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We conducted a systematic review to answer the following: (a) Is there any evidence to support increased prevalence of suicidality and self-harm (i.e. self-harm or suicidality) in urban versus rural environments? (b) What aspects of the urban environment pose risk for suicidality and self-harm? Thirty-five studies met our criteria. Our findings reflect a mixed picture, but with a tendency for urban living to be associated with an increased risk of suicidality and self-harm over rural living, particularly for those living in deprived areas. Further research should focus on the clustering and additive effects of risk and protective factors for suicidality and self-harm in urban environments.

Estimates indicate that individuals with coeliac disease are more likely to experience disordered eating and impaired well-being than healthy controls, but less is known about the mechanisms by which these factors are related. The aim of this study was to understand experiences of coeliac disease and influence on subsequent unhelpful eating and lifestyle patterns.An online focus group discussion, hosted through a synchronous chat log, with adults living with coeliac disease was conducted. Seven individuals discussed their condition, lifestyle, and dietary changes post-diagnosis. Discussions were analysed using an interpretative phenomenological approach, a technique that enables new practical or research insight into health conditions based upon participants' experiences of their condition.Three themes were identified: (i) Nobody knew what was happening to my body; (ii) I am so afraid of being 'glutened' that it is central to my thoughts and anxieties; and (iii) I am frightened but I can keep myself safe by being a 'good' coeliac. These appeared to contribute to participant distress or unhelpful eating or lifestyle behaviours. Participants appeared to develop severe anxiety around gluten, and implausible beliefs around diet and lifestyle management that appear to initiate and maintain unhelpful eating behaviours and maladaptive lifestyles changes, that contribute to distress.Extending current knowledge, we propose a novel cognitive perspective on the development and maintenance of disordered eating in coeliac disease. Implications for how health providers can better support individuals with coeliac disease, and the role of dietary management, anxiety, and gastrointestinal symptoms in the development of disordered eating are discussed.

Globally, a large proportion of birthing mothers, and a to a lesser extent their partners, experience birth trauma each year, and yet access to adequate post-natal trauma support is rarely available. Untreated birth trauma has been shown to negatively impact the family in terms of the parents’ relationship with one another, and long-term negative consequences for the child. Despite a drive towards integrating mental health support into maternity services and a call to provide mental health support for couples rather than solely the birthing mother, there is little research exploring what birthing couples find helpful in recovery from birth trauma. The current research interviewed six couples using an Interpretative Phenomenological Approach in order to explore their understanding of what supported their recovery from birth trauma. Four themes were identified: ‘We need validation’, ‘Feeling paper thin’, ‘This is a system failure’ and ‘Birth trauma is always going to be a part of you’. The data describes an understanding of parents’ feelings of vulnerability and loss of trust in services to provide support following birth trauma. Further, parents’ need for validation and repositioning of control away from healthcare professionals when considering the availability and knowledge of the support options available is discussed. Clinical implications for supporting parents following birth trauma are explored, including an identified need for trauma informed care communication training for all healthcare professionals involved in maternity care, and the requirement for sources of therapeutic support external from the parent dyad in order to maintain the couples’ interpersonal relationship.

AIMS Increasing evidence suggests that children and young people with type 1 diabetes (T1D) are at greater risk of disordered eating compared to children without T1D. Disordered eating in T1D has been linked to impaired wellbeing, increased health service use and early mortality. To address this problem, we will co-develop a psycho-education intervention for parents of children and young people with T1D, informed by the Information Motivation Behavioural Skills model. METHODS The objective of this study is to assess the feasibility and acceptability of the intervention compared to a waitlist control group using a feasibility randomised controlled trial (RCT) design. We aim to recruit 70 parents of children and young people with T1D (11-14 years), 35 in each arm. Those assigned to the intervention will be invited to participate in two workshops of 2 h each. Parents will be asked to complete outcome measures regarding eating habits, diabetes management, as well as a questionnaire based on the Information Motivation Behavioural Skills model which provides a theoretical foundation for the intervention. These will be completed at baseline, 1- and 3-month post-intervention. Children and young people will be asked to complete questionnaires on their eating behaviours at the same time intervals. Parents randomised to receive the intervention will be invited to take part in interviews to feedback on the intervention and research protocol acceptability. CONCLUSION It is anticipated that the psycho-education intervention aimed at parents will help prevent the development of disordered eating in children and young people with T1D and improve parental wellbeing. The results of this feasibility trial will determine whether this intervention approach is acceptable to families living with T1D, and whether a definitive RCT of intervention effectiveness is justified. Qualitative findings will be used to refine the intervention and study protocols. TRIAL REGISTRATION This protocol has been registered with ClinicalTrials.gov [Identifier: NCT04741568].

