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BackgroundEDs globally are under increasing pressure through rising demand. Frequent attenders are known to have complex health needs and use a disproportionate amount of resources. We hypothesised that heterogeneity of patients’ reason for attendance would be associated with multimorbidity and increasing age, and predict future attendance.MethodWe analysed an anonymised dataset of all ED visits over the course of 2014 in Yorkshire, UK. We identified 15 986 patients who had five or more ED encounters at any ED in the calendar year. Presenting complaint was categorised into one of 14 categories based on the Emergency Care Data Set (ECDS). We calculated measures of heterogeneity (count of ECDs categories and entropy of categories) and examined their relationship to total number of ED visits and to patient characteristics. We examined the predictive value of these and other features on future attendance.ResultsMost frequent attenders had more than one presenting complaint type. Heterogeneity increased with number of attendances, but heterogeneity adjusted for number of attendances did not vary substantially with age or sex. Heterogeneity was associated with the presence of one or more contacts for a mental health problem. For a given number of attendances, prior mental health contact but not heterogeneity was associated with further attendance.ConclusionsHeterogeneity of presenting complaint can be quantified and analysed for ED use: it is increased where there is a history of mental disorder but not with age. This suggests it reflects more than the number of medical conditions.

Background:Shortages of personal protective equipment during the coronavirus disease 2019 (COVID-19) pandemic have led to the extended use or reuse of single-use respirators and surgical masks by frontline healthcare workers. The evidence base underpinning such practices warrants examination.Objectives:To synthesize current guidance and systematic review evidence on extended use, reuse, or reprocessing of single-use surgical masks or filtering face-piece respirators.Data sources:We used the World Health Organization, the European Centre for Disease Prevention and Control, the US Centers for Disease Control and Prevention, and Public Health England websites to identify guidance. We used Medline, PubMed, Epistemonikos, Cochrane Database, and preprint servers for systematic reviews.Methods:Two reviewers conducted screening and data extraction. The quality of included systematic reviews was appraised using AMSTAR-2. Findings were narratively synthesized.Results:In total, 6 guidance documents were identified. Levels of detail and consistency across documents varied. They included 4 high-quality systematic reviews: 3 focused on reprocessing (decontamination) of N95 respirators and 1 focused on reprocessing of surgical masks. Vaporized hydrogen peroxide and ultraviolet germicidal irradiation were highlighted as the most promising reprocessing methods, but evidence on the relative efficacy and safety of different methods was limited. We found no well-established methods for reprocessing respirators at scale.Conclusions:Evidence on the impact of extended use and reuse of surgical masks and respirators is limited, and gaps and inconsistencies exist in current guidance. Where extended use or reuse is being practiced, healthcare organizations should ensure that policies and systems are in place to ensure these practices are carried out safely and in line with available guidance.

The coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is now a pandemic with devastating implications for populations, healthcare systems, and economies globally. Many healthcare workers (HCWs), including those in primary and community care settings, may be at increased risk of COVID-19 infection.1 COVID-19 is known to have three modes of transmission: contact (direct or via a fomite, that is, a contaminated surface or object), droplets (from the respiratory tract of an infected individual during coughing or sneezing transmitted onto a mucosal surface or conjunctiva of a susceptible individual), and aerosols (microbes within droplets that remain suspended in air for long periods).2,3 Personal protective equipment (PPE) reduces the transference of droplets or other body fluids onto HCWs’ skin and clothing or directly onto the mucous membranes of the eye or nasopharynx. PPE can also include respiratory protective equipment to protect against aerosol inhalation. Concerns have, however, been raised about PPE provision for preventing COVID-19 in primary and community care staff.4 This is a particularly pressing concern given the anxiety and stress of working in conditions that may pose a threat to health and which can negatively impact the productivity and care provided by HCWs.5 In this article we present findings from rapid reviews conducted regarding PPE for frontline primary care and community care staff, and what circumstances may potentially put HCWs at risk of contagion. Most guidance on PPE appears skewed to secondary care settings (emergency department or inpatient) and focuses mainly on ‘high-risk’ scenarios, for which full aerosol, droplet, and contact PPE (that is, disposable gloves, gown, eye protection, and respirator masks) are recommended. The highest number of contacts in many healthcare settings, however, will be within primary and community environments, including not just general practices but …

ObjectiveFrequent attendance at the ED is a worldwide problem. We hypothesised that frequent attendance could be understood as a feature of a complex system comprising patients, healthcare and society. Complex systems have characteristic statistical properties, with stable patterns at the level of the system emerging from unstable patterns at the level of individuals who make up the system.MethodsAnalysis of a linked dataset of routinely collected health records from all 13 hospital trusts providing ED care in the Yorkshire and Humber region of the UK (population 5.5 million). We analysed the distribution of attendances per person in each of 3 years and measured the transition of individual patients between frequent, infrequent and non-attendance. We fitted data to power law distributions typically seen in complex systems using maximum likelihood estimation.ResultsThe data included 3.6 million attendances at EDs in 13 hospital trusts. 29/39 (74.3%) analyses showed a statistical fit to a power law; 2 (5.1%) fitted an alternative distribution. All trusts’ data fitted a power law in at least 1 year. Differences over time and between hospital trusts were small and partly explained by demographics. In contrast, individual patients’ frequent attendance was unstable between years.ConclusionsED attendance patterns are stable at the level of the system, but unstable at the level of individual frequent attenders. Attendances follow a power law distribution typical of complex systems. Interventions to address ED frequent attendance need to consider the whole system and not just the individual frequent attenders.

Aims\ud \ud Aim of this study is to better understand the role of nurses’ professional judgment in nurse staffing systems.\ud Design\ud \ud Qualitative comparative case study design of nurse staffing systems in England and Wales.\ud Methods\ud \ud Data will be collected through a variety of sources: individual interviews, observations of relevant meetings and analysis of key documents. Ethical approval for the study was granted in August 2020 from The Healthcare Research Ethics Committee (SREC reference: REC741). Data generation will be informed by science and technology studies and practice theories.\ud Discussion\ud \ud Ensuring adequate numbers of nurses are available to care for patients in response to shifting demand is an international policy priority. Emerging evidence on the use of formal workforce planning methodologies across the developed world highlights both the centrality of nurses’ professional judgement in nurse staffing methodologies and the urgent need for theoretically informed research to better understand and conceptualise its contribution to decision-making. This study is designed to address this gap in understanding. It takes advantage of nurses’ experiences of managing the service and staffing impacts of the Covid-19 pandemic and differences in strategic approaches to nurse staffing systems between England and Wales.\ud Impact\ud The research will:\ud \ud make visible the knowledge and skills that underpin professional judgement in nurse staffing decisions and provide a conceptual language with which to articulate this;\ud lay the foundations for evidence-based programmes of nurse education and continuing professional development;\ud furnish the evidence to inform the development of nurse-led decision support tools to augment professional judgement; and\ud generate wider insights into the effectiveness of nurse staffing systems in practice.

