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Background: The National Health Service (NHS) and general practice are increasingly adopting digital services. These services can impact both positively and negatively upon patient experiences, and access to digital services is not equal amongst all groups. Within a wider project examining digital facilitation (the Di-Facto study) our team conducted a patient survey amongst English primary care practices aiming to investigate patient views of what supports uptake and use of web-based services. This paper reports on the analysis of the free-text responses from the patient survey. Methods: The Di-Facto patient survey was distributed to practices in eight clinical commissioning groups (CCGs) in England between 2021–2022. We examined free-text responses to two questions relating to access to primary care web-based and support for web-based services. We used qualitative reflexive thematic analysis based on a six-stage process to analyse responses. Results: Of the 3051 patients who responded to the Di-Facto survey, 2246 provided a free-text response. We present our findings in two major themes: systems and structures and their impact on use of web-based services, and 'what works for me', a description of how respondents described what worked, or did not work in terms of their interactions with web-based services. Respondents described how the technology, such as poor practice website design, confusion over multiple digital apps, data security and concerns about eConsultation offerings impacted on use of web-based services. Respondents described practice level barriers, such as a lack of or inconsistent provision, which prevented optimal use of web-based services. Respondents described personal and technical barriers that impacted on their use of digital services, and described which web-based services worked well for them. Respondents felt that web-based services were not a replacement for face-to-face interactions with a doctor. Conclusions: This analysis of free-text responses from a large patient survey highlights the system, practice, and person level barriers and facilitators to use of digital services in primary care. With an increasing push towards digital solutions in NHS primary care, practices should consider the design, rollout and communication of their web-based services to support patient access. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the impact a novel education programme - to improve research engagement, awareness, understanding and confidence - had on a diverse health and social care workforce. Barriers and facilitators to engagement were explored together with research capacity-building opportunities and ways to embed a research culture. The programme is entitled 'Supporting The Advancement of Research Skills' (STARS programme); the paper reports findings from a health and social care setting in England, UK. Methods: A four-level outcome framework guided the approach to evaluation and was further informed by key principles of research capacity development and relevant theory. Quantitative data were collected from learners before and after engagement; these were analysed descriptively. Semi-structured online interviews were conducted with learners and analysed thematically. A purposive sample was achieved to include a diversity in age, gender, health and social care profession, and level of attendance (regular attendees, moderate attendees and non-attenders). Results: The evaluation spanned 18 half-day workshops and 11 seminars delivered by expert educators. 165 (2% of total staff at Midlands Partnership University NHS Foundation Trust (MPFT)) staffs booked one or more education sessions; 128 (77%) including Allied Health Professionals (AHPs), psychologists, nursing and midwifery, and social workers attended one or more session. Key themes of engagement with teaching sessions, relevance and impact of training and promoting a research active environment were identified with relevant sub-themes. Positive impacts of training were described in terms of research confidence, intentions, career planning and application of research skills as a direct result of training. Lack of dedicated time for research engagement, work pressures and time commitments required for the programme were key barriers. Facilitators that facilitated engagement are also described. Conclusions: Findings demonstrate the impact that a free, virtual and high-quality research education programme had at individual and organisational levels. The programme is the product of a successful collaboration between health and social care and academic organisations; this provides a useful framework for others to adapt and adopt. Key barriers to attendance and engagement spoke to system-wide challenges that an education programme could not address in the short-term. Potential solutions are discussed in relation to protecting staff time, achieving management buy-in, recognising research champions, and having a clear communication strategy. [ABSTRACT FROM AUTHOR]

Background: Over 180,000 people use crack cocaine in England, yet provision of smoking equipment to support safer crack use is prohibited under UK law. Pipes used for crack cocaine smoking are often homemade and/or in short supply, leading to pipe sharing and injuries from use of unsafe materials. This increases risk of viral infection and respiratory harm among a marginalised underserved population. International evaluations suggest crack pipe supply leads to sustained reductions in pipe sharing and use of homemade equipment; increased health risk awareness; improved service access; reduction in injecting and crack-related health problems. In this paper, we introduce the protocol for the NIHR-funded SIPP (Safe inhalation pipe provision) project and discuss implications for impact. Methods: The SIPP study will develop, implement and evaluate a crack smoking equipment and training intervention to be distributed through peer networks and specialist drug services in England. Study components comprise: (1) peer-network capacity building and co-production; (2) a pre- and post-intervention survey at intervention and non-equivalent control sites; (3) a mixed-method process evaluation; and (4) an economic evaluation. Participant eligibility criteria are use of crack within the past 28 days, with a survey sample of ~ 740 for each impact evaluation survey point and ~ 40 for qualitative process evaluation interviews. Our primary outcome measure is pipe sharing within the past 28 days, with secondary outcomes pertaining to use of homemade pipes, service engagement, injecting practice and acute health harms. Anticipated impact: SIPP aims to reduce crack use risk practices and associated health harms; including through increasing crack harm reduction awareness among service providers and peers. Implementation has only been possible with local police approvals. Our goal is to generate an evidence base to inform review of the legislation prohibiting crack pipe supply in the UK. This holds potential to transform harm reduction service provision and engagement nationally. Conclusion: People who smoke crack cocaine in England currently have little reason to engage with harm reduction and drug services. Little is known about this growing population. This study will provide insight into population characteristics, unmet need and the case for legislative reform. Trial registration: ISRCTN12541454 https://doi.org/10.1186/ISRCTN12541454 [ABSTRACT FROM AUTHOR]

In 2016, England's National Institute for Health Research (NIHR) celebrated its tenth anniversary as an innovative national health research system with a focus on meeting patients' needs. This provides a good opportunity to reflect on how the creation of the NIHR has greatly enhanced important work, started in 1991, to develop a health research system in England that is embedded in the National Health Service.In 2004, WHO identified a range of functions that a national health research system should undertake to improve the health of populations. Health Research Policy and Systems (HRPS) has taken particular interest in the pioneering developments in the English health research system, where the comprehensive approach has covered most, if not all, of the functions identified by WHO. Furthermore, several significant recent developments in thinking about health research are relevant for the NIHR and have informed accounts of its achievements. These include recognition of the need to combat waste in health research, which had been identified as a global problem in successive papers in the Lancet, and an increasing emphasis on demonstrating impact. Here, pioneering evaluation of United Kingdom research, conducted through the impact case studies of the Research Excellence Framework, is particularly important. Analyses informed by these and other approaches identified many aspects of NIHR's progress in combating waste, building and sustaining research capacity, creating centres of research excellence linked to leading healthcare institutions, developing research networks, involving patients and others in identifying research needs, and producing and adopting research findings that are improving health outcomes.The NIHR's overall success, and an analysis of the remaining problems, might have lessons for other systems, notwithstanding important advances in many countries, as described in papers in HRPS and elsewhere. WHO's recently established Global Observatory for Health Research and Development provides an opportunity to promote some of these lessons. To inform its work, the Observatory is sponsoring a thematic series of papers in HRPS focusing on health research issues such as funding flows, priority setting, capacity building, utilisation and equity. While important papers on these have been published, this series is still open to new submissions. [ABSTRACT FROM AUTHOR]

The article describes some of the experiences involved in treating young adults with personality disorder in a residential setting through the medium of a therapeutic community at the Henderson Hospital in Surrey, England. It compares psychotherapy with sociotherapy. It discusses the pitfalls that complicate the normal processes of personality development and social learning. A description of personality disorder is given.

The article reports on clinical approaches to young disabled children in London, England. Many disabled children were victims of poliomyelitis, tuberculosis, rheumatic fever and chronic infections. These disabilities were acquired after a period of normal growth and development. In contrast, the disabled children have been affected from very early life, and therefore show multiple disabilities.

The article reports on a White Paper on care outside of hospitals in England that will be published at the end of 2005 or early in 2006. The potential impact of the document is revealed. The document will be about community health and care services and it will be a combined health and social care paper. The consultation process by which the paper is being developed is deliberative involving regional and national events with the public entitled "Your Health Your Care Your Say."

