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Stroke survivors often live with significant treatment burden yet our ability to examine this is limited by a lack of validated measurement instruments. We aimed to adapt the 60-item, 12-domain Patient Experience with Treatment and Self-Management (PETS) (version 2.0, English) patient-reported measure to create a stroke-specific measure (PETS-stroke) and to conduct content validity testing with stroke survivors. Step 1 – Adaptation of PETS to create PETS-stroke: a conceptual model of treatment burden in stroke was utilised to amend, remove or add items. Step 2 - Content validation: Fifteen stroke survivors in Scotland were recruited through stroke groups and primary care. Three rounds of five cognitive interviews were audio recorded and transcribed. Framework analysis was used to explore importance/relevance/clarity of PETS-stroke content. COSMIN reporting guidelines were followed. The adapted PETS-stroke had 34 items, spanning 13 domains; 10 items unchanged from PETS, 6 new and 18 amended. Interviews (n = 15) resulted in further changes to 19 items, including: instructions; wording; item location; answer options; and recall period. PETS-stroke has content that is relevant, meaningful and comprehensible to stroke survivors. Content validity and reliability testing are now required. The validated tool will aid testing of tailored interventions to lessen treatment burden. Treatment burden is reported by stroke survivors but no stroke-specific measure of treatment burden exists. We adapted an existing measure of treatment burden for use in multimorbid patients (PETS) to create a stroke specific version (PETS-stroke). The items in PETS-stroke are relevant and meaningful to people with stroke. Further testing will examine construct validity, reliability, and useability. This measure will be useful in future RCTs to measure treatment burden and to identify stroke patients who are at high risk of treatment burden. [ABSTRACT FROM AUTHOR]

Background: Drug-related deaths in Scotland are the highest in Europe. Half of all deaths in people experiencing homelessness are drug related, yet we know little about the unmet health needs of people experiencing homelessness with recent non-fatal overdose, limiting a tailored practice and policy response to a public health crisis. Methods: People experiencing homelessness with at least one non-fatal street drug overdose in the previous 6 months were recruited from 20 venues in Glasgow, Scotland, and randomised into PHOENIx plus usual care, or usual care. PHOENIx is a collaborative assertive outreach intervention by independent prescriber NHS Pharmacists and third sector homelessness workers, offering repeated integrated, holistic physical, mental and addictions health and social care support including prescribing. We describe comprehensive baseline characteristics of randomised participants. Results: One hundred and twenty-eight participants had a mean age of 42 years (SD 8.4); 71% male, homelessness for a median of 24 years (IQR 12–30). One hundred and eighteen (92%) lived in large, congregate city centre temporary accommodation. A quarter (25%) were not registered with a General Practitioner. Participants had overdosed a mean of 3.2 (SD 3.2) times in the preceding 6 months, using a median of 3 (IQR 2–4) non-prescription drugs concurrently: 112 (87.5%) street valium (benzodiazepine-type new psychoactive substances); 77 (60%) heroin; and 76 (59%) cocaine. Half (50%) were injecting, 50% into their groins. 90% were receiving care from Alcohol and Drug Recovery Services (ADRS), and in addition to using street drugs, 90% received opioid substitution therapy (OST), 10% diazepam for street valium use and one participant received heroin-assisted treatment. Participants had a mean of 2.2 (SD 1.3) mental health problems and 5.4 (SD 2.5) physical health problems; 50% received treatment for physical or mental health problems. Ninety-one per cent had at least one mental health problem; 66% had no specialist mental health support. Participants were frail (70%) or pre-frail (28%), with maximal levels of psychological distress, 44% received one or no daily meal, and 58% had previously attempted suicide. Conclusions: People at high risk of drug-related death continue to overdose repeatedly despite receiving OST. High levels of frailty, multimorbidity, unsuitable accommodation and unmet mental and physical health care needs require a reorientation of services informed by evidence of effectiveness and cost-effectiveness. Trial registration UK Clinical Trials Registry identifier: ISRCTN 10585019. [ABSTRACT FROM AUTHOR]

Many western countries used shielding (extended self-isolation) of people presumed to be at high-risk from COVID-19 to protect them and reduce healthcare demand. To investigate the effectiveness of this strategy, we linked family practitioner, prescribing, laboratory, hospital and death records and compared COVID-19 outcomes among shielded and non-shielded individuals in the West of Scotland. Of the 1.3 million population, 27,747 (2.03%) were advised to shield, and 353,085 (26.85%) were classified a priori as moderate risk. COVID-19 testing was more common in the shielded (7.01%) and moderate risk (2.03%) groups, than low risk (0.73%). Referent to low-risk, the shielded group had higher confirmed infections (RR 8.45, 95% 7.44–9.59), case-fatality (RR 5.62, 95% CI 4.47–7.07) and population mortality (RR 57.56, 95% 44.06–75.19). The moderate-risk had intermediate confirmed infections (RR 4.11, 95% CI 3.82–4.42) and population mortality (RR 25.41, 95% CI 20.36–31.71) but, due to their higher prevalence, made the largest contribution to deaths (PAF 75.30%). Age ≥ 70 years accounted for 49.55% of deaths. In conclusion, in spite of the shielding strategy, high risk individuals were at increased risk of death. Furthermore, to be effective as a population strategy, shielding criteria would have needed to be widely expanded to include other criteria, such as the elderly. [ABSTRACT FROM AUTHOR]

Background: General practice websites are an increasingly important point of interaction, but their readability is largely unexplored. One in four adults struggle with basic literacy, and there is a socioeconomic gradient. Readable content is a prerequisite to promoting health literacy.Aim: To assess general practice website readability by analysing text and design factors, and to assess whether practices adapted their website text to the likely literacy levels of their populations.Design and Setting: Websites for all general practices across Scotland were analysed from March to December 2019, using a cross-sectional design.Method: Text was extracted from five webpages per website and eight text readability factors were measured, including the Flesch Reading Ease and the Flesch-Kincaid Grade Level. The relationship between readability and a practice population's level of deprivation, measured using the Scottish Index of Multiple Deprivation (SIMD), was assessed. Overall, 10 design factors contributing to readability and accessibility were scored.Results: In total, 86.4% (n = 813/941) of Scottish practices had a website; 22.9% (n = 874/3823) of webpages were written at, or below, the government-recommended reading level for online content (9-14 years old), and the content of the remaining websites, 77.1% (n = 2949/3823), was suitable for a higher reading age. Of all webpages, 80.5% (n = 3077/3823) were above the recommended level for easy-to-understand 'plain English'. There was no statistically significant association between webpage reading age and SIMD. Only 6.7% (n = 51/764) of websites achieved all design and accessibility recommendations.Conclusion: Changes to practice websites could improve readability and promote health literacy, but practices will need financial resources and ongoing technical support if this is to be achieved and maintained. Failure to provide readable and accessible websites may widen health inequalities; the topic will become increasingly important as online service use accelerates. [ABSTRACT FROM AUTHOR]

