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Background Current National Health Service policy in England encourages enhanced digital access in primary care service provision. In this study, we investigate ‘digital facilitation’ – that range of processes, procedures and personnel which seeks to support National Health Service primary care patients in their uptake and use of online services. Objectives Identify, characterise and explore the potential benefits and challenges associated with different models of digital facilitation currently in use in general practice which are aimed at improving patient access to online services in general practice in England. Use the resulting intelligence to design a framework for future evaluations of the effectiveness and cost effectiveness of such interventions. Explore how patients with mental health conditions experience digital facilitation and gauge their need for this support. Design Observational mixed-methods study (literature review, surveys, ethnographic observation and interviews); formal synthesis of findings. Setting General practice in four regions of England. Participants Practice survey: 156 staff. Patient survey: 3051 patients. Mental health survey: 756 patients. General practitioner patient survey: 3 million responders. Ethnographic case-studies: 8 practices; interviews with 36 staff, 33 patients and 10 patients with a mental health condition. Stakeholder interviews: 19 participants. Intervention Digital facilitation as undertaken in general practice. Main outcome measures Patient and practice staff reported use of, and views of, digital facilitation. Data sources Surveys, qualitative research; national General Practitioner Patient Survey (2019–22). Review methods Scoping-review methodology applied to academic and grey literature published 2015–20. Results While we did find examples of digital facilitation in routine practice, these often involved using passive or reactive modes of support. The context of COVID, and the necessary acceleration (at that time) of the move to a digital-first model of primary care, shaped the way digital facilitation was delivered. There was lack of clarity over where the responsibility for facilitation efforts lay; it was viewed as the responsibility of ‘others’. Patients living with mental health conditions had similar needs and experiences regarding digital facilitation to other patients. Limitations The context of the COVID pandemic placed limitations on the project. Fewer practices responded to the practice survey than anticipated; reconfiguration of general practices to support COVID measures was a key consideration during non-participant observation with social distancing and other measures still in place during fieldwork. Conclusions Digital facilitation, while not a widely recognised concept, is important in supporting the move to a National Health Service with enhanced digital opportunities and enhanced digital access. General practice staff are allocating resources to provide such efforts in general practices in England. The establishment of clear lines of responsibility, the development of digital tools and platforms that work for patients and practice staff, and investment in staff time and training are needed if digital facilitation is to support the intended digital revolution. Future work We did not find one single dominant or preferred model of digital facilitation which might reasonably be considered to form the basis of an intervention to be tested. Rather, there is a need to co-develop such an intervention with patients, general practice staff and relevant policy experts. We outline a framework for a future evaluation of such an intervention. Study registration This study is registered as ResearchRegistry6523 (www.researchregistry.com/browse-the-registry#home/?view_2_search=Di-Facto&view_2_page=1) and PROSPERO CRD42020189019 (www.crd.york.ac.uk/prospero/display_record.php?RecordID=189019). Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128268) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 32. See the NIHR Funding and Awards website for further award information. Plain language summary Background Online services are common in the National Health Service. This research looked at ‘digital facilitation’ in general practices. Digital facilitation is about supporting National Health Service patients in their use of online services. We aimed to understand how much digital facilitation is being used by general practices. We also looked at how digital facilitation happens and if it affects the number of people using online services. Methods We looked at previous research to help us understand what approaches have been used to support patients to use online services. We used surveys to ask staff at general practices what they were already doing, and to ask patients about their experiences. We observed digital facilitation in general practices and spoke to patients and staff to help us understand the benefits and challenges of different approaches. We combined findings from the three stages outlined above to identify key aspects of digital facilitation. All stages of our research included discussions with the project’s patient advisory group. Key findings We found that digital facilitation is seen as important and has many forms. Most general practices are using passive and reactive types of facilitation. An example of passive facilitation, initiated by the service but not involving direct inter-personal interaction, is the use of text messaging relating to ordering of repeat prescriptions online. An example of reactive facilitation is providing a response to a patient-initiated query regarding online access. There is clear scope to develop a more proactive approach to facilitation that actively engages patients. Our research highlights a lack of clarity over who is responsible for digital facilitation. Different people (patients, staff, policy-makers) often think that the responsibility lies with others. Investment in digital facilitation is needed. Tools and platforms for digital facilitation that meet patients’ and general practices’ needs should be developed. Scientific