Background: In the English NHS, integrated care is seen as an opportunity to deliver joined-up care for children and families. This paper examines the lessons learnt by professional stakeholders in the process of developing different examples of integrated models of care/frameworks for children's services. Methods: Initial desk research was undertaken to identify different examples of integrated care models and systems/frameworks for children's services. This identified forty-three examples in England. Of these, twelve examples were shortlisted after consultation with the senior managers within the Health and Care Partnership that had commissioned the research, and a more detailed online search for published documents was undertaken. Semi-structured qualitative interviews were then conducted with sixteen professional stakeholders in eight of these examples, ranging from one to four interviewees per example. Interviews focused on the lessons learnt from integrating and transforming services. Data were analysed using framework analysis. Results: The eight examples vary in their design but have several broad commonalities. A number of common themes and learning have emerged, of which two were identified within all eight examples: the first is about focusing on children and young people; the second is about focusing on partner engagement and collaboration and the importance of building trust and relationships between partners. A number of other important themes also emerged together with several challenges. Conclusions: A number of common factors were identified that are essential to success in integrating health and care systems. Common across all localities were being child-centric and focusing on child outcomes plus the importance of building trust, engagement and relationships with partners. The findings can help health and care system leaders transform services to ensure efficiency, improvement in services and integration. [ABSTRACT FROM AUTHOR]

With increasing costs of healthcare in England and Wales following the COVID-19 pandemic, finding alternatives to traditional medical interventions is more important than ever. Social prescribing provides a way of addressing health and well-being through using non-medical methods that may help relieve costs to the NHS. Evaluating interventions, such as social prescribing, which have high social (but not easily quantifiable) value, can be problematic. Social return on investment (SROI) is a method of assigning monetary values to both social value as well as traditional assets, so provides a way of evaluating social prescribing initiatives. This protocol outlines the steps that will be taken in a systematic review of the SROI literature surrounding social prescribing-type integrated health and social care interventions based in the community in England and Wales. Online academic databases such as PubMed Central, ASSIA and Web of Science will be searched, as will grey literature sources such as Google Scholar, the Wales School for Social Prescribing Research (WSSPR) and Social Value UK. Titles and abstracts from the articles returned by the searches will be reviewed by one researcher. Those selected for full text review will be independently reviewed and compared by two researchers. Where the researchers disagree a third reviewer will help resolve any differences. Information collected will include identifying stakeholder groups, assessing the quality of SROI analyses, identifying intended and unintended changes of social prescribing interventions, and comparing social prescribing initiatives in terms of SROI costs and benefits. Quality assessment will be independently conducted on the selected papers by two researchers. The researchers will discuss to obtain consensus. Where there is disagreement, a third researcher will resolve these cases. A pre-existing quality framework will be developed and used to assess the quality of the literature. Protocol registration Prospero registration number:CRD42022318911. [ABSTRACT FROM AUTHOR]

Background: Obesity rates are higher among people of lower socioeconomic status. While numerous health behaviour interventions targeting obesity exist, they are more successful at engaging higher socioeconomic status populations, leaving those in less affluent circumstances with poorer outcomes. This highlights a need for more tailored interventions. The aim of this study was to enhance an existing weight loss course for adults living in low socioeconomic communities. Methods: The Behaviour Change Wheel approach was followed to design an add‐on intervention to an existing local authority‐run weight loss group, informed by mixed‐methods research and stakeholder engagement. Results: The COM‐B analysis of qualitative data revealed that changes were required to psychological capability, physical and social opportunity and reflective motivation to enable dietary goal‐setting behaviours. The resulting SMART‐C booklet included 6 weeks of dietary goal setting, with weekly behavioural contract and review. Conclusion: This paper details the development of the theory‐ and evidence‐informed SMART‐C intervention. This is the first report of the Behaviour Change Wheel being used to design an add‐on tool to enhance existing weight loss services. The process benefitted from a further checking stage with stakeholders. [ABSTRACT FROM AUTHOR]

Background: The population prevalence of multimorbidity (the existence of at least 2 or more long-term conditions [LTCs] in an individual) is increasing among young adults, particularly in minority ethnic groups and individuals living in socioeconomically deprived areas. In this study, we applied a data-driven approach to identify clusters of individuals who had an early onset multimorbidity in an ethnically and socioeconomically diverse population. We identified associations between clusters and a range of health outcomes. Methods and findings: Using linked primary and secondary care data from the Clinical Practice Research Datalink GOLD (CPRD GOLD), we conducted a cross-sectional study of 837,869 individuals with early onset multimorbidity (aged between 16 and 39 years old when the second LTC was recorded) registered with an English general practice between 2010 and 2020. The study population included 777,906 people of White ethnicity (93%), 33,915 people of South Asian ethnicity (4%), and 26,048 people of Black African/Caribbean ethnicity (3%). A total of 204 LTCs were considered. Latent class analysis stratified by ethnicity identified 4 clusters of multimorbidity in White groups and 3 clusters in South Asian and Black groups. We found that early onset multimorbidity was more common among South Asian (59%, 33,915) and Black (56% 26,048) groups compared to the White population (42%, 777,906). Latent class analysis revealed physical and mental health conditions that were common across all ethnic groups (i.e., hypertension, depression, and painful conditions). However, each ethnic group also presented exclusive LTCs and different sociodemographic profiles: In White groups, the cluster with the highest rates/odds of the outcomes was predominantly male (54%, 44,150) and more socioeconomically deprived than the cluster with the lowest rates/odds of the outcomes. On the other hand, South Asian and Black groups were more socioeconomically deprived than White groups, with a consistent deprivation gradient across all multimorbidity clusters. At the end of the study, 4% (34,922) of the White early onset multimorbidity population had died compared to 2% of the South Asian and Black early onset multimorbidity populations (535 and 570, respectively); however, the latter groups died younger and lost more years of life. The 3 ethnic groups each displayed a cluster of individuals with increased rates of primary care consultations, hospitalisations, long-term prescribing, and odds of mortality. Study limitations include the exclusion of individuals with missing ethnicity information, the age of diagnosis not reflecting the actual age of onset, and the exclusion of people from Mixed, Chinese, and other ethnic groups due to insufficient power to investigate associations between multimorbidity and health-related outcomes in these groups. Conclusions: These findings emphasise the need to identify, prevent, and manage multimorbidity early in the life course. Our work provides additional insights into the excess burden of early onset multimorbidity in those from socioeconomically deprived and diverse groups who are disproportionately and more severely affected by multimorbidity and highlights the need to ensure healthcare improvements are equitable. Fabiola Eto and co-workers study variations in comorbidity, service use and health outcomes by ethnicity and socioeconomic position, among people aged 16-39 years. Author summary: Why was this study done?: Most studies of multimorbidity focus on older adults, and only a few have investigated multimorbidity in younger populations. The prevalence of multimorbidity is increasing among young adults, particularly in minority ethnic groups and individuals living in socioeconomically deprived areas. There is evidence showing that individuals with socioeconomic vulnerability experience poorer health outcomes, such as lower quality healthcare provision, premature death, and higher mortality rates. The association between early onset multimorbidity and poor health outcomes in ethnically and socially diverse populations in England remains underinvestigated. What did the researchers do and find?: We used primary and secondary healthcare electronic health records from 837,869 individuals of White, South Asian, and Black African/Caribbean ethnicity in England with early onset of multimorbidity who were registered with an English general practice between 2010 and 2020. We found that the early onset of multimorbidity was more common among minority ethnic groups (59% and 56%, in the South Asian and Black populations, respectively) than in the White population (42%) living in the UK. South Asians and Black individuals with early onset multimorbidity died earlier than White individuals with early onset multimorbidity (52 and 48 years old in the median, respectively, versus 61 years old). South Asian and Black groups were more socioeconomically deprived than White groups, with a consistent deprivation gradient across all multimorbidity clusters. In White groups, the cluster of individuals with the highest rates/odds of the outcomes was more socioeconomically deprived than the cluster with the lowest rates/odds of the outcomes. What do these findings mean?: Our findings emphasise the need to identify, prevent, and manage multimorbidity early in the life course. Our work highlights the need to ensure that public health policies are equitable and reach those living in socioeconomic deprivation and minority ethnic groups who are disproportionately and more severely affected by early onset multimorbidity. [ABSTRACT FROM AUTHOR]