Background As people age and accumulate long-term conditions, their physical activity and physical function declines, resulting in disability and loss of independence. Primary care is well placed to empower individuals and communities to reduce this decline; however, the best approach is uncertain. Objectives To develop a programme theory to explain the mechanisms through which interventions improve physical activity and physical function in people with long-term conditions in different primary care contexts, and to co-design a prototype intervention. Data sources Systematic literature searches of relevant databases with forwards and backwards citation tracking, grey literature searches and further purposive searches were conducted. Qualitative data were collected through workshops and interviews. Design Realist evidence synthesis and co-design for primary care service innovation. Setting Primary care in Wales and England. Participants Stakeholders included people with long-term conditions, primary care professionals, people working in relevant community roles and researchers. Methods The realist evidence synthesis combined evidence from varied sources of literature with the views, experiences and ideas of stakeholders. The resulting context, mechanism and outcome statements informed three co-design workshops and a knowledge mobilisation workshop for primary care service innovation. Results Five context, mechanism and outcome statements were developed. (1) Improving physical activity and function is not prioritised in primary care (context). If the practice team culture is aligned to the elements of physical literacy (mechanism), then physical activity promotion will become routine and embedded in usual care (outcome). (2) Physical activity promotion is inconsistent and unco-ordinated (context). If specific resources are allocated to physical activity promotion (in combination with a supportive practice culture) (mechanism), then this will improve opportunities to change behaviour (outcome). (3) People with long-term conditions have varying levels of physical function and physical activity, varying attitudes to physical activity and differing access to local resources that enable physical activity (context). If physical activity promotion is adapted to individual needs, preferences and local resources (mechanism), then this will facilitate a sustained improvement in physical activity (outcome). (4) Many primary care practice staff lack the knowledge and confidence to promote physical activity (context). If staff develop an improved sense of capability through education and training (mechanism), then they will increase their engagement with physical activity promotion (outcome). (5) If a programme is credible with patients and professionals (context), then trust and confidence in the programme will develop (mechanism) and more patients and professionals will engage with the programme (outcome). A prototype multicomponent intervention was developed. This consisted of resources to nurture a culture of physical literacy, materials to develop the role of a credible professional who can promote physical activity using a directory of local opportunities and resources to assist with individual behaviour change. Limitations Realist synthesis and co-design is about what works in which contexts, so these resources and practice implications will need to be modified for different primary care contexts. Conclusions We developed a programme theory to explain how physical activity could be promoted in primary care in people with long-term conditions, which informed a prototype intervention. Future work A future research programme could further develop the prototype multicomponent intervention and assess its acceptability in practice alongside existing schemes before it is tested in a feasibility study to inform a future randomised controlled trial. Study registration This study is registered as PROSPERO CRD42018103027. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 16. See the NIHR Journals Library website for further project information.

BackgroundThe popularity of social prescribing has grown in recent years following a series of high-profile recommendations in scientific reviews, political reports, and media coverage. Social prescribing has the potential to address multiple health and social problems, but few studies have examined how it works.AimTo explore the ways by which social prescribing may be beneficial to individuals undertaking socially prescribed activity (SPA).Design and settingA qualitative interview study involving people attending a range of SPA.MethodParticipants were purposively recruited from a multi-activity social prescribing provider. Data were collected using semi-structured face-to-face interviews. Analysis used a thematic approach, in which emerging themes were contextualised with interview transcripts and findings from existing literature.ResultsThe study identified five themes, which together formed a journey of engagement and participation. While not always present for any one individual, the themes occurred in a consistent order: receiving professional support for social problems; engaging with others through participation in SPA; learning different ways to relate to other people and developing new skills; changing perceptions by realising personal assets and becoming open to the possibility of new futures; and developing a positive outlook on the present while moving forwards in pursuit of future goals and better health.ConclusionSPA appears to benefit individuals by a process that begins with personalised professional help to address social problems and moves through engagement with activities and others, to the recognition of personal and social assets and opportunities.

Background Strategies to improve the effectiveness and quality of health and care have predominantly emphasised the implementation of new research and evidence into service organisation and delivery. A parallel, but less understood issue is how clinicians and service leaders stop existing practices and interventions that are no longer evidence based, where new evidence supersedes old evidence, or interventions are replaced with those that are more cost effective. The aim of this evidence synthesis is to produce meaningful programme theory and practical guidance for policy makers, managers and clinicians to understand how and why de-implementation processes and procedures can work. Methods and analysis The synthesis will examine the attributes or characteristics that constitute the concept of de-implementation. The research team will then draw on the principles of realist inquiry to provide an explanatory account of how, in what context and for whom to explain the successful processes and impacts of de-implementation. The review will be conducted in four phases over 18 months. Phase 1: develop a framework to map the preliminary programme theories through an initial scoping of the literature and consultation with key stakeholders. Phase 2: systematic searches of the evidence to develop the theories identified in phase 1. Phase 3: validation and refinement of programme theories through stakeholder interviews. Phase 4: formulating actionable recommendations for managers, commissioners and service leaders about what works through different approaches to de-implementation. Discussion This evidence synthesis will address gaps in knowledge about de-implementation across health and care services and ensure that guidance about strategies and approaches accounts for contextual factors, which may be operating at different organisational and decision-making levels. Through the development of the programme theory, which explains what works, how and under which circumstances, findings from the evidence synthesis will support managers and service leaders to make measured decisions about de-implementation. Systematic review registration PROSPERO CRD42017081030

ObjectivesTo develop a taxonomy of interventions and a programme theory explaining how interventions improve physical activity and function in people with long-term conditions managed in primary care. To co-design a prototype intervention informed by the programme theory.DesignRealist synthesis combining evidence from a wide range of rich and relevant literature with stakeholder views. Resulting context, mechanism and outcome statements informed co-design and knowledge mobilisation workshops with stakeholders to develop a primary care service innovation.ResultsA taxonomy was produced, including 13 categories of physical activity interventions for people with long-term conditions.Abridged realist programme theoryRoutinely addressing physical activity within consultations is dependent on a reinforcing practice culture, and targeted resources, with better coordination, will generate more opportunities to address low physical activity. The adaptation of physical activity promotion to individual needs and preferences of people with long-term conditions helps affect positive patient behaviour change. Training can improve knowledge, confidence and capability of practice staff to better promote physical activity. Engagement in any physical activity promotion programme will depend on the degree to which it makes sense to patients and professions, and is seen as trustworthy.Co-designThe programme theory informed the co-design of a prototype intervention to: improve physical literacy among practice staff; describe/develop the role of a physical activity advisor who can encourage the use of local opportunities to be more active; and provide materials to support behaviour change.ConclusionsPrevious physical activity interventions in primary care have had limited effect. This may be because they have only partially addressed factors emerging in our programme theory. The co-designed prototype intervention aims to address all elements of this emergent theory, but needs further development and consideration alongside current schemes and contexts (including implications relevant to COVID-19), and testing in a future study. The integration of realist and co-design methods strengthened this study.