Aims The current model of hospital-centred paediatric care in high-income countries was developed to deliver acute specialist services, rather than high quality care for children and young people (CYP) with long term conditions (LTCs) that require multidisciplinary, integrated care. While the limitations of current child health services in the UK have been widely documented from the perspectives of clinicians, academics and policy makers, there is a lack of research into the lived experience of CYP receiving these services. This qualitative study explores CYP and caregivers’ experiences of health services for LTCs. Methods An inductive, qualitative design using in-depth, semi-structured interviews with children (4–16 years; n=20) and their caregivers, receiving care for one of four LTCs (constipation, eczema, asthma or epilepsy). These LTCs were chosen as they are examples of LTCs which provide generalisable lessons about improving outcomes for other LTCs. Art-based methods were used to engage younger children in the discussions. Data was analysed using interpretive thematic analysis. Results Families expressed several challenges associated with the healthcare they had received during the diagnostic process, including being unsure whether their symptoms warranted health intervention, a lack of specialist knowledge across primary care providers, and poor care continuity. After diagnosis, families desired further understanding around condition management, children wished to be included in discussions with health providers, and families felt there were no opportunities to discuss the psychosocial impact of the condition, particularly around the challenges managing health in school settings. Conclusions Families reflected on the health services failures to address their needs. Psychosocial support, continuity of care and opportunities for independence play a critical role in promoting the health of children with LTC. These features are essential in the development of integrated care models, to ensure suitability of the workforce and improve care delivery.

Background There is increasing evidence that integrated care improves child related quality of life and reduces health service use. However, there is limited evidence on family perspectives about the quality of integrated care for children’s services. This study aimed to understand children, young people, and caregivers’ perceptions of a new integrated care service, and to identify essential components of integrated care for children and young people with ongoing conditions. Methods A qualitative analysis of in-depth interviews with caregivers and children included families (N = 37) with children with one of four ongoing conditions (asthma, eczema, epilepsy, constipation) who had experienced a new integrated care service delivered in South London, UK. Results Four key components of integrated services identified were: that the key health-worker understood the health needs of the family in context; that professionals involved children and caregivers in treatment; that holistic care that supported the family unit was provided; and that families experienced coordination across health, social, and education systems. Conclusions Children and families identify care navigation and a holistic approach as key components that make high quality integrated care services. Service developments strengthening these aspects will align well with family perspectives on what works and what matters.

CONTEXT: Integrated care models may improve health care for children and young people (CYP) with ongoing conditions. OBJECTIVE: To assess the effects of integrated care on child health, health service use, health care quality, school absenteeism, and costs for CYP with ongoing conditions. DATA SOURCES: Medline, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library databases (1996–2018). STUDY SELECTION: Inclusion criteria consisted of (1) randomized controlled trials, (2) evaluating an integrated care intervention, (3) for CYP (0–18 years) with an ongoing health condition, and (4) including at least 1 health-related outcome. DATA EXTRACTION: Descriptive data were synthesized. Data for quality of life (QoL) and emergency department (ED) visits allowed meta-analyses to explore the effects of integrated care compared to usual care. RESULTS: Twenty-three trials were identified, describing 18 interventions. Compared with usual care, integrated care reported greater cost savings (3/4 studies). Meta-analyses found that integrated care improved QoL over usual care (standard mean difference = 0.24; 95% confidence interval = 0.03–0.44; P = .02), but no significant difference was found between groups for ED visits (odds ratio = 0.88; 95% confidence interval = 0.57–1.37; P = .57). LIMITATIONS: Included studies had variable quality of intervention, trial design, and reporting. Randomized controlled trials only were included, but valuable data from other study designs may exist. CONCLUSIONS: Integrated care for CYP with ongoing conditions may deliver improved QoL and cost savings. The effects of integrated care on outcomes including ED visits is unclear.