Background: Community-based multi-disciplinary teams (MDTs) are the most common means to encourage health and social care service integration in England yet are rarely studied or directly observed. This paper reports on two rounds of non-participant observations of community-based multi-disciplinary team (MDT) meetings in two localities, as part of an evaluation of the Integrated Care and Support Pioneers Programme. We sought to understand how MDT meetings coordinate care and identify their 'added value' over bilateral discussions.Methods: Two rounds of structured non-participant observations of 11 MDTs (28 meetings) in an inner city and mixed urban-rural area in England (June 2019-February 2020), using a group analysis approach.Results: Despite diverse settings, attendance and caseloads, MDTs adopted similar processes of case management: presentation; information seeking/sharing; narrative construction; solution seeking; decision-making and task allocation. Patient-centredness was evident but scope to strengthen 'patient-voice' exists. MDTs were hampered by information governance rules and lack of interoperability between patient databases. Meetings were characterised by mutual respect and collegiality with little challenge. Decision-making appeared non-hierarchical, often involving dyads or triads of professionals. 'Added value' lay in: rapid patient information sharing; better understanding of contributing agencies' services; planning strategies for patients that providers had struggled to find the right way to engage satisfactorily; and managing risk and providing mutual support in stressful cases.Conclusions: More attention needs to be given to removing barriers to information sharing, creating scope for constructive challenge between staff and deciding when to remove cases from the caseload. [ABSTRACT FROM AUTHOR]

Historically healthcare services have largely developed on an incremental basis, with various piecemeal changes and some notable policy leaps that illustrate a punctuated equilibrium health policy process. More recently policy-makers have attempted, successfully and unsuccessfully, to reconfigure healthcare services to address perceived problems in the delivery of important services such as stroke, cancer, and trauma. Perry et al provide a welcome addition to research in this area by focusing on the importance of history in a reconfiguration of cancer services in Greater Manchester (GM). Perry et al analyse how and why this configuration was successful after several failed attempts in the past and in this commentary, I want to reflect on the explanatory role health policy analysis can contribute to studying the reconfiguration of healthcare services. [ABSTRACT FROM AUTHOR]

In this short article we comment upon the recent article by Perry et al "Attending to History" in Major System Change in Healthcare in England: Specialist Cancer Surgery Service Reconfiguration. We welcome the engagement with power, history and heuristics in the Perry et al paper. Our article discusses the importance of researcher positionality in Major System Change research, alongside managerial power and the centrality of politics to remaking health and care services. Additionally, we highlight the work of Ansell and Gash focused on 'collaborative governance' and its potential to offer insight in relation to Major System Change. [ABSTRACT FROM AUTHOR]

Background: Consent remains a crucial, yet challenging, cornerstone of clinical practice. The ethical, legal and professional understandings of this construct have evolved away from a doctor-centred act to a patient-centred process that encompasses the patient's values, beliefs and goals. This alignment of consent with the philosophy of shared decision-making was affirmed in a recent high-profile Supreme Court ruling in England. The communication of information is central to this model of health care delivery but it can be difficult for doctors to gauge the information needs of the individual patient. The aim of this paper is to describe 'core information sets' which are defined as a minimum set of consensus-derived information about a given procedure to be discussed with all patients. Importantly, they are intended to catalyse discussion of subjective importance to individuals.Main Body: The model described in this paper applies health services research and Delphi consensus-building methods to an idea orginally proposed 30 years ago. The hypothesis is that, first, large amounts of potentially-important information are distilled down to discrete information domains. These are then, secondly, rated by key stakeholders in multiple iterations, so that core information of agreed importance can be defined. We argue that this scientific approach is key to identifying information important to all stakeholders, which may otherwise be communicated poorly or omitted from discussions entirely. Our methods apply systematic review, qualitative, survey and consensus-building techniques to define this 'core information'. We propose that such information addresses the 'reasonable patient' standard for information disclosure but, more importantly, can serve as a spring board for high-value discussion of importance to the individual patient.Conclusion: The application of established research methods can define information of core importance to informed consent. Further work will establish how best to incorporate this model in routine practice. [ABSTRACT FROM AUTHOR]

Background: England has a long history of government-commissioned reviews of national inequalities. The latest review, the Marmot Review, was commissioned by a government headed by the same party (the Labour Party) that had introduced the National Health Service in 1948, but the review was implemented by a coalition of different parties (Conservatives and Liberal Democrats). At the same time, a government reform of health services took place, and the monitoring of the existing inequality strategy was changed. Objectives: This paper examines the lessons that can be learned about indicators for monitoring social determinants of health inequalities from the Marmot Review and recent health inequality strategies in England. Design: The paper provides a narrative review of key findings on the collection, presentation, and analysis of routine data in England in the past 5 years, comparing what has been learned from the Marmot Review and other evaluations of the first health inequality strategy in England. Results: The emphasis on monitoring has progressively shifted from monitoring a small number of targets and supporting information to frameworks that monitor across a wide range of determinants of both the causes of ill-health and of health service performance. As these frameworks become ever larger, some consideration is being given to the key indicators. Conclusions: Although the frameworks used in England for monitoring health inequality strategies have developed considerably since the first strategy began, lessons continue to be learned about how monitoring could be improved. Many of these are applicable to countries initiating or reviewing their strategies. [ABSTRACT FROM AUTHOR]

Background Clinical commissioning groups (CCGs) were in early development when fieldwork took place. Public Health (PH) was moving into the local authority, and new ways of working were being established. Methods Three qualitative case studies in the North of England were undertaken using three different data collection methods: observations, interviews and the collection of documents that were related to the project. Comprehensive field notes were taken during observations, analysed alongside interview transcriptions and collected documentation using the software programme Atlas.ti. Results The relationship between the CCG and their local PH team was in development at the time of data collection. Three different PH roles could be discerned from the data: 'co-owner', 'service provider' and 'critical friend'. These roles impacted on the utilization of PH by CCGs and the wider relationship between the CCG and PH. Conclusions These models are 'ideal types', and in reality the CCG-PH relationship in most areas will contain elements of all three models. However, to think of them as set out in this paper is instructive for both CCGs and PH. It is important that CCGs and their PH colleagues to think clearly about what they are trying to achieve and how that can most effectively work together. [ABSTRACT FROM AUTHOR]

Background: In recent years joint commissioning has assumed an important place in the policy and practice of English health and social care. Yet, despite much being claimed for this way of working there is a lack of evidence to demonstrate the outcomes of joint commissioning. This paper examines the types of impacts that have been claimed for joint commissioning within the literature. Method: The paper reviews the extant literature concerning joint commissioning employing an interpretive schema to examine the different meanings afforded to this concept. The paper reviews over 100 documents that discuss joint commissioning, adopting an interpretive approach which sought to identify a series of discourses, each of which view the processes and outcomes of joint commissioning differently. Results: This paper finds that although much has been written about joint commissioning there is little evidence to link it to changes in outcomes. Much of the evidence base focuses on the processes of joint commissioning and few studies have systematically studied the outcomes of this way of working. Further, there does not appear to be one single definition of joint commissioning and it is used in a variety of different ways across health and social care. The paper identifies three dominant discourses of joint commissioning - prevention, empowerment and efficiency. Each of these offers a different way of seeing joint commissioning and suggests that it should achieve different aims. Conclusions: There is a lack of clarity not only in terms of what joint commissioning has been demonstrated to achieve but even in terms of what it should achieve. Joint commissioning is far from a clear concept with a number of different potential meanings. Although this ambiguity can be helpful in some ways in the sense that it can bring together disparate groups, for example, if joint commissioning is to be delivered at a local level then more specificity may be required in terms of what they are being asked to deliver. [ABSTRACT FROM AUTHOR]