Background Many dental ‘check-ups’ in the NHS result in no further treatment. The patient is examined by a dentist and returned to the recall list for a further check-up, commonly in 6 or 12 months’ time. As the oral health of regular dental attenders continues to improve, it is likely that an increasing number of these patients will be low risk and will require only a simple check-up in the future, with no further treatment. This care could be delivered by dental therapists. In 2013, the body responsible for regulating the dental profession, the General Dental Council, ruled that dental therapists could see patients directly and undertake check-ups and routine dental treatments (e.g. fillings). Using dental therapists to undertake check-ups on low-risk patients could help free resources to meet the future challenges for NHS dentistry. Objectives The objectives were to determine the most appropriate design for a definitive study, the most appropriate primary outcome measure and recruitment and retention rates, and the non-inferiority margin. We also undertook a realist-informed process evaluation and rehearsed the health economic data collection tool and analysis. Design A pilot randomised controlled trial over a 15-month period, with a realist-informed process evaluation. In parallel, we rehearsed the health economic evaluation and explored patients’ preferences to inform a preference elicitation exercise for a definitive study. Setting The setting was NHS dental practices in North West England. Participants A total of 217 low-risk patients in eight high-street dental practices participated. Interventions The current practice of using dentists to provide NHS dental check-ups (treatment as usual; the control arm) was compared with using dental therapists to provide NHS dental check-ups (the intervention arm). Main outcome measure The main outcome measure was difference in the proportion of sites with bleeding on probing among low-risk patients. We also recorded the number of ‘cross-over’ referrals between dentists and dental therapists. Results No differences were found in the health status of patients over the 15 months of the pilot trial, suggesting that non-inferiority is the most appropriate design. However, bleeding on probing suffered from ‘floor effects’ among low-risk patients, and recruitment rates were moderately low (39.7%), which suggests that an experimental design might not be the most appropriate. The theory areas that emerged from the realist-informed process evaluation were contractual, regulatory, institutional logistics, patients’ experience and logistics. The economic evaluation was rehearsed and estimates of cost-effectiveness made; potential attributes and levels that can form the basis of preference elicitation work in a definitive study were determined. Limitations The pilot was conducted over a 15-month period only, and bleeding on probing appeared to have floor effects. The number of participating dental practices was a limitation and the recruitment rate was moderate. Conclusions Non-inferiority, floor effects and moderate recruitment rates suggest that a randomised controlled trial might not be the best evaluative design for a definitive study in this population. The process evaluation identified multiple barriers to the use of dental therapists in ‘high-street’ practices and added real value. Future work Quasi-experimental designs may offer more promise for a definitive study alongside further realist evaluation. Trial registration Current Controlled Trials ISRCTN70032696. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 3. See the NIHR Journals Library website for further project information.

BackgroundHealth-care systems across the globe are facing increased pressures to balance the efficient use of resources and at the same time provide high-quality care. There is greater requirement for services to be evidence based, but practices that are of limited clinical effectiveness or cost-effectiveness still occur.ObjectivesOur objectives included completing a concept analysis of de-implementation, surfacing decision-making processes associated with de-implementing through stakeholder engagement, and generating an evidence-based realist programme theory of ‘what works’ in de-implementation.DesignA realist synthesis was conducted using an iterative stakeholder-driven four-stage approach. Phase 1 involved scoping the literature and conducting stakeholder interviews to develop the concept analysis and an initial programme theory. In Phase 2, systematic searches of the evidence were conducted to test and develop this theory, expressed in the form of contingent relationships. These are expressed as context–mechanism–outcomes to show how particular contexts or conditions trigger mechanisms to generate outcomes. Phase 3 consisted of validation and refinement of programme theories through stakeholder interviews. The final phase (i.e. Phase 4) formulated actionable recommendations for service leaders.ParticipantsIn total, 31 stakeholders (i.e. user/patient representatives, clinical managers, commissioners) took part in focus groups and telephone interviews.Data sourcesUsing keywords identified during the scoping work and concept analysis, searches of bibliographic databases were conducted in May 2018. The databases searched were the Cochrane Library, Campbell Collaboration, MEDLINE (via EBSCOhost), the Cumulative Index to Nursing and Allied Health Literature (via EBSCOhost), the National Institute for Health Research Journals Library and the following databases via the ProQuest platform: Applied Social Sciences Index and Abstracts, Social Services Abstracts, International Bibliography of the Social Sciences, Social Sciences Database and Sociological Abstracts. Alerts were set up for the MEDLINE database from May 2018 to December 2018. Online sources were searched for grey literature and snowballing techniques were used to identify clusters of evidence.ResultsThe concept analysis showed that de-implementation is associated with five main components in context and over time: (1) what is being de-implemented, (2) the issues driving de-implementation, (3) the action characterising de-implementation, (4) the extent that de-implementation is planned or opportunistic and (5) the consequences of de-implementation. Forty-two papers were synthesised to identify six context–mechanism–outcome configurations, which focused on issues ranging from individual behaviours to organisational procedures. Current systems can perpetuate habitual decision-making practices that include low-value treatments. Electronic health records can be designed to hide or remove low-value treatments from choice options, foregrounding best evidence. Professionals can be made aware of their decision-making strategies through increasing their attention to low-value practice behaviours. Uncertainty about diagnosis or patients’ expectations for certain treatments provide opportunities for ‘watchful waiting’ as an active strategy to reduce inappropriate investigations and prescribing. The emotional component of clinician–patient relationships can limit opportunities for de-implementation, requiring professional support through multimodal educational interventions. Sufficient alignment between policy, public and professional perspectives is required for de-implementation success.LimitationsSome specific clinical issues (e.g. de-prescribing) dominate the de-implementation evidence base, which may limit the transferability of the synthesis findings. Any realist inquiry generates findings that are essentially cumulative and should be developed through further investigation that extends the range of sources into, for example, clinical research and further empirical studies.ConclusionsThis review contributes to our understanding of how de-implementation of low-value procedures and services can be improved within health-care services, through interventions that make professional decision-making more accountable and the prominence of a whole-system approach to de-implementation. Given the whole-system context of de-implementation, a range of different dissemination strategies will be required to engage with different stakeholders, in different ways, to change practice and policy in a timely manner.Study registrationThis study is registered as PROSPERO CRD42017081030.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 9, No. 2. See the NIHR Journals Library website for further project information.

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Background: In healthcare, bridging the research-to-practice gap is a top priority. Knowledge mobilisation scholars suggest that this gap can be closed through collaboration between knowledge users and producers. The concept of boundary objects – shared things and ideas that enable communication – has gained popularity across various collaborative work practices, but their potential within knowledge mobilisation in health care is understudied. An ongoing challenge for designers of boundary objects is how to create objects that are valued and shared both in principle and in practice. Aims and objectives: This paper reports on a study of boundary objects used during knowledge mobilisation through NHS-university partnerships called Collaborations for Leadership in Applied Health Research and Care (CLAHRCs). The distinction is investigated between boundary objects-in-theory and boundary objects-in-use, considering whether the latter possess specific characteristics which make them more effective during knowledge mobilisation. Methods: A qualitative case study of three CLAHRCs was conducted. Twenty-one people employed as ‘boundary spanners’ were interviewed to explore whether boundary objects played a role in knowledge mobilisation. Findings: The most effective boundary objects-in-use were co-produced through a process of bricolage. These possessed high levels of meaningfulness and resonance, and reconciled multiple user perspectives. Together these properties contributed to the overall authenticity of boundary objects-in-use. Discussion and conclusion: This paper helps to explain why designated boundary objects frequently fail in practice, and why there is a need to focus on understanding boundary objects based on symbolic, rather than structural, dimensions.

