the final trailer:
Additionally, I had a chance to design the look of big machine that Ripley use to distract and escape from Alien.
My final task in the project was designing the motion tracker that Ripley assembles from toy robot and scrap parts at the end of a trailer.
Final trailer:


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If an item you ordered from TextbookRush does not meet your expectations due to an error on our part, simply fill out a return request and then return it by mail within 30 days of ordering it for a full refund of item cost.
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Description: In this innovative account of the way policy issues rise and fall on the national agenda—the first detailed study of so many issues over an extended period—Frank R. Baumgartner and Bryan D. Jones show that rapid change not only can but does happen in the hidebound institutions of government. Short-term, single-issue analyses of public policy, the authors contend, give a narrow and distorted view of public policy as the result of a cozy arrangement between politicians, interest groups, and the media. Baumgartner and Jones upset these notions by focusing on several issues—including civilian nuclear power, urban affairs, smoking, and auto safety—over a much longer period of time to reveal patterns of stability alternating with bursts of rapid, unpredictable change. A welcome corrective to conventional political wisdom,Agendas and Instabilityrevises our understanding of the dynamics of agenda-setting and clarifies a subject at the very center of the study of American politics.
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All the information you need in one place! Each Study Brief is a summary of one specific subject; facts, figures, and explanations to help you learn faster.
List price: $22.00Copyright year: 1993Publisher: University of Chicago PressPublication date: 4/1/1993Binding: PaperbackPages: 312Size: 6.00" wide x 9.00" long x 0.75" tall Weight: 0.946Language: English
Frank R. Baumgartner is a highly respected political scientist with a long list of scholarly writings based on his research interests. He was born in 1958 and educated at the University of Michigan (B.A., 1980; M.A., 1983; Ph.D., 1986). Included in his works are political planning, political jurisdictions, legislative behavior, comparative politics, French politics, American national institutions, and research design and measurement. Two of Baumgartner's better known books are Agendas and Instability in American Politics (1993), an account of how public policies can change rapidly even in established institutions; and Survey Research and Membership in Voluntary Organizations (1988), a study of the political action of lobbying and interest groups. Basic Interests: The Importance of Groups in Politics and in Political Science written with Beth L. Leech, is a work that reviews books and articles about interest groups from 1940 to the present, and examines the methodology of political scientists. The authors conclude that in order to improve the methodology of political scientists better research questions are needed along with more attention to the context of group behavior. Baumgartner is a professor of Political Science at Texas A&M University.
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Multi-Textured Four Bangle Set in Sterling Silver
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Daniel Baldwin says wife needs treatment
PORTLAND, Ore. (AP) Actor Daniel Baldwin says his decision to file for divorce says nothing about how he feels about his wife, but it's an attempt to encourage her to get treatment for alcoholism.
Baldwin discussed his marriage Friday with Portland television station KOIN. The 50-year-old actor says he was torn about how to handle her behavior, but he's focused on keeping their children safe.
Baldwin said his 41-year-old wife, Joanne, "ripped the house to shreds" Sunday morning as the children screamed and cried.
She is on probation for a drunken driving conviction and prohibited from drinking alcohol. She has been accused of violating the terms of her probation and jailed in Lake Oswego. A hearing is scheduled next week.
The municipal court says she has no attorney listed.
Copyright 2011 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.
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text: Youth Ministry Life is VERY Good Share: Life Is VERY Good Evening of Prayer and Morning Rally In 2018 the Evening of Prayer will be on Thursday, January 18 and the Morning Rally and Mass will be on Friday, January 19. We invite you to join groups from all over the country at one or both of these events! The Evening of Prayer is be an opportunity to pray for the success of the March for Life in changing our hearts and those of others in this country. The Morning Rally prepares us to take to the streets of Washington D.C. to make our voices heard as we proclaim the gospel of life. If you would like to take a look at Life is VERY Good 2017, please check out our LIVG 2017 Storify which includes a recap video, Bishop Burbidge's homily, and social media posts from many participants! We will continue to update this page with more information regarding Life is VERY Good 2018.Additional Information:If you would like more information or have any questions, please contact Christine at703-841-2559 or email@example.com Sites:• LIVG Facebook Page• March for Life• Office of Youth Ministry• Respect Life Office