This Viewpoint presents and discusses the development of the first core principles and standards for effective, personalised care of children living with complex care needs in Europe. These principles and standards emerged from an analysis of data gathered on several areas, including the integration of care for the child at the acute-community interface, the referral-discharge interface, the social care interface, nursing preparedness for practice, and experiences of the child and family. The three main principles, underpinned by a child-centric approach, are access to care, co-creation of care, and effective integrated governance. Collectively, the principles and standards offer a means to benchmark existing services for children living with complex care needs, to influence policy in relation to service delivery for these children, and to provide a suite of indicators with which to assess future service developments in this area.

Objectives A diagnosis of celiac disease (CD) requires individuals to adopt a strict gluten-free diet. As children with CD must rely on their caregivers for guidance and support with managing the gluten-free diet, CD may challenge the caregiver's emotional and social well-being. The primary objective of this mixed-methods systematic review was to synthesize research investigating the impact of CD on caregiver's well-being. Methods Five databases were systematically searched from 1990 to 2018 to identify all empirical studies that assessed well-being in caregivers of children (0-18 years) with CD. Qualitative and quantitative data were extracted separately before being integrated to explore key themes across the studies. Results Twelve studies were identified that explored the well-being of caregivers of children with CD (3 qualitative, 9 quantitative), reporting on 665 caregivers. The quality of evidence was limited across studies. Synthesis of results revealed 3 themes (Caregiver Responsibility, Caregiver Well-Being and Concern for Child's Health, Implications for the Family) describing the impact of a child with CD on caregiver well-being. Conclusions Caregivers of children with CD may experience difficulties that impact their well-being; specific difficulties identified included the impact of caregivers' social activities, finances, and anxiety. The findings detailed in this review point toward factors that may guide health care personnel to provide support for the caregivers of children with CD.

BackgroundLittle is known about the political views of doctors in the UK despite doctors' importance in the functioning of the National Health Service (NHS).MethodsThis is a survey-based, cross-sectional study in which we asked questions about voting behaviour in 2015 and 2017 UK general elections and 2016 referendum on leaving the European Union (EU) (Brexit), and questions relating to recent health policies.Results1172 doctors (45.1% women) from 1295 responded to an online survey. 60.5% described their political views as ‘left-wing’ and 62.2% described themselves as ‘liberal’. 79.4% of respondents voted to remain in the EU in the 2016 referendum compared with 48.1% of voters as a whole (χ2=819.8, pConclusionsUK doctors are left-leaning and liberal in general, which is reflected in their opinions on topical health policy issues. Doctors in the UK voted differently from the general electorate in recent polls.

Purpose The need for dietary management in coeliac disease may lead to the development of disordered eating. This study examined the prevalence of disordered eating and factors predicting disordered eating in women with coeliac disease, compared with other dietary-controlled conditions. Methods A cross-sectional, online survey assessing psychological well-being, disordered eating behaviours (Eating Attitudes Test 26 (EAT-26); Binge Eating Scale (BES)) was distributed using online forums, to those with coeliac disease (N = 157), inflammatory bowel disease (N = 116), type two diabetes (N = 88) and healthy controls (N = 142). Hierarchical regressions were conducted to explore and compare the predictors of EAT-26 and BES scores across all groups. Within the coeliac disease group, a cluster analysis was conducted to examine types of disordered eating. Results Higher EAT-26 scores were found in those with coeliac disease and inflammatory bowel disease compared with healthy controls and type two diabetes; participants with a chronic health condition had higher BES than healthy control participants. The factors associated with EAT-26 scores differed across the dietary-controlled health conditions, with dietary management being important for those with coeliac disease. Psychological distress was associated with binge-eating behaviour across all groups. Cluster analyses found two types of disordered eating in coeliac disease; a binge eating type and a restrictive type. Conclusions Disordered eating attitudes and behaviours are more prevalent in participants with chronic health conditions relative to healthy controls. The presence of binge eating behaviours in coeliac disease may be related to non-coeliac disease specific factors such as the distress associated with dietary-controlled illness. EAT-26 scores in coeliac disease are associated with disease specific factors, unique to following the gluten-free diet. These factors are important for identifying and supporting those with coeliac disease and disordered eating.