Background: Practice population socioeconomic status is associated with practice postgraduate training accreditation. General Practitioner recruitment to socioeconomically deprived areas is challenging, exposure during training may encourage recruitment.Objectives: To determine the association of practice population socioeconomic deprivation score and training status, and if this has changed over time.Methods: Cross-sectional study looking at socioeconomic deprivation and training status for all General Practices in Scotland (n = 982). Data from Information Services Division, from 2015, were combined with the Scottish Index of Multiple Deprivation to calculate weighted socioeconomic deprivation scores for every practice in Scotland. Scottish training body database identified training practices (n = 330). Mean deprivation score for training and non-training practices was calculated. Logistic regression was used to quantify the odds ratio of training status based on deprivation score, adjusted for practice list size, and compared with a similar 2009 analysis.Results: Socioeconomic deprivation score is associated with training status, but is not significant when adjusted for practice list size [OR (adjusted) 0.87, 95% CI: 0.74-1.04]. In contrast, in 2009, adjusted deprivation score remained significant. Mean deprivation score in training and non-training practices remained similar at both time points [2015: 2.98 (SD 0.88) versus 3.17 (SD 0.81); 2009: 2.95 versus 3.19), with a more deprived mean score in non-training practices.Conclusions: General practices in affluent areas remain more likely to train, although this association appears to be related to larger practice list sizes rather than socioeconomic factors. To ensure a variety of training environments training bodies should target, and support, smaller practices working in more socioeconomically deprived areas. [ABSTRACT FROM AUTHOR]

Background: Comorbidity is common in heart failure, but previous prevalence estimates have been based on a limited number of conditions using mainly non-primary care data sources.Aim: To compare prevalence rates of comorbidity and polypharmacy in those with and without chronic heart failure due to left ventricular systolic dysfunction (LVSD).Design and Setting: A cross-sectional study of 1.4 million patients in primary care in Scotland.Method: Data on the presence of LVSD, 31 other physical, and seven mental health comorbidities, and prescriptions were extracted from a database of 1 424 378 adults. Comorbidity prevalence was compared in patients with and without LVSD, standardised by age, sex, and deprivation. Pharmacology data were also compared between the two groups.Results: There were 17 285 patients (1.2%) who had a diagnosis of LVSD. Compared with standardised controls, the LVSD group had greater comorbidity, with the biggest difference found for seven or more conditions (odds ratio [OR] 4.10; 95% confidence interval (CI] = 3.90 to 4.32). Twenty-five physical conditions and six mental health conditions were significantly more prevalent in those with LVSD relative to standardised controls. Polypharmacy was higher in the LVSD group compared with controls, with the biggest difference found for ≥11 repeat prescriptions (OR 4.81; 95% CI = 4.60 to 5.04). However, these differences in polypharmacy were attenuated after controlling for the number of morbidities, indicating that much of the additional prescribing was accounted for by multimorbidity rather than LVSD per se.Conclusion: Extreme comorbidity and polypharmacy is significantly more common in patients with chronic heart failure due to LVSD. The efficient management of such complexity requires the integration of general and specialist expertise. [ABSTRACT FROM AUTHOR]

Background: The inverse equity hypothesis asserts that new health policies initially widen inequality, then attenuate inequalities over time. Since 2004, the UK's pay-for-performance scheme for chronic disease management (CDM) in primary care general practices (the Quality and Outcomes Framework) has permitted practices to except (exclude) patients from attending annual CDM reviews, without financial penalty. Informed dissent (ID) is one component of exception rates, applied to patients who have not attended due to refusal or non-response to invitations. 'Population achievement' describes the proportion receiving care, in relation to those eligible to receive it, including excepted patients. Examination of exception reporting (including ID) and population achievement enables the equity impact of the UK pay-for-performance contract to be assessed. We conducted a longitudinal analysis of practice-level rates and of predictors of ID, overall exceptions and population achievement for CDM to examine whether the inverse equity hypothesis holds true.Methods: We carried out a retrospective, longitudinal study using routine primary care data, analysed by multilevel logistic regression. Data were extracted from 793 practices (83% of Scottish general practices) serving 4.4 million patients across Scotland from 2010/2011 to 2012/2013, for 29 CDM indicators covering 11 incentivised diseases. This provided 68,991 observations, representing a total of 15 million opportunities for exception reporting.Results: Across all observations, the median overall exception reporting rate was 7.0% (7.04% in 2010-2011; 7.02% in 2011-2012 and 6.92% in 2012-2013). The median non-attendance rate due to ID was 0.9% (0.76% in 2010-2011; 0.88% in 2011-2012 and 0.96% in 2012-2013). Median population achievement was 83.5% (83.51% in 2010-2011; 83.41% in 2011-2012 and 83.63% in 2012-2013). The odds of ID reporting in 2012/2013 were 16.0% greater than in 2010/2011 (p < 0.001). Practices in Scotland's most deprived communities were twice as likely to report non-attendance due to ID (odds ratio 2.10, 95% confidence interval 1.83-2.40, p < 0.001) compared with those in the least deprived; rural practices reported lower levels of non-attendance due to ID. These predictors were also independently associated with overall exceptions. Rates of population achievement did not change over time, with higher levels (higher remuneration) associated with increased rates of overall and ID exception and more affluent practices.Conclusions: Non-attendance for CDM due to ID has risen over time, and higher rates are seen in patients from practices located in disadvantaged areas. This suggests that CDM incentivisation does not conform to the inverse equity hypothesis, because inequalities are widening over time with lower uptake of anticipatory care health checks and CDM reviews noted among those most in need. Incentivised CDM needs to include incentives for engaging with the 'hard to reach' if inequalities in healthcare delivery are to be tackled. [ABSTRACT FROM AUTHOR]

