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As an improvement method, experience-based co-design (EBCD) is premised on creating better quality experiences and systems of health care. Distinguishing features of EBCD are the way in which experience is central to the identification of and goals for improvements; and combined with participatory action research and design thinking approaches leading to the co-creation of improvements. Commonly shared challenges from completed EBCD studies include: the need to explore power dynamics; commitment to the process; methods to gather experience data; the design of improvements; and variations in implementation and subsequent impact. We discuss these challenges in the context of five examples from Australia. We offer a contribution to the international discussion on developing the next level of maturity to build on the acknowledged and agreed importance of collaborating with service users and staff to improve health care.

Understanding experiences of physical activity (PA) as we age requires an engagement with the ageing body. The purpose of this chapter is to explore the complexities of negotiating PA as we physically age and to consider what are appropriate ways of putting the ageing body into movement. Firstly, we present a brief outline of the sociological understandings of the ageing body and locate PA within this. We then draw on empirical data from three research projects which explore PA in older people. Before promoting PA to older people, we must understand that becoming and remaining physically active is akin to a career and is a fragile endeavour, conditional on physical, cultural and phenomenological understandings of the body.

Antidepressants are one of the most commonly prescribed drugs in primary care. The rise in use is mostly due to an increasing number of long-term users of antidepressants (LTU AD). Little is known about the factors driving increased long-term use. We examined the socio-demographic, clinical factors and health service use characteristics associated with LTU AD to extend our understanding of the factors that may be driving the increase in antidepressant use.Cross-sectional analysis of 789 participants with probable depression (CES-D≥16) recruited from 30 randomly selected Australian general practices to take part in a ten-year cohort study about depression were surveyed about their antidepressant use.165 (21.0%) participants reported2 years of antidepressant use and 145 (18.4%) reported ≥2 years of antidepressant use. After adjusting for depression severity, LTU AD was associated with: single (OR 1.56, 95%CI 1.05-2.32) or recurrent episode of depression (3.44, 2.06-5.74); using SSRIs (3.85, 2.03-7.33), sedatives (2.04, 1.29-3.22), or antipsychotics (4.51, 1.67-12.17); functional limitations due to long-term illness (2.81, 1.55-5.08), poor/fair self-rated health (1.57, 1.14-2.15), inability to work (2.49, 1.37-4.53), benefits as main source of income (2.15, 1.33-3.49), GP visits longer than 20min (1.79, 1.17-2.73); rating GP visits as moderately to extremely helpful (2.71, 1.79-4.11), and more self-help practices (1.16, 1.09-1.23).All measures were self-report. Sample may not be representative of culturally different or adolescent populations. Cross-sectional design raises possibility of "confounding by indication".Long-term antidepressant use is relatively common in primary care. It occurs within the context of complex mental, physical and social morbidities. Whilst most long-term use is associated with a history of recurrent depression there remains a significant opportunity for treatment re-evaluation and timely discontinuation.

Pace, penalty and pirouette: the sociology of physical culture was an event organised and hosted by PhD students Victoria Palmer (Glasgow Caledonian University) and Bethany Whiteside (Royal Conservatoire of Scotland). Funded by the British Sociological Association as a Postgraduate Regional Event, the day was primarily designed to be a supportive platform for postgraduate students from across Scotland and further afield to unite, discuss, present, and share their research with academics with similar interests. The event focused on aspects of ‘physical culture’, attracting scholars from several areas of study including dance, leisure studies, outdoor activity, physical activity, physical education, physical theatre, outdoor activity and sport. Broadly speaking, those who study physical culture are interested in the ways in which individuals engage in (or do not engage in) physical practices and how these individuals are affected by, or influence their social and cultural environment. Publisher PDF

