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Background During the COVID-19 pandemic, mental health problems increased as access to mental health services reduced. Recovery colleges are recovery-focused adult education initiatives delivered by people with professional and lived mental health expertise. Designed to be collaborative and inclusive, they were uniquely positioned to support people experiencing mental health problems during the pandemic. There is limited research exploring the lasting impacts of the pandemic on recovery college operation and delivery to students. Aims To ascertain how the COVID-19 pandemic changed recovery college operation in England. Method We coproduced a qualitative interview study of recovery college managers across the UK. Academics and co-researchers with lived mental health experience collaborated on conducting interviews and analysing data, using a collaborative thematic framework analysis. Results Thirty-one managers participated. Five themes were identified: complex organisational relationships, changed ways of working, navigating the rapid transition to digital delivery, responding to isolation and changes to accessibility. Two key pandemic-related changes to recovery college operation were highlighted: their use as accessible services that relieve pressure on mental health services through hybrid face-to-face and digital course delivery, and the development of digitally delivered courses for individuals with mental health needs. Conclusions The pandemic either led to or accelerated developments in recovery college operation, leading to a positioning of recovery colleges as a preventative service with wider accessibility to people with mental health problems, people under the care of forensic mental health services and mental healthcare staff. These benefits are strengthened by relationships with partner organisations and autonomy from statutory healthcare infrastructures.