Little is known about the factors which facilitate or impede the large-scale deployment of health and well-being consumer technologies. The Living-It-Up project is a large-scale digital intervention led by NHS 24, aiming to transform health and well-being services delivery throughout Scotland. We conducted a qualitative study of the factors affecting the implementation and deployment of the Living-It-Up services. We collected a range of data during the initial phase of deployment, including semi-structured interviews (N = 6); participant observation sessions (N = 5) and meetings with key stakeholders (N = 3). We used the Normalisation Process Theory as an explanatory framework to interpret the social processes at play during the initial phases of deployment.Initial findings illustrate that it is clear − and perhaps not surprising − that the size and diversity of the Living-It-Up consortium made implementation processes more complex within a ‘multi-stakeholder’ environment. To overcome these barriers, there is a need to clearly define roles, tasks and responsibilities among the consortium partners. Furthermore, varying levels of expectations and requirements, as well as diverse cultures and ways of working, must be effectively managed. Factors which facilitated implementation included extensive stakeholder engagement, such as co-design activities, which can contribute to an increased ‘buy-in’ from users in the long term. An important lesson from the Living-It-Up initiative is that attempting to co-design innovative digital services, but at the same time, recruiting large numbers of users is likely to generate conflicting implementation priorities which hinder − or at least substantially slow down − the effective rollout of services at scale.The deployment of Living-It-Up services is ongoing, but our results to date suggest that − in order to be successful − the roll-out of digital health and well-being technologies at scale requires a delicate and pragmatic trade-off between co-design activities, the development of innovative services and the efforts allocated to widespread marketing and recruitment initiatives. [ABSTRACT FROM AUTHOR]

Background Interest and investment in e-health continue to grow world-wide, but there remains relatively little engagement with the public on this subject, despite calls for more public involvement in health-care planning. Design This study used two modified citizen juries to explore barriers and facilitators to e-health implementation and the priorities for future e-health research from the perspective of health service users and lay representatives. Citizen juries bring together a group of people to deliberate over a specific issue. They are given information and invited to 'cross-examine' witnesses during the process. Results Jurors were very keen for lay views to be included in e-health development and embraced the citizen jury approach. They agreed unanimously that e-health should be developed and thought it was in many ways inevitable. Although there was much enthusiasm for a health-care system which offered e-health as an option, there was as much concern about what it might mean for patients if implemented inappropriately. E-health was preferred as an enhancement rather than substitute for, existing services. Lack of universal access was seen as a potential barrier to implementation but problems such as lack of computer literacy were seen as a temporary issue. Participants emphasized that e-health research needed to demonstrate both clinical and economic benefits. Conclusion There was broad support from the citizen juries for the development of e-health, although participants stressed that e-health should enhance, rather than substitute, face-to-face services. One-day citizen juries proved a practical method of public engagement on this subject. [ABSTRACT FROM AUTHOR]

Background: People with multimorbidity (>2 long-term conditions) have poorer outcomes in areas of high socioeconomic deprivation (SED). High-quality person-centred care (PCC) is important in those with multimorbidity, but socially vulnerable populations have not, to our knowledge, informed current PCC models., Aim: To explore how wider community factors influence management of multimorbidity in the context of high SED, how high-quality PCC is defined by patients, and whether this influences healthcare management., Design and Setting: Ethnographically informed case study in a community experiencing high SED in Scotland., Method: Participant observation (138 h) was undertaken within four community groups who also took part in two participatory workshops. There were 25 in-depth interviews with people with multimorbidity, recruited from local general practices; emerging findings were discussed with interviewees in one focus group. Field notes/transcripts were analysed using inductive thematic analysis., Results: Key aspects of PCC were 'patient as person', 'strong therapeutic relationship', 'coordination of care', and 'power sharing'; power sharing was particularly enabling but rarely happened (barriers often unseen by practitioners). Shared community experiences of 'being known', 'stigma', and 'none of the systems working' influenced how people approached health services and healthcare decisions. High-quality PCC may have been particularly effective in this setting because of its influence on ameliorating wider shared negative community experiences., Conclusion: In a high SED setting PCC is important and can enhance engagement. Wider community factors have a critical influence on engagement with health care in areas of high SED and PCC may be particularly important in this context because of its influence ameliorating these. Policymakers should prioritise and resource PCC., (© The Authors.)

There is uncertainty about how best to diagnose asthma, especially in primary care where mis-diagnosis is common. To address this, we developed a clinical decision support system (CDSS) for asthma diagnosis in children and young people (aged 5-25 years). This study explored the feasibility and acceptability of the CDSS in UK primary care. We recruited general practices from England and Scotland. The CDSS was available for use during routine consultations for six months. We analysed CDSS usage and, toward the end of the study, undertook qualitative interviews with clinicians who had used the CDSS. Within the 10 practices who completed the study, the CDSS was used by 75 out of 94 clinicians. 11 clinicians from 8 practices were interviewed. The CDSS was acceptable to participants who particularly commented on the ease of use and auto-population of information from the patient record. Barriers to use included the inability to record findings directly into the patient notes and a sense that, whilst possibly useful for trainees and junior colleagues, the CDSS would not necessarily lead to a change in their own practice. The CDSS was generally well received by primary care clinicians, though participants felt it would be most useful for trainees and less experienced colleagues., Competing Interests: Competing interests: C.S. reports unconditional honoraria via a Limited company for consultancy and delivery of education from AstraZeneca, Bedfont, Boehringer Inglehieim, Cheisi, GSK, Teva, and Trudell; policy lead PCRS and Co-chair of Early and Accurate Diagnosis working group of Taskforce for Lung Health. D.P. has advisory board membership with AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Novartis, Viatris, Teva Pharmaceuticals; consultancy agreements with AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Novartis, Viatris, Teva Pharmaceuticals; grants and unrestricted funding for investigator-initiated studies (conducted through Observational and Pragmatic Research Institute Pte Ltd.) from AstraZeneca, Chiesi, Viatris, Novartis, Regeneron Pharmaceuticals, Sanofi Genzyme, and UK National Health Service; payment for lectures/speaking engagements from AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, Inside Practice, GlaxoSmithKline, Medscape, Viatris, Novartis, Regeneron Pharmaceuticals and Sanofi Genzyme, Teva Pharmaceuticals; payment for travel/accommodation/meeting expenses from AstraZeneca, Boehringer Ingelheim, Novartis, Medscape, Teva Pharmaceuticals.; owns 74% of the social enterprise Optimum Patient Care Ltd. (Australia and UK) and 92.61% of Observational and Pragmatic Research Institute Pte Ltd. (Singapore); 5% shareholding in Timestamp which develops adherence monitoring technology; is peer reviewer for grant committees of the UK Efficacy and Mechanism Evaluation programme, and Health Technology Assessment; and was an expert witness for GlaxoSmithKline. H.P. has received fees for non-promotional talks in sponsored symposia from Teva and Sandoz Pharmaceuticals. The remaining authors declare no competing interests., (© 2024. The Author(s).)