Background and Objectives Sitting less can reduce older adults’ risk of ill health and disability. Effective sedentary behavior interventions require greater understanding of what older adults do when sitting (and not sitting), and why. This study compares the types, context, and role of sitting activities in the daily lives of older men and women who sit more or less than average. Research Design and Methods Semistructured interviews with 44 older men and women of different ages, socioeconomic status, and objectively measured sedentary behavior were analyzed using social practice theory to explore the multifactorial, inter-relational influences on their sedentary behavior. Thematic frameworks facilitated between-group comparisons. Results Older adults described many different leisure time, household, transport, and occupational sitting and non-sitting activities. Leisure-time sitting in the home (e.g., watching TV) was most common, but many non-sitting activities, including “pottering” doing household chores, also took place at home. Other people and access to leisure facilities were associated with lower sedentary behavior. The distinction between being busy/not busy was more important to most participants than sitting/not sitting, and informed their judgments about high-value “purposeful” (social, cognitively active, restorative) sitting and low-value “passive” sitting. Declining physical function contributed to temporal sitting patterns that did not vary much from day-to-day. Discussion and Implications Sitting is associated with cognitive, social, and/or restorative benefits, embedded within older adults’ daily routines, and therefore difficult to change. Useful strategies include supporting older adults to engage with other people and local facilities outside the home, and break up periods of passive sitting at home.

Background Engagement is essential in trials research but is rarely embedded across all stages of the research continuum. The development, use, effectiveness and value of engagement in trials research is poorly researched and understood, and models of engagement are rarely informed by theory. This article describes an innovative methodological approach for the development and application of a relational model of engagement in a stepped wedge designed cluster randomised controlled trial (RCT), the CORE study. The purpose of the model is to embed engagement across the continuum of the trial which will test if an experience-based co-design intervention improves psychosocial recovery for people affected by severe mental illness. Methods The model was developed in three stages and used a structured iterative approach. A context mapping assessment of trial sites was followed by a literature review on recruitment and retention of hard-to-reach groups in complex interventions and RCTs. Relevant theoretical and philosophical underpinnings were identified by an additional review of literature to inform model development and enactment of engagement activities. Results Policy, organisational and service user data combined with evidence from the literature on barriers to recruitment provided contextual information. Four perspectives support the theoretical framework of the relational model of engagement and this is organised around two facets: the relational and continuous. The relational facet is underpinned by relational ethical theories and participatory action research principles. The continuous facet is supported by systems thinking and translation theories. These combine to enact an ethics of engagement and evoke knowledge mobilisation to reach the higher order goals of the model. Conclusions Engagement models are invaluable for trials research, but there are opportunities to advance their theoretical development and application, particularly within stepped wedge designed studies where there may be a significant waiting period between enrolment in a study and receipt of an intervention.

There is an abundance of published literature documenting the important role of primary care in the recognition, treatment and management of mental disorders. Despite this, general practitioners, nurses, social workers, occupational therapists, physiotherapists, and other primary health care professionals remain under acknowledged, and the multidisciplinary team arrangements needed for effective management elusive. Individual and community stigma attached to seeking help has not been removed. This chapter provides an overview of these existing barriers and outlines strategies for implementation to improve recognition and treatment of mental disorders across the spectrum in primary care. These strategies are focused on the delivery of whole person, resulting in integrated and person-centred care.

Patient-centred practice has deep historical roots and offers exceptional potential in addressing the challenges of caring for people with mental disorders in primary care. In fact, primary care with its professional commitment to holistic care has been a champion and advocate for patient-centred practice. While the evidence base for patient centredness is complex, there are suggestions it can optimize some outcomes that are important to the notion of recovery in mental disorders. Patient centredness has been given new impetus as a model of care through its centrality in the Patient Centred Medical Home movement in the US, which in particular is trying to reintegrate care for mental disorders into generalist primary care, with an emphasis on safety and quality. Nevertheless, patient-centred practice is challenging and not without tensions. Particularly at an individual level, patient-centred practice is a socially contingent form of practice as much as a technical one. We describe how shared decision making gives insight into the need for specific strategies to ensure people with mental disorders receive recovery-oriented care. The chapter concludes by naming reflective practice as a key strategy in the operationalizing of patient-centred practice for mental disorders in primary care.

