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Introduction: Quality improvement (QI) is aimed at improving care. Equity is one of the six domains of healthcare quality, as defined by the Institute of Medicine. If this domain is ignored, QI projects have the potential to maintain or even worsen inequalities., Aims and Objectives: We aimed to understand why, how, for whom and in which contexts QI approaches increase, or do not change health inequalities in healthcare organisations., Methods: We conducted a realist review by first developing an initial programme theory, then searching MEDLINE, Embase, CINAHL, PsychINFO, Web of Science and Scopus for QI projects that considered health inequalities. Included studies were analysed to generate context-mechanism-outcome configurations (CMOCs) and develop an overall programme theory., Results: We screened 6259 records. Thirty-six records met our inclusion criteria, the majority of which were from the USA. We developed CMOCs covering four clusters: values and understanding, resources, data, and design. Five of these described circumstances in which QI may increase inequalities and 15 where it may reduce inequalities. We found that QI projects that are values-led and incorporate diverse, patient-led data into design are more likely to address health inequalities. However, when staff and patients cannot engage fully with equity-focused projects, due to practical or technological barriers, QI projects are more likely to worsen inequalities., Conclusions: The potential for QI projects to positively impact inequalities depends on embedding equity-focused values across organisations, ensuring sufficient and appropriate resources are provided to staff delivering QI, and using diverse disaggregated data alongside considered user involvement to inform and assess the success of QI projects. Policymakers and practitioners should ensure that QI projects are used to address inequalities., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY. Published by BMJ Group.)

Objectives: This study aimed to explore the policy implementation of non-specific symptom pathways within the English National Health Service., Methods: A multi-site ethnographic project was conducted in four hospitals that contained non-specific symptom pathways between November 2021 and February 2023. The research involved observation (44 h), interviews ( n = 54), patient shadowing, and document review., Results: The study examined how the policy concept of 'holistic' care was understood and put into practice within four non-specific symptom pathways. Several challenges associated with providing holistic care were identified. One key challenge was the conflict between delivering holistic care and meeting timed targets, such as the Faster Diagnosis Standard, due to limited availability of imaging and diagnostic tools. The interpretation of a holistic approach varied among participants, with some acknowledging that the current model did not recognise holistic care beyond cancer exclusion. The findings also revealed a lack of clarity and differing opinions on the boundaries of holistic care, resulting in wide variation in NSS pathway implementation across health care providers. Additionally, holistic investigation of non-specific symptoms in younger patients were seen to pose difficulties due to younger patients' history of health anxiety or depression, as well as concerns over radiological risk exposure., Conclusions: The study highlights the complexity of implementing non-specific symptom pathways in light of standardised timed cancer targets and local cancer policies. There is a need for appropriately funded organisational models of care that prioritise holistic care in a timely manner over solely meeting cancer targets. Decision-makers should also consider the role of non-specific symptom pathways within the broader context of chronic disease management, with a particular emphasis on expanding diagnostic capacity., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The UK National Institute for Health and Care (NICE) recommends that GPs inform patients referred onto the Urgent Suspected Cancer (USC) pathway about what to expect from the service. However, there is a lack of evidence on patient experience and information needs at the point of referral. It is a challenge for GPs to communicate the reasons for referral and provide reassurance., Aim: This study aimed to examine how GPs communicate a potential cancer diagnosis and USC referral in practice., Design & Setting: This is a secondary analysis of a dataset of 23 audio-recorded GP-patient consultations, selected from a larger dataset of 200 consultations collected in Surrey and London, UK in 2017-2018. The consultations were selected based on inclusion criteria related to cancer discussions., Method: This is a qualitative analysis of video recordings of face to face patient consultations., Results: We found that most GPs informed patients that they might have cancer and engaged in reassurance using personalised risk statements. Some GPs avoided all mention of cancer, using symptom-led language instead. GPs focused on communicating practical rather than support-based information. While most GPs informed patients that they would be seen by a specialist within two weeks, few discussed patients' support needs during the referral period., Conclusion: Clear communication about cancer in primary care is promoted in UK policy, and has an important role driving patient investigations attendance. The study highlights the need for further research on communication practices around cancer referral to improve patient understanding and experience. Our recommendations for enhanced communication may improve patient outcomes by optimising routes to diagnosis via primary care., (Copyright © 2024, The Authors.)