Background Bisphosphonates are a class of medication commonly used to treat osteoporosis. Alendronate is recommended as the first-line treatment; however, long-term adherence (both treatment compliance and persistence) is poor. Alternative bisphosphonates are available, which can be given intravenously and have been shown to improve long-term adherence. However, the most clinically effective and cost-effective alternative bisphosphonate regimen remains unclear. What is the most cost-effective bisphosphonate in clinical trials may not be the most cost-effective or acceptable to patients in everyday clinical practice. Objectives Explore patient, clinician and stakeholder views, experiences and preferences of alendronate compared to alternative bisphosphonates. Update and refine the 2016 systematic review and cost-effectiveness analysis of bisphosphonates, and estimate the value of further research into their benefits. Undertake stakeholder/consensus engagement to identify important research questions and further rank research priorities. Methods The study was conducted in two stages, stages 1A and 1B in parallel, followed by stage 2: Stage 1A – we elicited patient and healthcare experiences to understand their preferences of bisphosphonates for the treatment of osteoporosis. This was undertaken by performing a systematic review and framework synthesis of qualitative studies, followed by semistructured qualitative interviews with participants. Stage 1B – we updated and expanded the existing Health Technology Assessment systematic review and clinical and cost-effectiveness model, incorporating a more comprehensive review of treatment efficacy, safety, side effects, compliance and long-term persistence. Stage 2 – we identified and ranked further research questions that need to be answered about the effectiveness and acceptability of bisphosphonates. Results Patients and healthcare professionals identified a number of challenges in adhering to bisphosphonate medication, balancing the potential for long-term risk reduction against the work involved in adhering to oral alendronate. Intravenous zoledronate treatment was generally more acceptable, with such regimens perceived to be more straightforward to engage in, although a portion of patients taking alendronate were satisfied with their current treatment. Intravenous zoledronate was found to be the most effective, with higher adherence rates compared to the other bisphosphonates, for reducing the risk of fragility fracture. However, oral bisphosphonates are more cost-effective than intravenous zoledronate due to the high cost of zoledronate administration in hospital. The importance of including patients and healthcare professionals when setting research priorities is recognised. Important areas for research were related to patient factors influencing treatment selection and effectiveness, how to optimise long-term care and the cost-effectiveness of delivering zoledronate in an alternative, non-hospital setting. Conclusions Intravenous zoledronate treatment was generally more acceptable to patients and found to be the most effective bisphosphonate and with greater adherence; however, the cost-effectiveness relative to oral alendronate is limited by its higher zoledronate hospital administration costs. Future work Further research is needed to support people to make decisions influencing treatment selection, effectiveness and optimal long-term care, together with the clinical and cost-effectiveness of intravenous zoledronate administered in a non-hospital (community) setting. Limitations Lack of clarity and limitations in the many studies included in the systematic review may have under-interpreted some of the findings relating to effects of bisphosphonates. Trial registration This trial is registered as ISRCTN10491361. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR127550) and is published in full in Health Technology Assessment; Vol. 28, No. 21. See the NIHR Funding and Awards website for further award information. Plain language summary Background Bisphosphonates are drug treatments commonly used to treat osteoporosis. Alendronate is the most used and is taken by mouth, weekly at a specific time of the week, which can be challenging. Less than one in four people continue this treatment beyond 2 years. Alternative bisphosphonates are available, which vary in frequency and how they are administered. The most acceptable and best value-for-money regimen is unclear. Aim Our aim was to determine how effective alternative bisphosphonates are compared to alendronate at preventing fractures and whether reduction in fracture risk was achieved at a reasonable financial cost, but acceptable to patients. Design and methods The study was conducted in two stages, stages 1A and 1B in parallel, followed by stage 2: Stage 1A: a review of the published evidence on patients’ and doctors’ views, experiences and preferences regarding different bisphosphonate treatment regimens, followed by interviews with patients and healthcare professionals. Stage 1B: an update of an existing study on how effective bisphosphonates are in preventing fragility fractures caused by osteoporosis and whether they are good value for money. Stage 2: identification of questions that need to be answered about the effectiveness and acceptability of bisphosphonate treatments. Results Taking bisphosphonate medication often involves quite a lot of effort by patients, particularly when taking alendronate tablets. A yearly infusion of zoledronate treatment was more acceptable, easier to engage with and the most effective treatment compared to alendronate. However, the cost of administering zoledronate in hospital made alendronate better value for money. Conclusions Bisphosphonates are effective in reducing the risk of fracture, but ‘continuing with treatment’, particularly alendronate tablets, remains a challenge. A yearly infusion of zoledronate offers an acceptable and effective treatment, but further research is needed to support patients and healthcare professionals in making decisions about the various treatments, benefits and cost savings of administering zoledronate outside of hospital and in the community. Scientific summary Background Alendronate (ALN) is recommended as the first-line osteoporosis treatment to prevent osteoporotic fractures; however, long-term adherence (both treatment compliance and persistence) is poor. Alternative bisphosphonates (BP) are available, which vary in frequency of use and/or route of administration and have been shown to improve long-term adherence compared to ALN. However, the most clinically effective and cost-effective alternative regimen remains unclear. Furthermore, clinicians should optimise dosing regimens on the basis of the patient’s understanding, preference and characteristics. What is the most cost-effective BP in clinical trials may not be the most cost-effective or acceptable to patients in everyday clinical practice. Objectives Explore patient, clinician and stakeholder views, experiences and preferences of ALN compared to alternative BP. Update and refine the 2016 systematic review and cost-effectiveness analysis of BP and estimate the value of further research into the relative benefits. Undertake stakeholder/consensus engagement to identify important research questions and further rank research priorities. Methods The study was conducted in two stages, stages 1A and 1B in parallel, followed by stage 2: Stage 1A: we elicited patient and clinician experiences of different BP regimens to understand their preferences and those of other stakeholders compared to ALN. This was undertaken by performing a systematic review and framework synthesis of qualitative studies around clinician and patient views, followed by semistructured qualitative interviews with multidisciplinary stakeholders. Stage 1B: we updated and expanded the existing Health Technology Assessment systematic review and clinical and cost-effective health economic model (2016), incorporating a more comprehensive review of treatment efficacy, safety, side effects, compliance and long-term persistence. The model takes a NHS and Personal Social Services perspective, with future costs and quality-adjusted life-years (QALYs) discounted at 3.5% per annum. Costs are reported in pound sterling based on 2021 prices. Stage 2: using an approach based on the James Lind methodology for identification and prioritisation of research questions, we identified questions that needed to be answered about the effectiveness and acceptability of BP. Findings from stages 1A and 1B, together with multidisciplinary meetings, identified areas of uncertainty. These questions were then ranked in a multidisciplinary, nationally representative stakeholder event, conducted online over MS Teams. Results We identified, through a systematic review of previous studies on patient and clinician experiences of BP treatment, how patients and healthcare professionals make sense (coherence) of BP by balancing perceptions of need against concerns, how uncertainty prevails about BP-perceived effectiveness and a number of individual and service factors that have potential to increase self-efficacy in recommending and adhering to BP. The qualitative interview study examining experiences of alternate BP regimens found that intravenous (IV) BP zoledronate (ZOL) treatment was generally more acceptable to patients. Such IV regimens were perceived to be more straightforward to engage in, although a portion of patients taking ALN were satisfied with their current treatment. The systematic review and network meta-analysis of previous studies of effectiveness found that IV ZOL was the most effective BP compared to ALN, risedronate and oral ibandronate for reducing the risk of fragility fractures. Adherence was higher in IV ZOL users. It was found that clinical decision-making could be facilitated by considering adherence patterns in BP users who were at increased risk of fracture. However, the higher hospital administration costs for IV ZOL meant that the incremental cost-effectiveness ratios for IV ZOL compared to ALN were greater than £30,000 per QALY across all risk categories. This was despite the fact that IV ZOL was predicted to result in fewer fractures than ALN, due to its higher treatment persistence and a longer offset period. The prioritisation exercise highlighted a need for further research to tackle the issues relating to patient factors influencing treatment selection and effectiveness, including in younger adults, how to optimise long-term care and support patient and clinician decision-making and the clinical and cost-effectiveness of giving IV ZOL in alternate settings to hospital care. Conclusions We have identified the factors that influence how patients and clinicians make sense of BP, described the experience of BP taking in terms of burden and identified factors that both facilitate and hinder confidence in taking and prescribing and monitoring BP. IV ZOL treatment was generally more acceptable to patients. IV ZOL was found to be the most effective BP and with greater adherence; however, the cost-effectiveness of IV ZOL relative to ALN was limited by the high hospital administration costs. Further research is needed to support people to make decisions influencing treatment selection and effectiveness and establish how to optimise long-term care. In addition, research is needed to explore the clinical and cost-effectiveness of IV ZOL delivered in alternate settings, such as in the community, compared to ALN treatment. Patient and public involvement We have worked closely with the Royal Osteoporosis Society (ROS) and the Nottingham ROS (NotROS) Support Group, who together have influenced the design of this application, choice of study outcomes and were involved throughout the study. Trial registration This trial is registered as ISRCTN10491361. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR127550) and is published in full in Health and Social Care Delivery Research; Vol. 28, No. 21. See the NIHR Funding and Awards website for further award information.

