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The introduction discusses the changes in consumers' preferences and the symbolic and practical decline of ownership. Young consumers, especially millennials, prefer experiences over things, comfort and ease of use over ownership. It then presents the sharing economy phenomenon, renames it "the access economy" and introduces the main argument of the book: the sharing economy pushes for a mobile and flexible vision of engaging with possessions and, as a result, with other people. It then places this argument within the broader context of property discourse.
This chapter develops the necessary conditions for the vision of property flexibility to flourish and become a valuable normative alternative. It returns to the themes raised in previous chapters, and advances three main arguments. First, it offers a robust normative account of the institutional choices for access, arguing that peer-to-peer markets offer considerable benefits from a flexibility perspective. Instead of the current regulatory support for commercial access, the law should consider regulatory means that encourage the peer-to-peer model of access. The problem with this endorsement of the peer-to-peer model is the power of the platform. Second, this chapter calls for a better conceptualization of the role of platforms as powerful agents constituting the activity. It suggests two possible reforms: the promotion of platform alternatives that have some public oversight, and the regulation of platforms as market-constituting fiduciaries. Finally, the chapter evaluates the comparative normative value of each vision, stability and flexibility, and offers guidelines for a legal scheme that recognizes both the subversive and the ideal.
This chapter studies access, a short-term and casual use of property. Two forms of access are analyzed: independent access, and access in cooperative and communal projects. The chapter offers a normative evaluation of access and highlights the values and concerns associated with flexibility and mobility. It revisits the justifications for private property discussed in Chapter II and demonstrates that these justifications can also defend an alternative vision of flexibility and mobility. Yet there is an important twist. Instead of freedom from interference, access fosters freedom from being tied down to a particular space. Instead of personhood, access supports the ability to experiment with one’s personality and pushes the boundaries of the self. In addition, access affects communities and changes interactions with other people. Access also raises significant normative concerns, such as vulnerability to immediate changes in health or financial stability, and vulnerability to platform power. This chapter then suggests preliminary guidelines for reform that are later developed in Chapter VII, including removing barriers to access, promoting consumer protection, restraining platform power, and respecting the principles of communal access by adjusting the legal rules of cases involving the physical integrity of the property.
Homeless individuals often find that welfare services are inaccessible, despite being designed to meet their needs. This frictions with access which is a fundamental principle in western welfare states. Adaptations in social policy and service delivery are therefore made to deal with the problem of inaccessibility to services and welfare rights. One such adaptation is outreach work and is often developed to engage with homeless people and link them up with available services. This raises questions on the transformative potential of outreach work to deal with those mechanisms which result in inaccessibility. We argue that in a context in which accessibility is increasingly guaranteed by rights-based frameworks, exclusion management is also increasing. This is due to hybrid developments in social policy and welfare ideology. Nonetheless, the initial transformational potential of outreach work never really vanished.
Access has become a keyword of the twenty-first century. However, even in the 1960s, government data collection and growing computational power facilitated new forms of statistical analysis that people thought could become new ‘intelligence’ systems. The legislative response to these threats were new data protection and information privacy regimes that included ‘data subject rights’ – mechanisms by which individuals could obtain access to information about them held by others, and rectify any inaccuracy. This type of transparency gave individuals a way to participate in the profiling regime, by attempting to ensure that the data used by profilers was accurate and relevant. Informed by the German constitutional concept of informational self-determination, limitations to profiling in data protection are premised on the idea that a person’s self-image ought to be the primary determinant of their identity. However, it is argued here that this approach loses traction as the profiling environment becomes more sophisticated.
Advances in digital technology have a profound impact on conventional healthcare systems. We examine the trailblazing use of online interventions to enable autonomous psychological care which can greatly enhance individual- and population-level access to services. There is strong evidence supporting online cognitive–behavioural therapy and more engaging programmes are now appearing so as to reduce user ‘attrition’. The next generation of autonomous psychotherapy programmes will implement adaptive and personalised responses, moving beyond impersonalised advice on cognitive and behavioural techniques. This will be a more authentic form of psychotherapy that integrates therapy with the actual relationship experiences of the individual user.
Despite its established efficacy, access to internet-delivered CBT (iCBT) remains limited in a number of countries. Translating existing programs and using a minimally monitored model of delivery may facilitate its dissemination across countries.
This randomized control trial aims to evaluate the efficacy of an iCBT transdiagnostic program translated from English to French and offered in Canada using a minimally monitored delivery model for the treatment of anxiety and depression.