IntroductionChildren and young people (CYP) in many high-income settings have poor healthcare outcomes, especially those with long-term conditions (LTCs). Emergency and outpatient hospital service use is increasing unsustainably. To address these problems, the Children and Young People’s Health Partnership (CYPHP) has developed and is evaluating an integrated model of care as part of a health systems strengthening programme across two boroughs of London, UK that are characterised by mixed ethnic populations and varying levels of deprivation. The CYPHP Evelina London model of care comprises proactive case-finding and triage, specialist clinics and transformative education and training for professionals working with CYP. Services are delivered by multidisciplinary health teams with an emphasis on increased coordination across primary, community and hospital settings and integration of physical and mental healthcare that accounts for the CYP’s social context.Methods and analysisThe phased roll out of the CYPHP Evelina London model allows an opportunistic population-based evaluation using a cluster randomised controlled trial design. Seventy general practices across two London boroughs, grouped into 23 clusters, were randomised to provide either the CYPHP model of care (n=11) or enhanced usual care (n=12).The evaluation will measure the impact of the CYPHP Evelina London model of care on child and parent health and well-being, healthcare quality and health service use up to 2 years postimplementation. A population-level evaluation will use routinely collected pseudonymised healthcare data to conduct a service-use analysis for all CYP registered with a participating general practice (n=~90 000) with the rate of non-elective admissions as the primary outcome. We will seek consent from a subset of this population, with specific conditions (target n=2138) to assess the impact on patient-reported outcomes using the Paediatric Quality of Life Inventory (PedsQL) and Warwick-Edinburgh Mental Well-Being Scale (WEBWMS) as, respectively, the child- and parent-related primary outcomes.Ethics and disseminationEthics approval obtained from South West-Cornwall & Plymouth Research Ethics Committee. Results will be submitted for publication in peer-reviewed journals. Findings will be generalisable to community-based models of care, especially in urban settings. Our process evaluation will identify barriers and enablers of implementation and delivery of care salient to the context and condition.Trial registration numberNCT03461848; Pre-results.

Background: Children and young people’s (CYP) health outcomes in England are variable and often poor. Health systems throughout high income countries are struggling to adapt to epidemiological transitions, social change, rising demand, and budget cuts. There was a 58% rise in CYP attending EDs between 2007 and 2016, projected to rise 50-60% more by 2030. CYP from the most deprived backgrounds are 60-70% more likely to go to A&E than the least deprived. The majority of ED attendances by CYP are manageable in primary care or integrated models, yet 85% of ED attendances are for minor illnesses, increasing 5% annually. The Children and Young People’s Health Partnership (CYPHP) is a health system strengthening initiative implementing and evaluating a new model of care. Methods: Health system strengthening using the WHO building blocks model included service design by analysis of population need, systematic literature reviews, and extensive patient and public involvement. An evidence-based implementation plan was agreed for a child population of 90,000 in London, and we are evaluating using a cluster randomised control trial (cRCT) design with nested process evaluation and qualitative studies to assess CYP health and wellbeing, healthcare quality, patterns of healthcare use, and cost effectiveness. Results: CYPHP’s comprehensive care includes health promotion and supported self-management, proactive case-finding, biopsychosocial assessment and self-referral via a patient portal, with care delivered by a multidisciplinary team. Services are integrated vertically and horizontally incorporating physical and mental healthcare. Implementation has taken two years longer than anticipated due to technical and cultural challenges of health system strengthening. Early results indicate a reduction of 72 ED contacts per 100 children with asthma, 30 for children with epilepsy, and 15 for children with constipation. We estimate cost savings per 100 asthma patients to be over £15,000, for epilepsy over £6,000, and for constipation over £3,000. Of the first 200 patients, most were from socially deprived areas and 68% were from black and minority ethnic groups. Families report more confidence in managing their child’s condition. Discussion: As a clinical academic partnership, CYPHP combines pragmatic quality improvement and rigorous health services research. CYPHP demonstrates that health system strengthening in high income countries is feasible and effective for implementing and testing new models of care to improve child health. Conclusions: Early results suggest encouraging impact on patterns of healthcare use and potential cost savings. CYPHP’s population health approach provides care for those with greatest health and social need. Lessons learned: Rigorous health services and systems research is feasible in large scale system change in the NHS. Health system strengthening is a new concept in high income countries. It is slow and difficult, but important for effective implementation of new models of care. Fully integrated comprehensive models of care for children may improve health and healthcare outcomes. Limitations: Results are preliminary and reflect early implementation. Suggestions for future research: Rigorously designed health services research for ongoing large-scale health systems changes are an important source of new knowledge. There are few examples of such opportunistic research, representing new avenues for opportunity.