Background: Temporal structuring is determined by practices and social norms and affects the quality and timing of care . In this case study of hyperacute stroke wards which provide initial stroke investigation, treatment and care, we explored temporal structuring patterns to explain how these may affect quality of care., Methods: This paper presents a thematic analysis of qualitative interviews with hyperacute stroke staff (n=76), non-participant observations (n=41, ~102 hours) and documentary analysis of the relevant service standards guidance. We used an inductive coding process to generate thematic findings around the concept of temporal structuring, with graphically illustrated examples., Results: Five temporal structures influence what-happens-when: (1) clinical priorities and quality assurance metrics motivate rapid activity for the initial life-prolonging assessments and interventions; (2) static features of ward organisation such as rotas and ward rounds impact consistency of care, determining timing and quality of care for patients; (3) some services experimented with staff rotas to try to meet peaks in demand, sometimes unsuccessfully; (4) implicit social norms or heuristics about perceived necessity affected staff motivation to make changes or improvements to consistency of care, particularly around weekend work; and (5) after-effects such as bottlenecks or backlogs affect quality of care, which are hard to measure effectively to drive service improvement., Conclusions: Patients need temporally consistent high quality of care. Temporal consistency stems from the design of services, including staffing, targets and patient pathway design as well as cultural attitudes to working patterns. Improvements to consistency of care will be limited without changes to structures such as rotas and ward rounds, but also social norms around weekend work for certain professional groups., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: Managing diagnostic uncertainty is a major challenge in primary care due to factors such as the absence of definitive tests, variable symptom presentations and disease evolution. Maintaining patient trust during a period of investigative uncertainty, whilst minimising scope for diagnostic error is a challenge. Mismanagement can lead to diagnostic errors, treatment delays, and suboptimal patient outcomes., Objective: Our aim was to explore how UK primary care physicians (GPs) address and communicate diagnostic uncertainty in practice., Design: This qualitative study used video and audio-recordings. Verbatim transcripts were coded with a modified, validated tool to capture GPs' actions and communication in primary care consultations that included diagnostic uncertainty. The tool includes items relating to advice regarding new symptoms or symptom deterioration (sometimes called 'safety netting'). Video data was analysed to identify GP and patient body postures during and after the delivery of the management plan., Participants: All patient participants had a consultation with a GP, were over the age of 50 and had (1) at least one new presenting problem or (2) one persistent problem that was undiagnosed., Approach: Data collection occurred in GP-patient consultations during 2017-2018 across 7 practices in UK during 2017-2018., Key Results: GPs used various management strategies to address diagnostic uncertainty, including (1) symptom monitoring without treatment, (2) prescribed treatment with symptom monitoring, and (3) addressing risks that could arise from administrative tasks. GPs did not make management plans for potential treatment side effects. Specificity of uncertainty management plans varied among GPs, with only some offering detailed actions and timescales. The transfer of responsibility for the management plan to patients was usually delivered rather than negotiated, with most patients confirming acceptance before concluding the discussion., Conclusions: We offer guidance to healthcare professionals, improving awareness of using and communicating management plans for diagnostic uncertainty., (© 2024. The Author(s).)

Introduction: People being investigated for cancer face a wealth of complex information. Non-specific symptom pathways (NSS) were implemented in the United Kingdom in 2017 to address the needs of patients experiencing symptoms such as weight loss, fatigue or general practitioner 'gut feeling', who did not have streamlined pathways for cancer investigation. This study aimed to explore the health literacy skills needed by patients being investigated for cancer in NSS pathways., Methods: This study employed ethnographic methods across four hospitals in England, including interviews, patient shadowing and clinical care observations, to examine NSS pathways for cancer diagnosis. We recruited 27 patients who were shadowed and interviewed during their care. We also interviewed 27 professionals. The analysis focused on patient communication and understanding, drawing on the concepts of personal and organisational health literacy., Results: Our analysis derived six themes highlighting the considerable informational demands of the NSS pathway. Patients were required to understand complex blood tests and investigations in primary care and often did not understand why they were referred. The NSS pathway itself was difficult to understand with only a minority of patients appreciating that multiple organs were being investigated for cancer. The process of progressing through the pathway was also difficult to understand, particularly around who was making decisions and what would happen next. The results of investigations were complex, often including incidental findings. Patients whose persistent symptoms were not explained were often unsure of what to do following discharge., Conclusion: We have identified several potential missed opportunities for organisations to support patient understanding of NSS pathways which could lead to inappropriate help-seeking post-discharge. Patients' difficulties in comprehending previous investigations and findings could result in delays, overtesting or inadequately targeted investigations, hindering the effective use of their medical history. Third, patients' limited understanding of their investigations and results may impede their ability to engage in patient safety by reporting potential care errors., Patient or Public Contribution: Patient, public, clinical and policy representatives contributed to developing the research objectives through a series of meetings and individual conversations in preparation for the study. We have held several events in which patients and the public have had an opportunity to give feedback about our results, such as local interest groups in North London and academic conferences. A clinical contributor (J.-A. M.) was involved in data analysis and writing the manuscript., (© 2024 The Authors. Health Expectations published by John Wiley & Sons Ltd.)