Sixty-three French speakers recruited in Canada were randomized to iCBT or a waiting-list. A French translation of an established program, the Wellbeing Course, was offered over 8 weeks using a minimally monitored delivery model. Primary outcome measures were the Generalized Anxiety Disorder-7 (GAD-7) and the Patient Health Questionnaire-9 (PHQ-9), which were obtained pre-treatment, post-treatment and at 3-month follow-up.
Mixed-effects models revealed that participants in the treatment group had significantly lower PHQ-9 and GAD-7 scores post-treatment than controls with small between-groups effect sizes (d = 0.34 and 0.37, respectively). Within-group effect sizes on primary outcome measures were larger in the treatment than control group. Clinical recovery rates on the PHQ-9 and GAD-7 were significantly higher among the treatment group (40 and 56%, respectively) than the controls (13 and 16%, respectively).
The provision of a translated iCBT program using a minimally monitored delivery model may improve patients’ access to treatment of anxiety and depression across countries. This may be an optimal first step in improving access to iCBT before sufficient resources can be secured to implement a wider range of iCBT services.
To determine accessibility of the primary healthcare system for patients with stroke recently discharged from hospital.
This project mapped retrospective patient location data and the location of primary healthcare services in the same region. Patient location data were from all patients with stroke (N = 1595: January 2011–January 2017) discharged from one metropolitan hospital to the local Primary Health Network. Geographic Information System technology was used to map the patient discharge locations and the spatial distribution of primary healthcare services (general practitioner, pharmacy, allied health) across the region. Road network data were used to measure the level of access from each patient’s discharge location to the services.
Access to primary healthcare services was variable. Areas with larger proportions of patients with stroke did not necessarily have good service access. With an increase in travel time, the number of services accessible to patients also increased. However, the spatial variation of access to services remained largely unchanged.
Access to primary healthcare services for patients with stroke varies spatially, with a trend towards relatively low levels of accessibility for many patients. There is an urgent need for future planning to consider geographical access to primary healthcare services for patients with stroke.
Emergency department (ED) access block, the inability to provide timely care for high acuity patients, is the leading safety concern in First World EDs. The main cause of ED access block is hospital access block with prolonged boarding of inpatients in emergency stretchers. Cumulative emergency access gap, the product of the number of arriving high acuity patients and their average delay to reach a care space, is a novel access measure that provides a facility-level estimate of total emergency care delays. Many health leaders believe these delays are too large to be solved without substantial increases in hospital capacity. Our objective was to quantify cumulative emergency access blocks (the problem) as a fraction of inpatient capacity (the potential solution) at a large sample of Canadian hospitals.
In this cross-sectional study, we collated 2015 administrative data from 25 Canadian hospitals summarizing patient inflow and delays to ED care space. Cumulative access gap for high acuity patients was calculated by multiplying the number of Canadian Triage Acuity Scale (CTAS) 1-3 patients by their average delay to reach a care space. We compared cumulative ED access gap to available inpatient bed hours to estimate fractional access gap.
Study sites included 16 tertiary and 9 community EDs in 12 cities, representing 1.79 million patient visits. Median ED census (interquartile range) was 66,300 visits per year (58,700-80,600). High acuity patients accounted for 70.7% of visits (60.9%-79.0%). The mean (SD) cumulative ED access gap was 46,000 stretcher hours per site per year (± 19,900), which was 1.14% (± 0.45%) of inpatient capacity.
ED access gaps are large and jeopardize care for high acuity patients, but they are small relative to hospital operating capacity. If access block were viewed as a “whole hospital” problem, capacity or efficiency improvements in the range of 1% to 3% could profoundly mitigate emergency care delays.
The 2014 Wilson review of Indigenous Education in the Northern Territory recommended boarding school models as the preferred secondary education option for very remote Aboriginal students. This study considers boarding uptake by Aboriginal students from the Central Land Council region of the Northern Territory. An examination of boarding programs available to Aboriginal students in this region found that scholarship access is largely determined by socioeducational advantage and the perceived social stability of the family and student. To increase access and participation in boarding, more flexible funding assistance programs are needed. An expanded role for brokering could also increase retention and completion rates. Ultimately, more investment is also required in remote community schools, and in the development of ‘both ways’ capital if the social and educational aspirations of young Aboriginal students and their families in this region are to be realised through a boarding school model.
This contribution examines access to the African Court on Human and Peoples’ Rights in the first decade of its operation. Compared with other regional human rights Courts over the corresponding period, the African Court has decided more contentious cases. Direct access accounts for this difference. Acceptance by States of optional direct access is a necessary but insufficient condition for actual access. The reasons for the Commission's reluctance to refer cases, which hampered indirect access to the Court, are investigated. Although the Court's advisory jurisdiction has found limited application, it has welcomed amici curiae and showed some acceptance of the role of original complainants before the Court.