Abstract Background Bisphosphonate medications, including alendronate, ibandronate and risedronate administered orally and zoledronate, administered intravenously, are commonly prescribed for the treatment of osteoporosis based on evidence that, correctly taken, bisphosphonates can improve bone strength and lead to a reduction in the risk of fragility fractures. However, it is currently unclear how decisions to select between bisphosphonate regimens, including intravenous regimen, are made in practice and how clinicians support patients with different treatments. Methods This was an interpretivist qualitative study. 23 semi-structured telephone interviews were conducted with a sample of general practitioners (GPs), secondary care clinicians, specialist experts as well as those providing and leading novel treatments including participants from a community intravenous (IV) zoledronate service. Data analysis was undertaken through a process of iterative categorisation. Results The results report clinicians varying experiences of making treatment choices, as well as wider aspects of osteoporosis care. Secondary care and specialist clinicians conveyed some confidence in making treatment choices including on selecting IV treatment. This was aided by access to diagnostic testing and medication expertise. In contrast GPs reported a number of challenges in prescribing bisphosphonate medications for osteoporosis and uncertainty about treatment choice. Results also highlight how administering IV zoledronate was seen as an opportunity to engage in broader care practices. Conclusion Approaches to making treatment decisions and supporting patients when prescribing bisphosphonates for osteoporosis vary in practice. This study points to the need to co-ordinate osteoporosis treatment and care across different care providers.

Background The implementation of change in health and care services is often complicated by organisational micropolitics. There are calls for those leading change to develop and utilise political skills and behaviours to understand and mediate such politics, but to date only limited research offers a developed empirical conceptualisation of the political skills and behaviours for leading health services change.Methods A qualitative interview study was undertaken with 66 healthcare leaders from the English National Health Service (NHS). Participants were sampled on the basis of their variable involvement in leading change processes, taking into account anticipated differences in career stage, leadership level and role, care sector, and professional backgrounds. Interpretative data analysis led to the development of five themes.Results Participants’ accounts highlighted five overarching sets of political skills and behaviours: personal and interpersonal qualities relating to self-belief, resilience and the ability to adapt to different audiences; strategic thinking relating to the ability to understand the wider and local political landscape from which to develop realistic plans for change; communication skills for engaging and influencing stakeholders, especially for understanding and mediating stakeholders’ competing interests; networks and networking in terms of access to resources, and building connections between stakeholders; and relational tactics for dealing with difficult individuals through more direct forms of negotiation and persuasion.Conclusion The study offers further empirical insight the existing literature on healthcare organisational politics by describing and conceptualising the political skills and behaviours of implementing health services change.

Abstract Background Recovery Colleges are a relatively recent initiative within mental health services. The first opened in 2009 in London and since then numbers have grown. They are based on principles of personal recovery in mental health, co-production between people with lived experience of mental health problems and professionals, and adult learning. Student eligibility criteria vary, but all serve people who use mental health services, with empirical evidence of benefit. Previously we developed a Recovery College fidelity measure and a preliminary change model identifying the mechanisms of action and outcomes for this group, which we refer to as service user students. The Recovery Colleges Characterisation and Testing (RECOLLECT) study is a five-year (2020–2025) programme of research in England. The aim of RECOLLECT is to determine Recovery Colleges’ effectiveness and cost-effectiveness, and identify organisational influences on fidelity and improvements in mental health outcomes. Methods RECOLLECT comprises i) a national survey of Recovery Colleges, ii) a prospective cohort study to establish the relationship between fidelity, mechanisms of action and psychosocial outcomes, iii) a prospective cohort study to investigate effectiveness and cost-effectiveness, iv) a retrospective cohort study to determine the relationship between Recovery College use and outcomes and mental health service use, and v) organisational case studies to establish the contextual and organisational factors influencing fidelity and outcomes. The programme has been developed with input from individuals who have lived experience of mental health problems. A Lived Experience Advisory Panel will provide input into all stages of the research. Discussion RECOLLECT will provide the first rigorous evidence on the effectiveness and cost effectiveness of Recovery Colleges in England, to inform their prioritising, commissioning, and running. The validated RECOLLECT multilevel change model will confirm the active components of Recovery Colleges. The fidelity measure and evidence about the fidelity-outcome relationship will provide an empirically-based approach to develop Recovery Colleges, to maximise benefits for students. Findings will be disseminated through the study website (researchintorecovery.com/recollect) and via national and international Recovery College networks to maximise impact, and will shape policy on how Recovery Colleges can help those with mental health problems lead empowered, meaningful and fulfilling lives.