summary Background The NHS is facing the increasing demands of a growing and ageing population, technological progress and changing public expectations. Current NHS policy in England encourages enhanced digital opportunities and enhanced digital access in primary care provision. Drivers behind this move include the assumption that online services lead to improved choice, convenience, and ease of access for users, improved triage systems and streamlining of service delivery. In this research, we addressed ‘digital facilitation’ [digital facilitation (DF)] – ‘that range of processes, procedures and personnel which seeks to support NHS patients in their uptake and use of online services’. We investigated the provision by general practices to support access to NHS online primary care services by their registered patients and carers of those patients. Support in accessing and using services is required at all stages: initial registration for online services; subsequent continued use; and navigating the wide range of NHS online provision. Hence, it is important to understand the extent to which approaches to DF are applied, how they are applied, the impact such efforts have on uptake of online services, and how such uptake may affect patient health and access to healthcare information and services. Aims Identify, characterise and explore the potential benefits and challenges associated with different models of DF currently in use in general practice in England which are aimed at improving patient access to online primary care services. Use the resulting intelligence to design a framework for future evaluations of the effectiveness and cost effectiveness of such interventions. Explore how patients with mental health conditions experience DF and gauge their need for this support. Methods The project comprised four interlinked elements. Initially we undertook a scoping review and narrative synthesis of published literature, seeking to understand and characterise the range, effectiveness and cost effectiveness of models of DF for improving access to online services within health. Searches of academic databases and grey literature published between 2015 and 2020 were undertaken, including snowballing from the publications they cited. We surveyed general practice staff and patients (with an additional boost sample of patients living with mental health conditions, which was in direct response to a National Institute for Health and Care Research commissioning brief) and undertook analyses of data from the national General Practice Patient Survey (GPPS). The practice staff questionnaire included items addressing which online services were being used and what steps had been implemented in practices to promote and support the use of such services. We implemented a sequential mixed mode when inviting staff from 500 general practices to complete the survey online or on paper. The patient questionnaire addressed patients’ familiarity and confidence with information technology (IT) and internet use, their awareness and uptake of online services, and their experiences of any support provided by their practice. Questionnaires were sent by post with the option of replying online or by post. We also analysed responses to questions from the English national GPPSs (2019–22) concerning awareness and use of online booking of appointments, ordering repeat prescriptions and accessing medical records, and additionally the use of online consultations. Logistic regression models were used to examine how the awareness and use of online services, the awareness and use of facilitation efforts, and experience of other support varied by patient characteristics. We undertook a qualitative exploration of DF comprising two elements: focused ethnographic case studies in general practices, and an interview study with key stakeholders. Focused ethnography was used to explore, in-depth, the use of DF in general practices. Eight general practice case study sites were recruited to provide variation in terms of their DF offering, and in terms of a range of practice characteristics (practice setting, deprivation status and size, and the age profile of registered patients). We undertook: non-participant observation of the process of DF and how practice staff and patients/carers interact with different types of DF, semistructured interviews with staff members and patients in each practice, and collected secondary analysis of documentation pertaining to digital services or facilitation within the practice. This was augmented by 10 interviews with patients living with mental health conditions from the case study sites; these sought to explore their experiences of DF. The interview study with key stakeholders sought understanding of the broader context and wider drivers of DF in primary care. We conducted semistructured interviews with stakeholders providing a level of insight beyond individual practices, including policy-makers, commissioners and third- sector organisations. Data from the focused ethnographic case studies and stakeholder interviews were analysed together using thematic analysis. We conducted a synthesis of the evidence generated by each element of the study. We employed Weiss’s approach to theory-based evaluation as a theoretical framework. A pragmatic, iterative and cumulative approach was applied to synthesising the findings from all elements and to developing programme and implementation theories. We triangulated findings, summarising the results in a matrix, which evolved into thematic groupings as the study progressed and as evidence from our work packages (WPs) became available. Findings were brought together in a series of three workshop meetings of researchers and patient/public participants as individual WPs were completed. The synthesis process concluded following an online discussion with national and regional stakeholders. We used the synthesised findings to identify the key aspects of a framework aimed at informing future research on DF. Patient and public involvement and engagement (PPIE) was embedded throughout this research, from the original conception through to the design and conduct of the