To study (a) the covariation between patient reported experience measures (PREMs) and registered process measures of access and continuity when ranking providers in a primary care setting, and (b) whether registered process measures or PREMs provided more or less information about potential linkages between levels of access and continuity and explaining variables.
Access and continuity are important objectives in primary care. They can be measured through registered process measures or PREMs. These measures do not necessarily converge in terms of outcomes. Patient views are affected by factors not necessarily reflecting quality of services. Results from surveys are often uncertain due to low response rates, particularly in vulnerable groups. The quality of process measures, on the other hand, may be influenced by registration practices and are often more easy to manipulate. With increased transparency and use of quality measures for management and governance purposes, knowledge about the pros and cons of using different measures to assess the performance across providers are important.
Four regression models were developed with registered process measures and PREMs of access and continuity as dependent variables. Independent variables were characteristics of providers as well as geographical location and degree of competition facing providers. Data were taken from two large Swedish county councils.
Although ranking of providers is sensitive to the measure used, the results suggest that providers performing well with respect to one measure also tended to perform well with respect to the other. As process measures are easier and quicker to collect they may be looked upon as the preferred option. PREMs were better than process measures when exploring factors that contributed to variation in performance across providers in our study; however, if the purpose of comparison is continuous learning and development of services, a combination of PREMs and registered measures may be the preferred option. Above all, our findings points towards the importance of a pre-analysis of the measures in use; to explore the pros and cons if measures are used for different purposes before they are put into practice.
There are an estimated 1.5 million internally displaced persons (IDPs) in Ukraine because of the armed conflict in the east of the country. The aim of this paper is to examine utilisation patterns of mental health and psychosocial support (MHPSS) care among IDPs in Ukraine.
A cross-sectional survey design was used. Data were collected from 2203 adult IDPs throughout Ukraine between March and May 2016. Data on mental health care utilisation were collected, along with outcomes including post-traumatic stress disorder (PTSD), depression and anxiety. Descriptive and multivariate regression analyses were used.
PTSD prevalence was 32%, depression prevalence was 22%, and anxiety prevalence was 17%. Among those that likely required care (screened positive with one of the three disorders, and also self-reporting a problem) there was a large treatment gap, with 74% of respondents who likely required MHPSS care over the past 12 months not receiving it. For the 26% (N = 180) that had sought care, the most common sources of services/support were pharmacies, family or district doctor/paramedic (feldsher), neurologist at a polyclinic, internist/neurologist at a general hospital, psychologists visiting communities, and non-governmental organisations/volunteer mental health/psychosocial centres. Of the 180 respondents who did seek care, 163 could recall whether they had to pay for their care. Of these 163 respondents, 72 (44%) recalled paying for the care they received despite government care officially being free in Ukraine. The average costs they paid for care was US$107 over the previous 12 months. All 180 respondents reported having to pay for medicines and the average costs for medicines was US$109 over the previous 12 months. Among the 74% had not sought care despite likely needing it; the principal reasons for not seeking care were: thought that they would get better by using their own medications, could not afford to pay for health services or medications, no awareness of where to receive help, poor understanding by health care providers, poor quality of services, and stigma/embarrassment. The findings from multivariate regression analysis show the significant influence of a poor household economic situation on not accessing care.
The study highlights a high burden of mental disorders and large MHPSS treatment gap among IDPs in Ukraine. The findings support the need for a scaled-up, comprehensive and trauma-informed response to provision of MHPSS care of IDPs in Ukraine alongside broader health system strengthening.
