The ability of a patient to access physiotherapy directly (patient self-referral), although used widely in the private sector, is not the mechanism in use within the NHS where there exists a system of open access controlled by doctors. This study aimed to develop, implement and investigate a direct access physiotherapy service within a primary care setting in a health district of Scotland. The service was introduced and compared to the existing system of open access over a twelve-month period (1997-1998). Demographic and clinical data was collected relating to two samples: Control Year Group: All GP referrals for a year prior to the study year collected retrospectively. Study Year Group: General practitioner (GP) and direct access (DA) referrals. All patients were followed up one-month after discharge, and the number of associated GP consultations collated together with patient, physiotherapist, general practitioner and service non-user views of physiotherapy generally and direct access specifically. There were similar numbers of referrals (339 vs. 340) with no significant differences with regard to patient age or gender between the Control and Study Year Groups. The Study Year Group however revealed significant differences between DA and GP referrals. DA referrals, all of which were appropriate, accounted for 22.4% of total referrals in comparison to 77.6% GP referrals. DA patients were more likely to have been: male, younger, suffering from conditions of a shorter duration, in paid employment with less work absence, who were more compliant with attendance, had fewer physiotherapy contacts, lower reporting of symptom severity at discharge and were more highly satisfied with their physiotherapy care. This group also demonstrated a greater confidence in knowing when to access physiotherapy and were highly supportive of the effectiveness of physiotherapy. DA patients also consulted their general practitioner significantly less often than GP referrals (p = 0.001). Support for direct access was strongly expressed by service users and nonusers, physiotherapists and general practitioners. Direct access to physiotherapy is an example of an innovative, flexible approach to primary care service provision encouraged by current health policy.

Background and objectives There has been a steady annual increase in the number of deliveries performed at Chris Hani Baragwanath Hospital in recent years. A 2004 audit found that approximately one third of deliveries conducted at the hospital were of women who had referred themselves and were low risk and as such did not require delivery at a specialist centre. A triage down-referral system back to midwife obstetric units was implemented in 2008 to address the problem of low-risk self-referrals at the hospital. This study was conducted after the establishment of the triage system to find out whether the establishment of the triage system had been accompanied by a decrease in the proportion of self-referred women presenting to Chris Hani Baragwanath Hospital in labour, and to assess delivery outcomes in these patients. Literature review The literature review was conducted using Pubmed and MDConsult using the key words self referral, triage, gatekeeper, low-risk pregnancy, maternity / labour and referral systems. Relevant references were accessed via the University of the Witwatersrand eJournal portal. Appropriate articles cited by other authors were also reviewed. Appropriate websites were also used and referenced. Methods This was a retrospective descriptive study which included all women presenting in labour to the hospital maternity admissions area. The study population was clinical case-files of all births that were admitted in labour from 1 May to 31 May 2010. A simple random sample of these files was drawn. Results One hundred and eighty two intra-partum admissions were sampled. Thirty-five (19%) of these women were self-referred. Seven out of the 35 (20%) required caesarean sections. Five more (14%) needed oxytocin augmentation of labour, and one more (3%) had a vacuum delivery. Twenty women (57%) did not develop any complications during labour and could have been delivered at their midwife obstetrics units. During the month of the study, the triage down-referral system attended to 171 women and down-referred 83 (49%). Conclusion The establishment of a triage down- referral system has been accompanied by a curtailment in the number of low-risk pregnancies presenting self-referred at the referral hospital labour ward, compared with the audit in 2004.

Doctor Legum - LLD / The main contributor of situations before the International Criminal Court (hereinafter ICC) has been state parties that have referred situations on their own territory to the ICC through “self-referral”. This study examines the concept of self-referral tracing the history of voluntary deferral by states of their jurisdiction over international crimes up to the enactment of the Rome Statute. The study finds that states were historically reluctant to have international crimes committed on their territory handled by other bodies or states. The self-referrals under the ICC regime are therefore a novelty in international criminal law. The legality of the act of self-referral under the Rome Statute is also examined and it is concluded that self-referrals are provided for within the Statute, although their legality has been questioned. The study establishes that self-referrals have seen unprecedented cooperation by territorial states but have also been selective in nature, targeting only non-state actors (rebel groups) .The study further compares the ICC’s handling of two other situations (Kenya and Darfur) which were triggered by antagonistic proprio motu and UN Security Council referrals respectively. The ultimate collapse of cases arising out of the Kenyan situation plus the suspension of investigations in Darfur due to non-cooperation is significant when compared with the relative successes registered with self-referred situations. The study concludes that whereas self-referrals may involve concessions to the territorial state like non-prosecution of state actors, this is a necessary evil to ensure successful investigations and prosecutions of international crimes. I recommend at the end of the study that in order to shield the office of the ICC Prosecutor from the diplomacy, dirty international politics and compromises at play in securing referrals as well as cooperation during the entire prosecution process, there should be a separate organ of the ICC handling investigations and interactions with states.

