Metaphors are inescapable in human discourse. Policy researchers have suggested that the use of particular metaphors by those implementing policy changes both influences perceptions of underlying reality and determines what solutions seem possible, and that exploring ‘practice languages’ is important in understanding how policy is enacted. This paper contributes to the literature exploring the generative nature of metaphors in policy implementation, demonstrating their role in not just describing the world, but also framing it, determining what is seen/unseen, and what solutions seem possible. The metaphor ‘care pathway’ is ubiquitous and institutionalised in healthcare. We build upon existing work critiquing its use in care delivery, and explore its use in health care commissioning, using evidence from the recent reorganisation of the English NHS. We show that the pathways metaphor is ubiquitous, but not necessarily straightforward. Conceptualising health care planning as ‘designing a pathway’ may make the task more difficult, suggesting a limited range of approaches and solutions. We offer an alternative metaphor: the service map. We discuss how approaches to care design might be altered by using this different metaphor, and explore what it might offer. We argue not for a barren language devoid of metaphors, but for their more conscious use.

The optimal balance between central governmental authority and the degree of autonomy of local public bodies is an enduring issue in public policy. The UK National Health Service is no exception, with NHS history, in part at least, a history of repeated cycles of centralisation and decentralisation of decision-making power. Most recently, a significant reorganisation of the NHS in 2012–13 was built around the creation of new and supposedly more autonomous commissioning organisations (Clinical Commissioning Groups – CCGs). Using Bossert's (1998) concept of ‘decision space’, we explored the experiences of local commissioners as they took on their new responsibilities. We interviewed commissioning staff from all of the CCGs in two regional health care ‘economies’, exploring their perceptions of autonomy and their experiences over time. We found significant early enthusiasm for, and perceptions of, increased autonomy tempered in the vertical dimension by increasingly onerous and prescriptive monitoring regimes, and in the horizontal dimension by the proliferation of overlapping networks, inter-organisational groups and relationships. We propose that, whatever the balance between central and local control that is adopted, complex public services require some sort of meso-level oversight from organisations able to ‘hold the ring’ between competing interests and to take a regional view of the needs of the local health system. This suggests that local organisational autonomy in such services will always be constrained.

Strabismus represents a complex oculomotor disorder characterized by the deviation of one or both eyes and poor vision. A more sophisticated understanding of the genetic liability of strabismus is required to guide searches for associated molecular variants. In this classical twin study of 1,462 twin pairs, we examined the relative influence of genes and environment in comitant strabismus, and the degree to which these influences can be explained by factors in common with refractive error. Participants were examined for the presence of latent (‘phoria’) and manifest (‘tropia’) strabismus using cover–uncover and alternate cover tests. Two phenotypes were distinguished: eso-deviation (esophoria and esotropia) and exo-deviation (exophoria and exotropia). Structural equation modeling was subsequently employed to partition the observed phenotypic variation in the twin data into specific variance components. The prevalence of eso-deviation and exo-deviation was 8.6% and 20.7%, respectively. For eso-deviation, the polychoric correlation was significantly greater in monozygotic (MZ) (r = 0.65) compared to dizygotic (DZ) twin pairs (r = 0.33), suggesting a genetic role (p = .003). There was no significant difference in polychoric correlation between MZ (r = 0.55) and DZ twin pairs (r = 0.53) for exo-deviation (p = .86), implying that genetic factors do not play a significant role in the etiology of exo-deviation. The heritability of an eso-deviation was 0.64 (95% CI 0.50–0.75). The additive genetic correlation for eso-deviation and refractive error was 0.13 and the bivariate heritability (i.e., shared variance) was less than 1%, suggesting negligible shared genetic effect. This study documents a substantial heritability of 64% for eso-deviation, yet no corresponding heritability for exo-deviation, suggesting that the genetic contribution to strabismus may be specific to eso-deviation. Future studies are now needed to identify the genes associated with eso-deviation and unravel their mechanisms of action.

Visual impairment is a leading cause of morbidity and poor quality of life in our community. Unravelling the mechanisms underpinning important blinding diseases could allow preventative or curative steps to be implemented. Twin siblings provide a unique opportunity in biology to discover genes associated with numerous eye diseases and ocular biometry. Twins are particularly useful for quantitative trait analysis through genome-wide association and linkage studies. Although many studies involving twins rely on twin registries, we present our approach to the Twins Eye Study in Tasmania to provide insight into possible recruitment strategies, expected participation rates and potential examination strategies that can be considered by other researchers for similar studies. Five separate avenues for cohort recruitment were adopted: (1) piggy-backing existing studies where twins had been recruited, (2) utilizing the national twin registry, (3) word-of-mouth and local media publicity, (4) directly approaching schools, and finally (5) collaborating with other research groups studying twins.

A microsporidium, isolated from echinostome and strigeid larval trematodes in Lymnaea peregra, is described as a new species Unikaryon slaptonleyi sp.nov. The nuclei isolated at all stages of development, the disporoblastic sporogony and development in contact with host cell cytoplasm are used to assign the species to the genus Unikaryon. The absence of a vacuolar membrane to isolate the meronts and stages of sporulation from the host cell cytoplasm differentiates this genus from Encephalitozoon. Spores are uninucleate, have 17–21 turns of the polar filament coil and measure 5·0 × 2·8/μm fresh. U. slaptonleyi was isolated from rediae and metacercariae of Echinoparyphium recurvatum and sporo-cysts and cercariae of an unidentified strigeid trematode in L. peregra. It was transmitted in the laboratory to unidentified echinostomes in L. peregra and to unidentified strigeids in Planorbis planorbis by feeding the spores to field-collected snails from which cercariae were already emerging. In these natural and experimental hyperinfections the snail tissues were lightly infected but, in the helminths, much of the parenchyma and germinal tissue was destroyed, so that few cercariae were released and most of those were distorted. Similar heavy infections were produced in Fasciola hepatica in Lymnaea truncatula, when spores were fed to the snails 14 days after miracidial penetration, but even high doses (106 spores/snail) produced only light infections in Schistosoma mansoni in Biomphalaria glabrata, in only 2 out of 9 snails. No infections were obtained in larvae producing xiphidiocercariae in P. planorbis although echinostomes became infected under the same conditions. Of a number of aquatic and terrestrial arthropods tested for susceptibility by feeding or by inoculation of spores into the haemocoele, only Pieris brassicae became infected. In a small proportion of pupae surviving from larvae which had been inoculated with spores at 3rd or 4th instar, there was clear evidence of spore replication.