research, and the synthesis and interpretation of findings. Our team has benefited from a patient co-investigator, a dedicated PPIE co-ordinator, and an actively engaged Patient Advisory Group (PAG). All WPs have worked with the PAG to ensure the research is patient focused and addresses patient needs. The PAG was augmented with additional members with lived experience of mental health conditions to ensure that the additional work focused on patients living with mental health conditions was appropriately framed. Members of the PAG were fully involved as equal voices alongside the research team in the synthesis workshops. Results The synthesis of findings from the literature review, surveys and qualitative work resulted in the identification of 11 thematic groups (distinct from, but incorporating, the results of the qualitative thematic analysis): 3 scene-setting themes relating to the context in which DF takes place, and 8 themes related to types of DF, their implementation and effectiveness. Scene-setting themes: The first theme related to the value and purpose of digital services. The qualitative exploration found that the need for, and value of, digital services are not always clear and that there is a lack of shared understanding or belief about what digital services should achieve. The second theme related to conflation of the digital environment with other routes to access. For example, the qualitative exploration found that digital services can both enable access and be a barrier to access, and that patient priorities are often to navigate the system to access health care, making access a more important concept than DF to many. The third theme related to the impact of the COVID pandemic. Many practices responding to the practice survey reported increased digital service offerings and reduced provision of traditional forms of access. The exception to this was in relation to online appointment booking, where 44% of responding practices reported that they had offered this service pre-pandemic but did not do so at the time of the survey. Furthermore, in the qualitative exploration we found that the pandemic was associated with some initiatives being halted that have not subsequently resumed. Digital facilitation themes: The fourth theme related to how people define and identify DF. While, as a research team, we proposed a definition of digital facilitation, it is not yet a widely recognised concept and the qualitative exploration found that it was often difficult to have a working definition for DF given that it is movable and relative to a person’s circumstance. The fifth theme related to the types of DF. In our literature review, we found a focus on interventions that require practices to actively support patients to use digital services. This was in striking contrast with our practice survey where we found that the majority of practices reported passive and reactive modes of facilitation (e.g. 88% of practices used text messages or e-mails for DF and 91% provided ad hoc support to patients). The sixth theme relates to the differing foci of DF on initial sign-up versus supporting sustained use over time. The majority of research found in our review focused on initial sign-up. While in the patient survey we did find that registration was a substantial barrier (20% of responders to the patient survey cited not knowing how to register or finding registration too difficult as a reason for not using online services), the qualitative exploration found that supporting patients to register was often still reactive. Furthermore, although recognising that DF could go beyond initial sign-up, some practices felt that this was their only required contribution to the task of extending digital access. The seventh theme relates to who delivers facilitation. There was a mismatch between existing evidence identified in WP1, which suggested that general practitioners (GPs) and nurses undertake most facilitation, and our survey and qualitative findings that most facilitation efforts were conducted by receptionists and administrative staff. We also found a ‘bystander effect’, with patients, different staff groups and stakeholders all assuming that responsibility for DF lies elsewhere. The eighth and ninth themes related to the enablers and barriers of DF, respectively. Findings from our qualitative work were consistent with much of what emerged from the literature review. Enablers of DF include someone having specific responsibility for such efforts, with associated funding, time and other resources, platforms that enable easy registration and use, and a clear rationale for the digital services that can be understood by practice and patient (i.e. products that have a ‘good fit’ with what is needed). Barriers to effective facilitation include confusion about who is responsible for DF and why; practices using a variety of digital platforms; lack of consideration for the individual circumstances of patients; and assumptions being made about what people can and cannot do digitally based on stereotypes. In our patient survey, we found very low awareness of DF activities (apart from use of e-mail and text messages). Few (13%) responders to the patient survey reported being given help to use online services, but when that help was given, it was generally rated as useful. The 10th theme focuses on digital access and DF for patient subgroups. Age emerged as a common important dimension across the WPs. The literature review identified that older people may particularly benefit from direct, human support in accessing digital services. In the practice survey, most practices reported targeting older adults. However, in the patient survey we found that older patients were less likely to be aware of or make use of DF and were less likely to be told about or receive help to use digital services. In the qualitative work we found that the age of the individual is perceived to have an impact on both staff and patients’ digital knowledge, understanding, experience and confidence. Responders to the patient survey who were from ethnic minorities had long-term health conditions, did not speak English as a first language, or