INTRODUCTION AND BACKGROUND: Traditionally, patient referral occurs from a primary healthcare facility to a secondary or tertiary healthcare facility. Despite these formalised procedures in place, it has been reported within the global context that patients often circumvent these procedures and apply various forms of selfreferral to tertiary hospitals. Through self –referral to the high level of care, patients’ diagnoses and care are interrupted and get lost along the way. AIM/ OBJECTIVES: The overall aim of this study was to develop strategies for patients’ self-referral in tertiary hospitals in Gauteng. In order to achieve this aim, the specific objectives of the study were: Phase 1 Objective 1: To explore and describe current patients’ self-referral patterns from patients and healthcare professionals’ perspectives in tertiary hospitals in Gauteng Province. Phase 2 Objective 2: To develop strategies for managing patients’ self-referral in tertiary hospitals in Gauteng Province. METHODOLOGY: A qualitative research approach using critical ethnography was used. Purposive or judgment sampling was used as the researcher considers the participants to have a profound knowledge and in-depth information on the phenomenon. Data was generated through three phases: in-depth interviews with patients and healthcare professionals (registered nurses and doctors) rendering services to self-referred patients in Gauteng Chronic clinics based in tertiary hospitals; reviewing of relevant site documents; and imbizo as policy discussion forum between the service providers and users of the services were held for the development of patient self-referral strategies. Data was analysed through the analytic five steps framework as advocated by the nurse ethnographers Roper and Shapira (2000: 98). FINDINGS: From the analysis of data five themes emerged as the pathways.. These pathways are emergency admissions, word of mouth, admissions in disguise, enabling patients to pay for admission, human rights, and sense of belonging. CONCLUSION: This study provided a baseline data on self –referral of chronic disease patients in tertiary hospitals in Gauteng Province. Given the epidemiology of chronic disease in South Africa, there is a need for innovative ways of bending the costs for treatment of such. The implementation of National Health Insurance (NHI) will address this problem as NHI has to have a self –referral scheme. The use of the hybrid (new technology and traditional) strategies will facilitate access to care and empowerment of patients to initiate self –referral. / Thesis (PhD)--University of Pretoria, 2019. / Nursing Science / PhD / Unrestricted

Background and Purpose A debate over the practice of physician self-referral has been ongoing in health care since the 1980s. At issue is the practice of physicians who refer patients to facilities in which they share a financial interest, a phenomenon known as referral for profit. Physician investment or ownership interest in ancillary (e.g., physical therapy) services has been shown to have an impact on utilization rates, costs, access to care, and quality of care. What has not been identified in previous research is the influence of physicians‘ selective referral on competing clinics, particularly the hospital-based outpatient centers that share their health care markets. The purpose of this research was to examine the relationship between the emergence of orthopaedic physician owned physical therapy services (POPTS) and changes in physical therapy referrals made to two groups of not-for-profit, hospital-based outpatient physical therapy (OPPT) centers in one health care market. Methods This study examined the referrals made by orthopaedic physicians to two large hospital systems in the Orlando, Florida, outpatient physical therapy market between 1999 and 2007. This study was conducted using existing proprietary databases maintained by the Orlando Regional Healthcare System (ORHS) and Florida Hospital System (FHS), as well as phone surveys conducted by the primary investigator. Information regarding the orthopaedic physicians‘ ownership status and the patients‘ payer types was combined into analyses to determine if physician status was related to the number of physical therapy patients from each payer type referred, or the number of total referrals made to the hospital-based outpatient physical therapy facilities. Comparisons were made between physicians who became owners of physical therapy services during the study period and physicians who never became owners of physical therapy services. Mixed Linear Models (MLM) were used to test for the effects of physician ownership and the combined influence of physician ownership and payer type on referrals for OPPT. Point estimates and 95% confidence intervals were calculated for the mean differences between Group 1 and Group 3 physicians for changes in OPPT referrals over time. The analyses were conducted first with samples of physicians who met a minimum criterion of ten referrals within the first year of data included in the data sets. Use of this criterion resulted in a small pool of physicians who qualified for inclusion in the testing. Data were compared between years 1 and 5 and then between years 1 and 2 versus 4 and 5. The criterion for physicians‘ inclusion was revised for post hoc analysis in an attempt to increase the sample size. All of the statistical tests were repeated in post hoc with the larger samples of physicians who met the minimum criterion of an average of ten referrals per year for years 1 and 2 rather than just the referral count for year 1. Results Overall, there was no statistically significant change in the total referrals as a result of a change in physicians‘ ownership status. Tests for the influence of payer type, physician group, and ownership status on referrals also revealed no significant differences between the two physician groups. Point estimates of the differences between Group 1 and Group 3 for changes in mean referrals supported the hypothesized relationships between physicians‘ ownership status and total referrals, referrals of commercially insured patients, and referrals of underinsured patients; however, the 95% confidence intervals for the point estimates were consistent with the non-significant MLM results. The hypothesized relationship between POPTS and referrals of Medicare patients was not supported in any of the analyses. In post hoc testing of the combined influence of payer type, physician group, and ownership status on referrals, a three-way interaction between physician group, payer type, and status was found (p=0.034, α<0.05). Including a larger sample size in the post hoc analyses led to outcomes that were different than those seen in the initial statistical tests. Conclusion This research outlines a novel approach to analyzing the influence of physician ownership and payer type on referral behaviors. The findings suggest that physicians‘ ownership of physical therapy services was not a predictor of their referrals to hospital-based OPPT services. Specifically, there was no significant effect of physician ownership of OPPT services on the total volume of referrals made to two hospital-systems‘ OPPT clinics. There also was no significant relationship between physician ownership, payer type, and referrals made to the hospital-based clinics. The theory predicting that POPTS physicians would work to eliminate market competition by reducing referral volumes and retaining patients with more lucrative reimbursement for their own practices was not supported. However, post hoc analysis with a larger sample size provided some evidence that a larger sample may have revealed the hypothesized relationships between physician ownership, payer type, and referrals for OPPT. Future research utilizing larger samples and data tracking physicians‘ OPPT referrals from their origins to their final dispositions are needed to clarify the relationships between physicians‘ ownership of OPPT services and the referrals they make for those services.