What you need to know Functional disorders are conditions whose origin arises primarily from a disorder of nervous system functioning rather than clearly identifiable pathophysiological disease—such as irritable bowel syndrome, fibromyalgia, and functional neurological disorder (FND)—they are the second commonest reason for new neurology consultations.1 FND is common in emergency settings,2 stroke,3 and rehabilitation services.4 It causes considerable physical disability and distress, and often places an economic burden both on patients and health services.5 Many clinicians have had little formal clinical education on the assessment and management of these disorders, and patients are often not offered potentially effective treatments. In practice, FND should be diagnosed by someone with specific expertise in the diagnosis of neurological conditions. Our recommendation is to refer all patients with a suspected diagnosis of FND to secondary care. However, the diagnosis may be raised as a possibility with the patient in primary care, and knowledge of how the diagnosis is confirmed greatly aids subsequent management. In this article we offer evidence based advice to generalists on how to recognise FND, based on clinical diagnostic and prognostic studies. Although the focus of this paper is on recognising FND, we have included a short box on management to make readers aware that there are good treatments available for FND and that some patients can get better. ### Sources and selection criteria We conducted a PubMed search of evidence for diagnosis of functional neurological disorder (FND) until June 2020, especially systematic reviews.14 …

ObjectiveHigh use of the ED is a worldwide problem. We hypothesised that high use of the ED could be understood as a feature of a complex system comprising patients, healthcare and society. Complex systems have characteristic statistical properties, with stable patterns at the level of the system emerging from unstable patterns at the level of individuals who make up the system.MethodsAnalysis of a linked dataset of routinely collected health records from all 13 hospital trusts providing ED care in the Yorkshire and Humber region of the UK (population 5.5 million). We analysed the distribution of attendances per person in each of three years and measured the transition of individual patients between high, low and non-attendance. We fitted data to power law distributions typically seen in complex systems using maximum likelihood estimation.ResultsThe data included 3.6 million attendances at EDs in 13 hospital trusts. 29/39 (74.3%) analyses showed a statistical fit to a power law; 2 (5.1%) fitted an alternative distribution.. All trusts’ data fitted a power law in at least one year. Differences over time and between hospital trusts were small and partly explained by demographics. In contrast, individual patients’ high use was unstable between years.ConclusionsED attendance patterns are stable at the level of the system, but unstable at the level of individual high users. Attendances follow a power law distribution typical of complex systems. Interventions to address ED high use need to consider the whole system and not just the individual high users.

Research engaging qualitatively with clinical practitioners' understanding of, and response to, self-harm has been limited. Self-harm offers a particularly compelling case through which to examine the enduring challenges faced by practitioners in treating patients whose presenting symptoms are not clearly biomedical in nature. In this paper, we present an analysis of 30 General Practitioners' (GPs') accounts of treating patients who had self-harmed. Our analysis demonstrates the complex ways in which GPs seek to make sense of self-harm. Illustrated through three common 'types' of patients (the 'good girl', the 'problem patient' and the 'out of the blue'), we show how GPs grapple with ideas of 'social' and 'psychological' causes of self-harm. We argue that these tensions emerge in different ways according to the social identities of patients, with accounts shaped by local contexts, including access to specialist services, as well as by cultural understandings regarding the legitimacy of self-harming behaviour. We suggest that studying the social life of self-harm in general practice extends a sociological analysis of self-harm more widely, as well as contributing to sociological theorisation on the doctor-patient relationship.

BackgroundThe COVID-19 pandemic has led to unprecedented demand for personal protective equipment. Shortages of surgical masks and filtering facepiece respirators has led to the extended use or re-use of single-use respirators and surgical masks by frontline healthcare workers. The evidence base underpinning such practices has been questioned.ObjectivesTo summarise guidance and synthesise systematic review evidence on extended use, re-use or reprocessing of single-use surgical masks or filtering facepiece respirators.MethodsA targeted search of the World Health Organization, European Centre for Disease Prevention and Control, the US Centers for Disease Control and Prevention, and Public Health England websites was conducted to identify guidance. Four databases (Medline, Pubmed, Epistemonikos, Cochrane Database of Systematic Reviews) and three preprint repositories (Litcovid, MedRxiv and Open Science Framework) were searched for relevant systematic reviews. Record screening and data extraction was conducted by two reviewers. Quality of included systematic reviews was appraised using the AMSTAR-2 checklist. Findings were integrated and narratively synthesised to highlight the extent to which key claims in guidance documents were supported by research evidence.ResultsSix guidance documents were identified. All note that extended use or re-use of single-use surgical masks and respirators (with or without reprocessing) should be considered only in situations of critical shortage. Extended use was generally favoured over re-use because of reduced risk of contact transmission. Four high-quality systematic reviews were included: three focused on reprocessing (decontamination) of N95 respirators and one focused on reprocessing of surgical masks. There was limited evidence on the impact of extended use on masks and respirators. Vaporised hydrogen peroxide and ultraviolet germicidal irradiation were highlighted as the most promising reprocessing methods, but evidence on the relative efficacy and safety of different methods was limited. We found no well-established methods for reprocessing respirators at scale.ConclusionsThere is limited evidence on the impact of extended use and re-use of surgical masks and respirators. Where extended use or re-use is being practiced, healthcare organisations should ensure that policies and systems are in place to ensure these practices are carried out safely and in line with available guidance.

Background Parkinson’s disease (PD) affects approximately 145,519 people in the UK. Speech impairments are common with a reported prevalence of 68%, which increase physical and mental demands during conversation, reliance on family and/or carers, and the likelihood of social withdrawal reducing quality of life. In the UK, two approaches to Speech and Language Therapy (SLT) intervention are commonly available: National Health Service (NHS) SLT or Lee Silverman Voice Treatment (LSVT LOUD®). NHS SLT is tailored to the individuals’ needs per local practice typically consisting of six to eight weekly sessions; LSVT LOUD® comprises 16 sessions of individual treatment with home-based practice over 4 weeks. The evidence-base for their effectiveness is inconclusive. Methods/design PD COMM is a phase III, multicentre, three-arm, unblinded, randomised controlled trial. Five hundred and forty-six people with idiopathic PD, reporting speech or voice problems will be enrolled. We will exclude those with a diagnosis of dementia, laryngeal pathology or those who have received SLT for speech problems in the previous 2 years. Following informed consent and completion of baseline assessments, participants will be randomised in a 1:1:1 ratio to no-intervention control, NHS SLT or LSVT LOUD® via a central computer-generated programme, using a minimisation procedure with a random element, to ensure allocation concealment. Participants randomised to the intervention groups will start treatment within 4 (NHS SLT) or 7 (LSVT LOUD®) weeks of randomisation. Primary outcome: Voice Handicap Index (VHI) total score at 3 months. Secondary outcomes include: VHI subscales, Parkinson’s Disease Questionnaire-39; Questionnaire on Acquired Speech Disorders; EuroQol-5D-5 L; ICECAP-O; resource utilisation; adverse events and carer quality of life. Mixed-methods process and health economic evaluations will take place alongside the trial. Assessments will be completed before randomisation and at 3, 6 and 12 months after randomisation. The trial started in December 2015 and will run for 77 months. Recruitment will take place in approximately 42 sites around the UK. Discussion The trial will test the hypothesis that SLT is effective for the treatment of speech or voice problems in people with PD compared to no SLT. It will further test whether NHS SLT or LSVT LOUD® provide greater benefit and determine the cost-effectiveness of both interventions. Trial registration International Standard Randomised Controlled Trials Number (ISRCTN) Registry, ID: 12421382. Registered on 18 April 2016.