Background Depression is a highly prevalent and costly disorder. Effective treatments are available but are not always delivered to the right person at the right time, with both under- and over-treatment a problem. Up to half the patients presenting to general practice report symptoms of depression, but general practitioners have no systematic way of efficiently identifying level of need and allocating treatment accordingly. Therefore, our team developed a new clinical prediction tool (CPT) to assist with this task. The CPT predicts depressive symptom severity in three months’ time and based on these scores classifies individuals into three groups (minimal/mild, moderate, severe), then provides a matched treatment recommendation. This study aims to test whether using the CPT reduces depressive symptoms at three months compared with usual care. Methods The Target-D study is an individually randomized controlled trial. Participants will be 1320 general practice patients with depressive symptoms who will be approached in the practice waiting room by a research assistant and invited to complete eligibility screening on an iPad. Eligible patients will provide informed consent and complete the CPT on a purpose-built website. A computer-generated allocation sequence stratified by practice and depressive symptom severity group, will randomly assign participants to intervention (treatment recommendation matched to predicted depressive symptom severity group) or comparison (usual care plus Target-D attention control) arms. Follow-up assessments will be completed online at three and 12 months. The primary outcome is depressive symptom severity at three months. Secondary outcomes include anxiety, mental health self-efficacy, quality of life, and cost-effectiveness. Intention-to-treat analyses will test for differences in outcome means between study arms overall and by depressive symptom severity group. Discussion To our knowledge, this is the first depressive symptom stratification tool designed for primary care which takes a prognosis-based approach to provide a tailored treatment recommendation. If shown to be effective, this tool could be used to assist general practitioners to implement stepped mental-healthcare models and contribute to a more efficient and effective mental health system. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR 12616000537459). Retrospectively registered on 27 April 2016. See Additional file 1 for trial registration data. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2089-y) contains supplementary material, which is available to authorized users.

Over the past few decades advance care planning (ACP) has become the subject of debate, research and legislation in many countries. Encouraging people to express their preference for treatment in advance, ideally in written form, seems a natural way to identify what someone might have wanted when they can no longer participate in decision-making. The notion of ACP as an unequivocal good permeates much of the research and policy work in this area. For example, ACP is now actively encouraged in Australian federal and state government policies and the Victorian Government has recently published a practical ACP strategy for Victorian health services (2014-2018). However, advance care plan is ethically complex and the introduction of the Victorian health services strategy provides an opportunity to reflect on this complexity, particularly on the benefits and risks of ACP.

Like many governments across the globe, the Australian Government has embarked on major healthcare reforms. Part of this reform agenda included the establishment of sixty-two primary healthcare organisations (PHOs) originally called Medicare Locals (MLs), currently to be re-structured as primary healthcare networks. Primary health organisations were tasked with the coordination of primary health care delivery and with tackling local healthcare needs and service gaps. They were to drive improvements in primary healthcare and ensure that services are better tailored and integrated to meet the needs of local communities. This article puts forward the argument that new primary healthcare organisations have the potential and the ethical aspects of healthcare organisations are largely overlooked in the literature. To address this gap we outline two complementary frameworks: a theory of ethical communities and an emancipatory method. We conclude that these frameworks could be used as potential guides for new healthcare organisations to become transformative organisations.

Objective To describe the characteristics of primary care attendees with depressive symptoms who use mental health websites. Methods 789 individuals with depressive symptoms recruited and followed up annually for nine years. Self-reported written surveys included mental health, professional and self-help use, e-mental health interventions or therapeutic websites. Marginal logistic regression examined association between mental health website (MHW) use and patient’s mental health, health services use, anti-depressant use and self-help strategies. Results 36% of participants used an MHW at least once. MHW users were more likely to be female, younger, highly educated and employed. MHW use increased with depressive symptom severity; reported in 16% of assessments when minimal symptoms were present and 28% when severe symptoms were present. MHW use was associated with: GP mental health visits, psychologist and psychiatrist visits and other self-help strategies including self-help books and telephone helplines. Conclusion(s) Mental health websites were more likely to be used by those with severe depressive symptoms rather than those with mild depression as recommended in current guidelines. Practice implication(s) Whilst mental health websites offer potential to support the high volume of people with mild depression new strategies may be required to ensure uptake.

Depression is a complex problem, commonly but not always successfully managed in primary care. We know relatively little about the system of primary care for depression particularly at the level of organisations. In this paper, we describe the use of mandalas as a visual data collection method within an in-depth programme of participatory action research undertaken in six primary care organisations in Victoria, Australia. We draw on mandala images, selected and discussed by 49 multidisciplinary primary health care professionals and demonstrate how they can be employed as an effective graphic elicitation method. We conclude that mandalas offer an innovative approach for qualitative data collection for two reasons. First, they can engage busy research participants in a reflective space. Second, using the mandalas as an elicitation method generates meaningful data: it provides new insights, reveals unrecognised aspects of practice, generates new learning, gives physical form to tacit processes and enables co...

