Abstract:A simple process-based approach to predict regional-scale loading of nitrate at the water table was implemented in a GIS for Great Britain. This links a nitrate input function, unsaturated zone thickness and lithologically-dependent rate of nitrate unsaturated zone travel to estimate arrival time of nitrate at the water table. The nitrate input function is the loading at the base of the soil and has been validated using unsaturated zone pore-water profiles. The unsaturated zone thickness uses groundwater levels based on regional-scale observations infilled by interpolated river base levels. Estimates of the rate of unsaturated zone travel are attributed from regional-scale hydrogeological mapping. The results indicate that peak nitrate loading may have already arrived at the water table for many aquifers, but that it has not where the unsaturated zone is relatively thick There are contrasting outcomes for the two main aquifers which have similar unsaturated zone velocities, the predominantly low relief Permo-Triassic sandstones and the Chalk, which forms significant topographic features. For about 60% of the Chalk, the peak input has not yet reached the water table and will continue to arrive over the next 60 years. The methodology is readily transferable and provides a robust method for estimating peak arrival time for any diffuse conservative pollutant where an input function can be defined at a regional scale and requires only depth to groundwater and a hydrogeological classification. The methodology is extendable in that if additional information is available this can easily be incorporated into the model scheme.

Risk management has reduced vulnerability to floods and droughts globally1,2, yet their impacts are still increasing3. An improved understanding of the causes of changing impacts is therefore needed, but has been hampered by a lack of empirical data4,5. On the basis of a global dataset of 45 pairs of events that occurred within the same area, we show that risk management generally reduces the impacts of floods and droughts but faces difficulties in reducing the impacts of unprecedented events of a magnitude not previously experienced. If the second event was much more hazardous than the first, its impact was almost always higher. This is because management was not designed to deal with such extreme events: for example, they exceeded the design levels of levees and reservoirs. In two success stories, the impact of the second, more hazardous, event was lower, as a result of improved risk management governance and high investment in integrated management. The observed difficulty of managing unprecedented events is alarming, given that more extreme hydrological events are projected owing to climate change3.

This paper describes the development of the first operational seasonal hydrological forecasting service for the UK, the Hydrological Outlook UK (HOUK). Since June 2013, this service has delivered monthly forecasts of streamflow and groundwater levels, with an emphasis on forecasting hydrological conditions over the next three months, accompanied by outlooks over longer time horizons. This system is based on three complementary approaches combined to produce the outlooks: (i) national-scale modelling of streamflow and groundwater levels based on dynamic seasonal rainfall forecasts, (ii) catchment-scale modelling where streamflow and groundwater level models are driven by historical meteorological forcings (i.e. the Ensemble Streamflow Prediction, ESP, approach), and (iii) a catchment-scale statistical method based on persistence and historical analogues. This paper provides the background to the Hydrological Outlook, describes the various component methods in detail and then considers the impact and usefulness of the product. As an example of a multi-method, operational seasonal hydrological forecasting system, it is hoped that this overview provides useful information and context for other forecasting initiatives around the world.ARTICLE HISTORY

BackgroundIn 2011, a decision was made to scale up a pilot innovation involving ‘adherence clubs’ as a form of differentiated care for HIV positive people in the public sector antiretroviral therapy programme in the Western Cape Province of South Africa. In 2016 we were involved in the qualitative aspect of an evaluation of the adherence club model, the overall objective of which was to assess the health outcomes for patients accessing clubs through epidemiological analysis, and to conduct a health systems analysis to evaluate how the model of care performed at scale. In this paper we adopt a complex adaptive systems lens to analyse planned organisational change through intervention in a state health system. We explore the challenges associated with taking to scale a pilot that began as a relatively simple innovation by a non-governmental organisation.ResultsOur analysis reveals how a programme initially representing a simple, unitary system in terms of management and clinical governance had evolved into a complex, differentiated care system. An innovation that was assessed as an excellent idea and received political backing, worked well whilst supported on a small scale. However, as scaling up progressed, challenges have emerged at the same time as support has waned. We identified a ‘tipping point’ at which the system was more likely to fail, as vulnerabilities magnified and the capacity for adaptation was exceeded. Yet the study also revealed the impressive capacity that a health system can have for catalysing novel approaches.ConclusionsWe argue that innovation in largescale, complex programmes in health systems is a continuous process that requires ongoing support and attention to new innovation as challenges emerge. Rapid scaling up is also likely to require recourse to further resources, and a culture of iterative learning to address emerging challenges and mitigate complex system errors. These are necessary steps to the future success of adherence clubs as a cornerstone of differentiated care. Further research is needed to assess the equity and quality outcomes of a differentiated care model and to ensure the inclusive distribution of the benefits to all categories of people living with HIV.

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