Introduction: Unhealthy lifestyle factors, such as smoking, high alcohol intake, poor diet and physical inactivity, are key risk factors for premature mortality. How unhealthy lifestyle factors are viewed in the wider context of socioeconomic deprivation is rarely considered. Understanding key stakeholder views on lifestyle factors in the context of deprivation is critical to intervention development and reducing harm in more deprived populations. The aim of this study was to explore public, healthcare professional and policymaker views around unhealthy lifestyle factors in the context of deprivation. The aim was broad to facilitate iterative development of ideas, as the views of this wide range of stakeholders are rarely captured., Methods: Twenty-five adult members of the public in Scotland took part in four focus groups between August 2022 and June 2023. Eighteen semi-structured interviews were conducted with professionals: 12 primary-care practitioners and 6 public-health practitioners and policymakers. Reflexive thematic analysis was undertaken., Results: Four main themes were developed: (1) Evolving complexity of lifestyle factors - the number of lifestyle factors that adversely impact health has grown, with increasingly complex interactions, (2) Social determinants of lifestyle - numerous links were made between socioeconomic conditions and unhealthy lifestyle factors by all participants, (3) Poverty as a fundamental social determinant - poverty was identified as a core factor for unhealthy lifestyle factors, and (4) Agency versus structure in relation to lifestyle - individual agency to address lifestyle factors was limited by structural constraints. Among professionals, understanding the challenging social determinants of unhealthy lifestyle factors was countered by a desire to support healthy change in those affected by deprivation., Conclusion: Public and professional views around lifestyle highlight an evolving understanding of the new and growing number of lifestyle factors as well as the increasingly complex interplay between lifestyle factors. Views of the social determinants of lifestyle and structural limits to agency strengthen arguments for reduced emphasis on individual-level responsibility for unhealthy lifestyle factors and for deeper integration of social determinants into lifestyle interventions. In addition to addressing poverty and socioeconomic inequalities directly, innovative policy, planning and legislation that incorporate wider approaches could tackle upstream determinants of numerous unhealthy lifestyle factors simultaneously., Patient or Public Contribution: Members of the public who participated in this study have made contributions by sharing their views and perspectives. The National Health Service Research Scotland Primary Care Patient and Public Involvement (NRS PPI) Group contributed to the development of this work. The NRS PPI Group was consulted as part of the preparatory work for H. M. E. F.'s doctoral thesis funding application. The findings of the qualitative work were presented to them, and they informed the interpretation of those findings and related work presented at conferences and public engagement events., (© 2024 The Author(s). Health Expectations published by John Wiley & Sons Ltd.)

Background: Diagnostic blood tests have the potential to identify lung cancer in people at high risk. We assessed the cost-effectiveness of a lung cancer screening intervention, using the EarlyCDT ® -Lung Test (ECLS) with subsequent X-ray and low-dose chest CT scans (LDCT) for patients with a positive test result, compared to both usual care and LDCT screening for the target population., Methods: We conducted a model-based lifetime analysis from a UK NHS and personal social services perspective. We estimated incremental net monetary benefit (NMB) for the ECLS intervention compared to no screening and to LDCT screening., Results: The incremental NMB of ECLS intervention compared to no screening was GBP 33,179 (95% CI: -GBP 81,396, GBP 147,180) and GBP 140,609 (95% CI: -GBP 36,255, GBP 316,612), respectively, for a cost-effectiveness threshold of GBP 20,000 and GBP 30,000 per quality-adjusted life year. The same figures compared with LDCT screening were GBP 162,095 (95% CI: GBP 52,698, GBP 271,735) and GBP 52,185 (95% CI: -GBP 115,152, GBP 219,711)., Conclusions: The ECLS intervention is the most cost-effective screening alternative, with the highest probability of being cost-effective, when compared to no screening or LDCT screening. This result may change with modifications of the parameters, suggesting that the three alternatives considered in the main analysis are potentially cost-effective., Competing Interests: All authors report grants from Oncimmune Ltd., and grants from the Scottish Government Health & Social Care Directorate of the Chief Scientist Office (CSO), during the conduct of the study.

Background: People experiencing homelessness (PEH) who have problem drug use have complex medical and social needs, with barriers to accessing services and treatments. Their treatment burden (workload of self-management and impact on wellbeing) remains unexplored., Aim: To investigate treatment burden in PEH with a recent non-fatal overdose using a validated questionnaire, the Patient Experience with Treatment and Self-management (PETS)., Design and Setting: The PETS questionnaire was collected as part of a pilot randomised control trial (RCT) undertaken in Glasgow, Scotland; the main outcome is whether this pilot RCT should progress to a definitive RCT., Method: An adapted 52-item, 12-domain PETS questionnaire was used to measure treatment burden. Greater treatment burden was indicated by higher PETS scores., Results: Of 128 participants, 123 completed PETS; mean age was 42.1 (standard deviation [SD] 8.4) years, 71.5% were male, and 99.2% were of White ethnicity. Most (91.2%) had >5 chronic conditions, with an average of 8.5 conditions. Mean PETS scores were highest in domains focusing on the impact of self-management on wellbeing: physical and mental exhaustion (mean 79.5, SD 3.3) and role and social activity limitations (mean 64.0, SD 3.5) Scores were higher than those observed in studies of patients who are not homeless., Conclusion: In a socially marginalised patient group at high risk of drug overdose, the PETS showed a very high level of treatment burden and highlights the profound impact of self-management work on wellbeing and daily activities. Treatment burden is an important person-centred outcome to help compare the effectiveness of interventions in PEH and merits inclusion in future trials as an outcome measure., (© The Authors.)