Background: Lung cancer clinical guidelines and risk tools often rely on smoking history as a significant risk factor. However, never-smokers make up 14% of the lung cancer population, and this proportion is rising. Consequently, they are often perceived as low-risk and may experience diagnostic delays. This study aimed to explore how clinicians make risk-informed diagnostic decisions for never-smokers., Methods: Qualitative interviews were conducted with 10 lung cancer diagnosticians, supported by data from interviews with 20 never-smoker lung cancer patients. The data were analyzed using a framework analysis based on the Model of Pathways to Treatment framework and data-driven interpretations., Results: Participants described 3 main strategies for making risk-informed decisions incorporating smoking status: guidelines, heuristics, and potential harms. Clinicians supplemented guidelines with their own heuristics for never-smokers, such as using higher thresholds for chest X-ray. Decisions were easier for patients with high-risk symptoms such as hemoptysis. Clinicians worried about overinvestigating never-smoker patients, particularly in terms of physical and psychological harms from invasive procedures or radiation. To minimize unnecessary anxiety about lung cancer risk, clinicians made efforts to downplay this. Conversely, some patients found that this caused process harms such as delays and miscommunications., Conclusion: Improved guidance and methods of risk differentiation for never-smokers are needed to avoid diagnostic delays, overreassurance, and clinical pessimism. This requires an improved evidence base and initiatives to increase awareness among clinicians of the incidence of lung cancer in never-smokers. As the proportion of never-smoker patients increases, this issue will become more urgent., Highlights: Smoking status is the most common risk factor used by clinicians to guide decision making, and guidelines often focus on this factor.Some clinicians also use their own heuristics for never-smokers, and this becomes particularly relevant for patients with lower risk symptoms.Clinicians are also concerned about the potential harms and risks associated with deploying resources on diagnostics for never-smokers.Some patients find it difficult to decide whether or not to go ahead with certain procedures due to efforts made by clinicians to downplay the risk of lung cancer.Overall, the study highlights the complex interplay between smoking history, clinical decision making, and patient anxiety in the context of lung cancer diagnosis and treatment., Competing Interests: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This article presents the results of The PEARL study (Patient Experience of symptoms, help-seeking And Risk factors in Lung cancer), which was funded by a Cancer Research UK research grant (C50716/A30771). GBB is supported by The Health Foundation’s grant to the University of Cambridge for The Healthcare Improvement Studies Institute. GBB and SLQ acknowledge salary support from Barts Charity (award G-001520). Financial support for this study was provided entirely by a grant from Cancer Research UK. The funding agreement ensured the authors’ independence in designing the study, interpreting the data, writing, and publishing the report.

Competing Interests: We declare no competing interests.

Background: The potential of the electronic health record to support safety netting has been recognised and a number of electronic safety-netting (E-SN) tools developed., Aim: To establish the most important features of E-SN tools., Design & Setting: User-experience interviews followed by a Delphi study in a primary care setting in the UK., Method: The user-experience interviews were carried out remotely with primary care staff who had trialled the EMIS E-SN toolkit for suspected cancer. An electronic modified Delphi approach was used, with primary care staff involved in safety netting in any capacity, to measure consensus on tool features., Results: Thirteen user-experience interviews were carried out and features of E-SN tools seen as important formed the majority of the features included in the Delphi study. Three rounds of Delphi survey were administered. Sixteen responders (64%) completed all three rounds, and 28 out of 44 (64%) features reached consensus. Primary care staff preferred tools that were general in scope., Conclusion: Primary care staff indicated that tools that were not specific to cancer or any other disease, and had features that promoted their flexible, efficient, and integrated use, were important. However, when the important features were discussed with the patient and public involvement (PPI) group, they expressed disappointment that features they believed would make E-SN tools robust and provide a safety net that is difficult to fall through did not reach consensus. The successful adoption of E-SN tools will rely on an evidence base of their effectiveness. Efforts should be made to assess the impact of these tools on patient outcomes., (Copyright © 2023, The Authors.)