Introduction: New models of healthcare have largely focussed on adults, with increasing policy and practice interest in integrated care across many high-income countries. Integrated care models have been identified as a promising solution by children and young people (CYP), and by policy-makers, to target the gaps in healthcare delivery for CYP with on-going conditions. However, there has been limited work on developing and evaluating integrated models of child healthcare, so there is an evidence gap in this important area of policy. This systematic review and meta-analysis assessed the effects of integrated care interventions on child health, health service use, and healthcare quality for CYP with on-going conditions. Methods: Articles were eligible for the review if they 1) reported randomised controlled trials (RCTs), published between 1996 and September 2018; 2) evaluated an integrated healthcare intervention designed to improve child health; 3) included CYP (0-18 years) with an on-going health condition; 4) included at least one health-related outcome. Descriptive data on a range of outcomes was synthesised for all included papers, and data homogeneity allowed further meta-analyses to explore the effects of integrated care interventions compared with usual care, on health-related quality of life (QOL) and number of emergency department visits. Results: Twenty-three randomised controlled trials were identified, describing 18 interventions. Studies had medium risk of bias, as assessed by the Cochrane Risk of Bias tool. Improvements were found for quality of care (87% of interventions found a positive effect for intervention) and child health (39% found a positive effect for intervention). The meta-analyses found that integrated care interventions have a positive effect in improving QOL over usual care (n=5 trials; SMD = 0.24; 95% CI = 0.03, 0.44; P=0.02), but no significant difference across groups for emergency department contacts (n=5 trials; OR=0.82; 95% CI = 0.53, 1.26; p=0.37). Conclusion and Discussion: Integrated care interventions for CYP with on-going conditions may deliver improved quality of life for children, health, and quality of care. However, no conclusions can be made about the direction or magnitude of the effect for integrated care interventions on emergency department contacts in CYP with on-going conditions. However, only 23 RCTs were included in this review, which were of moderate quality, highlighting the need for more robust trials to inform current health service delivery in this area and fully establish the effectiveness of integrated healthcare interventions on CYP outcomes. In collaboration with NHS Trusts, local councils, CYP and families, the findings from this review have been used to inform a fully integrated healthcare model for CYP that will be implemented at scale, and rigorously evaluated using an RCT design.

Background Children and young people’s (CYP) healthcare outcomes should be better. CYP represent 25% of emergency department (ED) attendances; a 58% rise from 2007 to 2016, projected further 50%–60% by 2030. CYP from the most deprived backgrounds are 60%–70% more likely to attend A and E. Most ED attendances by CYP are manageable in primary or integrated care models, yet 85% are of low severity and the number of children presenting to ED with minor ailments increases 5% annually. Methods CYPHP is a clinical academic partnership for health system strengthening. Model design included analysis of segmented population need, systematic literature reviews, co-production with families and professionals. Health promotion and self-management materials had extensive patient and public involvement. Implementation was agreed for 120,000 CYP. CYPHP delivers practical results and iterative learning as a QI programme, and is evaluating the service as to research standards by a cluster randomised control trial (cRCT) with nested process evaluation and qualitative studies on health, healthcare quality, patterns of healthcare use, and cost effectiveness. Results CYPHP’s child and family-centred care coordinates across primary, community, and hospital settings to better integrate physical and mental healthcare for CYP’s social context. Care is delivered by multidisciplinary teams and includes health promotion, proactive case-finding, biopsychosocial assessment, self-referral via a patient portal, and holistic tailored care. Early results indicate a reduction of 72 ED contacts per 100 children with asthma, 30 for children with epilepsy, 15 for children with constipation. Estimated cost savings per 100 asthma patients >£15,000, for epilepsy >£6,000, for constipation >£3000. Of the first 200 patients with ongoing conditions, most were from socially deprived areas: 68% were from black and minority ethnic groups, suggesting that the CYPHP population health approach provides care for those with greatest need. The average referral-to-treatment time for CYPHP’s Child Health Clinics is 18 days. Families report more confidence in managing their child’s condition out of the hospital. Implications CYPHP is implementing and evaluating a new model of care to improve health, healthcare quality, and outcomes for local CYP, contribute generalizable evidence about children’s health services and systems, and shape child health policy. Early results suggest encouraging impact on access to care and patterns of healthcare use.