Background: Cohorts such as UK Biobank are increasingly used to study multimorbidity; however, there are concerns that lack of representativeness may lead to biased results. This study aims to compare associations between multimorbidity and adverse health outcomes in UK Biobank and a nationally representative sample., Methods and Findings: These are observational analyses of cohorts identified from linked routine healthcare data from UK Biobank participants (n = 211,597 from England, Scotland, and Wales with linked primary care data, age 40 to 70, mean age 56.5 years, 54.6% women, baseline assessment 2006 to 2010) and from the Secure Anonymised Information Linkage (SAIL) databank (n = 852,055 from Wales, age 40 to 70, mean age 54.2, 50.0% women, baseline January 2011). Multimorbidity (n = 40 long-term conditions [LTCs]) was identified from primary care Read codes and quantified using a simple count and a weighted score. Individual LTCs and LTC combinations were also assessed. Associations with all-cause mortality, unscheduled hospitalisation, and major adverse cardiovascular events (MACEs) were assessed using Weibull or negative binomial models adjusted for age, sex, and socioeconomic status, over 7.5 years follow-up for both datasets. Multimorbidity was less common in UK Biobank than SAIL (26.9% and 33.0% with ≥2 LTCs in UK Biobank and SAIL, respectively). This difference was attenuated, but persisted, after standardising by age, sex, and socioeconomic status. The association between increasing multimorbidity count and mortality, hospitalisation, and MACE was similar between both datasets at LTC counts of ≤3; however, above this level, UK Biobank underestimated the risk associated with multimorbidity (e.g., mortality hazard ratio for 2 LTCs 1.62 (95% confidence interval 1.57 to 1.68) in SAIL and 1.51 (1.43 to 1.59) in UK Biobank, hazard ratio for 5 LTCs was 3.46 (3.31 to 3.61) in SAIL and 2.88 (2.63 to 3.15) in UK Biobank). Absolute risk of mortality, hospitalisation, and MACE, at all levels of multimorbidity, was lower in UK Biobank than SAIL (adjusting for age, sex, and socioeconomic status). Both cohorts produced similar hazard ratios for some LTCs (e.g., hypertension and coronary heart disease), but UK Biobank underestimated the risk for others (e.g., alcohol-related disorders or mental health conditions). Hazard ratios for some LTC combinations were similar between the cohorts (e.g., cardiovascular conditions); however, UK Biobank underestimated the risk for combinations including other conditions (e.g., mental health conditions). The main limitations are that SAIL databank represents only part of the UK (Wales only) and that in both cohorts we lacked data on severity of the LTCs included., Conclusions: In this study, we observed that UK Biobank accurately estimates relative risk of mortality, unscheduled hospitalisation, and MACE associated with LTC counts ≤3. However, for counts ≥4, and for some LTC combinations, estimates of magnitude of association from UK Biobank are likely to be conservative. Researchers should be mindful of these limitations of UK Biobank when conducting and interpreting analyses of multimorbidity. Nonetheless, the richness of data available in UK Biobank does offers opportunities to better understand multimorbidity, particularly where complementary data sources less susceptible to selection bias can be used to inform and qualify analyses of UK Biobank., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: FM is principal supervisor of PH (first author) who is funded by a MRC Clinical Research Training Fellowship (Grant reference: MR/S021949/1) which supported PH to do this work. FM is also Principle Investigator or Co-Investigator on grants funded by the MRC, NIHR, Wellcome, CSO, and EPSRC to undertake multimorbidity research. The funds go to FM’s institution, the University of Glasgow.

Objective: To assess the prevalence of frailty in rheumatoid arthritis (RA) and its association with baseline and longitudinal disease activity, all-cause mortality and hospitalisation., Participants: People with RA identified from the Scottish Early Rheumatoid Arthritis (SERA) inception cohort (newly diagnosed, mean age 58.2 years) and UK Biobank (established disease identified using diagnostic codes, mean age 59 years). Frailty was quantified using the frailty index (both datasets) and frailty phenotype (UK Biobank only). Disease activity was assessed using Disease Activity Score in 28 joints (DAS28) in SERA. Associations between baseline frailty and all-cause mortality and hospitalisation was estimated after adjusting for age, sex, socioeconomic status, smoking and alcohol, plus DAS28 in SERA., Results: Based on the frailty index, frailty was common in SERA (12% moderate, 0.2% severe) and UK Biobank (20% moderate, 3% severe). In UK Biobank, 23% were frail using frailty phenotype. Frailty index was associated with DAS28 in SERA, as well as age and female sex in both cohorts. In SERA, as DAS28 lessened over time with treatment, mean frailty index also decreased. The frailty index was associated with all-cause mortality (HR moderate/severe frailty vs robust 4.14 (95% CI 1.49 to 11.51) SERA, 1.68 (95% CI 1.26 to 2.13) UK Biobank) and unscheduled hospitalisation (incidence rate ratio 2.27 (95% CI 1.45 to 3.57) SERA 2.74 (95% CI 2.29 to 3.29) UK Biobank). In UK Biobank, frailty phenotype also associated with mortality and hospitalisation., Conclusion: Frailty is common in early and established RA and associated with hospitalisation and mortality. Frailty in RA is dynamic and, for some, may be ameliorated through controlling disease activity in early disease., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