Background: Recovery Colleges (RCs) are mental health and well-being education centres where people come together and learn skills that support their wellness. Co-production, co-learning and transformative education are fundamental to RCs. People with lived experience are recognized as experts who partner with health professionals in the design and actualization of educational programming. The pandemic has changed how RCs operate by necessitating a shift from in-person to virtual offerings. Given the relational ethos of RCs, it is important to explore how the experiences of RC members and communities were impacted during this time. To date, there has been limited scholarship on this topic., Methods: In this exploratory phase of a larger project, we used participatory action research to interview people who were accessing, volunteering and/or working in RCs across Canada. Semi-structured interviews were conducted with twenty-nine individuals who provided insights on what is important to them about RC programming., Results: Our study was conducted amid the COVID-19 pandemic. Accordingly, participants elucidated how their involvement in RCs was impacted by pandemic related restrictions. The results of this study demonstrate that RC programming is most effective when it: (1) is inclusive; (2) has a "good vibe"; and (3) equips people to live a fuller life., Conclusions: The pandemic, despite its challenges, has yielded insights into a possible evolution of the RC model that transcends the pandemic-context. In a time of great uncertainty, RCs served as safe spaces where people could redefine, pursue, maintain or recover wellness on their own terms., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: This evaluation assesses the impact of an electronic safety netting software (E-SN) package, C the Signs, in primary care services across five boroughs in North East London (NEL)., Aim: This study evaluates the use of E-SN software in primary care, examining its benefits and barriers, safety implications, and overall impact on individual and practice usage., Design and Setting: The study is based on semi-structured interviews with 21 clinical and non-clinical members of staff from all primary care services using the software in NEL., Method: Semi-structured interviews were conducted to gather data on individual use of the software, safety implications and practice use of features such as the monitoring dashboard. Data were analysed using a rapid qualitative methodology., Results: Two approaches to E-SN software adoption were reported: whole practice adoption and self-directed use. Practices benefitted from shared responsibility for safety netting and using software to track patients' progress in secondary care. Adoption was affected by information technology and administrative resources. Decision-support tools were used infrequently due to a lack of appreciation for their benefits. Selective adoption of different E-SN functions restricted its potential impact on early diagnosis., Conclusion: The use of E-SN software in primary care services in NEL varied among participants. While some found it to be beneficial, others were sceptical of its impact on clinical decision-making. Nonetheless, the software was found to be effective in managing referral processes and tracking patients' progress in other points of care., Competing Interests: Competing interests: DC works in the Cancer Alliance where this evaluation took place. AC and SP-D worked in the NEL Commissioning Support Unit at the time this evaluation was undertaken. The results of the evaluation had a direct impact on ongoing funding decisions in relation to the software., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Integrated care systems present enduring governance challenges associated with fostering interorganisational collaboration., Aim: To understand how clinical leaders can make a distinct contribution to the governance and system leadership of integrated care systems., Methods: A qualitative interview study carried out between 2018 and 2019 with 24 clinical leaders, and a further 47 non-clinical leaders, involved in the governance of three Sustainability and Transformation Partnership in the English National Health Service., Results: Clinical leaders were found to make four distinct contributions: (1) making analytical insights into integration strategies that ensured their relevance and quality to clinical communities; (2) representing the views of clinicians in system decision-making thereby enhancing the legitimacy of change; (3) translation and communication activities to articulate integration strategies in favourable ways and ensure clinical engagement; and (4) relational work in the form of brokering and building connections and mediating conflict between multiple stakeholders. These activities varied across the levels of system governance and at different stages in the processes of change., Conclusions: Clinical leaders can make a distinct contribution to the governance and leadership of integrated care systems based on their clinical expertise, membership professional networks, reputation and formal authority., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Purpose: The COVID-19 pandemic presented new barriers and exacerbated existing inequities for physician scholars. While COVID-19's impact on academic productivity among women has received attention, the pandemic may have posed additional challenges for scholars from a wider range of equity-deserving groups, including those who hold multiple equity-deserving identities. To examine this concern, the authors conducted a scoping review of the literature through an intersectionality lens., Method: The authors searched peer-reviewed literature published March 1, 2020, to December 16, 2021, in Ovid MEDLINE, Ovid Embase, and PubMed. The authors excluded studies not written in English and/or outside of academic medicine. From included studies, they extracted data regarding descriptions of how COVID-19 impacted academic productivity of equity-deserving physician scholars, analyses on the pandemic's reported impact on productivity of physician scholars from equity-deserving groups, and strategies provided to reduce the impact of the COVID-19 pandemic on academic productivity of physician scholars from equity-deserving groups., Results: Of 11,587 unique articles, 44 met inclusion criteria, including 15 nonempirical studies and 29 empirical studies (22 bibliometrics studies, 6 surveys, and 1 qualitative study). All included articles focused on the gendered impact of the pandemic on academic productivity. The majority of their recommendations focused on how to alleviate the burden of the pandemic on women, particularly those in the early stages of their career and/or with children, without consideration of scholars who hold multiple and intersecting identities from a wider range of equity-deserving groups., Conclusions: Findings indicate a lack of published literature on the pandemic's impact on physician scholars from equity-deserving groups, including a lack of consideration of physician scholars who experience multiple forms of discrimination. Well-intentioned measures by academic institutions to reduce the impact on scholars may inadvertently risk reproducing and sustaining inequities that equity-deserving scholars faced during the pandemic., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Association of American Medical Colleges.)