Background: Process evaluations are essential to understand the contextual, relational, and organizational and system factors of complex interventions. The guidance for developing process evaluations for randomized controlled trials (RCTs) has until recently however, been fairly limited. Method/Design: A nested process evaluation (NPE) was designed and embedded across all stages of a stepped wedge cluster RCT called the CORE study. The aim of the CORE study is to test the effectiveness of an experience-based codesign methodology for improving psychosocial recovery outcomes for people living with severe mental illness (service users). Process evaluation data collection combines qualitative and quantitative methods with four aims: (1) to describe organizational characteristics, service models, policy contexts, and government reforms and examine the interaction of these with the intervention; (2) to understand how the codesign intervention works, the cluster variability in implementation, and if the intervention is or is not sustained in different settings; (3) to assist in the interpretation of the primary and secondary outcomes and determine if the causal assumptions underpinning the codesign interventions are accurate; and (4) to determine the impact of a purposefully designed engagement model on the broader study retention and knowledge transfer in the trial. Discussion: Process evaluations require prespecified study protocols but finding a balance between their iterative nature and the structure offered by protocol development is an important step forward. Taking this step will advance the role of qualitative research within trials research and enable more focused data collection to occur at strategic points within studies.

Many researchers within the social sciences, medicine, and humanities have examined the ways people talk and think about depression. In their research and published literature they have attempted to determine the theoretical frameworks and appropriate language for categorizing such concepts and understandings. Drawing from mental health and broader social science scholarship, in this article we examine three approaches to developing an inclusive understanding of depression experiences: explanatory models, exploratory maps, and illness narratives. Utilizing these terms in the analysis of a single dataset, we identified multiple conceptual terms with potential analytical validity. Furthermore, we argue that variable usage and meanings of these concepts among lay people might contribute to a shared understanding of depression between lay people and experts, and ultimately have positive consequences for clinical practice.

Background. The World Health Organization and the World Organization of Family Doctors have called for ‘doable’ and ‘limited’ tasks to integrate mental health into primary care. Little information is provided about tasks GPs can undertake outside of guidelines that suggest to prescribe medication and refer to specialists. Objectives. The reorder study aimed to gather diverse patient and community perspectives to inform the development of an effective system of depression care. Method. Five hundred and seventy-six patients completed computer-assisted telephone interviews. Two hundred and seventy-six community stakeholders completed a modified two round Delphi. Responses were analysed to identify tasks and these were synthesised into a conceptual design. Results. Fifteen core tasks were identified, 5 were agreed upon and a further 10 identified by each group but not agreed upon. Listen, understand and empathize, provide thorough and competent diagnosis and management, follow-up and monitor patients, be accessible and do not rush appointments and provide holistic approach and tailor care to individual needs were agreed on. Other tasks included: develop plans with patients, assess for severity and suicide risk, account for social factors, be well trained in depression care and offer a range of treatment options, appropriate and timely referral, support and reassurance, educate patients about depression, prescribe appropriately and manage medication and be positive and encouraging. Conclusions. The tasks form the basis of a conceptual design for developing a primary care response to depression. They fit within three domains of care: the relational, competency and systems domains. This illustrates tasks for GPs beyond prescription and referral.

This paper explores how an ideal relational ethic based on Zygmunt Bauman’s (1995) notion of forms of togetherness is needed to underpin university-community engagement processes and practices. We focus on the notion of being-for, and suggest that it can be used as an ‘engagement bridge’ between higher education institutions, the creation of human capital and communities, and can be a means to achieve ethical outcomes to local concerns. Much of Bauman’s (1995; 2001; 2007) theoretical development has focussed on the liquidity of modernity, to give the impression that community - in the spatially, physically located and fixed sense of the term - no longer exists. This paper proposes that spatial dimensions, particularly in the context of developing relational ethics, are important. This is particularly so for paying adequate attention to context-specific values, principles and issues in communities, for developing enterprising human capital via engagement, and for addressing matters of socio-political importance such as the environment. Contemporary neo-liberal times require ethical and moral leadership from universities. This paper suggests that such leadership can be developed from focussing attention on the forms of togetherness fostered by university-community engagement.