Introduction: In the province of Québec, roughly 20% of the population lives in rural areas. Rural emergency departments (EDs) face different challenges than their urban counterparts. Yet, few studies have sought to understand these challenges. This study aims to survey Québec’s emergency physicians to: 1) identify problems specific to rural EDs, 2) find solutions for improving accessibility and quality of care offered in rural regions and, 3) rank solutions in order of priority. These results will allow data triangulation with other of our studies that seek to identify challenges faced by rural EDs and potential solutions. Methods: During the 2016 annual conference of the Québec Emergency Physicians’ Association, we asked physicians and residents (including those from urban EDs), to complete a survey about the challenges faced by rural EDs. The survey contained two sections. The first took the form of open-ended questions in which respondents could write three challenges about accessibility and quality of care in rural EDs (objective 1) and three solutions to address these challenges (objective 2). The second section listed 11 potential solutions identified in our previous study. The solutions were ranked based on their priority level on a five-point Likert scale that ranged from “not a priority” to “an absolute priority” (objective 3). We added the total number of points for each solution and produced a ranking list. Results: Ninety-one physicians out of the 417 at the conference completed the survey; 58% came from urban EDs and 42% from rural EDs. Open-ended questions suggest that access to specialists and interfacility transfers are the principal challenges faced by rural EDs. The top five solutions identified as the highest priorities were: 1) care protocols, 2) improvement of interfacility transfers, 3) training with simulators, 4) targeted ultrasound and, 5) implementation of staff retention and recruitment strategies. Conclusion: This study is relevant and useful as roughly a quarter of attendants at the conference spontaneously volunteered to help identify and prioritize solutions to foster the accessibility and quality of care in rural EDs. Furthermore, it represents a stepping stone for our recently-launched wide-scope study, Urgences Rurales 360, that aims to explore problems faced by every of the 28 rural EDs in Québec and the solutions that could be implemented to resolve them.
Trauma systems have been widely implemented across Canada, but access to trauma care remains a challenge for much of the population. This study aims to develop and validate a model to quantify the accessibility of definitive care within one provincial trauma system and identify populations with poor access to trauma care.
A geographic information system (GIS) was used to generate models of pre-scene and post-scene intervals, respectively. Models were validated using a population-based trauma registry containing data on prehospital time intervals and injury locations for Nova Scotia (NS). Validated models were then applied to describe the population-level accessibility of trauma care for the NS population as well as a cohort of patients injured in motor vehicle collisions (MVCs).
Predicted post-scene intervals were found to be highly correlated with documented post-scene intervals (β 1.05, p<0.001). Using the model, it was found that 88.1% and 42.7% of the population had access to Level III and Level I trauma care within 60 minutes of prehospital time from their residence, respectively. Access for victims of MVCs was lower, with 84.3% and 29.7% of the cohort having access to Level III and Level I trauma care within 60 minutes of the location of injury, respectively.
GIS models can be used to identify populations with poor access to care and inform service planning in Canada. Although only 43% of the provincial population has access to Level I care within 60 minutes, the majority of the population of NS has access to Level III trauma care.
The aim of this paper is to highlight the neglected role of archaeological archives in Cultural Resource Management in particular and in the discipline of archaeology in general. Through reference to a major recent survey of the size, condition, usage and future prospects of archaeological archives in England, it is argued that the neglect of archives leads to fundamental questions regarding the purpose of archaeology in general. Why are archaeological archives generated and kept ‘for posterity’? If they are worthy of retention, how can they be better used and integrated into the discipline? It is argued that there is a need to recognize the ‘ex situ’ archaeological resource as a concept and that archaeology should recognize that the study of this resource should be a major area of activity alongside the generation of new information through fieldwork.
In recent years a number of intergovernmental initiatives have been activated in order to enhance the capacity of countries to improve access to essential medicines, particularly for mental disorders. In May 2013 the 66th World Health Assembly adopted the World Health Organization (WHO) Comprehensive Mental Health Action Plan 2013–2020, which builds upon the work of WHO's Mental Health Gap Action Programme. Within this programme, evidence-based guidelines for mental disorders were developed, including recommendations on appropriate use of medicines. Subsequently, the 67th World Health Assembly adopted a resolution on access to essential medicines, which urged Member States to improve national policies for the selection of essential medicines and to promote their availability, affordability and appropriate use.
Following the precedent set by these important initiatives, this article presents eleven actions for improving access and appropriate use of psychotropic medicines.
A 4 × 4 framework mapping actions as a function of the four components of access – selection, availability, affordability and appropriate use – and across four different health care levels, three of which belong to the supply side and one to the demand side, was developed. The actions are: developing a medicine selection process; promoting information and education activities for staff and end-users; developing a medicine regulation process; implementing a reliable supply system; implementing a reliable quality-control system; developing a community-based system of mental health care and promoting help-seeking behaviours; developing international agreements on medicine affordability; developing pricing policies and a sustainable financing system; developing or adopting evidence-based guidelines; monitoring the use of psychotropic medicines; promoting training initiatives for staff and end-users on critical appraisal of scientific evidence and appropriate use of psychotropic medicines.
Activating these actions offers an unique opportunity to address the broader issue of increasing access to treatments and care for mental disorders, as current lack of attention to mental disorders is a central barrier across all domains of the 4 × 4 access framework.