Magister Legum - LLM

Magister Legum - LLM

La collaboration entre la CCJA et les juridictions nationales de cassation, s’effectue dans le contentieux des Actes uniformes. Il met en oeuvre la supranationalité judiciaire de la CCJA qui se manifeste par sa substitution aux juridictions nationales de cassation soulevant des questions liées aux Actes uniformes. Il faut reconnaître que la complémentarité de la collaboration entre la CCJA et les juridictions nationales de cassation dans le recours en cassation devant la CCJA fait ressortir différents des problèmes : une inconstitutionnalité du Traité ou des Actes uniformes dans le processus d’intégration, des inquiétudes dans la procédure de recours en cassation (pas d’auto-saisine de la CCJA, absence de cas d’ouverture à cassation devant la CCJA, formule exécutoire sur les arrêts de la CCJA), l’évocation, la substitution des juridictions nationales de cassation créent devant la CCJA, une controverse dans l’identification du juge compétent dans les procédures de l’AUPSRVE, un risque de conflit de compétence et de lois avec des organisations régionales surtout (UEMOA). Cette collaboration se poursuit entre le juge étatique et la CCJA dans l’arbitrage, c’est le mode de règlement des litiges dans le système OHADA, à cause de l’éthique de l’arbitrage. Ce mode de règlement des litiges dans le mode des affaires ne répond plus au critère du monde des affaires. Même si l’arbitrage OHADA est dual (ad hoc et CCJA), il faut trouver des moyens dans divers droits plus adéquats pour pallier aux divers problèmes évoqués dans le monde des affaires. / The collaboration between the CCJA and the national courts of cassation, in substance, takes place in the dispute of the Uniform Acts. It implements a judicial supranationality of the CCJA that manifests itself by its substitution to the national courts of cassation of substance raising issues related to the Uniform Act. It must be recognized that the complementarity between the collaboration between the CCJA and the national courts in the cassation appeal before the CCJA brings out different problems : an unconstitutionality of the Treaty even see uniform Acts in the process of integration, Concerns in the procedure upon appeal in cassation (no self-referral of the CCJA, no case of opening to cassation before the CCJA, the executory formula on the judgments of the CCJA), the evocation, the substitution of national courts of cassation, grounds before the CCJA, controversy in identifying the judge competent in the procedures of the AUPSRVE, the risks of conflict of competence and laws with regional organizations ( UEMOA). This collaboration continues between the state judge and the CCJA in arbitration, this is the mode of dispute resolution in the OHADA system, in the face of the ethics of arbitration. This mode of dispute resolution in the business mode no longer meets the criteria of the business world. Even though the OHADA arbitration is dual (ad hoc and CCJA), it is necessary to find ways in various law more adequate to address the various problems evoking for the business world.

Magister Legum - LLM