were in receipt of repeat prescriptions, were more likely to report awareness of and use of (passive) facilitation than other patients. But these groups were also less likely to be told about online services or to have received help to use them. The findings of our work focusing on patients living with mental health conditions were largely concordant with the findings of the main patient survey and qualitative research. There were some differences in the way that specific mental health conditions impacted on individuals’ contact with their practice, and consequently in the use by such individuals of digital services and in their need for DF. Responders in the patient survey mental health sample were more likely to report using digital services and to being aware of DF efforts than were responders to the main survey, but this was largely explained by differences in the sample demographics. The final theme considered the effectiveness of DF. There was no evidence around the cost effectiveness of DF, and the limited existing evidence on effectiveness almost entirely focused on initial sign-up of services. Reflecting this, our qualitative exploration found that some practices focused on the number of patients signed up to a service as evidence of the effectiveness of their facilitation efforts. Conclusions Digital facilitation is important in the context of the move to an NHS-enhanced digital opportunities and enhanced digital access in primary care service provision. Staff are spending time and effort to provide DF in general practices in England. Digital facilitation is viewed to have value and potential to increase the uptake of online services. Digital facilitation can take many forms, though most such efforts are reactive and passive. There is clear scope to develop a more proactive approach to facilitation that actively engages patients. There is currently a disconnect between the expectations and perceptions of what DF is happening and its potential effectiveness, and the reality seen in everyday practice. This is related to a lack of clarity over the responsibility for delivering DF and pressures on the time of general practice staff. Establishing clear lines of responsibility, and the development of digital tools and platforms that work for patients and practice staff, will both be needed, alongside investment in staff time and training, if DF is to deliver on the intended digital revolution. This project set out to explore DF that was already underway, with the potential of identifying good practice. However, we did not find an example of what might form a complete, practical intervention package. Future research should therefore focus on: co-development, involving patients and general practice staff, of DF, seeking to ensure a responsive and adaptive approach improving the presentation of practice websites for patient engagement with the intent of increasing uptake of digital tools and reducing the need for DF the best approaches to tailoring DF to different patient groups and identifying which patient groups are most likely to benefit from such efforts ensuring that the digital exclusion of certain groups, including, but not limited to, older patients, is investigated monitoring the sustained use of online services, not merely initial sign-up. Study registration This study is registered as ResearchRegistry6523 (www.researchregistry.com/browse-the-registry#home/?view_2_search=Di-Facto&view_2_page=1) and PROSPERO CRD42020189019 (www.crd.york.ac.uk/prospero/display_record.php?RecordID=189019). Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128268) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 32. See the NIHR Funding and Awards website for further award information. more...

In this paper, we explore the rationale for a combined art therapy and mentalization-based treatment (MBT) group course for those experiencing a first episode of psychosis (FEP). We discuss the theoretical background for how art and MBT theory can help us better understand and work with groups of individuals experiencing FEP, particularly focusing on avoidance and insecure attachment styles. We outline the delivery of a ten-week psychoeducational Art MBT course within an Early Intervention in Psychosis (EIP) Service and discuss our experiential insights into this new modality as co-therapists. We conclude by proposing that art therapy and mentalizing practice together offer an accessible, useful and practical group structure for EIP services, which could improve individuals’ mentalizing capacity and overall social functioning. more...

As detailed in its flagship report, Genome UK, the UK government recognises the vital role that broad public engagement across whole populations plays in the field of genomics. However, there is limited evidence about how to do this at scale. Most public audiences do not feel actively connected to science, are often unsure of the relevance to their lives and rarely talk to their family and friends about it; we term this dis-connection a ‘disengaged public audience’. We use a narrative review to explore: (i) UK attitudes towards genetics and genomics and what may influence reluctance to engage with these topics; (ii) innovative public engagement approaches that have been used to bring diverse public audiences into conversations about the technology. Whilst we have found some novel engagement methods that have used participatory arts, film, social media and deliberative methods, there is no clear agreement on best practice. We did not find a consistently used, evidence-based strategy for delivering public engagement about genomics across diverse and broad populations, nor a specific method that is known to encourage engagement from groups that have historically felt (in terms of perception) and been (in reality) excluded from genomic research. We argue there is a need for well-defined, tailor-made engagement strategies that clearly articulate the audience, the purpose and the proposed impact of the engagement intervention. This needs to be coupled with robust evaluation frameworks to build the evidence-base for population-level engagement strategies. more...