Although the National Health Service was created to achieve equity of access to health care in 1948, over twenty years later an ‘inverse care law’ was seen to operate. The 1976 Report of the Resource Allocation Working Party laid the principles of formula funding to achieve an equitable distribution of resources, to move, over time, towards the operation of a proportionate care law. These principles have been applied ever since in England. This paper describes the context, governance and subsequent development of formulas and three persistent problems: accounting for populations, their needs and variations in the unavoidable costs of providers. The paper concludes by outlining continuing problems from the past and new challenges of formula funding in England to reduce ‘avoidable’ inequalities in health. [ABSTRACT FROM AUTHOR]

In this paper, I explore how viability, meaning the ability of the fetus to survive post-delivery, features in the law regulating abortion provision in England and Wales and the USA. I demonstrate that viability is formalized differently in the criminal law in England and Wales and the USA, such that it is quantified and defined differently. I consider how the law might be applied to the examples of artificial womb technology and anencephalic fetuses. I conclude that there is incoherence in the meaning of viability and argue that it is thus a conceptually illegitimate basis on which to ground abortion regulation. This is both because of the fluidity of the concept and because how it has been thus far understood in the law is unsupported by medical realities. Furthermore, it has the effect of heavily diluting pregnant people's rights with overly moralistic limitations on access to healthcare. [ABSTRACT FROM AUTHOR]

Background: Rapid evaluation was at the heart of National Health Service England's evaluation strategy of the new models of care vanguard programme. This was to facilitate the scale and spread of successful models of care throughout the health & social care system. The aim of this paper is to compare the findings of the two evaluations of the Enhanced health in Care Homes (EHCH) vanguard in Gateshead, one using a smaller data set for rapidity and one using a larger longitudinal data set and to investigate the implications of the use of rapid evaluations using interrupted time series (ITS) methods.Methods: A quasi-experimental design study in the form of an ITS was used to evaluate the impact of the vanguard on secondary care use. Two different models are presented differing by timeframes only. The short-term model consisted of data for 11 months data pre and 20 months post vanguard. The long-term model consisted of data for 23 months pre and 34 months post vanguard.Results: The cost consequences, including the cost of running the EHCH vanguard, were estimated using both a single tariff non-elective admissions methodology and a tariff per bed day methodology. The short-term model estimated a monthly cost increase of £73,408 using a single tariff methodology. When using a tariff per bed day, there was an estimated monthly cost increase of £14,315. The long-term model had, using a single tariff for non-elective admissions, an overall cost increase of £7576 per month. However, when using a tariff per bed-days, there was an estimated monthly cost reduction of £57,168.Conclusions: Although it is acknowledged that there is often a need for rapid evaluations in order to identify "quick wins" and to expedite learning within health and social care systems, we conclude that this may not be appropriate for quasi-experimental designs estimating effect using ITS for complex interventions. Our analyses suggests that care must be taken when conducting and interpreting the results of short-term evaluations using ITS methods, as they may produce misleading results and may lead to a misallocation of resources. [ABSTRACT FROM AUTHOR]

Introduction: The adoption of remote healthcare methods has been accelerated by the COVID‐19 pandemic, but evidence suggests that some patients need additional support to engage remotely, potentially increasing health disparities if needs are not met. This study of COVID‐19 remote home monitoring services across England explores experiences of and engagement with the service across different patient groups. Methods: This was a mixed‐methods study with survey and interview data collected from 28 services across England between February and June 2021. Surveys were conducted with staff and patients and carers receiving the service. Interviews with staff service leads, patients and carers were conducted in 17 sites. Quantitative data were analysed using univariate and multivariate methods, and qualitative data were analysed using thematic analysis. Findings: Survey responses were received from 292 staff and 1069 patients and carers. Twenty‐three staff service leads, 59 patients and 3 carers were interviewed. Many service leads reported that they had considered inclusivity when adapting the service for their local population; strategies included widening the eligibility criteria, prioritising vulnerable groups and creating referral pathways. However, disparities were reported across patient groups in their experiences and engagement. Older patients reported the service to be less helpful (p = 0.004), were more likely to report a problem (p < 0.001) and had more difficulty in understanding information (p = 0.005). Health status (p = 0.004), ethnicity (p < 0.001), gender (p < 0.001) and employment (p = 0.007) were associated with differential engagement with monitoring, and minority ethnic groups reported more difficulty understanding service information (p = 0.001). Qualitative data found illness severity to be an important factor in the support required, and patients' living situation and social network affected whether they found the service reassuring. Conclusion: Addressing health disparities must be a key focus in the design and delivery of remote care. Services should be tailored to match the needs of their local population, encourage access through collaboration and referral pathways with other services and monitor their inclusiveness. Involving patients and staff in service design can illuminate the diversity of patients' needs and experiences of care. Patient or Public Contribution: The study team met with service user and public members of the BRACE PPI group and patient representatives from RSET in a series of workshops. Workshops informed study design, data collection tools, data interpretation and dissemination activities. Study documents (such as consent forms, topic guides, surveys and information sheets) were reviewed by PPI members; patient surveys and interview guides were piloted, and members also commented on the manuscript. [ABSTRACT FROM AUTHOR]

Background: Debate surrounding the organisation and sustainability of primary care in England highlights the desirability of a more integrated approach to patient care across all settings. One such approach is ‘vertical integration’, where a provider of specialist care, such as a hospital, also runs general practices. Aim: To quantify the impact of vertical integration on hospital use in England. Design & setting: Analysis of activity data for NHS hospitals in England between April 2013 and February 2020. Method: Analysis of NHS England data on hospital activity, which looked at the following seven outcome measures: accident and emergency (A&E) department attendances; outpatient attendances; total inpatient admissions; inpatient admissions for ambulatory care sensitive conditions; emergency admissions; emergency readmissions; and length of stay. Rates of hospital use by patients of vertically integrated practices and controls were compared, before and after the former were vertically integrated. Results: In the 2 years after a GP practice changes, for the population registered at that practice, compared with controls, vertical integration is associated with modest reductions in rates of A&E attendances (2% reduction [incidence rate ratio {IRR} 0.98, 95% confidence interval {CI} = 0.96 to 0.99, P<0.0001]), outpatient attendances (1% reduction [IRR 0.99, 95% CI = 0.99 to 1.00, P = 0.0061]), emergency inpatient admissions (3% reduction [IRR 0.97, 95% CI = 0.95 to 0.99, P = 0.0062]), and emergency readmissions within 30 days (5% reduction [IRR 0.95, 95% CI = 0.91 to 1.00, P = 0.039]), with no impact on length of stay, overall inpatient admissions, or inpatient admissions for ambulatory care sensitive conditions. Conclusion: Vertical integration is associated with modest reductions in use of some hospital services and no change in others. [ABSTRACT FROM AUTHOR]

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Introduction. The global shift towards digital education in the wake of the COVID-19 pandemic has reshaped the landscape of higher education. Public health and social care programmes have adapted to this transformation, embracing online learning strategies to engage students. This study focuses on the assessment of online learning experiences in public health and social care education, particularly during the post-COVID-19 period. Materials and Methods. This qualitative study employed semi-structured interviews and focus groups with 49 university students in England. These phases, conducted both in person and via video, were audio and video recorded and transcribed verbatim. A purposive sampling technique was employed to gather data, and framework analysis facilitated data management and interpretation. Results. The presentation highlights three main themes and 12 accompanying sub-themes that capture the clear preferences of students for both in-person and online learning methods. The findings elucidate the merits and demerits of online learning strategies in contrast to traditional face-to-face classes. Online classes offer distinct advantages in terms of flexibility, cost-effectiveness, time efficiency, and technological proficiency. However, they also bring to the fore concerns related to social isolation, mental health challenges, technical challenges, and distractions within the home environment. Conclusion. Considering the global transition to digital education, this study contributes to the dynamic discourse surrounding online learning in the post-COVID-19 era. The diverse preferences expressed by students highlight the importance of personalised and flexible teaching methods in online education, underlining the need for adaptability and inclusivity to meet the diverse needs of today's learners. [ABSTRACT FROM AUTHOR]