The EarlyCDT-Lung test is a high-specificity blood-based autoantibody biomarker that could contribute to predicting lung cancer risk. We report on the results of a phase IV biomarker evaluation of whether using the EarlyCDT-Lung test and any subsequent computed tomography (CT) scanning to identify those at high risk of lung cancer reduces the incidence of patients with stage III/IV/unspecified lung cancer at diagnosis compared with the standard clinical practice at the time the study began.The Early Diagnosis of Lung Cancer Scotland (ECLS) trial was a randomised controlled trial of 12 208 participants at risk of developing lung cancer in Scotland in the UK. The intervention arm received the EarlyCDT-Lung test and, if test-positive, low-dose CT scanning 6-monthly for up to 2 years. EarlyCDT-Lung test-negative and control arm participants received standard clinical care. Outcomes were assessed at 2 years post-randomisation using validated data on cancer occurrence, cancer staging, mortality and comorbidities.At 2 years, 127 lung cancers were detected in the study population (1.0%). In the intervention arm, 33 out of 56 (58.9%) lung cancers were diagnosed at stage III/IV compared with 52 out of 71 (73.2%) in the control arm. The hazard ratio for stage III/IV presentation was 0.64 (95% CI 0.41-0.99). There were nonsignificant differences in lung cancer and all-cause mortality after 2 years.ECLS compared EarlyCDT-Lung plus CT screening to standard clinical care (symptomatic presentation) and was not designed to assess the incremental contribution of the EarlyCDT-Lung test. The observation of a stage shift towards earlier-stage lung cancer diagnosis merits further investigations to evaluate whether the EarlyCDT-Lung test adds anything to the emerging standard of low-dose CT., Competing Interests: Conflict of interest: F.M. Sullivan reports grants from Oncimmune and the Scottish Government Health and Social Care Directorate of the Chief Scientist Office, during the conduct of the study. Conflict of interest: F.S. Mair reports grants from Oncimmune and the Scottish Government Health and Social Care Directorate of the Chief Scientist Office, during the conduct of the study. Conflict of interest: W. Anderson has nothing to disclose. Conflict of interest: P. Armory reports grants from Oncimmune and the Scottish Government Health and Social Care Directorate of the Chief Scientist Office, during the conduct of the study. Conflict of interest: A. Briggs reports grants from the Scottish Government Health and Social Care Directorate of the Chief Scientist Office and Oncimmune, during the conduct of the study. Conflict of interest: C. Chew has nothing to disclose. Conflict of interest: A. Dorward has nothing to disclose. Conflict of interest: J. Haughney has nothing to disclose. Conflict of interest: F. Hogarth reports grants from the Scottish Government Health and Social Care Directorate of the Chief Scientist Office and from Oncimmune, during the conduct of the study. Conflict of interest: D. Kendrick has nothing to disclose. Conflict of interest: R. Littleford reports grants from the Scottish Government Health and Social Care Directorate of the Chief Scientist Office and Oncimmune, during the conduct of the study. Conflict of interest: A. McConnachie reports grants from Oncimmune and the Scottish Government Health and Social Care Directorate of the Chief Scientist Office, during the conduct of the study. Conflict of interest: C. McCowan has nothing to disclose. Conflict of interest: N. McMeekin reports grants from Oncimmune and the Scottish Government Health and Social Care Directorate of the Chief Scientist Office, during the conduct of the study. Conflict of interest: M. Patel has nothing to disclose. Conflict of interest: P. Rauchhaus reports grants from Oncimmune and the Scottish Government Health and Social Care Directorate of the Chief Scientist Office, during the conduct of the study. Conflict of interest: L. Ritchie has nothing to disclose. Conflict of interest: C. Robertson reports personal fees and other funding from Oncimmune, outside the study. Conflict of interest: J. Robertson reports other funding from Oncimmune, during the conduct of the study; and other funding from Oncimmune, outside the study. J. Robertson was a founder of Oncimmune, a company spun out from the University of Nottingham based on his academic research. Between 2003 and 2013 he was Chief Scientific Officer of Oncimmune and a Director of the company. During this time, he was responsible for the original drafting of the ECLS protocol. Since 2013 he has had no involvement in the science or management of the company. He has been and remains a shareholder in the company. Conflict of interest: J. Robles-Zurita reports grants from the Scottish Government Health and Social Care Directorate of the Chief Scientist Office and Oncimmune, during the conduct of the study. Conflict of interest: J. Sarvesvaran has nothing to disclose. Conflict of interest: H. Sewell reports other funding from Oncimmune, outside the submitted work; and was an external member of the Oncimmune Scientific Advisory Board from 2006 to 2013. Conflict of interest: M. Sproule has nothing to disclose. Conflict of interest: T. Taylor reports grants, nonfinancial support and other funding from Oncimmune, grants and personal fees from the Chief Scientist Office for Scotland, and grants and nonfinancial support from the Scottish Government, outside the submitted work. Conflict of interest: A. Tello reports grants from Oncimmune, during the conduct of the study. Conflict of interest: S. Treweek reports grants from Oncimmune and the Scottish Government Health and Social Care Directorate of the Chief Scientist Office, during the conduct of the study. Conflict of interest: K. Vedhara has nothing to disclose. Conflict of interest: S. Schembri reports grants from Oncimmune and the Scottish Government Health and Social Care Directorate of the Chief Scientist Office, during the conduct of the study; and nonfinancial support from GlaxoSmithKline and AstraZeneca, outside the submitted work., (Copyright ©ERS 2021.)

Background: Homelessness and associated mortality and multimorbidity rates are increasing. Systematic reviews have demonstrated a lack of complex interventions that decrease unscheduled emergency health services utilisation or increase scheduled care. Better evidence is needed to inform policy responses. We examined the feasibility of a complex intervention (PHOENIx: Pharmacist led Homeless Outreach Engagement Nonmedical Independent prescribing (Rx)) to inform a subsequent pilot randomised controlled trial (RCT)., Methods: Non-randomised trial with Usual Care (UC) comparator group set in Greater Glasgow and Clyde Health Board, Scotland. Participants were adult inpatients experiencing homelessness in a city centre Glasgow hospital, referred to the PHOENIx team at the point of hospital discharge, from 19th March 2018 until 6th April 2019. The follow up period for each patient started on the day the patient was first seen (Intervention group) or first referred (UC), until 24th August 2019, the censor date for all patients. All patients were offered and agreed to receive serial consultations with the PHOENIx team (NHS Pharmacist prescriber working with Simon Community Scotland (third sector homeless charity worker)). Patients who could not be reached by the PHOENIx team were allocated to the UC group. The PHOENIx intervention included assessment of physical/mental health, addictions, housing, benefits and social activities followed by pharmacist prescribing with referral to other health service specialities as necessary. All participants received primary (including specialist homelessness health service based general practitioner care, mental health and addictions services) and secondary care. Main outcome measures were rates of: recruitment; retention; uptake of the intervention; and completeness of collected data, from recruitment to censor date., Results: Twenty four patients were offered and agreed to participate; 12 were reached and received the intervention as planned with a median 7.5 consultations (IQR3.0-14.2) per patient. The pharmacist prescribed a median of 2 new (IQR0.3-3.8) and 2 repeat (1.3-7.0) prescriptions per patient; 10(83%) received support for benefits, housing or advocacy. Twelve patients were not subsequently contactable after leaving hospital, despite agreeing to participate, and were assigned to UC. Two patients in the UC group died of drug/alcohol overdose during follow up; no patients in the Intervention group died. All 24 patients were retained in the intervention or UC group until death or censor date and all patient records were accessible at follow up: 11(92%) visited ED in both groups, with 11(92%) hospitalisations in intervention group, 9(75%) UC. Eight (67%) intervention group patients and 3(25%) UC patients attended scheduled out patient appointments., Conclusions: Feasibility testing of the PHOENIx intervention suggests merit in a subsequent pilot RCT.