Background: Up to 10% of children and young people have a specific phobia that can significantly affect their mental health, development and daily functioning. Cognitive–behavioural therapy-based interventions remain the dominant treatment, but limitations to their provision warrant investigation into low-intensity alternatives. One-session treatment is one such alternative that shares cognitive–behavioural therapy principles but has a shorter treatment period. Objective: This research investigated the non-inferiority of one-session treatment to cognitive–behavioural therapy for treating specific phobias in children and young people. The acceptability and cost-effectiveness of one-session treatment were examined. Design: A pragmatic, multicentre, non-inferiority randomised controlled trial, with embedded economic and qualitative evaluations. Settings: There were 26 sites, including 12 NHS trusts. Participants: Participants were aged 7–16 years and had a specific phobia defined in accordance with established international clinical criteria. Interventions: Participants were randomised 1 : 1 to receive one-session treatment or usual-care cognitive–behavioural therapy, and were stratified according to age and phobia severity. Outcome assessors remained blind to treatment allocation. Main outcome measures: The primary outcome measure was the Behavioural Avoidance Task at 6 months’ follow-up. Secondary outcomes included the Anxiety Disorder Interview Schedule, Child Anxiety Impact Scale, Revised Children’s Anxiety and Depression Scale, a goal-based outcome measure, Child Health Utility 9D, EuroQol-5 Dimensions Youth version and resource usage. Treatment fidelity was assessed using the Cognitive Behaviour Therapy Scale for Children and Young People and the One-Session Treatment Rating Scale. Results: A total of 274 participants were recruited, with 268 participants randomised to one-session treatment (n = 134) or cognitive–behavioural therapy (n = 134). A total of 197 participants contributed some data, with 149 participants in the intention-to-treat analysis and 113 in the per-protocol analysis. Mean Behavioural Avoidance Task scores at 6 months were similar across treatment groups when both intention-to-treat and per-protocol analyses were applied [cognitive–behavioural therapy: 7.1 (intention to treat), 7.4 (per protocol); one-session treatment: 7.4 (intention to treat), 7.6 (per protocol); on the standardised scale adjusted mean difference for cognitive–behavioural therapy compared with one-session treatment –0.123, 95% confidence interval –0.449 to 0.202 (intention to treat), mean difference –0.204, 95% confidence interval –0.579 to 0.171 (per protocol)]. These findings were wholly below the standardised non-inferiority limit of 0.4, which suggests that one-session treatment is non-inferior to cognitive–behavioural therapy. No between-group differences in secondary outcome measures were found. The health economics evaluation suggested that, compared with cognitive–behavioural therapy, one-session treatment marginally decreased the mean service use costs and maintained similar mean quality-adjusted life-year improvement. Nested qualitative evaluation found one-session treatment to be considered acceptable by those who received it, their parents/guardians and clinicians. No adverse events occurred as a result of phobia treatment. Limitations: The COVID-19 pandemic meant that 48 children and young people could not complete the primary outcome measure. Service waiting times resulted in some participants not starting therapy before follow-up. Conclusions: One-session treatment for specific phobia in UK-based child mental health treatment centres is as clinically effective as multisession cognitive–behavioural therapy and highly likely to be cost-saving. Future work could involve improving the implementation of one-session treatment through training and commissioning of improved care pathways. Trial registration: This trial is registered as ISRCTN19883421. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 42. See the NIHR Journals Library website for further project information. more...