Governments across the English-speaking world have stated that mental health services for people with severe mental illness (SMI) must focus on the redefined notion of recovery.1 In what has become the seminal definition, Anthony states that: ‘Recovery … is a way of living a satisfying, hopeful, and contributing life. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of psychiatric disability.’2 This emphasis on recovery derives from evidence that SMI is not necessarily a lifelong, chronic, and disabling condition. On the contrary, people with SMI can make an excellent recovery.1,3 Numerous national mental health strategies, including those of England, Canada, and Australia, recommend that GPs and primary health care could and should play a greater role in enhancing recovery. The mental health strategy for England has ‘an ambitious aim to mainstream mental health in England’, stating that local GP consortia should provide and/or commission high-quality mental health care, as well as taking action to reduce the multiple physical comorbidities frequently afflicting those with SMI.4 Likewise, the Canadian national strategy states that a priority must be to ‘expand the role of primary care in meeting mental health needs’. More specifically it states that action should be taken to ‘integrate recovery approaches into primary care’.5 Drake and Whitley recently argued that a shift in continuing care from tertiary and secondary care to …

The role that family plays in Physical Activity (PA) practices is often overlooked in the PA literature. Nevertheless, family is often identified as a determinant of PA (Bauman et al., 2012; Sherwood and Jeffrey, 2000). Additionally, research into the role that family plays in PA practices tends to focus on children and their parents, rather than how the family may influence PA throughout the life course. Thus, very little is known about how family can impact the PA of older adults or how older adults can influence their families’ PA. Therefore, unpacking the role that family plays in PA choices throughout the life course may allow us further insights into the way PA beliefs, understandings and practices are formed, maintained and embodied.

In 1999, NASA Johnson Space Center (JSC) initiated a Cockpit Avionics Upgrade (CAU) project to increase shuttle mission safety by improving the crew's situation awareness, reducing their workload, and improving their performance. The primary focus of the project was a complete redesign of the current cockpit displays. To determine the effectiveness of the redesigns, a human-centered evaluation was conducted in the Shuttle Mission Simulator (SMS) at NASA JSC in 2003 and 2004. Measures of crew situation awareness, workload, and nominal and off-nominal task handling performance were made in a series of simulations of off-nominal flight situations during the dynamic flight phases of ascent and entry. The redesigned display formats yielded dramatic increases in situation awareness, reductions in workload, and improvements in performance.

Objectives Provision of person-centred generalist care is a core component of quality primary care systems. The World Health Organisation believes that a lack of generalist primary care is contributing to inefficiency, ineffectiveness and inequity in healthcare. In UK primary care, General Practitioners (GPs) are the largest group of practising generalists. Yet GPs fulfil multiple roles and the pressures of delivering these roles along with wider contextual changes create real challenges to generalist practice. Our study aimed to explore GP perceptions of enablers and constraints for expert generalist care, in order to identify what is needed to ensure health systems are designed to support the generalist role. Design Qualitative study in General Practice. Setting UK primary care. Main outcome measures A qualitative study – interviews, surveys and focus groups with GPs and GP trainees. Data collection and analysis was informed by Normalisation Process Theory. Design and setting Qualitative study in General Practice. We conducted interviews, surveys and focus groups with GPs and GP trainees based mainly, but not exclusively, in the UK. Data collection and analysis were informed by Normalization Process Theory. Participants UK based GPs (interview and surveys); European GP trainees (focus groups). Results Our findings highlight key gaps in current training and service design which may limit development and implementation of expert generalist practice (EGP). These include the lack of a consistent and universal understanding of the distinct expertise of EGP, competing priorities inhibiting the delivery of EGP, lack of the consistent development of skills in interpretive practice and a lack of resources for monitoring EGP. Conclusions We describe four areas for change: Translating EGP, Priority setting for EGP, Trusting EGP and Identifying the impact of EGP. We outline proposals for work needed in each area to help enhance the expert generalist role.