ObjectivesIn the context of the Covid-19 pandemic, to identify the range of filtering respirators that can be used in patient care and synthesise evidence to guide the selection and use of different respirator types.DesignComparative analysis of international standards for filtering respirators and rapid review of their performance and impact in healthcare.Data sourcesWebsites of international standards organisations, Medline and EMBASE (final search 11th May 2020), with hand-searching of references and citations.Study selectionGuided by the SPIDER tool, we included studies whose sample was healthcare workers (including students). The phenomenon of interest was respirators, including disposable and reusable types. Study designs including cross-sectional, observational cohort, simulation, interview and focus group. Evaluation approaches included test of respirator performance, test of clinician performance or adherence, self-reported comfort and impact, and perceptions of use. Research types included quantitative, qualitative and mixed methods. We excluded studies comparing the effectiveness of respirators with other forms of protective equipment.Data extraction, analysis and synthesisTwo reviewers extracted data using a template. Suitability for inclusion in the analysis was judged by two reviewers. We synthesised standards by tabulating data according to key criteria. For the empirical studies, we coded data thematically followed by narrative synthesis.ResultsWe included relevant standards from 8 authorities across Europe, North and South America, Asia and Australasia. 39 research studies met our inclusion criteria. There were no instances of comparable publications suitable for quantitative comparison. There were four main findings. First, international standards for respirators apply across workplace settings and are broadly comparable across jurisdictions. Second, effective and safe respirator use depends on proper fitting and fit-testing. Third, all respirator types carry a burden to the user of discomfort and interference with communication which may limit their safe use over long periods; studies suggest that they have little impact on specific clinical skills in the short term but there is limited evidence on the impact of prolonged wearing. Finally, some clinical activities, particularly chest compressions, reduce the performance of filtering facepiece respirators.ConclusionA wide range of respirator types and models is available for use in patient care during respiratory pandemics. Careful consideration of performance and impact of respirators is needed to maximise protection of healthcare workers and minimise disruption to the delivery of care.

Background Ankylosing spondylitis (AS) often has a long period from first symptom presentation to diagnosis. We examined the occurrence of symptoms, prescriptions and diagnostic tests in primary care electronic records over time prior to a diagnosis of AS. Methods Nested case-control study using anonymised primary care electronic health records from Scotland. Cases were 74 adults with a first diagnosis of AS between 2000 and 2010. Controls were matched for age, sex and GP practice: (a) 296 randomly selected adults (b) 169 adults whose records contained codes indicating spinal conditions or symptoms. We extracted clinical features (symptoms, AS-related disorders, prescriptions and diagnostic tests). Conditional logistic regression was used to examine the association between clinical features (both individually and in combinations) and diagnosis of AS. We examined the associations between clinical features and diagnosis over time prior to diagnosis. Results Several new composite pointers were predictive of AS: including distinct episodes of axial pain separated by more than 6 months (OR 12.7, 95% CI 4.7 to 34.6); the occurrence of axial pain with and tendon symptoms within the same year (OR 21.7, 95% CI 2.6 to 181.5); and the co-occurrence (within 30 days) of axial pain and a prescription for nonsteroidal anti-inflammatory drug (OR 10.4, 95%CI 4.9 to 22.1). Coded episodes of axial pain increased steadily over the 3 years before diagnosis. In contrast, large joint symptoms and enthesopathy showed little or no time trend prior to diagnosis. Conclusions We identified novel composite pointers to a diagnosis of AS in GP records. These may represent valuable targets for diagnostic support systems.

ObjectivesTo examine how much of the variation between general practices in referral rates and cancer detection rates is attributable to local health services rather than the practices or their populations.DesignEcological analysis of national data on fast-track referrals for suspected cancer from general practices. Data were analysed at the levels of general practice, primary care organisation (Clinical Commissioning Group) and secondary care provider (Acute Hospital Trust) level. Analysis of variation in detection rate was by multilevel linear and Poisson regression.Setting6379 group practices with data relating to more than 50 cancer cases diagnosed over the 5 years from 2013 to 2017.OutcomesProportion of observed variation attributable to primary and secondary care organisations in standardised fast-track referral rate and in cancer detection rate before and after adjustment for practice characteristics.ResultsPrimary care organisation accounted for 21% of the variation between general practices in the standardised fast-track referral rate and 42% of the unadjusted variation in cancer detection rate. After adjusting for standardised fast-track referral rate, primary care organisation accounted for 31% of the variation in cancer detection rate (compared with 18% accounted for by practice characteristics). In areas where a hospital trust was the main provider for multiple primary care organisations, hospital trusts accounted for the majority of the variation attributable to local health services (between 63% and 69%).ConclusionThis is the first large-scale finding that a substantial proportion of the variation between general practitioner practices in referrals is attributable to their local healthcare systems. Efforts to reduce variation need to focus not just on individual practices but on local diagnostic service provision and culture at the interface of primary and secondary care.

IntroductionPeople with long-term conditions typically have reduced physical functioning, are less physically active and therefore become less able to live independently and do the things they enjoy. However, assessment and promotion of physical function and physical activity is not part of routine management in primary care. This project aims to develop evidence-based recommendations about how primary care can best help people to become more physically active in order to maintain and improve their physical function, thus promoting independence.Methods and analysisThis study takes a realist synthesis approach, following RAMESES guidance, with embedded co-production and co-design. Stage 1 will develop initial programme theories about physical activity and physical function for people with long-term conditions, based on a review of the scientific and grey literature, and two multisector stakeholder workshops using LEGO® SERIOUS PLAY®. Stage 2 will involve focused literature searching, data extraction and synthesis to provide evidence to support or refute the initial programme theories. Searches for evidence will focus on physical activity interventions involving the assessment of physical function which are relevant to primary care. We will describe ‘what works’, ‘for whom’ and ‘in what circumstances’ and develop conjectured programme theories using context, mechanism and outcome configurations. Stage 3 will test and refine these theories through individual stakeholder interviews. The resulting theory-driven recommendations will feed into Stage 4 which will involve three sequential co-design stakeholder workshops in which practical ideas for service innovation in primary care will be developed.Ethics and disseminationHealthcare and Medical Sciences Academic Ethics Committee (Reference 2018-16308) and NHS Wales Research Ethics Committee 5 approval (References 256 729 and 262726) have been obtained. A knowledge mobilisation event will address issues relevant to wider implementation of the intervention and study findings. Findings will be disseminated through peer-reviewed journal publications, conference presentations and formal and informal reports.PROSPERO registration numberCRD42018103027.