Abstract Background Guidance for choosing face-to-face vs remote consultations (RCs) encourages clinicians to consider patient preferences, however, little is known about acceptability of, and preferences for RCs, particularly amongst patients with musculoskeletal conditions. This study aimed to explore the acceptability of, and preferences for, RC among patients with osteoporosis and rheumatoid arthritis. Methods Three UK qualitative studies, exploring patient experiences of accessing and receiving healthcare, undertaken during the pandemic, with people with osteoporosis and rheumatoid arthritis. Study team members agreed a consistent approach to conduct rapid deductive analysis using the Theoretical Framework of Acceptability (TFA) on transcripts from each data set relating to RC, facilitated by group meetings to discuss interpretations. Findings from the three studies were pooled. Results Findings from 1 focus group and 64 interviews with 35 people were included in the analysis. Participants’ attitudes to RC, views on fairness (ethicality) and sense-making (intervention coherence) varied according to their needs within the consultation and views of the pandemic. Some participants valued the reduced burden associated with RC, while others highly valued non-verbal communication and physical examination associated with face-to-face consults (opportunity costs). Some participants described low confidence (self-efficacy) in being able to communicate in RCs and others perceived RCs as ineffective, in part due to suboptimal communication. Conclusions Acceptability of, and preferences for RC appear to be influenced by societal, healthcare provider and personal factors and in this study, were not condition-dependant. Remote care by default has the potential to exacerbate health inequalities and needs nuanced implementation.

Physical inactivity is a prevalent concern amongst adults living with sight loss. It is essential to understand why these individuals are inactive and how we can increase physical activity levels among them. Therefore, this study aims to explore the barriers and facilitators to physical activity for individuals living with sight loss. Seven individuals with self-reported sight loss living in Cambridgeshire were recruited for three focus groups. Focus group data were analysed using thematic analysis to identify key themes. Seven themes which represented a barrier, or a facilitator were identified: transport, accessing information, one size fits all, negative previous experience, visually impaired sport, women in disability sport, and taster days. To increase physical activity levels amongst those living with sight loss, interventions need to be focused on the organisational level. This includes producing more accessible environments that can be produced by providing training for sport and physical activity professionals and by ensuring the physical environment is inclusive for those living with sight loss.

Abstract Background The implementation of strategic health system change is often complicated by informal ‘politics’ in healthcare organisations. Leadership development programmes increasingly call for the development and use of ‘political skill’ as a means for understanding and managing the politics of healthcare organisations. The primary purpose of this review is to determine how political skill contributes to the implementation of health services change, within and across organisations. The secondary purpose is to demonstrate the conceptual variations within the literature. Methods The article is based upon a narrative synthesis that included quantitative, qualitative and mixed methods research papers, review articles and professional commentaries that deployed the concept of political skill (or associated terms) to describe and analyse the implementation of change in healthcare services. Results Sixty-two papers were included for review drawn from over four decades of empirically and conceptually diverse research. The literature is comprised of four distinct literatures with a lack of conceptual coherence. Within and across these domains, political skill is described as influencing health services change through five dimensions of leadership: personal performance; contextual awareness; inter-personal influence; stakeholder engagement, networks and alliances; and influence on policy processes. Conclusion There is a growing body of evidence showing how political skill can contribute to the implementation of health services change, but the evidence on explanatory processes is weak. Moreover, the conceptualisation of political skill is variable making comparative analysis difficult, with research often favouring individual-level psychological and behavioural properties over more social or group processes.

Abstract Background From late February 2020, English care homes rapidly adapted their practices in response to the COVID-19 pandemic. In addition to accommodating new guidelines and policies, staff had to adjust to rapid reconfiguration of services external to the home that they would normally depend upon for support. This study examined the complex interdependencies of support as staff responded to COVID-19. The aim was to inform more effective responses to the ongoing pandemic, and to improve understanding of how to work with care home staff and organisations after the pandemic has passed. Methods Ten managers of registered care homes in the East Midlands of England were interviewed by videoconference or phone about their experiences of the crisis from a structured organisational perspective. Analysis used an adapted organisational framework analysis approach with a focus on social ties and interdependencies between organisations and individuals. Results Three key groups of interdependencies were identified: care processes and practice; resources; and governance. Care home staff had to deliver care in innovative ways, making high stakes decisions in circumstances defined by: fluid ties to organisations outside the care home; multiple, sometimes conflicting, sources of expertise and information; and a sense of deprioritisation by authorities. Organisational responses to the pandemic by central government resulted in resource constraints and additional work, and sometimes impaired the ability of staff and managers to make decisions. Local communities, including businesses, third-sector organisations and individuals, were key in helping care homes overcome challenges. Care homes, rather than competing, were found to work together to provide mutual support. Resilience in the system was a consequence of dedicated and resourceful staff using existing local networks, or forging new ones, to overcome barriers to care. Conclusions This study identified how interdependency between care home organisations, the surrounding community, and key statutory and non-statutory organisations beyond their locality, shaped decision making and care delivery during the pandemic. Recognising these interdependencies, and the expertise shown by care home managers and staff as they navigate them, is key to providing effective healthcare in care homes as the pandemic progresses, and as the sector recovers afterwards.