Background: Primary care networks are groups of general practices brought together in July 2019 to hold shared budgets and develop new services in response to NHS England (now NHS England and Improvement) policy. This study examined the early implementation of primary care networks, especially what has helped or hindered progress, how they operate in relation to pre-existing collaborations and issues for rural networks. Objective: To produce early evidence about the development of primary care networks to inform policy for their future development. Our research questions were to investigate (1) the contextual background of primary care networks; (2) the rationale for general practices to enter into collaborations; (3) the early learning from establishing primary care networks; (4) barriers to and facilitators of effective collaboration across general practices; and (5) the likely future progress of primary care networks in the English NHS, including in the light of COVID-19. Design: A qualitative cross-comparative case study evaluation comprised four work packages: (1) a rapid evidence assessment; (2) a workshop with academics, policy experts and patient/public representatives; (3) interviews with stakeholders, observations of meetings, a survey and documentary analysis across four case study sites; and (4) analysis and synthesis of findings to develop recommendations for the next stage of the development of primary care networks. Results: Primary care networks have been implemented in a timely manner and have established a range of new local health services. Previous general practice collaborations provide much-needed support in terms of management, leadership and infrastructure, although they can be a source of tension within networks where interests, goals and ways of working do not align. Reasons for collaborative working typically focus on the sustainability of primary care and a desire for better-integrated services, although those cited as the basis for joining primary care networks were mostly related to policy and financial incentives. Early evidence reveals operational success in establishing organisational structures, recruiting to new roles and providing services as required by the national specification. Effective management and leadership, particularly with respect to having a committed clinical director, and constructive relationships between primary care networks and clinical commissioning groups, are important in ensuring success. In rural areas there was some perceived lack of fit with aspects of the primary care network specification, alongside existing challenges of providing primary care to rural populations. Limitations: Arranging and carrying out interviews proved difficult given the workload associated with implementing networks and wider time pressures. Following the onset of the COVID-19 pandemic, the team was unable to undertake planned face-to-face workshops to explore findings. Given that primary care networks were in their first year of operation at the time of this evaluation, we were cautious in drawing definitive conclusions. Conclusions: Key lessons focus on increasing the engagement of general practices and wider primary care teams with networks; building leadership and management capacity to support networks in fulfilling their contractual obligations and meeting local health needs; and clarifying how primary care networks will operate in the post-COVID-19 health and social care system. Future work: Future work could involve evaluating the impact and effectiveness of primary care networks using quantitative and qualitative measures; undertaking research in both rural and urban areas, exploring the extent to which this context is significant; examining the cost and effectiveness of sustaining and extending leadership and management support within primary care networks; and understanding the relationships between primary care networks and the wider health and care system. Study registration: This study is registered as PROSPERO CRD42018110790. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care and Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 27. See the NIHR Journals Library website for further project information. more...

BackgroundThe use of web-based services within primary care (PC) in the National Health Service in England is increasing, with medically underserved populations being less likely to engage with web-based services than other patient groups. Digital facilitation—referring to a range of processes, procedures, and personnel that seek to support patients in the uptake and use of web-based services—may be a way of addressing these challenges. However, the models and impact of digital facilitation currently in use are unclear. ObjectiveThis study aimed to identify, characterize, and differentiate between different approaches to digital facilitation in PC; establish what is known about the effectiveness of different approaches; and understand the enablers of digital facilitation. MethodsAdopting scoping review methodology, we searched academic databases (PubMed, EMBASE, CINAHL, Web of Science, and Cochrane Library) and gray literature published between 2015 and 2020. We conducted snowball searches of reference lists of included articles and articles identified during screening as relevant to digital facilitation, but which did not meet the inclusion criteria because of article type restrictions. Titles and abstracts were independently screened by 2 reviewers. Data from eligible studies were analyzed using a narrative synthesis approach. ResultsA total of 85 publications were included. Most (71/85, 84%) were concerned with digital facilitation approaches targeted at patients (promotion of services, training patients to improve their technical skills, or other guidance and support). Further identified approaches targeted PC staff to help patients (eg, improving staff knowledge of web-based services and enhancing their technical or communication skills). Qualitative evidence suggests that some digital facilitation may be effective in promoting the uptake and use of web-based services by patients (eg, recommendation of web-based services by practice staff and coaching). We found little evidence that providing patients with initial assistance in registering for or accessing web-based services leads to increased long-term use. Few studies have addressed the effects of digital facilitation on health care inequalities. Those that addressed this suggested that providing technical training for patients could be effective, at least in part, in reducing inequalities, although not entirely. Factors affecting the success of digital facilitation include perceptions of the usefulness of the web-based service, trust in the service, patients’ trust in providers, the capacity of PC staff, guidelines or regulations supporting facilitation efforts, and staff buy-in and motivation. ConclusionsDigital facilitation has the potential to increase the uptake and use of web-based services by PC patients. Understanding the approaches that are most effective and cost-effective, for whom, and under what circumstances requires further research, including rigorous evaluations of longer-term impacts. As efforts continue to increase the use of web-based services in PC in England and elsewhere, we offer an early typology to inform conceptual development and evaluations. Trial RegistrationPROSPERO International Prospective Register of Systematic Reviews CRD42020189019; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=189019 more...