BackgroundPolicy and reviews of health-care safety and quality emphasise the role of NHS managers in ensuring safe, good-quality patient care through effective staffing. Guidance requires that NHS managers combine professional judgement with evidence-based workforce planning and deployment tools and technologies (WPTs). Evidence has focused on the effectiveness of WPTs, but little is known about supporting their implementation, or the impact of using WPTs across settings.ObjectivesThe review answered the following question: ‘NHS managers’ use of workforce planning and deployment technologies and their impacts on nursing staffing and patient care: what works, for whom, how and in what circumstances?’.DesignA realist synthesis was conducted. A programme theory was formulated and expressed as hypotheses in the form of context, mechanisms and outcomes; this considered how, through using WPTs, particular conditions produced responses to generate outcomes. There were four phases: (1) development of a theoretical territory to understand nurse workforce planning and deployment complexity, resulting in an initial programme theory; (2) retrieval, review and synthesis of evidence, guided by the programme theory; (3) testing and refinement of the programme theory for practical application; and (4) actionable recommendations to support NHS managers in the implementation of WPTs for safe staffing.ParticipantsNHS managers, patient and public representatives and policy experts informed the programme theory in phase 1, which was validated in interviews with 10 NHS managers. In phase 3, 11 NHS managers were interviewed to refine the programme theory.ResultsWorkforce planning and deployment tools and technologies can be characterised functionally by their ability to summarise and aggregate staffing information, communicate about staffing, allocate staff and facilitate compliance with standards and quality assurance. NHS managers need to combine local knowledge and professional judgement with data from WPTs for effective staffing decisions. WPTs are used in a complex workforce system in which proximal factors (e.g. the workforce satisfaction with staffing) can influence distal factors (e.g. organisational reputation and potential staff recruitment). The system comprises multiple organisational strategies (e.g. professional and financial), which may (or may not) align around effective staffing. The positive impact of WPTs can include ensuring that staff are allocated effectively, promoting the patient safety agenda within an organisation, learning through comparison about ‘what works’ in effective staffing and having greater influence in staffing work. WPTs appear to have a positive impact when they visibly integrate data on needs and resources and when there is technical and leadership support. A collaborative process appears to be best for developing and implementing WPTs, so that they are fit for purpose.LimitationsThe evidence, predominantly from acute care, often lacked detail on how managers applied professional judgement to WPTs for staffing decisions. The evidence lacked specificity about how managers develop skills on communicating staffing decisions to patients and the public.Conclusions and recommendationsThe synthesis produced initial explanations of the use and impact of WPTs for decision-making and what works to support NHS managers to use these effectively. It is suggested that future research should further evaluate the programme theory.Study registrationThis study is registered as PROSPERO CRD42016038132.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

BackgroundGPs working in areas of high socioeconomic deprivation face particular challenges, and are at increased risk of professional burnout. Understanding how GPs working in such areas perceive professional resilience is important in order to recruit and retain a GP workforce in these areas.AimTo understand how GPs working in areas of high socioeconomic deprivation consider professional resilience.Design and settingA qualitative study of GPs practising in deprived areas within one primary care region of England.MethodIn total, 14 individual interviews and one focus group of eight participants were undertaken, with sampling to data saturation. A framework approach was used for data analysis.ResultsParticipants described three key themes relating to resilience. First, resilience was seen as involving flexibility and adaptability. This involved making trade-offs in order to keep going, even if this was imperfect. Second, resilience was enacted through teams rather than through individual strength. Third, resilience required the integration of personal and professional values rather than keeping the two separate. This dynamic adaptive view, with an emphasis on the importance of individuals within teams rather than in isolation, contrasts with the discourse of resilience as a personal characteristic, which should be strengthened at the individual level.ConclusionProfessional resilience is about more than individual strength. Policies to promote professional resilience, particularly in settings such as areas of high socioeconomic deprivation, must recognise the importance of flexibility, adaptability, working as teams, and successful integration between work and personal values.

BackgroundEndometriosis is a condition with relatively non-specific symptoms, and in some cases a long time elapses from first-symptom presentation to diagnosis.AimTo develop and test new composite pointers to a diagnosis of endometriosis in primary care electronic records.Design and settingThis is a nested case-control study of 366 cases using the Practice Team Information database of anonymised primary care electronic health records from Scotland. Data were analysed from 366 cases of endometriosis between 1994 and 2010, and two sets of age and GP practice matched controls: (a) 1453 randomly selected females and (b) 610 females whose records contained codes indicating consultation for gynaecological symptoms.MethodComposite pointers comprised patterns of symptoms, prescribing, or investigations, in combination or over time. Conditional logistic regression was used to examine the presence of both new and established pointers during the 3 years before diagnosis of endometriosis and to identify time of appearance.ResultsA number of composite pointers that were strongly predictive of endometriosis were observed. These included pain and menstrual symptoms occurring within the same year (odds ratio [OR] 6.5, 95% confidence interval [CI] = 3.9 to 10.6), and lower gastrointestinal symptoms occurring within 90 days of gynaecological pain (OR 6.1, 95% CI = 3.6 to 10.6). Although the association of infertility with endometriosis was only detectable in the year before diagnosis, several pain-related features were associated with endometriosis several years earlier.ConclusionUseful composite pointers to a diagnosis of endometriosis in GP records were identified. Some of these were present several years before the diagnosis and may be valuable targets for diagnostic support systems.

Objective: The harmonization of core outcome domains in clinical trials facilitates comparison and pooling of data, and simplifies the preparation and review of research projects and comparison of risks and benefits of treatments. Therefore, we provide recommendations for the core outcome domains that should be considered in clinical trials on the efficacy and effectiveness of interventions for somatic symptom disorder, bodily distress disorder, and functional somatic syndromes.Methods: The European Network on Somatic Symptom Disorders group of more than 20 experts in the field met twice in Hamburg to discuss issues of assessment and intervention research in somatic symptom disorder, bodily distress disorder, and functional somatic syndromes. The consensus meetings identified core outcome domains that should be considered in clinical trials evaluating treatments for somatic symptom disorder and associated functional somatic syndromes.Results: The following core domains should be considered when defining ascertainment methods in clinical trials: a) classification of somatic symptom disorder/bodily distress disorder, associated functional somatic syndromes, and comorbid mental disorders (using structured clinical interviews), duration of symptoms, medical morbidity, and prior treatments; b) location, intensity, and interference of somatic symptoms; c) associated psychobehavioral features and biological markers; d) illness consequences (quality of life, disability, health care utilization, health care costs; e) global improvement and treatment satisfaction; and f) unwanted negative effects.Conclusions: The proposed criteria are intended to improve synergies of clinical trials and to facilitate decision making when comparing different treatment approaches. These recommendations should not result in inflexible guidelines, but increase consistency across investigations in this field.

Background The PD COMM trial is a phase III multi-centre randomised controlled trial whose aim is to evaluate the effectiveness and cost-effectiveness of two approaches to speech and language therapy (SLT) compared with no SLT intervention (control) for people with Parkinson’s disease who have self-reported or carer-reported problems with their speech or voice. Our protocol describes the process evaluation embedded within the outcome evaluation whose aim is to evaluate what happened at the time of the PD COMM intervention implementation and to provide findings that will assist in the interpretation of the PD COMM trial results. Furthermore, the aim of the PD COMM process evaluation is to investigate intervention complexity within a theoretical model of how the trialled interventions might work best and why. Methods/design Drawing from the Normalization Process Theory and frameworks for implementation fidelity, a mixed method design will be used to address process evaluation research questions. Therapists’ and participants’ perceptions and experiences will be investigated via in-depth interviews. Critical incident reports, baseline survey data from therapists, treatment record forms and home practice diaries also will be collected at relevant time points throughout the running of the PD COMM trial. Process evaluation data will be analysed independently of the outcome evaluation before the two sets of data are then combined. Discussion To date, there are a limited number of published process evaluation protocols, and few are linked to trials investigating rehabilitation therapies. Providing a strong theoretical framework underpinning design choices and being tailored to meet the complex characteristics of the trialled interventions, our process evaluation has the potential to provide valuable insight into which components of the interventions being delivered in PD COMM worked best (and what did not), how they worked well and why. Trial registration ISRCTN Registry, ISRCTN12421382. Registered on 18 April 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2130-1) contains supplementary material, which is available to authorized users.