Background: Safety netting in primary care is considered an important intervention for managing diagnostic uncertainty. This is the first study to examine how patients understand and interpret safety netting advice around low-risk potential lung cancer symptoms, and how this affects reconsultation behaviours., Methods: Qualitative interview study in UK primary care. Pre-covid-19, five patients were interviewed in person within 2-3 weeks of a primary care consultation for potential lung cancer symptom(s), and again 2-5 months later. The general practitioner (GP) they last saw was interviewed face-to-face once. During the covid-19 pandemic, an additional 15 patients were interviewed only once via telephone, and their GPs were not interviewed or contacted in any way. Audio-recorded interviews were transcribed verbatim and analysed using inductive thematic analysis., Results: The findings from our thematic analysis suggest that patients prefer active safety netting, as part of thorough and logical diagnostic uncertainty management. Passive or ambiguous safety netting may be perceived as dismissive and cause delayed reconsultation. GP safety netting strategies are not always understood, potentially causing patient worry and dissatisfaction. Telephone consultations and the diagnostic overshadowing of COVID-19 on respiratory symptoms impacted GPs' safety netting strategies and patients' appetite for active follow up measures., Conclusions: Safety netting guidelines do not yet offer solutions that have been proven to promote symptom vigilance and timely reconsultation for low-risk lung cancer symptoms. This may have been affected by primary care practices during the COVID-19 pandemic. Patients prefer active or pre-planned safety netting coupled with thorough consultation techniques and a comprehensible diagnostic strategy, and may respond adversely to passive safety netting advice., (© 2022. The Author(s).)

The UK has a long history of attempts to integrate child health services to improve outcomes, an ambition renewed in the recent The NHS Long Term Plan . It's therefore timely to review the history of integration to inform future initiatives. Key milestones include the Platt report (1959), Court report (1976), Sure Start (1999), National service framework (2004) and Facing the future report (2015). These stand against a backdrop of national NHS policy changes, with a myriad of local integration initiatives and research efforts in parallel. We suggest lessons for future integration initiatives: integration may support the quadruple aim; integration depends on addressing divides between primary and secondary care; workforce and funding challenges need to be resolved before integration can thrive; high-quality research and evaluation of integrated interventions is required; strong relationships between professional groups are key to integration; and integration can help address health inequalities., (© Royal College of Physicians 2022 All rights reserved.)