Background: Since 1991, there has been a series of reforms of the English National Health Service (NHS) entailing an increasing separation between the commissioners of services and a widening range of public and independent sector providers able to compete for contracts to provide services to NHS patients. We examine the extent to which local commissioners had adopted a market-oriented (transactional) model of commissioning of care for people with long term conditions several years into the latest period of market-oriented reform. The paper also considers the factors that may have inhibited or supported market-oriented behaviour, including the presence of conditions conducive to a health care quasi-market. Methods: We studied the commissioning of services for people with three long term conditions - diabetes, stroke and dementia - in three English primary care trust (PCT) areas over two years (2010-12). We took a broadly ethnographic approach to understanding the day-to-day practice of commissioning. Data were collected through interviews, observation of meetings and from documents. Results: In contrast to a transactional, market-related approach organised around commissioner choice of provider and associated contracting, commissioning was largely relational, based on trust and collaboration with incumbent providers. There was limited sign of commissioners significantly challenging providers, changing providers, or decommissioning services. In none of the service areas were all the conditions for a well functioning quasi-market in health care in place. Choice of provider was generally absent or limited; information on demand and resource requirements was highly imperfect; motivations were complex; and transaction costs uncertain, but likely to be high. It was difficult to divide care into neat units for contracting purposes. As a result, it is scarcely surprising that commissioning practice in relation to all six commissioning developments was dominated by a relational approach. Conclusions: Our findings challenge the notion of a strict separation of commissioners and providers, and instead demonstrate the adaptive persistence of relational commissioning based on continuity of provision, trust and interdependence between commissioners and providers, at least for services for people with long-term conditions. [ABSTRACT FROM AUTHOR]

The article presents a study conducted by the authors to evaluate how data collected through National Adult Inpatient Survey in England has been used. It states that majority of studies were reports of organizations contracted to gather data and used mainly descriptive statistics. It mentions that patients' socio-economic status influenced their evaluation of their care. It highlights that the data is yet to be fully used to its potential.

Background: For over 20 years, the National Health Service in England has run a system of national planning for highly specialised healthcare services. The aim is to ensure that very rare diseases are treated, and very complex procedures performed, in only a few centres, each of which maintains a volume high enough to maintain excellent outcomes. The commissioning strategy for the provision of these national services in England is strongly centralising. Centralising does however create a duty to ensure that patients distant from the treatment centres are not thereby disadvantaged. The commissioning process ensures sufficient capacity to treat the entire national caseload of clinically eligible patients. The aim of this paper is to apply the Systematic Component of Variation (SCV) to study access to services commissioned by the National Specialised Commissioning Team (NSCT) in England. The discussion focuses on the potential explanations for a high level of systematic variation between areas and on the use of the SCV to support the monitoring and development of these nationally commissioned services. Method: Data from nationally commissioned services for the year ending 2011 were received from treating hospital. Mid year age and sex appropriate population estimates were then obtained to provide denominator data. Data were analysed at the geographic level of strategic health authority. Results: 30 services met all requirements for analysis. There is no apparent relationship between SCV and number of locations from which the service is provided. On inspection high SCV is more common among recently commissioned services. Discussion: The importance of the SCV lies in its ability to support the development of highly specialised services. Once the random variation has been accounted for, the reasons for a systematic component can be explored. While no absolute cut- off exists, the SCV can be used to gauge and explore services that are potentially not covering the national caseload. The reason for a high SCV may not be immediately apparent; thus the SCV can aid those responsible for commissioning the service to seek potential explanations and identify improvements. Conclusion: We have reviewed spatial variation in access to a set of highly specialised services in England. On inspecting our results, we believe that they suggest that equity of access can usually be achieved at about five years after establishing a service, and this is not dependent, within the geography of England, on the number of centres designated. [ABSTRACT FROM AUTHOR]

Purpose - This paper aims to examine the Victorian attitude to the poor by focussing on the health care provided at a large provincial hospital, the Newcastle Infirmary. Design/methodology/approach - The archives of the Newcastle Infirmary are reviewed alongside the local trade directories. These primary sources are examined in conjunction with the writings of contemporary social theorists on poverty. Findings - At a time when poverty was seen as a sin, an act against God, it would be easy to assume that the Victorians faced no moral dilemma in dismissing the poor, particularly what were seen as the "undeserving poor", out of hand. Yet, the paper observes how accounting was used both to persuade the wealthier citizens to contribute funds and to enable the hospital to exercise compassion in treating paupers despite this being prohibited under the hospital's rules. Such a policy conflicted with the dominant utilitarian view of society, which emphasised the twin pillars of economic expediency and self-help. Research limitations/implications - More case studies are needed of other hospitals to ascertain how typical the Newcastle Infirmary was of the voluntary hospital sector as a whole. Originality/value - Although many histories of British hospitals exist and some have examined how accounting was used to manage within these institutions, the concern has not been with accounting as a moral practice. [ABSTRACT FROM AUTHOR]

Dentistry is responsible for around 10% of antibiotic prescribing across global healthcare, with up to 80% representing inappropriate use. Facilitating shared decision-making has been shown to optimise antibiotic prescribing (antibiotic stewardship) in primary medical care. Our aim was to co-develop a shared decision-making antibiotic stewardship tool for dentistry. Dentists, patients and other stakeholders prioritised factors to include in the new tool, based on previous research (a systematic review and ethnographic study) about dentists' decision-making during urgent appointments. Candidate behaviour-change techniques were identified using the Behaviour Change Wheel and selected based on suitability for a shared decision-making approach. A 'think aloud' study helped fine-tune the tool design and Crystal Marking ensured clarity of messaging. The resulting paper-based worksheet for use at point-of-care incorporated various behaviour change techniques, such as: 'information about (and salience of) health consequences', 'prompts and cues', 'restructuring the physical (and social) environment' and 'credible sources'. The think aloud study confirmed the tool's acceptability to dentists and patients, and resulted in the title: 'Step-by-step guide to fixing your toothache.' Further testing will be necessary to evaluate its efficacy at safely reducing dental antibiotic prescribing during urgent dental appointments in England and, with translation, to other dental contexts globally. [ABSTRACT FROM AUTHOR]

Widespread health service goals to improve consistency and safety in patient care have prompted considerable investment in the development of evidence-based clinical guidelines. Computerised decision support (CDS) systems have been proposed as a means to implement guidelines in practice. This paper discusses the general concept in oncology and presents an evaluation of a CDS system to support triple assessment (TA) in breast cancer care. Balanced-block crossover experiment and questionnaire study. One stop clinic for symptomatic breast patients. Twenty-four practising breast clinicians from United Kingdom National Health Service hospitals. A web-based CDS system. Clinicians made significantly more deviations from guideline recommendations without decision support (60 out of 120 errors without CDS; 16 out of 120 errors with CDS, P < 0.001). Ignoring minor deviations, 16 potentially critical errors arose in the no-decision-support arm of the trial compared with just one (P = 0.001) when decision support was available. Opinions of participating clinicians towards the CDS tool became more positive after they had used it (P < 0.025). The use of decision support capabilities in TA may yield significant measurable benefits for quality and safety of patient care. This is an important option for improving compliance with evidence-based practice guidelines. [ABSTRACT FROM AUTHOR]

Governments face a formidable combination of principal/agent problems as third party payers for professional services. Health care is an exemplar of these difficulties. This paper develops the concept of discretionary services for acute hospitals from analysis of services with high variations in admission rates. It argues that this concept offers a way of challenging professional discretion and raising new kinds of questions over volumes and quality of services supplied. It illustrates the wider applicability of this concept with two examples: legal aid, and investigation of directors for fraud following bankruptcy. [ABSTRACT FROM AUTHOR]