Abstract Background Engagement with conventional weight management group programmes is low. Objective To understand participant experience of accessing an adapted programme via videoconference. Participants Adults with obesity (BMI ≥ 35kg/m2), referred to an NHS Dietetics service in Wales, were offered a group videoconference weight management programme as an optional alternative to in‐person groups. Thirteen participants (mean age 48.5 ± 20.2 years, 8 female) recruited to two videoconference groups were interviewed. Study design A Registered Dietitian delivered a behavioural programme using Skype for Business in 10 sessions over 6 months. Participants joined the groups from any Internet‐connected device with a webcam. Participant perspectives were audiorecorded in one‐to‐one, semi‐structured interviews. Interviews were transcribed verbatim and thematically analysed using self‐determination theory as a theoretical framework. Results Ten themes were identified, three relating to service engagement and seven relating to behaviour change facilitation. Key themes in engagement included ‘reduced burden’, described as saving time and travel and ‘reduced threat’ as participants perceived joining a group from home as less daunting compared to attending in‐person. Despite reporting some initial technical difficulties with establishing video and audio connection, participants described beneficial peer support although not physically with other group members. Conclusion Accessing a group weight management programme via videoconference may be the preferred option for some participants, overcoming some of the barriers to access to standard in‐person programmes, particularly in rural areas. Participants are able to experience peer support via videoconference. During the COVID‐19 pandemic, weight management programmes could utilize videoconference groups to continue to provide support.

Background: The implementation of change in health and care services is often complicated by the ‘micropolitics’ of the care system. There is growing recognition that health and care leaders need to develop and use types of ‘political skill’ or ‘political astuteness’ to understand and manage the micropolitics of change. Aim: The aim of this study was to produce a new empirical and theoretical understanding of the acquisition, use and contribution of leadership with ‘political astuteness’, especially in the implementation of major system change, from which to inform the co-design of training, development and recruitment resources. Methods: The qualitative study comprised four work packages. Work package 1 involved two systematic literature reviews: one ‘review of reviews’ on the concept of political astuteness and another applying the learning from this to the health services research literature. Work package 2 involved biographical narrative interviews with 66 health and care leaders to investigate their experiences of acquiring and using political skills in the implementation of change. Work package 3 involved in-depth qualitative case study research with nine project teams drawn from three regional Sustainability and Transformation Partnerships operating in different English regions. Work package 4 involved a series of co-design workshops to develop learning materials and resources to support service leaders’ acquisition and use of political skills and astuteness. Results: The concepts of political skills and astuteness have had growing influence on health services research, yet these have tended to emphasise a relatively individualised and behavioural view of change leadership. The interview study suggests that, although leaders certainly use individual skills and behaviours when implementing change, change processes are contingent on local contextual factors and the patterns of collective action in the forms of interlocking constellations of political interactions. The in-depth case study research further shows these interactive, contingent and collective processes in the implementation of major system change. The study finds that major system change occurs over several linked stages, each involving particular controversies for which skills, strategies and actions are needed. Informed by these findings, and through a series of co-design workshops, the study has produced a set of resources and materials and a workbook to support individuals and project teams to acquire and develop political skill. Limitations: The study was complicated by the COVID-19 pandemic and there were difficulties in recruiting in-depth cases for observational research, and also recruiting patient and community groups. Conclusions: Health and care leaders can develop and use a range of skills, strategies and actions to understand and navigate the diverse interests that complicate change. Building on the literature, the study presents a novel empirical framework of these skills, strategies and behaviours, and shows how they are used in the implementation of major system change. This study concludes with a set of co-designed learning resources and materials to support future leaders to develop similar skills and strategies. Further evidence is needed on the contribution of the learning resources on leadership activities and to understand the contribution of political skills to other areas of service governance. Study registration: This study is registered as researchregistery4020. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 11. See the NIHR Journals Library website for further project information.