Purpose Intimate partner violence (IPV) is a pervasive public health issue impacting one in three women, worldwide. Broadly defined as any act of coercive control within the context of an intimate relationship, IPV often results in significant negative health outcomes. Cognitive Behavioral Therapy (CBT), a mainstay treatment for relational trauma, has particular relevance for women undergoing the many transformations associated with the perinatal period. The findings of this case analysis build upon existing literature supporting the positive impact of Trauma and Violence- Informed CBT (TVICBT) for women who have experienced IPV and are living with mental health challenges. Methods As part of a larger mixed-methods study, three women who experienced IPV and received TVICBT during pregnancy participated in in-depth, semi-structured interviews to determine the perceived value and acceptability of this intervention. Findings Insights gained herein, serve to enrich current evidence, suggesting that TVICBT provided during pregnancy may hold promise for the treatment of IPV-related mood and anxiety disorders. Conclusions Given that improved perinatal mental health has been linked to enhanced maternal resiliency and quality of life, greater maternal-infant attachment, and positive child health outcomes, this research has the potential to bridge the critical knowledge gap at the intersection of motherhood, trauma, and mental health. more...

Previous studies have shown that autistic people often display atypical responses when processing sensory information, with particular prevalence within the auditory domain. Often provoked by common everyday sounds, auditory hypersensitivity can result in self-regulatory fear responses. This can be potentially harmful to autistic individuals and the people around them and is associated with greater occurrence of anxiety, depression, and poorer overall quality of life in the autistic population. Rather than a physiological causation, the literature suggests that hypersensitivity to sound is likely to be caused by how auditory stimuli are processed in the brain. This paper reports a home-based digital intervention aimed to address auditory hypersensitivity in autistic children. Developed as an interactive virtual reality game, the system integrates exposure-based therapy techniques into game mechanics and delivers target auditory stimuli to the player rendered via binaural-based spatial audio. The performance of the platform was evaluated in a 10-week feasibility study, during which children (n = 7) engaged weekly with the game during a 30 min session. Following this period, a comparison of pre- and post-study measurements showed a decrease in sensitivity for five participants, with qualitative feedback highlighting an increase in tolerance towards real-world stimuli and challenging environments. These results provide initial support for SoundFields as a home-based intervention targeting auditory hypersensitivity experienced by autistic children. more...

Objectives Primary care networks (PCNs) were introduced in the National Health Service (NHS) in England in 2019 to improve integrated care for patients and help address financial and workforce sustainability issues in general practice. The purpose of this study was to collect early evidence on their implementation and development, including motivations to participate and what enables or inhibits progress. This paper considers the core characteristics of PCNs, and how this informs their management.Design A qualitative mixed-methods rapid evaluation was conducted across four case study sites in England, informed by a literature review and stakeholder workshop. Data collection comprised interviews, non-participant observation of meetings, an online survey and documentary review.Results General practitioners (GPs) are motivated to participate in PCNs for their potential to improve patient care, enable better coordinated services and enhance financial and workforce sustainability within primary care. However, PCNs also have an almost mandatory feel, based on the national policy context and significant financial incentives associated with joining them. PCNs offer potential to bring GPs together to work towards common goals, deliver national priorities and respond rapidly to local needs.Conclusions PCNs face similar challenges to other meso-level primary care organisations internationally, as they respond to local and national priorities and operate in a context of multiple goals and interests. In managing these organisations, it is important to find a balance between local and national autonomy, decision making and control. more...