Objectives: Treatment burden is the healthcare workload experienced by individuals with long-term conditions and the impact on well-being. Excessive treatment burden can negatively affect quality-of-life and adherence to treatments. Patient capacity is the ability of an individual to manage their life and health problems and is dependent on a variety of physical, psychological and social factors. Previous work has suggested that stroke survivors experience considerable treatment burden and limitations on their capacity to manage their health. We aimed to examine the potential barriers and enablers to minimising treatment burden and maximising patient capacity faced by health professionals and managers providing care to those affected by stroke., Setting: Primary and secondary care stroke services in a single health board area in Scotland., Participants: Face-to-face qualitative interviews with 21 participants including stroke consultants, nurses, physiotherapists, occupational therapists, speech and language therapists, psychologists, general practitioners and health-service managers., Outcome Measures: Data were analysed using thematic analysis to ascertain any factors that influence the provision of low-burden healthcare., Results: Barriers and facilitators to the provision of healthcare that minimises treatment burden and maximises patient capacity were reported under five themes: healthcare system structure (e.g. care coordination and autonomous working); resources (e.g. availability of ward nurses and community psychologists); knowledge and awareness (e.g. adequate time and materials for optimal information delivery); availability of social care (e.g. waiting times for home adaptations or extra social support) and patient complexity (e.g. multimorbidity)., Conclusions: Our findings have important implications for the design and implementation of stroke care pathways, emphasising the importance of removing barriers to health professional provision of person-centred care. This work can inform the design of interventions aimed at nurturing autonomous working by health professionals, improving communication and care coordination or ensuring availability of a named person throughout the patient journey., Competing Interests: Competing interests: KIG received funding from The Stroke Association to complete this work. FSM received payment for educational activities from Janssen outside the submitted work., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Guidelines and training initiatives (G/TIs) available to support communication in cross-cultural primary health care consultations are not routinely used. We need to understand more about levers and barriers to their implementation and identify G/TIs likely to be successfully implemented in practice., Objective: To report a mapping process used to identify G/TIs and to prospectively appraise their implementability, using Normalization Process Theory (NPT)., Methods: RESTORE is a 4-year EU FP-7 project. We used purposeful and network sampling to identify experts in statutory and non-statutory agencies across Austria, England, Greece, Ireland, Scotland and the Netherlands who recommended G/TI data from the grey literature. In addition, a peer review of literature was conducted in each country. Resulting data were collated using a standardized Protocol Mapping Document. G/TIs were identified for inclusion by (i) initial elimination of incomplete G/TI material; (ii) application of filtering criteria; and (iii) application of NPT., Results: 20 G/TIs met selection criteria: 8 guidelines and 12 training initiatives. Most G/TIs were identified in the Netherlands (n = 7), followed by Ireland (n = 6) and England (n = 5). Fewer were identified in Scotland (n = 2), and none in Greece or Austria. The majority (n = 13) were generated without the inclusion of migrant service users. All 20 were prospectively appraised for potential implementability by applying NPT., Conclusions: NPT is useful as a means of prospectively testing G/TIs for implementability. Results indicate a need to initiate meaningful engagement of migrants in the development of G/TIs. A European-based professional standard for development and assessment of cross-cultural communication resources is advised., (© The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Effective surgical pre-assessment will depend upon the collection of relevant medical information, good data management and communication between the members of the preoperative multi-disciplinary team. NHS Greater Glasgow and Clyde has implemented an electronic preoperative integrated care pathway (eForm) allowing all hospitals to access a comprehensive patient medical history via a clinical portal on the health-board intranet., Methods: We conducted six face-to-face semi-structured interviews and participated in one focus group and two workshops with key stakeholders involved in the Planned Care Improvement (PCIP) and Electronic Patient Record programmes. We used qualitative methods and Normalisation Process Theory in order to identify the key factors which led to the successful deployment of the preoperative eForm in the health-board., Results: In January 2013, more than 90,000 patient preoperative assessments had been completed via the electronic portal. Two complementary strategic efforts were instrumental in the successful deployment of the preoperative eForm. At the local health-board level: the PCIP led to the rationalisation of surgical pre-assessment clinics and the standardisation of preoperative processes. At the national level: the eHealth programme selected portal technology as an iterative strategic technology solution towards a virtual electronic patient record. Our study has highlighted clear synergies between these two standardisation efforts., Conclusion: The adoption of the eForm into routine preoperative work practices can be attributed to: (i) a policy context - including performance targets - promoting the rationalisation of surgical pre-assessment pathways, (ii) financial and organisational resources to support service redesign and the use of information technology for operationalising the standardisation of preoperative processes, (iii) a sustained engagement with stakeholders throughout the iterative phases of the preoperative clinics redesign, guidelines standardisation and the eForm development, (iv) the use of a pragmatic and domain-agnostic technology solution and finally: (v) a consensual and contextualised implementation.

Background: The ever increasing volume of referrals from primary care to specialist services is putting considerable pressure on resource-constrained health services while effective communication across fragmented services remains a substantial challenge. Previous studies have suggested that electronic referrals (eReferral) can bear important benefits for cross-organisational processes and patient care management., Methods: We conducted 25 semi-structured interviews and 1 focus group with primary care providers to elucidate General Practitioners' (GPs) perspectives on information management processes in the patient pathway in NHSScotland, 1 focus group with members of the Scottish Electronic Patient Record programme and one interview with a senior architect of the Scottish Care Information national eReferral System (SCI Gateway). Using Normalisation Process Theory, we performed a qualitative analysis to elucidate GPs' perspectives on eReferral to identify the factors which they felt either facilitated or hindered referral processes., Results: The majority of GPs interviewed felt that eReferral substantially streamlined communication processes, with the immediate transfer of referral documents and the availability of an electronic audit trail perceived as two substantial improvements over paper-based referrals. Most GPs felt that the SCI Gateway system was reasonably straightforward to use. Referral protocols and templates could be perceived as useful by some GPs while others considered them to be cumbersome at times., Conclusion: Our study suggests that the deployment and adoption of eReferral across the NHS in Scotland has been achieved by a combination of factors: (i) a policy context - including national mandatory targets for eReferral - which all NHS health-boards were bound to operationalise through their Local Delivery Plans and also (ii) the fact that primary care doctors considered that the overall benefits brought by the deployment of eReferral throughout the patient pathway significantly outweigh any potential disbenefits.