Background: The relationship between ethnography and healthcare improvement has been the subject of methodological concern. We conducted a scoping review of ethnographic literature on healthcare improvement topics, with two aims: (1) to describe current ethnographic methods and practices in healthcare improvement research and (2) to consider how these may affect habit and skill formation in the service of healthcare improvement., Methods: We used a scoping review methodology drawing on Arksey and O'Malley's methods and more recent guidance. We systematically searched electronic databases including Medline, PsychINFO, EMBASE and CINAHL for papers published between April 2013 - April 2018, with an update in September 2019. Information about study aims, methodology and recommendations for improvement were extracted. We used a theoretical framework outlining the habits and skills required for healthcare improvement to consider how ethnographic research may foster improvement skills., Results: We included 283 studies covering a wide range of healthcare topics and methods. Ethnography was commonly used for healthcare improvement research about vulnerable populations, e.g. elderly, psychiatry. Focussed ethnography was a prominent method, using a rapid feedback loop into improvement through focus and insider status. Ethnographic approaches such as the use of theory and focus on every day practices can foster improvement skills and habits such as creativity, learning and systems thinking., Conclusions: We have identified that a variety of ethnographic approaches can be relevant to improvement. The skills and habits we identified may help ethnographers reflect on their approaches in planning healthcare improvement studies and guide peer-review in this field. An important area of future research will be to understand how ethnographic findings are received by decision-makers., (© 2021. The Author(s).)

Background: Studies have been published regarding the impact of major system change (MSC) on care quality and outcomes, but few evaluate implementation costs or include them in cost-effectiveness analysis (CEA). This is despite large potential costs of MSC: change planning, purchasing or repurposing assets, and staff time. Implementation costs can influence implementation decisions. We describe our framework and principles for costing MSC implementation and illustrate them using a case study., Methods: We outlined MSC implementation stages and identified components, using a framework conceived during our work on MSC in stroke services. We present a case study of MSC of specialist surgery services for prostate, bladder, renal and oesophagogastric cancers, focusing on North Central and North East London and West Essex. Health economists collaborated with qualitative researchers, clinicians and managers, identifying key reconfiguration stages and expenditures. Data sources (n = approximately 100) included meeting minutes, interviews, and business cases. National Health Service (NHS) finance and service managers and clinicians were consulted. Using bottom-up costing, items were identified, and unit costs based on salaries, asset costs and consultancy fees assigned. Itemised costs were adjusted and summed., Results: Cost components included options appraisal, bidding process, external review; stakeholder engagement events; planning/monitoring boards/meetings; and making the change: new assets, facilities, posts. Other considerations included hospital tariff changes; costs to patients; patient population; and lifetime of changes. Using the framework facilitated data identification and collection. The total adjusted implementation cost was estimated at £7.2 million, broken down as replacing robots (£4.0 million), consultancy fees (£1.9 million), staff time costs (£1.1 million) and other costs (£0.2 million)., Conclusions: These principles can be used by funders, service providers and commissioners planning MSC and researchers evaluating MSC. Health economists should be involved early, alongside qualitative and health-service colleagues, as retrospective capture risks information loss. These analyses are challenging; many cost factors are difficult to identify, access and measure, and assumptions regarding lifetime of the changes are important. Including implementation costs in CEA might make MSC appear less cost effective, influencing future decisions. Future work will incorporate this implementation cost into the full CEAs of the London Cancer MSC., Trial Registration: Not applicable., (© 2021. The Author(s).)

Objectives: The physical and technical responses of experienced (≥5 years) and less experienced (1-4 years) elite Australian Football (AF) players were compared following the most intense passages of match-play., Design: Descriptive cohort study., Methods: Time-motion analyses were performed using global positioning systems (MinimaxX S4, Catapult Innovations, Melbourne, Australia) on one elite AF team during 13 matches. The global positioning data were categorised into total distance, low-speed activity (0-2.78ms(-1)), moderate-speed running (2.79-4.14ms(-1)) and high-speed running (≥4.15ms(-1)) distances. A standardised 5-point technical coding criteria was used to rate the number and quality of skill involvements during match-play., Results: Following the most intense 3-min running period the experienced players covered greater distances at high-speeds in match quarters two (effect size, ES=0.42±0.30) and three (ES=0.38±0.33) than their less experienced counterparts. Compared with less experienced players, experienced players performed more skill involvements during the second quarter (ES=0.42±0.33) and fourth quarter peak 3-min bouts of exercise intensity (ES=0.40±0.30) and quarter one (ES=0.49±0.29) and three subsequent periods (ES=0.33±0.20)., Conclusions: Less experienced players exhibited greater reductions in physical and technical performance following peak periods of match-play. These findings suggest that training may require a greater emphasis on developing the ability of less experienced players to maintain physical performance and gain possession of the football following intense periods of match-play., (Copyright © 2015 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.)