Abstract Background The implementation of strategic health system change is often complicated by the informal politics and power of health systems, such as competing interests and resistant groups. Evidence from other industries shows that strategic leaders need to be aware of and manage such ‘organisational politics’ when implementing change, which involves developing and using forms of political ‘skill’, ‘savvy’ or ‘astuteness’. The purpose of this study is to investigate the acquisition, use and contribution of political ‘astuteness’ in the implementation of strategic health system change. Methods The qualitative study comprises four linked work packages. First, we will complete a systematic ‘review of reviews’ on the topic of political skill and astuteness, and related social science concepts, which will be used to then review the existing health services research literature to identify exemplars of political astuteness in health care systems. Second, we will carry out semi-structured biographical interviews with regional and national service leaders, and recent recipients of leadership training, to understand their acquisition and use of political astuteness. Third, we will carry out in-depth ethnographic research looking at the utilisation and contribution of political astuteness in three contemporary examples of strategic health system change. Finally, we will explore and discuss the study findings through a series of co-production workshops to inform the development and testing of new learning resources and materials for future NHS leaders. Discussion The research will produce evidence about the relatively under-researched contribution that political skill and astuteness makes in the implementation of strategic health system change. It intends to offer new understanding of these skills and capabilities that takes greater account of the wider social, cultural organisational landscape, and offers tangible lessons and case examples for service leaders. The study will inform future learning materials and processes, and create spaces for future leaders to reflect upon their political astuteness in a constructive and development way. Trial registration Researchregistery4020 [23rd April 2018].

Objective To explore the acceptability of different bisphosphonate regimens for the treatment of osteoporosis among patients, clinicians and managers, payers and academics.Design A systematic review of primary qualitative studies. Seven databases were searched from inception to July 2019. Screening, data extraction and quality assessment of full-articles selected for inclusion were performed independently by two authors. A framework synthesis was applied to extracted data based on the theoretical framework of acceptability (TFA). The TFA includes seven domains relating to sense-making, emotions, opportunity costs, burden, perceived effectiveness, ethicality and self-efficacy. Confidence in synthesis findings was assessed.Setting Any developed country healthcare setting.Participants Patients, healthcare professionals, managers, payers and academics.Intervention Experiences and views of oral and intravenous bisphosphonates.Results Twenty-five studies were included, mostly describing perceptions of oral bisphosphonates. We identified, with high confidence, how patients and healthcare professionals make sense (coherence) of bisphosphonates by balancing perceptions of need against concerns, how uncertainty prevails about bisphosphonate perceived effectiveness and a number of individual and service factors that have potential to increase self-efficacy in recommending and adhering to bisphosphonates. We identified, with moderate confidence, that bisphosphonate taking induces concern, but has the potential to engender reassurance, and that both side effects and special instructions for taking oral bisphosphonates can result in treatment burden. Finally, we identified with low confidence that multimorbidity plays a role in people’s perception of bisphosphonate acceptability.Conclusion By using the lens of acceptability, our findings demonstrate with high confidence that a theoretically informed, whole-system approach is necessary to both understand and improve adherence. Clinicians and patients need supporting to understand the need for bisphosphonates, and clinicians need to clarify to patients what constitutes bisphosphonate treatment success. Further research is needed to explore perspectives of male patients and those with multimorbidity receiving bisphosphonates, and patients receiving intravenous treatment.PROSPERO registration number CRD42019143526.

ObjectiveTo identify factors influencing the provision, utilisation and sustainability of midwifery units (MUs) in England.DesignCase studies, using individual interviews and focus groups, in six National Health Service (NHS) Trust maternity services in England.Setting and participantsNHS maternity services in different geographical areas of England Maternity care staff and service users from six NHS Trusts: two Trusts where more than 20% of all women gave birth in MUs, two Trusts where less than 10% of all women gave birth in MUs and two Trusts without MUs. Obstetric, midwifery and neonatal clinical leaders, managers, service user representatives and commissioners were individually interviewed (n=57). Twenty-six focus groups were undertaken with midwives (n=60) and service users (n=52).Main outcome measuresFactors influencing MU use.FindingsThe study findings identify several barriers to the uptake of MUs. Within a context of a history of obstetric-led provision and lack of decision-maker awareness of the clinical and economic evidence, most Trust managers and clinicians do not regard their MU provision as being as important as their obstetric unit (OU) provision. Therefore, it does not get embedded as an equal and parallel component in the Trust’s overall maternity package of care. The analysis illuminates how implementation of complex interventions in health services is influenced by a range of factors including the medicalisation of childbirth, perceived financial constraints, adequate leadership and institutional norms protecting the status quo.ConclusionsThere are significant obstacles to MUs reaching their full potential, especially free-standing midwifery units. These include the lack of commitment by providers to embed MUs as an essential service provision alongside their OUs, an absence of leadership to drive through these changes and the capacity and willingness of providers to address women’s information needs. If these remain unaddressed, childbearing women’s access to MUs will continue to be restricted.