Background Dementia and diabetes mellitus are common long-term conditions and co-exist in a large number of older people. People living with dementia (PLWD) may be less able to manage their diabetes, putting them at increased risk of complications such as hypoglycaemia. The aim of this review was to identify key mechanisms within different interventions that are likely to improve diabetes outcomes in PLWD. Methods This is a realist review involving scoping of the literature and stakeholder interviews to develop theoretical explanations of how interventions might work, systematic searches of the evidence to test and develop the theories and their validation with a purposive sample of stakeholders. Twenty-six stakeholders — user/patient representatives, dementia care providers, clinicians specialising in diabetes or dementia and researchers — took part in interviews, and 24 participated in a consensus conference. Results We included 89 papers. Ten focused on PLWD and diabetes, and the remainder related to people with either dementia, diabetes or other long-term conditions. We identified six context-mechanism-outcome configurations which provide an explanatory account of how interventions might work to improve the management of diabetes in PLWD. This includes embedding positive attitudes towards PLWD, person-centred approaches to care planning, developing skills to provide tailored and flexible care, regular contact, family engagement and usability of assistive devices. An overarching contingency emerged concerning the synergy between an intervention strategy, the dementia trajectory and social and environmental factors, especially family involvement. Conclusions Evidence highlighted the need for personalised care, continuity and family-centred approaches, although there was limited evidence that this happens routinely. This review suggests there is a need for a flexible service model that prioritises quality of life, independence and patient and carer priorities. Future research on the management of diabetes in older people with complex health needs, including those with dementia, needs to look at how organisational structures and workforce development can be better aligned to their needs. Trial registration PROSPERO, CRD42015020625. Registered on 18 May 2015.

Background Interventions for somatoform disorders typically address a range of outcomes. We aimed to examine treatment effects across outcome domains and specifically assess the association, at study level, between short and long term treatment effects and between treatment effects in different outcome domains. Methods We used data from recent systematic reviews of interventions for somatoform disorders to address three questions: We described outcome domains and measures by compiling forest plots of standardised mean difference. We examined the association of changes in outcome between short and long-term and between different outcome domains by non-parametric correlation. Results We analysed data from 47 studies across four outcome domains: physical symptoms, health-related quality of life, depression and anxiety. Short-term and long-term treatment effects within each outcome domain were broadly similar and were correlated Reported reduction in physical symptoms was correlated with reductions in depression (rho = 0.73, p = 0.002) and anxiety (0.70, p Conclusion Short term changes in outcome measures are correlated with longer term changes; outcome changes are correlated across domains independently of the type of treatment.

MS and IB were supported by the University of Manchester's Health eResearch Centre (HeRC) funded by the Medical Research Council (MRC) Grant MR/K006665/1.

Purpose To develop a novel digital intervention to optimise cancer pain control in the community. This paper describes intervention development, content/rationale and initial feasibility testing. Methods Determinants of suboptimal cancer pain management were characterised through two systematic reviews; patient, caregiver and healthcare professional (HCP) interviews (n = 39); and two HCP focus groups (n = 12). Intervention mapping was used to translate results into theory-based content, creating the app “Can-Pain”. Patients with/without a linked caregiver, their general practitioners and community palliative care nurses were recruited to feasibility test Can-Pain over 4 weeks. Results Patients on strong opioids described challenges balancing pain levels with opioid intake, side effects and activities and communicating about pain management problems with HCPs. Can-Pain addresses these challenges through educational resources, contemporaneous short-acting opioid tracking and weekly patient-reported outcome monitoring. Novel aspects of Can-Pain include the use of contemporaneous breakthrough analgesic reports as a surrogate measure of pain control and measuring the level at which pain becomes bothersome to the individual. Patients were unwell due to advanced cancer, making recruitment to feasibility testing difficult. Two patients and one caregiver used Can-Pain for 4 weeks, sharing weekly reports with four HCPs. Can-Pain highlighted unrecognised problems, promoted shared understanding about symptoms between patients and HCPs and supported shared decision-making. Conclusions Preliminary testing suggests that Can-Pain is feasible and could promote patient-centred pain management. We will conduct further small-scale evaluations to inform a future randomised, stepped-wedge trial. Trial registration Qualitative research: ClinicalTrials.gov, reference NCT02341846 Feasibility study: NIHR CPMS database ID 34172

BackgroundPrimary care guidelines for the management of persistent, often ‘medically unexplained’, physical symptoms encourage GPs to discuss with patients how these symptoms relate to negative emotions. However, many GPs experience difficulties in reaching a shared understanding with patients.AimTo explore how patients with persistent symptoms describe their negative emotions in relation to their physical symptoms in primary care consultations, in order to help GPs recognise the patient’s starting points in such discussions.Design and settingA qualitative analysis of 47 audiorecorded extended primary care consultations with 15 patients with persistent physical symptoms.MethodThe types of relationships patients described between their physical symptoms and their negative emotions were categorised using content analysis. In a secondary analysis, the study explored whether patients made transitions between the types of relations they described through the course of the consultations.ResultsAll patients talked spontaneously about their negative emotions. Three main categories of relations between these emotions and physical symptoms were identified: separated (negation of a link between the two); connected (symptom and emotion are distinct entities that are connected); and inseparable (symptom and emotion are combined within a single entity). Some patients showed a transition between categories of relations during the intervention.ConclusionPatients describe different types of relations between physical symptoms and negative emotions in consultations. Physical symptoms can be attributed to emotions when patients introduce this link themselves, but this link tends to be denied when introduced by the GP. Awareness of the ways patients discuss these relations could help GPs to better understand the patient’s view and, in this way, collaboratively move towards constructive explanations and symptom management strategies.

Background Managing demand for urgent and unscheduled care is a major problem for health services globally. A particular issue is that some patients appear to make heavy use of services, including primary care out of hours. We hypothesised that greater variation (statistical complexity) in reasons for attending primary care out of hours services may be a useful marker of patients at high risk of ongoing heavy service use. Methods We analysed an anonymised dataset of contacts with the primary care out of hours care for Scotland in 2011. This contained 120,395 contacts from 13,981 high-using patients who made 5 or more contacts during a calendar year. We allocated the stated reason for each encounter into one of 14 categories. For each patient we calculated measures of statistical complexity of reasons for encounter including the count of different categories, Herfindahl index and statistical entropy of either the categories themselves, or the category transitions. We examined the association of these measures of statistical complexity with patient and healthcare use characteristics. Results The high users comprised 2.4% of adults using the service and accounted for 15% of all contacts. Statistical complexity (as entropy of categories) increased with number of contacts but was not substantially influenced by either patient age or sex. This lack of association with age was unexpected as with increasing multi-morbidity one would expect greater variability in reason for encounter. Between 5 and 10 consultations, higher entropy was associated with a reduced likelihood of further consultations. In contrast, the occurrence of one or more contacts for a mental health problem was associated with increased likelihood of further consultations. Conclusion Complexity of reason for encounter can be estimated in an out of hours primary care setting. Similar levels of statistical complexity are seen in younger and older adults (suggesting that it is more to do with consultation behaviour than morbidity) but it is not a predictor of ongoing high use of urgent care. Electronic supplementary material The online version of this article (10.1186/s12913-019-3938-z) contains supplementary material, which is available to authorized users.