Introduction New models of healthcare have largely focussed on adults, with increasing interest in integrated care. Integrated care models have been identified as a promising solution by policy makers, children and young people (CYP), to target the gaps in healthcare delivery for CYP with on-going conditions. However, there has been limited work on developing and evaluating integrated models of child healthcare. This systematic review and meta-analysis assessed the effects of integrated care on child health, health service use, and healthcare quality for CYP with on-going conditions. Methods Articles were eligible for the review if they 1) reported randomised controlled trials (RCTs), published between 1996 and 2018; 2) evaluated an integrated healthcare intervention designed to improve child health; 3) included CYP (0–18 years) with an on-going health condition; 4) included at least one health-related outcome. Descriptive data was synthesised for all included papers, and data homogeneity allowed further meta-analyses to explore the effects of integrated care interventions compared with usual care, on health-related quality of life (QOL) and number of emergency department visits. Results Twenty-three randomised controlled trials were identified, describing 18 interventions. Studies had medium risk of bias. Improvements were found for quality of care (87% of interventions found a positive effect for intervention) and child health (39% found a positive effect for intervention). The meta-analyses found that integrated care interventions have a positive effect in improving QOL over usual care (n=5 trials; SMD=0.24; 95% CI=0.03, 0.44; p=0.02), but no significant difference across groups for emergency department contacts (n=5 trials;OR=0.82; 95% CI=0.53, 1.26; p=0.37). Conclusion Integrated care interventions for CYP with on-going conditions may deliver improved QOL for children, health, and quality of care. However, no conclusions can be made about the direction or magnitude of the effect for integrated care interventions on emergency department contacts in CYP with on-going conditions. Only 23 RCTs were included in this review, which were of moderate quality, highlighting the need for more robust trials to inform current health service delivery in this area and fully establish the effectiveness of integrated healthcare interventions on CYP outcomes.

Aims Integrated General Practitioner-Paediatrician ‘In-Reach’ clinics aim to improve access to care and professional learning across primary-secondary care. The aim of this pilot project is to understand the range of presenting conditions and outcomes among children referred by General Practitioners (GP) to GPs-Paediatrician ‘In-Reach’ clinics, instead of hospital outpatients’. Methods Retrospective case review of 101 patient’s notes. Cases identified through an electronic search of consultations during a 6 month period in 2017. 202 cases were identified, listed alphabetically by patient surname, and alternate records were chosen systematically for inclusion. A senior clinician identified the presenting problem using ICD10 codes grouped into tier one categories, and clinic outcomes. Results Our sample comprised 101 children (0–18 years) presenting with 115 problems. Constipation, eczema, and asthma accounted for 25% of problems. The top 5 ICD10 categories, representing 60% of the total, were digestive, dermatological, musculoskeletal, nervous, and respiratory problems (‘other’ comprised a large range of conditions each with small numbers of patients) (table 1). Nearly a third of problems required only reassurance, one in five required a prescription, and a specialist referral was made for 24% of children seen (table 2). Conclusion A substantial proportion of children had common problems requiring reassurance or simple management in primary care. Specialist referral was required for 24% of children. If this sample is representative, approximately three quarters of children, who would otherwise have been referred for hospital outpatients’ appointments, could be seen and managed with support in primary care settings. These preliminary results suggest that integrating care across the primary-secondary care interface could help improve access to care.

Aims Rising use of emergency departments has resulted in increased costs and poor quality of care for children and young people. Clear evidence on which interventions work in reducing the number of unplanned admissions is important for those who use and commission emergency department services and to improve the quality of healthcare services. There is a policy imperative to shift care out of hospitals but insufficient evidence on the effectiveness of out of hospital care. This review aims to identify, critique, and collate outcomes in published evidence for nurse-led out hospital care for children and young people with chronic conditions. Methods Two databases were systematically searched from 1965–2017, to identify randomised controlled trials that used nurse-led out of hospital care to reduce emergency department attendances in children and young people (0–18 years) with at least one chronic condition. The pooled incidence rate ratio (IRR) was estimated using the R package metaphor. Results Five randomised controlled trials (3 USA, 1 Canada, 1 Scotland) met the inclusion criteria. All five trials were included in the qualitative review but four were included in the meta-analysis due to heterogeneity in outcome measures. Four papers reported on CYP with asthma and the fifth on chronic illness. Only three papers reported significant effect for a reduction in emergency department attendances. Study quality was moderate, with a medium risk of bias. The meta-analysis fitted a random-effects model, which estimated a pooled IRR of 0.65 (95% CI 0.40, 1.03) implying a non-significant positive effect of nurse-led out of hospital care on reducing emergency department attendance. Conclusions Although this review found no association between emergency department usage and nurse-led out of hospital care, the effect sizes were large and three papers found positive associations. Only five randomised controlled trials were included in this review, most of which studied children and young people with asthma, highlighting the need for further research in this area.