Background: Midwifery-led units (MUs) are recommended for ‘low-risk’ births by the National Institute for Health and Care Excellence but according to the National Audit Office were not available in one-quarter of trusts in England in 2013 and, when available, were used by only a minority of the low-risk women for whom they should be suitable. This study explores why. Objectives: To map the provision of MUs in England and explore barriers to and facilitators of their development and use; and to ascertain stakeholder views of interventions to address these barriers and facilitators. Design: Mixed methods – first, MU access and utilisation across England was mapped; second, local media coverage of the closure of free-standing midwifery units (FMUs) were analysed; third, case studies were undertaken in six sites to explore the barriers and facilitators that have an impact on the development of MUs; and, fourth, by convening a stakeholder workshop, interventions to address the barriers and facilitators were discussed. Setting: English NHS maternity services. Participants: All trusts with maternity services. Interventions: Establishing MUs. Main outcome measures: Numbers and types of MUs and utilisation of MUs. Results: Births in MUs across England have nearly tripled since 2011, to 15% of all births. However, this increase has occurred almost exclusively in alongside units, numbers of which have doubled. Births in FMUs have stayed the same and these units are more susceptible to closure. One-quarter of trusts in England have no MUs; in those that do, nearly all MUs are underutilised. The study findings indicate that most trust managers, senior midwifery managers and obstetricians do not regard their MU provision as being as important as their obstetric-led unit provision and therefore it does not get embedded as an equal and parallel component in the trust’s overall maternity package of care. The analysis illuminates how provision and utilisation are influenced by a complex range of factors, including the medicalisation of childbirth, financial constraints and institutional norms protecting the status quo. Limitations: When undertaking the case studies, we were unable to achieve representativeness across social class in the women’s focus groups and struggled to recruit finance directors for individual interviews. This may affect the transferability of our findings. Conclusions: Although there has been an increase in the numbers and utilisation of MUs since 2011, significant obstacles remain to MUs reaching their full potential, especially FMUs. This includes the capacity and willingness of providers to address women’s information needs. If these remain unaddressed at commissioner and provider level, childbearing women’s access to MUs will continue to be restricted. Future work: Work is needed on optimum approaches to improve decision-makers’ understanding and use of clinical and economic evidence in service design. Increasing women’s access to information about MUs requires further studies of professionals’ understanding and communication of evidence. The role of FMUs in the context of rural populations needs further evaluation to take into account user and community impact. 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. 8, No. 12. See the NIHR Journals Library website for further project information.

ABSTRACT To summarize the historical events and drivers underlying public policy for the prevention and control of healthcare-associated infections in Brazil and in the United Kingdom. In doing so, the article aims to identify lessons and recommendations for future development of public policy. The analysis is based on a historical overview of national healthcare-associated infections programs taken from previously published sources. Findings highlight how the development of healthcare-associated infections prevention and control policies followed similar trajectories in Brazil and the United Kingdom. This can be conceptualized around four sequential phases: Formation, Consolidation, Standardization, and Monitoring and Evaluation. However, while we identified similar phases of development in Brazil and the United Kingdom, it can be seen that the former entered each stage around 20 years after the latter.

Neurotrophism, structural plasticity, learning and long-term memory in mammals critically depend on neurotrophins binding Trk receptors to activate tyrosine kinase (TyrK) signaling, but Drosophila lacks full-length Trks, raising the question of how these processes occur in the fly. Paradoxically, truncated Trk isoforms lacking the TyrK predominate in the adult human brain, but whether they have neuronal functions independently of full-length Trks is unknown. Drosophila has TyrK-less Trk-family receptors, encoded by the kekkon (kek) genes, suggesting that evolutionarily conserved functions for this receptor class may exist. Here, we asked whether Keks function together with Drosophila neurotrophins (DNTs) at the larval glutamatergic neuromuscular junction (NMJ). We tested the eleven LRR and Ig-containing (LIG) proteins encoded in the Drosophila genome for expression in the central nervous system (CNS) and potential interaction with DNTs. Kek-6 is expressed in the CNS, interacts genetically with DNTs and can bind DNT2 in signaling assays and co-immunoprecipitations. Ligand binding is promiscuous, as Kek-6 can also bind DNT1, and Kek-2 and Kek-5 can also bind DNT2. In vivo, Kek-6 is found presynaptically in motoneurons, and DNT2 is produced by the muscle to function as a retrograde factor at the NMJ. Kek-6 and DNT2 regulate NMJ growth and synaptic structure. Evidence indicates that Kek-6 does not antagonise the alternative DNT2 receptor Toll-6. Instead, Kek-6 and Toll-6 interact physically, and together regulate structural synaptic plasticity and homeostasis. Using pull-down assays, we identified and validated CaMKII and VAP33A as intracellular partners of Kek-6, and show that they regulate NMJ growth and active zone formation downstream of DNT2 and Kek-6. The synaptic functions of Kek-6 could be evolutionarily conserved. This raises the intriguing possibility that a novel mechanism of structural synaptic plasticity involving truncated Trk-family receptors independently of TyrK signaling may also operate in the human brain.