It is 30 years since 3000 delegates from 134 governments, 67 international organisations and many non-government organisations gathered in Alma-Ata, Kazakhstan, to agree upon a declaration about how primary health care could achieve “health for all by 2000”.1 The conference was convened by the World Health Organization and the United Nations Children’s Fund (UNICEF) in response to the growing inequality among large sections of the world’s population. The conference was influenced by global political and social change in the preceding decades and a strong desire to move away from medical dominance and elitism,2 to focus on developing countries rather than dominant Western nations, and to propose a model of health as a tool for economic development.1 The leadership of WHO Director-General Halfdan Mahler (1973–1988) was crucial to the direction of the declaration, as he had been impressed by developments in China, India, Africa and Latin America that provided health care via local community-controlled services using lay participation, and he envisioned such programs addressing health inequalities across the world.3 The resulting Declaration of Alma-Ata consisted of 10 sections (Box 1).

The concept of mental health “recovery” is based on evidence that people with severe mental illnesses can live autonomous, contributing and satisfying lives in the community, even in the presence of persisting symptoms. Jurisdictions around the world, including Canada, are calling for mental

Background Intervention studies for depression and intimate partner violence (IPV) commonly incorporate screening to identify eligible participants. The challenge is that current ethical evaluation is largely informed by the four principle approach applying principles of beneficence, non-maleficence, and respect for justice and autonomy. We examine three intervention studies for IPV, postnatal depression (PND) and depression that used screening from the perspective of principlism, followed by the perspective of a narrative and relational approach. We suggest that a narrative and relational approach to ethics brings to light concerns that principlism can overlook. Discussion The justification most commonly used to incorporate screening is that the potential benefits of identifying intervention efficacy balance the risk of individual harm. However, considerable risks do exist. The discovery of new information may result in further depression or worries, people might feel burdened, open to further risk, unsure of whether to disclose information to family members and disappointed if they are allocated to a control group. This raises questions about study design and whether the principle of equipoise remains an adequate justification in studies with vulnerable groups. In addition, autonomy is said to be respected because participants give informed consent to participate. However, the context of where recruitment is undertaken has been shown to influence how people make decisions. Summary The four principles have been subjected to criticisms in recent years but they remain prominent in public health and medical research. We provide a set of simple, interrogative questions that are narrative and relationally driven which may assist to further evaluate the potential impacts of using screening to identify eligible research participants in intervention studies. A narrative and relational based approach requires seeing people as situated within their social and cultural contexts, and as existing within relationships that are likely to be affected by the results of screening information.

Background Depression and related disorders represent a significant part of general practitioners (GPs) daily work. Implementing the evidence about what works for depression care into routine practice presents a challenge for researchers and service designers. The emerging consensus is that the transfer of efficacious interventions into routine practice is strongly linked to how well the interventions are based upon theory and take into account the contextual factors of the setting into which they are to be transferred. We set out to develop a conceptual framework to guide change and the implementation of best practice depression care in the primary care setting. Methods We used a mixed method, observational approach to gather data about routine depression care in a range of primary care settings via: audit of electronic health records; observation of routine clinical care; and structured, facilitated whole of organisation meetings. Audit data were summarised using simple descriptive statistics. Observational data were collected using field notes. Organisational meetings were audio taped and transcribed. All the data sets were grouped, by organisation, and considered as a whole case. Normalisation Process Theory (NPT) was identified as an analytical theory to guide the conceptual framework development. Results Five privately owned primary care organisations (general practices) and one community health centre took part over the course of 18 months. We successfully developed a conceptual framework for implementing an effective model of depression care based on the four constructs of NPT: coherence, which proposes that depression work requires the conceptualisation of boundaries of who is depressed and who is not depressed and techniques for dealing with diffuseness; cognitive participation, which proposes that depression work requires engagement with a shared set of techniques that deal with depression as a health problem; collective action, which proposes that agreement is reached about how care is organised; and reflexive monitoring, which proposes that depression work requires agreement about how depression work will be monitored at the patient and practice level. We describe how these constructs can be used to guide the design and implementation of effective depression care in a way that can take account of contextual differences. Conclusions Ideas about what is required for an effective model and system of depression care in primary care need to be accompanied by theoretically informed frameworks that consider how these can be implemented. The conceptual framework we have presented can be used to guide organisational and system change to develop common language around each construct between policy makers, service users, professionals, and researchers. This shared understanding across groups is fundamental to the effective implementation of change in primary care for depression.