Background: Establishing day-case surgery as the preferred hospital admission route for all eligible patients requires adequate preoperative assessment of patients in order to quickly distinguish those who will require minimum assessment and are suitable for day-case admission from those who will require more extensive management and will need to be admitted as inpatients., Methods: As part of a study to elucidate clinical and information management processes within the patient surgical pathway in NHS Scotland, we conducted a total of 10 in-depth semi-structured interviews during 4 visits to the Dumfries & Galloway Royal Infirmary surgical pre-assessment clinic. We modelled clinical processes using process-mapping techniques and analysed interview data using qualitative methods. We used Normalisation Process Theory as a conceptual framework to interpret the factors which were identified as facilitating or hindering information elucidation tasks and communication within the multi-disciplinary team., Results: The pre-assessment clinic of Dumfries & Galloway Royal Infirmary was opened in 2008 in response to clinical and workflow issues which had been identified with former patient management practices in the surgical pathway. The preoperative clinic now operates under well established processes and protocols. The use of a computerised system for managing preoperative documentation substantially transformed clinical practices and facilitates communication and information-sharing among the multi-disciplinary team., Conclusion: Successful deployment and normalisation of innovative clinical and information management processes was possible because both local and national strategic priorities were synergistic and the system was developed collaboratively by the POA staff and the health-board IT team, resulting in a highly contextualised operationalisation of clinical and information management processes. Further concerted efforts from a range of stakeholders are required to fully integrate preoperative assessment within the health-board surgical care pathway. A substantial - yet unfulfilled - potential benefit in embedding information technology in routine use within the preoperative clinic would be to improve the reporting of surgical outcomes.

Background: Primary care doctors in NHSScotland have been using electronic medical records within their practices routinely for many years. The Scottish Health Executive eHealth strategy (2008-2011) has recently brought radical changes to the primary care computing landscape in Scotland: an information system (GPASS) which was provided free-of-charge by NHSScotland to a majority of GP practices has now been replaced by systems provided by two approved commercial providers. The transition to new electronic medical records had to be completed nationally across all health-boards by March 2012., Methods: We carried out 25 in-depth semi-structured interviews with primary care doctors to elucidate GPs' perspectives on their practice information systems and collect more general information on management processes in the patient surgical pathway in NHSScotland. We undertook a thematic analysis of interviewees' responses, using Normalisation Process Theory as the underpinning conceptual framework., Results: The majority of GPs' interviewed considered that electronic medical records are an integral and essential element of their work during the consultation, playing a key role in facilitating integrated and continuity of care for patients and making clinical information more accessible. However, GPs expressed a number of reservations about various system functionalities - for example: in relation to usability, system navigation and information visualisation., Conclusion: Our study highlights that while electronic information systems are perceived as having important benefits, there remains substantial scope to improve GPs' interaction and overall satisfaction with these systems. Iterative user-centred improvements combined with additional training in the use of technology would promote an increased understanding, familiarity and command of the range of functionalities of electronic medical records among primary care doctors.

We conducted a study of information management processes across the patient surgical pathway in NHSScotland. While the majority of general practitioners (GPs) consider electronic medical records systems as an essential and integral part of their work during the patient consultation, many were not fully satisfied with the functionalities of these systems. A majority of GPs considered that the national eReferral system streamlined referral processes. Almost all GPs reported marked variability in the quality of discharge information. Preoperative processes vary significantly across Scotland, with most services using paper-based systems. Insufficient use is made of information provided through the patient electronic referral leading to a considerable duplication of tasks already performed in primary care. Three health-boards have implemented electronic preoperative information systems. These have transformed clinical practices and facilitated communication and information-sharing among the multi-disciplinary team and within the health-boards. Substantial progress has been made towards improving information transfer and sharing within the surgical pathway in recent years. However, there remains scope for further improvements at the interface between services.

Background: The major problem facing health and social care systems globally today is the growing challenge of an elderly population with complex health and social care needs. A longstanding challenge to the provision of high quality, effectively coordinated care for those with complex needs has been the historical separation of health and social care. Access to timely and accurate data about patients and their treatments has the potential to deliver better care at less cost., Methods: To explore the way in which structural, professional and geographical boundaries have affected e-health implementation in health and social care, through an empirical study of the implementation of an electronic version of Single Shared Assessment (SSA) in Scotland, using three retrospective, qualitative case studies in three different health board locations., Results: Progress in effectively sharing electronic data had been slow and uneven. One cause was the presence of established structural boundaries, which lead to competing priorities, incompatible IT systems and infrastructure, and poor cooperation. A second cause was the presence of established professional boundaries, which affect staffs' understanding and acceptance of data sharing and their information requirements. Geographical boundaries featured but less prominently and contrasting perspectives were found with regard to issues such as co-location of health and social care professionals., Conclusions: To provide holistic care to those with complex health and social care needs, it is essential that we develop integrated approaches to care delivery. Successful integration needs practices such as good project management and governance, ensuring system interoperability, leadership, good training and support, together with clear efforts to improve working relations across professional boundaries and communication of a clear project vision. This study shows that while technological developments make integration possible, long-standing boundaries constitute substantial risks to IT implementations across the health and social care interface which those initiating major changes would do well to consider before committing to the investment.

Background: Telecare could greatly facilitate chronic disease management in the community, but despite government promotion and positive demonstrations its implementation has been limited. This study aimed to identify factors inhibiting the implementation and integration of telecare systems for chronic disease management in the community., Methods: Large scale comparative study employing qualitative data collection techniques: semi-structured interviews with key informants, task-groups, and workshops; framework analysis of qualitative data informed by Normalization Process Theory. Drawn from telecare services in community and domestic settings in England and Scotland, 221 participants were included, consisting of health professionals and managers; patients and carers; social care professionals and managers; and service suppliers and manufacturers., Results: Key barriers to telecare integration were uncertainties about coherent and sustainable service and business models; lack of coordination across social and primary care boundaries, lack of financial or other incentives to include telecare within primary care services; a lack of a sense of continuity with previous service provision and self-care work undertaken by patients; and general uncertainty about the adequacy of telecare systems. These problems led to poor integration of policy and practice., Conclusion: Telecare services may offer a cost effective and safe form of care for some people living with chronic illness. Slow and uneven implementation and integration do not stem from problems of adoption. They result from incomplete understanding of the role of telecare systems and subsequent adaption and embeddedness to context, and uncertainties about the best way to develop, coordinate, and sustain services that assist with chronic disease management. Interventions are therefore needed that (i) reduce uncertainty about the ownership of implementation processes and that lock together health and social care agencies; and (ii) ensure user centred rather than biomedical/service-centred models of care.

We searched the National Research Register (NRR) to identify funded research in Scotland (or in collaboration with a Scottish partner) in the area of implementation and evaluation of e-health services. A total of 61 research projects were identified which had been funded since 1 January 1995. These projects shared almost 7 million pound of funding (1 pound is $1.9 or 1.3 euro), the main funding sources being the Scottish Government and the European Union. Based on the projects reviewed, the majority of e-health research in Scotland was being conducted within the communication systems domain. Most of the research was being conducted at a single centre: only 14 studies (23%) were multisite. Future collaboration between these researchers, involving larger scale funding bids, may increase the quantity of e-health implementation and evaluation research.