Background: Collaborations for Leadership in Applied Health Research and Care (CLAHRCs) are a time-limited funded initiative to form new service and research collaboratives in the English health system. Their aim is to bring together NHS organisations and universities to accelerate the translation of evidence-based innovation into clinical practice. In doing so, CLAHRCs are positioned to help close the second translation gap (T2), which is described as the problem of introducing and implementing new research and products into clinical practice. Objectives: In this study, we draw on ideas from institutional theory and institutional entrepreneurship to examine how actors may engage in reshaping existing institutional practices in order to support, and help sustain efforts to close the T2. Our objective was to understand how the institutional context shapes actors’ attempts to close the T2 by focusing on the CLAHRC initiative. Methods: The study employed a longitudinal mixed-methods approach. Qualitative case studies combined interview data (174 in total across all nine CLAHRCs and the four in-depth sites), archival data and field notes from observations, over a 4-year period (2009–13). Staff central to the initiatives were interviewed, including CLAHRC senior managers; theme leads; and other higher education institution and NHS staff involved in CLAHRCs. Quantitative social network analysis (SNA) employed a web-based sociometric approach to capture actors’ own individual (i.e. ego) networks of interaction across two points in time (2011 and 2013) in the four in-depth sites, and their personal characteristics and roles. Results: We developed a process-based model of institutional entrepreneurship that encompassed the different types of work undertaken. First, ‘envisaging’ was the work undertaken by actors in developing an ‘embryonic’ vision of change, based on the interplay between themselves and the context in which they were situated. Second, ‘engaging’ was the work through which actors signed up key stakeholders to the CLAHRC. Third, ‘embedding’ was the work through which actors sought to reshape existing institutional practices so that they were more aligned with the ideals of CLAHRC. ‘Reflecting’ involved actors reconsidering their initial decisions, and learning from the process of establishing CLAHRCs. Furthermore, we employed the qualitative data to develop five different archetype models for organising knowledge translation, and considered under what founding conditions they are more or less likely to emerge. The quantitative SNA results suggested that actors’ networks changed over time, but that important institutional influences continued to constrain patterns of interactions of actors across different groups. Conclusion: The development of CLAHRCs holds important lessons for policy-makers. Policy-makers need to consider whether or not they set out a defined template for such translational initiatives, since the existence of institutional antecedents and the social position of actors acted to ‘lock in’ many CLAHRCs. Although antecedent conditions and the presence of pre-existing organisational relationships are important for the mobilisation of CLAHRCs, these same conditions may constrain radical change, innovation and the translation of research into practice. Future research needs to take account of the effects of institutional context, which helps explain why many initiatives may not fully achieve their desired aims. Funding: The National Institute for Health Research Health Services and Delivery Research programme.

Background: Hospital discharge is a vulnerable stage in the patient pathway. Research highlights communication failures and the problems of co-ordination as resulting in delayed, poorly timed and unsafe discharges. The complexity of hospital discharge exemplifies the threats to patient safety found ‘between’ care processes and organisations. In developing this perspective, safe discharge is seen as relying upon enhanced knowledge sharing and collaboration between stakeholders, which can mitigate system complexity and promote safety. Aim: To identify interventions and practices that support knowledge sharing and collaboration in the processes of discharge planning and care transition. Setting: The study was undertaken between 2011 and 2013 in two English health-care systems, each comprising an acute health-care provider, community and primary care providers, local authority social services and social care agencies. The study sites were selected to reflect known variations in local population demographics as well as in the size and composition of the care systems. The study compared the experiences of stroke and hip fracture patients as exemplars of acute care with complex discharge pathways. Design: The study involved in-depth ethnographic research in the two sites. This combined (a) over 180 hours of observations of discharge processes and knowledge-sharing activities in various care settings; (b) focused ‘patient tracking’ to trace and understand discharge activities across the entire patient journey; and (c) qualitative interviews with 169 individuals working in health, social and voluntary care sectors. Findings: The study reinforces the view of hospital discharge as a complex system involving dynamic and multidirectional patterns of knowledge sharing between multiple groups. The study shows that discharge planning and care transitions develop through a series of linked ‘situations’ or opportunities for knowledge sharing. It also shows variations in these situations, in terms of the range of actors, forms of knowledge shared, and media and resources used, and the wider culture and organisation of discharge. The study also describes the threats to patient safety associated with hospital discharge, as perceived by participants and stakeholders. These related to falls, medicines, infection, clinical procedures, equipment, timing and scheduling of discharge, and communication. Each of these identified risks are analysed and explained with reference to the observed patterns of knowledge sharing to elaborate how variations in knowledge sharing can hinder or promote safe discharge. Conclusions: The study supports the view of hospital discharge as a complex system involving tightly coupled and interdependent patterns of interaction between multiple health and social care agencies. Knowledge sharing can help to mitigate system complexity through supporting collaboration and co-ordination. The study suggests four areas of change that might enhance knowledge sharing, reduce system complexity and promote safety. First, knowledge brokers in the form of discharge co-ordinators can facilitate knowledge sharing and co-ordination; second, colocation and functional proximity of stakeholders can support knowledge sharing and mutual appreciation and alignment of divergent practices; third, local cultures should prioritise and value collaboration; and finally, organisational resources, procedures and leadership should be aligned to fostering knowledge sharing and collaborative working. These learning points provide insight for future interventions to enhance discharge planning and care transition. Future research might consider the implementation of interviews to mediate system complexity through fostering enhanced knowledge sharing across occupational and organisational boundaries. Research might also consider in more detail the underlying complexity of both health and social care systems and how opportunities for knowledge sharing might be engendered to promote patient safety in other areas. Funding: The National Institute for Health Research Health Services and Delivery Research programme.