Background: Point of care testing (POCT) for infectious diseases is testing conducted near the patient. It allows clinicians to offer the most appropriate treatment more quickly. As POCT devices have increased in accuracy and become more cost-effective, their use has grown, but a systematic assessment of their use for clinical and public health management of infectious diseases in EU/EEA countries has not been previously undertaken.Methods: A scoping review of the literature on POCT in EU/ EEA countries as at November 2019, and a survey of key stakeholders.Results: 350 relevant articles were identified and 54 survey responses from 26 EU/EEA countries were analysed. POCT is available for a range of infectious diseases and in all countries responding to the survey (for at least one disease). POCT is commonly available for influenza, HIV/AIDS, Legionnaires' disease and malaria, where it is used in at least half of EU/EEA countries. While POCT has the potential to support many improvements to clinical care of infectious diseases (e.g., faster diagnosis, more appropriate use of antimicrobials), the results suggest POCT is infrequently used to support public health functions (e.g., disease surveillance and reporting).Conclusion: Although POCT is in use to some extent in all EU/EEA countries, the full benefits of POCT in wider public health functions have yet to be realised. Further research on barriers and facilitators to implementation is warranted. more...

Background: Primary care networks are groups of general practices brought together in July 2019 to develop new services in response to NHS England/Improvement policy using a shared budget. This study examined the early implementation of primary care networks, especially what has helped or hindered progress, how they operate in relation to pre-existing collaborations, and issues for rural networks. Objective: To produce early evidence about the development of primary care networks to inform policy for their future development. Our research questions were to investigate 1) the contextual background of primary care networks; 2) the rationale for general practices to enter into collaborations; 3) the early learning from establishing primary care networks; 4) barriers to and facilitators of effective collaboration across GP practices; and, 5) the likely future progress of primary care networks in the English NHS, including in light of Covid-19. Design: A qualitative cross-comparative case study evaluation comprised of four work packages: Results: Primary care networks have been implemented in a timely manner and have established a range of new local health services. Previous GP collaborations provide much-needed support in terms of management, leadership and infrastructure, although they can be a source of tension within networks where interests, goals and ways of working do not align.: Reasons for collaborative working typically focus on the sustainability of primary care and a desire for better integrated services, although those cited as the basis for joining primary care networks were mostly related to policy and financial incentives. Early evidence reveals operational success in establishing organisational structures, recruiting to new roles, and providing services as required by the national specification.: Effective management and leadership, particularly with respect to having a committed clinical director, and constructive relationships between primary care networks and clinical commissioning groups, are important in ensuring success. In rural areas there was some perceived lack of fit with aspects of the primary care network specification, alongside existing challenges of providing primary care to rural populations. Limitations: Arranging and completing interviews proved difficult given the workload associated with implementing networks and wider time pressures. Following the onset of the Covid-19 pandemic, the team was unable to undertake planned face-to-face workshops to explore findings. Given that primary care networks were in their first year of operation at the time of this evaluation, we were cautious in drawing definitive conclusions. Conclusions: Key lessons focus on: Future work: Evaluating the impact and effectiveness of primary care networks using quantitative and qualitative measures; undertaking research in both rural and urban areas, exploring the extent to which this context is significant; the cost and effectiveness of sustaining and extending leadership and management support within primary care networks; and understanding the relationships between primary care networks and the wider health and care system. Study registration: Ethical approval from the University of Birmingham Research Ethics Committee (ERN_13-1085AP34). Rapid Evidence Assessment protocol registered with PROSPERO (CRD42018110790) Funding: This project was funded by the National Institute of Health Research (NIHR) Health Services and Delivery Research programme (16/138/31 – Birmingham, RAND and Cambridge Evaluation Centre). more...

Layers diets typically contain 15–20% soya due to its high crude protein content (ca. 36%). Reliance on soya for protein can result in large increases in cost of feed due to the law of supply and demand as a global commodity. Lupin grains have high protein content (35–40%) but previous experience with white lupins has shown toxic effects in poultry due to high levels alkaloids and poor performance due to anti-nutritional Non-starch polysaccharides (NSP). Here blue lupins either processed or whole were trialled for their potential as a protein source. Point of lay chickens (64) at 16 weeks of age were weighed and allocated to 16 coops of four hens. Coops, as the experimental unit, were randomly allocated to four treatments: layers mash with soya (Control); or layers mash with 150 g of lupin/kg diet with the lupin either: whole (Whole); dehulled (Dehulled) or dehulled + a solid state fermentation enzyme extract (SSF; 150 g/tonne DM). All diets were ground and formulated to be balanced for energy, crude protein and essential amino acids using NIRS. No difference in growth rate, final hen weight, DM and water intake, eggs per day, mean egg weight, yellowness of yolk or chroma was found between treatments. There was a trend (P more...