Background Implementing best practice in healthcare is complex. There is evidence to suggest that certain individuals, collectively termed ‘intermediaries', can contribute to implementation processes, but understanding exactly what happens and how intermediaries promote best practice is unclear. Objectives The aim of this study was to evaluate the role of intermediaries in promoting infection prevention, and provide an explanation about what works, for whom, how, and under which conditions. Methods Realist methodology was used as the underpinning explanatory framework for the study. From a concept mining of the existing literature, a set of hypothetical statements about the plausible range of context–mechanism–outcome propositions that postulate how intermediaries can contribute to promoting best practice were developed and evaluated. Design Case studies were conducted consecutively to refine and test the propositions. Data included semi-structured interviews ( n =32), non-participant observations ( n =5) and documentation review. Data were analysed by open coding, content and pattern matching. Settings Case studies were undertaken in two hospitals within the United Kingdom. Participants Purposive sampling was used to identify individuals within the organisations who had professional or organisational responsibilities for infection prevention. The inclusion criteria were; employees of the chosen organisations who would consent to take part in the study, participants with infection prevention responsibilities, adults over 18 years with the capacity to consent. The exclusion criteria were; participants outside of the chosen organisation, participants under 18 years of age, and participants who lacked the capacity to consent. Results Four context–mechanism–outcome configurations contribute to advancing our understanding about the potential of intermediaries to promote best practice. Findings showed that the ways in which intermediaries watch over practice (their human surveillance), promoted better adherence with infection control practices. Particular styles and approaches used by intermediaries led to individual staff feeling personally supported. Distinct ways of providing performance feedback for staff together with the policy discourse promoted good habitual behaviours. Practice-based teaching heightened awareness of individuals' own practice and made learning more real. Conclusions Findings offer a new lens on the role of intermediaries in bridging the evidence to practice gap. As such they could be considered when reviewing or developing new interventions/programmes that use intermediaries to plug the gap between theory and practice. The findings could also be used to guide the design and development of new intermediary models in healthcare, to promote best practice and support the quality of patient care.

Background Modern demands and challenges among healthcare professionals can be particularly stressful and resilience is increasingly necessary to maintain an effective, adaptable, and sustainable workforce. However, definitions of, and associations with, resilience have not been examined within the primary care context. Aim To examine definitions and measures of resilience, identify characteristics and components, and synthesise current evidence about resilience in primary healthcare professionals. Design and setting A systematic review was undertaken to identify studies relating to the primary care setting. Method Ovid ® , Embase ® , CINAHL, PsycINFO, and Scopus databases were searched in December 2014. Text selections and data extraction were conducted by paired reviewers working independently. Data were extracted on health professional resilience definitions and associated factors. Results Thirteen studies met the inclusion criteria: eight were quantitative, four qualitative, and one was an intervention study. Resilience, although multifaceted, was commonly defined as involving positive adaptation to adversity. Interactions were identified between personal growth and accomplishment in resilient physicians. Resilience, high persistence, high self-directedness, and low avoidance of challenges were strongly correlated; resilience had significant associations with traits supporting high function levels associated with demanding health professional roles. Current resilience measures do not allow for these different aspects in the primary care context. Conclusion Health professional resilience is multifaceted, combining discrete personal traits alongside personal, social, and workplace features. A measure for health professional resilience should be developed and validated that may be used in future quantitative research to measure the effect of an intervention to promote it.

Background\ud There is a need for primary care interventions for patients with multiple medically unexplained symptoms (MUS). We examined whether GPs could be taught to deliver one such intervention, the Symptoms Clinic Intervention (SCI), to patients. The intervention includes recognition and validation of patients' symptoms, explanation of symptoms and actions to manage symptoms.\ud \ud Methods\ud We conducted an uncontrolled observational study in Northeast Scotland. GPs were recruited and received two days of structured training. Patients were identified via a two stage process (database searching followed by postal questionnaire) and received the SCI intervention from a GP in their practice.\ud \ud Treatment fidelity was assessed by applying a coding framework to consultation transcripts. Safety was assessed by examining changes in patient symptoms (PHQ-15) and checking for unexpected events. Acceptability was primarily assessed by patient interview.\ud \ud Results\ud Four GPs delivered the SCI to 23 patients. GPs delivered all core components of the SCI, and used the components flexibly across the consultations and between patients. They spent more time on recognition than either explanation or actions components. 10 out of 17 patients interviewed described feeling validated, receiving useful explanation and learning actions. 9 out of 20 patients (45%) reported an improvement in PHQ-15 of between 3 and 8 points. Patients who reported the most improvement also described receiving all three components of the intervention.\ud \ud Conclusions\ud GPs can be taught to deliver the SCI with reasonable fidelity, safety and acceptability, although some items were inconsistently delivered: further training would be needed before use.

BackgroundProfessional interpreters are considered to be the gold standard when meeting the needs of patients with limited English proficiency (LEP) in primary care. The models by which CCGs supply interpreting services (IS) vary. Many CCGs use external commercial IS, while other CCGs commission ‘not for profit’ services such as the Advocacy and Interpreting Service in Tower Hamlets, the Sussex Interpreting Service, and the decommissioned Sheffield Community Access and Interpreting Service. Research on comparative costs and needs of the LEP population is lacking.AimTo compare the costs of interpreting services between CCG’s in England.MethodA cross-sectional study involving CCGs in England. A standardised request was sent to 195 CCGs inviting comment on how much the CCG spent (2017–2018) on IS. The data were plotted against a number of demographic variables (https://fingertips.phe.org.uk) and analysed using regression analysis.ResultsSurvey response rate: 86% of CCGs (n = 169). Of those CCGs who responded, 39% (n = 66) did not hold IS cost data. NHS England spent £2 951 348.16 for IS services for the year 2017–2018. A positive correlation was noted with increased cost of interpreting services when plotted against increasing percentage BME or percentage birth to non-UK parents. However, there were wide variations around correlation of best fit indicating variation in spending between CCGs for similar populations.ConclusionInter CCG variation in correlations between demographic variables and expenditure suggests further research is needed to determine how to optimise and resource safe and equitable IS across the UK population.

This qualitative study develops a programme theory demonstrating the complexity embedded in sleep hygiene education (SHE) as an intervention to improve sleep problems in children with developmental disabilities. In co-design workshops, eight parents and six sleep practitioners deliberated themes developed from findings of an earlier exploratory study of stakeholder perceptions of SHE. A SHE tool underpinned by programme theory was developed evidenced by mid-range theories of change. Analytical themes were developed to explain the programme theory and the complexities of a successful SHE intervention: the need to legitimize children’s sleep problems and consider the nature of customization, knowledge sharing, health expectation and impact of sleep service rationing and gaming strategies on implementation success. Policy and practice implications include a need to raise the public profile of children’s sleep problems and promote parental involvement in intervention implementation. Further research is needed to test out this theory-driven framework for evaluating SHE.