There is a global shift to foster patient-centred and recovery-oriented mental health services. This has resulted from the expansion of how the concept of recovery is understood in mental health literature and practice. Recovery is now more than a return to function or reduction in symptoms; it is a subjective, individualised and multi-faceted experience. To date there has not been investigation of how recovery-oriented services can be translated and implemented into the primary mental health care system. This paper presents the results of a survey from a prospective cohort of primary care patients with probable depression about the importance of written plans to recover. The benefits of having a written plan to recover from depression, as outlined by the participants, were analysed using Leximancer software. The findings provide insights into how written plans may be an important mechanism for implementing a recovery-oriented primary mental health care system. We conclude that the benefits of a written plan provide insight into how patients conceptualise recovery.

Background The general practitioner9s (GP) role in advance care planning is commonly tied to their knowledge of the patient and the family, but with limited attention to the nature of this knowing or the expectations it may give rise to (2012). GPs are often involved in advance care planning with the aim of having the patient complete formal documentation (2012). This paper proposes a broader role for the GP based on findings from a PhD study exploring older people9s understandings of decision making in incompetence. Aim To explore patient9s understanding of the GP9s role in decision making in incompetence. Methods In-depth interviews with 19 people, aged ≥65 years, recruited from five general practices analysed using Giligan9s (Gilligan et al., 2006) listening guide. Results Participants distinguished between their GP and other doctors. Participants described their relationship with their GP as grounds for providing the GP with a distinct role in the event of their future incompetence. Participants expected this relationship to inform the way their GP approached advance care planning. Discussion Participants expected the GP to have a richer role reflective than they are commonly provided. Relational ethics and the concept of ‘generalism’ provide a theoretical basis for expanding the GP9s role. Conclusion Current characterisations of the GP9s role overlook much of what they can bring to the process of advance care planning.

Background Social and structural inequities shape health and illness; they are an everyday presence within the doctor-patient encounter yet, there is limited ethical guidance on what individual physicians should do. This paper draws on a study that explored how doctors and their professional associations ought to respond to the issue of social health inequities. Results Some see doctors as bound by a notion of care that is blind to a patient's social position, while others respond to this issue through invoking notions of justice and human rights where access to care is a prime focus. Both care and justice orientations however conceal important tensions linked to the presence of bioethical principles underpinning these. Other normative ethical theories like deontology, virtue ethics and utilitarianism do not provide adequate guidance on the problem of social health inequities either. Conclusion This paper explores if Bauman's notion of "forms of togetherness" provides the basis of a relational ethical theory that can help to develop a response to social health inequities of relevance to individual physicians. This theory goes beyond silence on the influence of social position of health and avoids amoral regulatory approaches to monitoring equity of care provision.

Introduction User engagement in mental health service design is heralded as integral to health systems quality and performance, but does engagement improve health outcomes? This article describes the CORE study protocol, a novel stepped wedge cluster randomised controlled trial (SWCRCT) to improve psychosocial recovery outcomes for people with severe mental illness. Methods An SWCRCT with a nested process evaluation will be conducted over nearly 4 years in Victoria, Australia. 11 teams from four mental health service providers will be randomly allocated to one of three dates 9 months apart to start the intervention. The intervention, a modified version of Mental Health Experience Co-Design (MH ECO), will be delivered to 30 service users, 30 carers and 10 staff in each cluster. Outcome data will be collected at baseline (6 months) and at completion of each intervention wave. The primary outcome is improvement in recovery score using the 24-item Revised Recovery Assessment Scale for service users. Secondary outcomes are improvements to user and carer mental health and well-being using the shortened 8-item version of the WHOQOL Quality of Life scale (EUROHIS), changes to staff attitudes using the 19-item Staff Attitudes to Recovery Scale and recovery orientation of services using the 36-item Recovery Self Assessment Scale (provider version). Intervention and usual care periods will be compared using a linear mixed effects model for continuous outcomes and a generalised linear mixed effects model for binary outcomes. Participants will be analysed in the group that the cluster was assigned to at each time point. Ethics and dissemination The University of Melbourne, Human Research Ethics Committee (1340299.3) and the Federal and State Departments of Health Committees (Project 20/2014) granted ethics approval. Baseline data results will be reported in 2015 and outcomes data in 2017. Trial registration number Australian and New Zealand Clinical Trials Registry ACTRN12614000457640.