Purpose: To systematically review evidence concerning disordered eating practices in dietary-controlled gastrointestinal conditions. Three key questions were examined: a) are disordered eating practices a feature of GI disorders?; b) what abnormal eating practices are present in those with GI disorders?; and c) what factors are associated with the presence of disordered eating in those with GI disorders? By exploring these questions, we aim to develop a conceptual model of disordered eating development in GI disease. Methods: Five key databases, Web of Science with Conference Proceedings (1900–2014) and MEDLINE (1950–2014), PubMed, PsycINFO (1967–2014) and Google Scholar, were searched for papers relating to disordered eating practices in those with GI disorders. All papers were quality assessed before being included in the review. Results: Nine papers were included in the review. The majority of papers reported that the prevalence of disordered eating behaviours is greater in populations with GI disorders than in populations of healthy controls. Disordered eating patterns in dietary-controlled GI disorders may be associated with both anxiety and GI symptoms. Evidence concerning the correlates of disordered eating was limited. Conclusions: The presence of disordered eating behaviours is greater in populations with GI disorders than in populations of healthy controls, but the direction of the relationship is not clear. Implications for further research are discussed.

Background: Chronic, non-communicable disease, accounts for the vast majority of all disability adjusted life years lost (DALYS), among children and young people in high income countries. Our current model of hospital‐centred paediatric care was developed to deliver acute inpatient and high intensity specialist services rather than high quality care for children and young people (CYP) with long-term conditions. The CYPHP Evelina London model was developed with key stakeholders including CYP, carers, front line practitioners and health service commissioners in response to these evolving health care needs. The CYPHP Evelina London model is an innovative approach to reshaping everyday healthcare services, expanding on the principles of integrated care. CYPHP brings together physical and mental healthcare, addresses the social context of families, integrates primary and secondary healthcare, and links healthcare with local government efforts to improve the wider determinants of health. A major focus of the CYPHP Evelina London model is improving front line care for all CYP. Methods: The CYPHP model will be rolled out in phases, allowing an opportunistic evaluation using a cluster Randomised Controlled Trial (cRCT) design involving 90,000 children and young people in 23 clusters. The evaluation has four component parts: 1- Pseudonymised population-based evaluation for all children and young people in participating GP practices to assess health service use; 2- An evaluation of consented children with asthma, eczema, and constipation to assess impact on health-related quality of life, parental-reported disease severity, prevalence and severity of mental health difficulties, and mental wellbeing among parents, using validated questionnaires. 3- A mixed-methods process evaluation to understand the barriers and facilitators to implementing the model of care; 4- Economic evaluation. Results: Initial baseline results from the first 219 Health Checks showed poorly controlled symptoms for asthma, eczema and constipation in between 60 and 76% of young people. In total, 28% of CYP scored ‘High’/’Very High’ on Strengths & Difficulties Questionnaire for mental health difficulties. Over a quarter of families reported problems paying bills and 12% of parents expressed concerns regarding their own mental health. Discussion: The ongoing CYPHP evaluation is the largest population based evaluation of a pediatrics integrated care model to date in the UK. We will discuss the need for robust evaluation in the space of health transformation using CYPHP as an exemplar. Conclusions: Initial results show high levels of unmet physical, psychological and social needs in children and young people with common and chronic illness. Clinical academic partnerships are key to robust evaluation of health service models at scale. Lessons learned: The difficulties, of carrying out a large randomised controlled trial of a health systems transformation programme across two London Boroughs including partnership working, funding models, ethics approval and recruitment will be discussed. Limitations: Though final results are not available, initial results show high levels of unmet need in our population which the CYPHP model of care is meeting. Suggestions for future research: Robust evaluation using experimental designs is possible and needed in the health systems space. These evaluations at scale will inform new health system design.