This letter is a response to a research article titled "Online Survey to Investigate Asthma Medication Prescription and Adherence from the Perspective of Patients and Healthcare Practitioners in England." The author commends the study for providing valuable insights into the motivations behind inhaler use and the challenges of medication adherence. The study suggests the need for improved asthma control and prescribing practices, as well as personalized self-management care plans involving mobile technology interventions. However, the author identifies limitations in the self-reported nature of the survey and the small sample size. To overcome these limitations, the author suggests diversifying data collection methods, using clear survey instructions, and validating data reported by respondents. Overall, research like this is important for advancing healthcare practice and improving patient outcomes. [Extracted from the article]

Copyright of International Journal for Quality in Health Care is the property of Oxford University Press / USA and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: To increase the uptake of research evidence in practice, responsive research services have been developed within universities that broker access to academic expertise for practitioners and decision-makers. However, there has been little examination of the process of knowledge brokering within these services. This paper reflects on this process within the AskFuse service, which was launched in June 2013 by Fuse, the Centre for Translational Research in Public Health, in North East England. The paper outlines the challenges and opportunities faced by both academics and health practitioners collaborating through the service.Methods: The authors reflected on conversations between the AskFuse Research Manager and policy and practice partners accessing the service between June 2013 and March 2017. Summary notes of these conversations, including emails and documents relating to over 240 enquiries, have been analysed using an auto-ethnographic approach.Findings: We identified five challenges to knowledge brokering in an institutional service, namely length of brokerage time required, limits to collaboration, lack of resources, brokering research in a changing system, and multiple types of knowledge.Conclusions: To understand and overcome some of the identified challenges, we employ Goffman's dramaturgical perspective and argue for making better use of the distinction between front and back stages in the knowledge brokering process. We emphasise the importance of back stages for defusing destructive information that could discredit collaborative performances. [ABSTRACT FROM AUTHOR]

Background: Local health protection systems play a crucial role in infectious disease prevention and control and were critical to COVID-19 pandemic responses. Despite this vital function, few studies have explored the lived experience of health protection responders managing COVID-19. We provide new insights by examining how COVID-19 shaped infectious disease prevention and control in local health protection systems in England. Methods: Semi-structured interviews were conducted with twenty local health protection responders from three contrasting local authority areas, and Public Health England (PHE) health protection teams, in England between June 2021 - March 2022. Participants were from: PHE health protection teams (n=6); local authority public health teams (n=5); local authority Public Protection Services (n=7); and local authority commissioned Infection Prevention and Control Teams (n=2). Data were analysed using reflexive thematic analysis. Results: First, participants acknowledged the pandemic caused an unprecedented workload and disruption to local health protection service delivery. There was not enough capacity within existing local health protection systems to manage the increased workload. PHE health protection teams therefore transferred some COVID-19 related health protection tasks to other staff, mainly those employed by local authorities. Second, health protection responders highlighted how COVID-19 drew attention to the weaknesses in local health protection systems already stressed by reduced funding in the years leading up to the pandemic. Injecting money into the COVID-19 response did not completely overcome former losses in specialist health protection workforce. Third, health protection responders described how pandemic management raised the profile of public health, especially infectious disease prevention and control. Managing COVID-19 strengthened collaborative working, resulting in enhanced capacity of local health protection systems at the time. Conclusion: The COVID-19 pandemic challenged the public health preparedness of all countries. Health protection responders in this study also expressed many challenges. There was insufficient resilience in these local health protection systems and an inability to scale up the specialist health protection workforce, as required in a pandemic situation. The UK needs to learn from the pandemic experience by acknowledging and addressing the challenges faced by local health protection responders so that it can more effectively respond to future threats. [ABSTRACT FROM AUTHOR]

Background: The National Health Service Type 2 Diabetes Path to Remission programme in England (known as the NHS Low Calorie Diet programme when piloted) was established to support people living with excess weight and Type 2 Diabetes to lose weight and improve their glycaemic control. A mixed method evaluation was commissioned to provide an enhanced understanding of the long-term cost effectiveness of the pilot programme, its implementation, equity and transferability across broad and diverse populations. This study provided key insights on implementation and equity from the service providers' perspective. Methods: Thirteen focus groups were conducted with commercial providers of the programme, during the initial pilot rollout. Participants were purposively sampled across all provider organisations and staff roles involved in implementing and delivering the programme. Normalisation Process Theory (NPT) was used to design the topic schedule, with the addition of topics on equity and person-centredness. Data were thematically analysed using NPT constructs with additional inductively created codes. Codes were summarised, and analytical themes generated. Results: The programme was found to fulfil the requirements for normalisation from the providers' perspective. However, barriers were identified in engaging GP practices and receiving sufficient referrals, as well as supporting service users through challenges to remain compliant. There was variation in communication and training between provider sites. Areas for learning and improvement included adapting systems and processes and closing the gap where needs of service users are not fully met. Conclusions: The evaluation of the pilot programme demonstrated that it was workable when supported by effective primary care engagement, comprehensive training, and effective internal and external communication. However, limitations were identified in relation to programme specifications e.g. eligibility criteria, service specification and local commissioning decisions e.g. pattern of roll out, incentivisation of general practice. A person-centred approach to care is fundamental and should include cultural adaptation(s), and the assessment and signposting to additional support and services where required. [ABSTRACT FROM AUTHOR]

Background: Following the onset of the COVID-19 pandemic, in March 2020 health care delivery underwent considerable changes. It is unclear how this may have affected the delivery of Brief Interventions (BIs) for smoking and alcohol. We examined the impact of the COVID-19 pandemic on the receipt of BIs for smoking and alcohol in primary care in England and whether certain priority groups (e.g., less advantaged socioeconomic positions, or a history of a mental health condition) were differentially affected. Methods: We used nationally representative data from a monthly cross-sectional survey in England between 03/2014 and 06/2022. Monthly trends in the receipt of BIs for smoking and alcohol were examined using generalised additive models among adults who smoked in the past-year (weighted N = 31,390) and those using alcohol at increasing and higher risk levels (AUDIT score 38, weighted N = 22,386), respectively. Interactions were tested between social grade and the change in slope after the onset of the COVID-19 pandemic, and results reported stratified by social grade. Further logistic regression models assessed whether changes in the of receipt of BIs for smoking and alcohol, respectively, from 12/2016 to 01/2017 and 10/2020 to 06/2022 (or 03/2022 in the case of BIs for alcohol), depended on history of a mental health condition. Results: The receipt of smoking BIs declined from an average prevalence of 31.8% (95%CI 29.4–35.0) pre-March 2020 to 24.4% (95%CI 23.5–25.4) post-March 2020. The best-fitting model found that after March 2020 there was a 12-month decline before stabilising by June 2022 in social grade ABC1 at a lower level (~ 20%) and rebounding among social grade C2DE (~ 27%). Receipt of BIs for alcohol was low (overall: 4.1%, 95%CI 3.9–4.4) and the prevalence was similar pre- and post-March 2020. Conclusions: The receipt of BIs for smoking declined following March 2020 but rebounded among priority socioeconomic groups of people who smoked. BIs for alcohol among those who use alcohol at increasing and higher risk levels were low and there was no appreciable change over time. Maintaining higher BI delivery among socioeconomic and mental health priority groups of smokers and increasing and higher risk alcohol users is important to support reductions in smoking and alcohol related inequalities. [ABSTRACT FROM AUTHOR]

The authors reflect on the performance of health in England, as published in the November 2004 White Paper of Great Britain's government. They stressed that most of the consumers wish to make their own health choices though they still need help in coping with harmful factors. They assessed that this paper differs from any previous document in proposing public health back to the public. They pointed out that the current emphasis on preventive targets boosts strong emotions among clinicians.

Background: Society is failing in its moral obligation to improve the standard of healthcare provided to vulnerable populations, such as people who lack decision making capacity, by a misguided paternalism that seeks to protect them by excluding them from medical research. Uncertainties surround the basis on which decisions about research participation is made under dual regulatory regimes, which adds further complexity. Vulnerable individuals' exclusion from research as a result of such regulation risks condemning such populations to poor quality care as a result of 'evidence biased' medicine.Main Text: This paper explores the research regulation provisions for proxy decision making for those unable to provide informed consent for themselves, and the subsequent legal and practical difficulties for decision-makers. There are two separate regulatory regimes governing research involving adults who lack capacity to consent in England and Wales. The Mental Capacity Act 2005 governs how incapacitated adults can be involved in research, however clinical trials of medicinal products are separately regulated by the Medicines for Human Use (Clinical Trials) Regulations 2004. There are significant differences under these dual regimes in the provisions for those lacking capacity to participate in medical research. The level of risk permitted differs, with a greater requirement for justification for participation in a clinical trial than other types of research. Who acts as proxy decision maker, how much information is provided to the person lacking capacity, and whether they retain the power of veto also significantly differs.Conclusion: The development of two separate regulatory regimes has resulted in significant differences between the provisions for clinical trials and other forms of research, and from usual medical practice. The resulting uncertainty has reinforced the tendency of those approving and conducting research to exclude adults lacking capacity to avoid difficult decisions about seeking consent for their participation. Future developments, such as the incoming EU Regulations, may address some of these differences, however the justification and level of risk permitted requires review to ensure that requirements are appropriate and proportionate to the burdens and risks for the individual, and also to the benefits for the wider population represented. [ABSTRACT FROM AUTHOR]

Background: There is a political drive in the UK to use assistive technologies such as telehealth and telecare as an innovative and efficient approach to healthcare delivery. However, the success of implementation of such services remains dependent on the ability to engage the wider population to adopt these services. It has been widely acknowledged that low acceptance of technology, forms a key barrier to adoption although findings been mixed. Further, it remains unclear what, if any barriers exist between patients and how these compare to those who have declined or withdrawn from using these technologies. This research aims to address this gap focusing on the UK based Cambridgeshire Community Services Assistive Telehealth and Telecare service, an integrated model of telehealth and telecare.Methods: Qualitative semi-structured interviews were conducted between 1st February 2014 and 1st December 2014, to explore the views and experiences of 'users' and 'non-users' using this service. 'Users' were defined as patients who used the service (N = 28) with 'non-users' defined as either referred patients who had declined the service before allocation (N = 3) or had withdrawn after using the ATT service (N = 9). Data were analysed using the Framework Method.Results: This study revealed that there are a range of barriers and facilitators that impact on the decision to adopt and continue to engage with this type of service. Having a positive attitude and a perceived need that could be met by the ATT equipment were influential factors in the decision to adopt and engage in using the service. Engagement of the service centred on 'usability', 'usefulness of equipment', and 'threat to identity and independence'.Conclusions: The paper described the influential role of referrers in decision-making and the need to engage with such agencies on a strategic level. The findings also revealed that reassurance from the onset was paramount to continued engagement, particularly in older patients who appeared to have more negative feelings towards technology. In addition, there is a clear need for continued product development and innovation to not only increase usability and functionality of equipment but also to motivate other sections of the population who could benefit from such services. Uncovering these factors has important policy implications in how services can improve access and patient support through the application of assistive technology which could in turn reduce unnecessary cost and burden on overstretched health services. [ABSTRACT FROM AUTHOR]

Background: Increasingly, it is being suggested that translational gaps might be eradicated or narrowed by bringing research users and producers closer together, a theory that is largely untested. This paper reports a national study to fill a gap in the evidence about the conditions, processes and outcomes related to collaboration and implementation.Methods: A longitudinal realist evaluation using multiple qualitative methods case studies was conducted with three Collaborations for Leadership in Applied Health Research in Care (England). Data were collected over four rounds of theory development, refinement and testing. Over 200 participants were involved in semi-structured interviews, non-participant observations of events and meetings, and stakeholder engagement. A combined inductive and deductive data analysis process was focused on proposition refinement and testing iteratively over data collection rounds.Results: The quality of existing relationships between higher education and local health service, and views about whether implementation was a collaborative act, created a path dependency. Where implementation was perceived to be removed from service and there was a lack of organisational connections, this resulted in a focus on knowledge production and transfer, rather than co-production. The collaborations' architectures were counterproductive because they did not facilitate connectivity and had emphasised professional and epistemic boundaries. More distributed leadership was associated with greater potential for engagement. The creation of boundary spanning roles was the most visible investment in implementation, and credible individuals in these roles resulted in cross-boundary work, in facilitation and in direct impacts. The academic-practice divide played out strongly as a context for motivation to engage, in that 'what's in it for me' resulted in variable levels of engagement along a co-operation-collaboration continuum. Learning within and across collaborations was patchy depending on attention to evaluation.Conclusions: These collaborations did not emerge from a vacuum, and they needed time to learn and develop. Their life cycle started with their position on collaboration, knowledge and implementation. More impactful attempts at collective action in implementation might be determined by the deliberate alignment of a number of features, including foundational relationships, vision, values, structures and processes and views about the nature of the collaboration and implementation. [ABSTRACT FROM AUTHOR]

Background: The Public Health Responsibility Deal (RD) in England is a public-private partnership involving voluntary pledges between government, industry, and other organisations to improve public health by addressing alcohol, food, health at work, and physical activity. This paper analyses the RD physical activity (PA) pledges in terms of the evidence of their potential effectiveness, and the likelihood that they have motivated actions among organisations that would not otherwise have taken place. Methods: We systematically reviewed evidence of the effectiveness of interventions proposed in four PA pledges of the RD, namely, those on physical activity in the community; physical activity guidelines; active travel; and physical activity in the workplace. We then analysed publically available data on RD signatory organisations' plans and progress towards achieving the physical activity pledges, and assessed the extent to which activities among organisations could be attributed to the RD. Results: Where combined with environmental approaches, interventions such as mass media campaigns to communicate the benefits of physical activity, active travel in children and adults, and workplace-related interventions could in principle be effective, if fully implemented. However, most activities proposed by each PA pledge involved providing information or enabling choice, which has limited effectiveness. Moreover, it was difficult to establish the extent of implementation of pledges within organisations, given that progress reports were mostly unavailable, and, where provided, it was difficult to ascertain their relevance to the RD pledges. Finally, 15 % of interventions listed in organisations' delivery plans were judged to be the result of participation in the RD, meaning that most actions taken by organisations were likely already under way, regardless of the RD. Conclusions: Irrespective of the nature of a public health policy to encourage physical activity, targets need to be evidence-based, well-defined, measurable and encourage organisations to go beyond business as usual. RD physical activity targets do not adequately fulfill these criteria. [ABSTRACT FROM AUTHOR]

Context In 2004, the English Public Health White Paper Choosing Health introduced 'health trainers' as new members of the National Health Service (NHS) workforce. Health trainers would offer one-to-one peer-support to anyone who wished to adopt and maintain a healthier lifestyle. Choosing Health implicitly envisaged health trainers working in community settings in order to engage 'hard-to-reach' individuals and other groups who often have the poorest health but who engage the least with traditional health promotion and other NHS services. Methods During longitudinal case studies of 6 local health trainer services, we conducted in-depth interviews with key stakeholders and analyzed service activity data. Findings Rather than an unproblematic and stable implementation of community-focused services according to the vision in Choosing Health, we observed substantial shifts in the case studies' configuration and delivery as the services embedded themselves in the local NHS systems. To explain these observations, we drew on a recently proposed conceptual framework to examine and understand the adoption and diffusion of innovations in health care systems. Conclusions The health trainer services have become more 'medicalized' over time, and in doing so, the original theory underpinning the program has been threatened. The paradox is that policymakers and practitioners recognize the need to have a different service model for traditional NHS services if they want hard-to-reach populations to engage in preventive actions as a first step to redress health inequalities. The long-term sustainability of any new service model, however, depends on its aligning with the established medical system's (ie, the NHS's) characteristics. [ABSTRACT FROM AUTHOR]