Background: Children and young people’s (CYP) health and healthcare outcomes are often poor. Demand for urgent healthcare is rising. The current model of care is primarily reactive and acute rather than proactive and preventative; leading to increased use and reliance on secondary healthcare services. Over the past 5 years there has been increases in non-elective admissions and attendances and outpatient appointments (1.7%, 3% and 3.2%). At a population level, these small increases incur increasing financial cost and burden on services already at capacity. The clinical-academic Children and Young People’s Health Partnership (CYPHP) is delivers new care models to improve CYP health; with evaluation using robust designs to determine the extent the new model of care is curbing rising healthcare use. Methods: CYPHP is a partnership between 3 large NHS Trusts, including mental health and children’s, 2 Clinical Commissioning Groups and Local Authorities, and a University. Model design included analysis of segmented population need, systematic literature reviews, and extensive engagement with CYP, parents, health professionals, providers, and commissioners. An evidence-based implementation plan was agreed to roll out services to a child population of 120,000. We are opportunistically evaluating the service using a cluster randomised control trial (cRCT) design. Results: We are implementing and evaluating an evidence-based comprehensive new child and family-centred integrated cycle of care including individual and population health promotion; proactive case-finding and triage for ongoing conditions at a population-level; biopsychosocial assessment and self-referral via a patient portal; holistic tailored care, specialist clinics and increased education and training for professionals working with CYP. Services are delivered by multidisciplinary health teams to increase coordination across primary, community, and hospital settings and to better integrate physical and mental healthcare for CYP’s social context. The cRCT evaluation design, with nested process evaluation and qualitative studies, will provide high quality evidence of the impact of the CYPHP model on outcomes including CYP health and wellbeing, healthcare quality, and health service and system measures. Implications: CYPHP is implementing and evaluating a new model of care to improve health, heathcare quality, and outcomes for local CYP, contribute generalizable evidence about children’s health services and systems, and shape child health policy.

IntroductionChildren and young people (CYP) in the UK have poor health outcomes, and there is increasing emergency department and hospital outpatient use. To address these problems in Lambeth and Southwark (two boroughs of London, UK), the local Clinical Commissioning Groups, Local Authorities and Healthcare Providers formed The Children and Young People’s Health Partnership (CYPHP), a clinical-academic programme for improving child health. The Partnership has developed the CYPHP Evelina London model, an integrated healthcare model that aims to deliver effective, coordinated care in primary and community settings and promote better self-management to over approximately 90 000 CYP in Lambeth and Southwark. This protocol is for the process evaluation of this model of care.Methods and analysisAlongside an impact evaluation, an in-depth, mixed-methods process evaluation will be used to understand the barriers and facilitators to implementing the model of care. The data collected mapped onto a logic model of how CYPHP is expected to improve child health outcomes. Data collection and analysis include qualitative interviews and focus groups with stakeholders, a policy review and a quantitative analysis of routine clinical and administrative data and questionnaire data. Information relating to the context of the trial that may affect implementation and/or outcomes of the CYPHP model of care will be documented.Ethics and disseminationThe study has been reviewed by NHS REC Cornwall & Plymouth (17/SW/0275). The findings of this process evaluation will guide the scaling up and implementation of the CYPHP Evelina London Model of Care across the UK. Findings will be disseminated through publications and conferences, and implementation manuals and guidance for others working to improve child health through strengthening health systems.Trial registration numberNCT03461848

Research with violent offenders has consistently shown impaired recognition of other’s facial expressions of emotion. However, the extent to which similar problems can be observed among sexual offenders remains unknown. Using a computerized task, we presented sexual and violent offenders, and non-offenders, with male and female expressions of anger, disgust, fear, happiness, sadness, and surprise, morphed with neutral expressions at varying levels of intensity (10%, 55%, and 90% expressive). Based on signal detection theory, we used hit rates and false alarms to calculate the sensitivity index d-prime (d’) and criterion (c) for each emotional expression. Overall, sexual offenders showed reduced sensitivity to emotional expressions across intensity, sex, and type of expression, compared with non-offenders, while both sexual and violent offenders showed particular reduced sensitivity to fearful expressions. We also observed specific effects for high (90%) intensity female faces, with sexual offenders showing reduced sensitivity to anger compared with non-offenders and violent offenders, and reduced sensitivity to disgust compared with non-offenders. Furthermore, both sexual and violent offenders showed impaired sensitivity to high intensity female fearful expressions compared with non-offenders. Violent offenders also showed a higher criterion for classifying moderate and high intensity male expressions as fearful, indicative of a more conservative response style, compared with angry, happy, or sad. These results suggest that both types of offender show problems in emotion recognition, and may have implications for understanding the inhibition of violent and sexually violent behaviors.