Introduction: The COVID-19 pandemic globally impacted healthcare provision. Prescribing changes in common medications can be used as a marker for new diagnoses. We describe how the prescribing of specific psychotropics was impacted by the pandemic. Methods: Primary Care Prescribing data for different classes of drugs from March 2017 to February 2022 were considered. To capture the impact during periods of restricted access to health services for new diagnoses/existing conditions, repeat prescriptions/episodic prescribing were included with account taken of historical trends. The pre-pandemic prescriptions issued each month from March 2018 to February 2020 were linearly extrapolated forward to give an expected annual growth (EAG). The monthly average expected prescriptions for the pandemic period (March 2020–February 2022) were compared. Results: Physical health medications had lower monthly prescriptions during the pandemic, most markedly for antibiotics − 12.5% (EAG − 1.3%). Bronchodilator prescribing showed a marked increase in the early pandemic months from March 2020 of 5% (EAG 0.1%). Mental health medication prescribing increased above trend for hypnotics/anxiolytics by 0.2% (EAG − 2.3%), while antidepressants fell by − 0.2% (EAG 5.0%), with no net change for antipsychotics (EAG 2.8%), but a temporary increase in antipsychotic prescribing in the early pandemic period. For all the main antidepressants prescribed in England (Sertraline, Mirtazapine, Venlafaxine, Fluoxetine and Citalopram), prescribing actually decreased in the main pandemic period vs historical trend. Conclusions: The increase in anxiolytic/hypnotic prescribing above trend links to pandemic effects on anxiety/worry. If anything, there was a slight fall in prescribing of the main antidepressants prescribed, which given prevailing circumstances at the time, suggests that access to services may have restricted access to timely assessment. [ABSTRACT FROM AUTHOR]

Current research ethics frameworks were developed on the footprint of biomedical, experimental research and present several pitfalls when applied to non-experimental social sciences. This work explores how the normative principles underpinning policy and regulatory frameworks of research ethics and the related operational processes work in practice in the context of collaborative health and social care research. The work was organised in three phases. First, UK research ethics policy documents were analysed thematically, with themes further organised under the categories of 'Principles' and 'Processes'. Next, we conducted a scoping review of articles about research ethics in the context of collaborative health and social care research, published in English between 2010 and 2022. We then held an exploratory focus group with ten academic researchers with relevant experience to gather their views on how the research ethics system works in practice in England (UK). The thematic framework developed in the first phase supported the analysis of the articles included in the scoping review and of focus group data. The analysis of policy documents identified twelve themes. All were associated to both a principle and a related operational process. The scoping review identified 31 articles. Across these, some themes were barely acknowledged (e.g., Compliance with legislation). Other themes were extensively covered (e.g., The working of Research Ethics Committees), often to discuss issues and limitations in how, in practice, the research ethics system and its processes deal with collaborative research and to suggest options for improvement. Focus group data were largely consistent with the findings of the scoping review. This work provides evidence of the poor alignment between how the research ethics system is normatively expected to work and how it works in practice and offers options that could make research ethics more fit for purpose when addressing collaborative research in health and social care. [ABSTRACT FROM AUTHOR]

The article focuses on the cases of infant mortality and morbidity in England in 1909 until the present. In 1909, there are bout 120 of the 1,000 infants born alive died before reaching their first birthday not only in England but also to countries which were now considered developed or industrialized. However, infant mortality today in most rich countries had been cut down to about 10 percent than what it was 70 years ago which is primarily because of better social welfare and public health services. One reason for the adequate decline in infant mortality during the twentieth century is the improvement in nutrition which plays a very important role in infant mortality. In the decline in the U.S. infant mortality is the spread of various family planning methods.

Background: In quasi-markets governance over healthcare providers is mediated by commissioners. Different commissioners apply different combinations of six methods of control ('media of power') for exercising governance: managerial performance, negotiation, discursive control, incentives, competition and juridical control. This paper compares how English and German healthcare commissioners do so. Methods: Systematic comparison of observational national-level case studies in terms of six media of power, using data from multiple sources. Results: The comparison exposes and contrasts two basic generic modes of commissioning: 1. Surrogate planning (English NHS), in which a negotiated order involving micro-commissioning, provider competition, financial incentives and penalties are the dominant media of commissioner power over providers. 2. Case-mix commissioning (Germany), in which managerial performance, an 'episode based' negotiated order and juridical controls appear the dominant media of commissioner power. Conclusions: Governments do not necessarily maximise commissioners' power over providers by implementing as many media of power as possible because these media interact, some complementing and others inhibiting each other. In particular, patient choice of provider inhibits commissioners' use of provider competition as a means of control. [ABSTRACT FROM AUTHOR]

Background: This paper examines NHS secondary care contracting in England and Wales in a period which saw increasing policy divergence between the two systems. At face value, England was making greater use of market levers and utilising harder-edged service contracts incorporating financial penalties and incentives, while Wales was retreating from the 1990s internal market and emphasising cooperation and flexibility in the contracting process. But there were also cross-border spill-overs involving common contracting technologies and management cultures that meant that differences in on-the-ground contracting practices might be smaller than headline policy differences suggested. Methods: The nature of real-world contracting behaviour was investigated by undertaking two qualitative case studies in England and two in Wales, each based on a local purchaser/provider network. The case studies involved ethnographic observations and interviews with staff in primary care trusts (PCTs) or local health boards (LHBs), NHS or Foundation trusts, and the overseeing Strategic Health Authority or NHS Wales regional office, as well as scrutiny of relevant documents. Results: Wider policy differences between the two NHS systems were reflected in differing contracting frameworks, involving regional commissioning in Wales and commissioning by either a PCT, or co-operating pair of PCTs in our English case studies, and also in different oversight arrangements by higher tiers of the service. However, longterm relationships and trust between purchasers and providers had an important role in both systems when the financial viability of organisations was at risk. In England, the study found examples where both PCTs and trusts relaxed contractual requirements to assist partners faced with deficits. In Wales, news of plans to end the purchaser/provider split meant a return to less precisely-specified block contracts and a renewed concern to build cooperation between LHB and trust staff. Conclusions: The interdependency of local purchasers and providers fostered long-term relationships and cooperation that shaped contracting behaviour, just as much as the design of contracts and the presence or absence of contractual penalties and incentives. Although conflict and tensions between contracting partners sometimes surfaced in both the English and Welsh case studies, cooperative behaviour became crucial in times of trouble. [ABSTRACT FROM AUTHOR]

Background: The direction of health service policy in England is for more diversification in the design, commissioning and provision of health care services. The case study which is the subject of this paper was selected specifically because of the partnering with a private sector organisation to manage whole system redesign of primary care and to support the commissioning of services for people with long term conditions at risk of unplanned hospital admissions and associated service provision activities. The case study forms part of a larger Department of Health funded project on the practice of commissioning which aims to find the best means of achieving a balance between monitoring and control on the one hand, and flexibility and innovation on the other, and to find out what modes of commissioning are most effective in different circumstances and for different services. Methods: A single case study method was adopted to explore multiple perspectives of the complexities and uniqueness of a public-private partnership referred to as the "Livewell project". 10 single depth interviews were carried out with key informants across the GP practices, the PCT and the private provider involved in the initiative. Results: The main themes arising from single depth interviews with the case study participants include a particular understanding about the concept of commissioning in the context of primary care, ambitions for primary care redesign, the importance of key roles and strong relationships, issues around the adoption and spread of innovation, and the impact of the current changes to commissioning arrangements. The findings identified a close and high trust relationship between GPs (the commissioners) and the private commissioning support and provider firm. The antecedents to the contract for the project being signed indicated the importance of leveraging external contacts and influence (resource dependency theory). Conclusions: The study has surfaced issues around innovation adoption in the healthcare context. The case identifies 'negotiated order', managerial performance of providers and disciplinary control as three media of power used in combination by commissioners. The case lends support for stewardship and resource dependency governance theories as explanations of the underpinning conditions for effective commissioning in certain circumstances within a quasi marketised healthcare system. [ABSTRACT FROM AUTHOR]