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Abstract Introduction Preventative spend is a global health and social care strategy. Improving Cancer Journeys (ICJ) is a proactive, holistic, multidisciplinary project consistent with this agenda, currently being rolled out across Scotland and parts of UK. ICJ helps people with cancer access whatever support they need to mitigate their most pressing concerns. This study hypothesised that ICJ service users should subsequently use less unscheduled care than matched cohorts not using ICJ. Methods Retrospective observational cohort study using linked national datasets. N = 1,214 ICJ users in Glasgow were matched for age, sex, deprivation, cancer type, stage, and diagnosis year to two control groups: 1. Cancer patients from Glasgow before ICJ (pre-2014), 2. Cancer patients from rest of Scotland during study period (2014–2018). Cancer registrations were linked for 12-month baseline and study periods to: NHS24 calls, A&E admissions, inpatient hospital admissions, unscheduled care, number & cost of psychotropic prescriptions. Per-person mean service uses were compared between groups. Results There was a significant increase in NHS24 calls in the ICJ group (0.36 per person vs. -0.03 or 0.35), more and longer A&E attendances in ICJ (0.37 per person vs. 0.19 or 0.26; 2.19 h per person vs. 0.81–0.92 h), more and longer hospital admissions in ICJ (4.25 vs. 2.59 or 2.53; 12.05 days vs. 8.37 or 8.64), more care pathways involving more steps in ICJ (0.77 spells vs. 0.39 or 0.57; 1.88 steps vs. 1.56 or 1.21), more psychotropic drug prescriptions and higher costs in ICJ (1.88 prescription vs. 1.56 or 1.21; £9.51 vs. £9.57 or £6.95) in comparison to both control groups. Discussion ICJ users sourced significantly more unscheduled care than matched cohorts. These findings were consistent with much of the comparable literature examining the impact of non-health interventions on subsequent health spend. They also add to the growing evidence showing that ICJ reached its intended target, those with the greatest need. Together these findings raise the possibility that those choosing to use ICJ may also be self-identifying as a cohort of people more likely to use unscheduled care in future. This needs to be tested prospectively, because this understanding would be very helpful for health and social care planners in all countries where proactive holistic services exist.

This article reports on the findings from a small-scale co-produced qualitative study on experiences of distress caused by the war in Bosnia and Herzegovina (BiH). Inspired by the emerging interdisciplinary field of Mad Studies, the study is novel and unique in two ways. First, it prioritises social understanding and interpretation of madness and distress. Second, an emphasis is placed on experiential knowledge. Beyond interviews with 20 people who experienced distress due to political conflict, this included contextualisation of the study in the knowledge generated through survivor research and within the field of Mad Studies. Study findings highlight the social causes and consequences of distress caused by conflict, such as war-related violence, gender-based violence, experiences of poverty and corruption. Participants stressed the importance of safety and support within their own home, mutual and supportive relationships with their families, friends, other people who experienced distress, the broader community and opportunities to do everyday activities they enjoy. In terms of professional support, the findings suggest that poverty alleviation and protection of people's right to self-determination through access to human rights advocacy and representation may be as relevant as non-coercive community-based services. This indicates that support for distress caused by political conflict need not be different from any other support for people who experience distress. Emphasis should be placed on survivor-run initiatives and non-coercive, community-based support which addresses social causes of distress and enables people to exercise self-determination. [ABSTRACT FROM AUTHOR]

ObjectiveTo evaluate the barriers and facilitators to implementing Alberta Family Integrated Care (AB-FICare [2019 Benzies]), a model of care for integrating parents into level II neonatal intensive care units (NICUs) care teams, from the perspective of healthcare providers (HCP) and hospital administrators.DesignQualitative process evaluation substudy.SettingTen level II NICUs in six cities across Alberta, Canada.ParticipantsHCP and hospital administrators (n=32) who were involved in the cluster-randomised controlled trial of AB-FICare in level II NICUs.MethodsPost-implementation semi-structured interviews were conducted via phone or in-person. The Consolidated Framework for Implementation Research was used to develop interview guides, code transcripts and analyse data.ResultsKey facilitators to implementation of AB-FICare included (1) a receptive implementation climate, (2) compatibility of the intervention with individual and organisational practices, (3) available resources and access to knowledge and information for HCP and hospital administrators, (4) engagement of key stakeholders across the organisation, (5) engagement of and outcomes for intervention participants, and (6) reflecting and evaluating on implementation progress and patient and family outcomes. Barriers were (1) design quality and packaging of the intervention, (2) relative priority of AB-FICare in relation to other initiatives, and (3) learning climate within the organisation. Mixed influences on implementation depending on contextual factors were coded to eight constructs: intervention source, cost, peer pressure, external policy and incentives, staff needs and resources, structural characteristics, organisational incentives and rewards, and knowledge, beliefs and attitudes.ConclusionsThe characteristics of an organisation and the implementation process had largely positive influences, which can be leveraged for implementation of AB-FICare in the NICU. We recommend site-specific consultations to mitigate barriers and assess how swing factors might impact implementation given the local context, with the goal that strategies can be put in place to manage their influence on implementation.Trial registration numberNCT02879799.

ObjectivesThe Global Kidney Health Atlas (GKHA) is a multinational, cross-sectional survey designed to assess the current capacity for kidney care across all world regions. The 2017 GKHA involved 125 countries and identified significant gaps in oversight, funding and infrastructure to support care for patients with kidney disease, especially in lower-middle-income countries. Here, we report results from the survey for the second iteration of the GKHA conducted in 2018, which included specific questions about health financing and oversight of end-stage kidney disease (ESKD) care worldwide.SettingA cross-sectional global survey.ParticipantsKey stakeholders from 182 countries were invited to participate. Of those, stakeholders from 160 countries participated and were included.Primary outcomesPrimary outcomes included cost of kidney replacement therapy (KRT), funding for dialysis and transplantation, funding for conservative kidney management, extent of universal health coverage, out-of-pocket costs for KRT, within-country variability in ESKD care delivery and oversight systems for ESKD care. Outcomes were determined from a combination of desk research and input from key stakeholders in participating countries.Results160 countries (covering 98% of the world's population) responded to the survey. Economic factors were identified as the top barrier to optimal ESKD care in 99 countries (64%). Full public funding for KRT was more common than for conservative kidney management (43% vs 28%). Among countries that provided at least some public coverage for KRT, 75% covered all citizens. Within-country variation in ESKD care delivery was reported in 40% of countries. Oversight of ESKD care was present in all high-income countries but was absent in 13% of low-income, 3% of lower-middle-income, and 10% of upper-middle-income countries.ConclusionSignificant gaps and variability exist in the public funding and oversight of ESKD care in many countries, particularly for those in low-income and lower-middle-income countries.

Abstract Background Hospital visits constitute a ‘window of opportunity’ for initiating smoking cessation attempts, and healthcare providers (HCPs) play an important role in supporting patients to stop smoking. Yet, the current practices of supporting smoking cessation in the hospital setting are largely unexplored. The aim of this study was to explore practices of smoking cessation support among hospital-based HCPs. Methods HCPs working in a large hospital in the secondary care sector completed an online, cross-sectional survey, including sociodemographic and work-related factors as well as 21 questions assessing practices of smoking cessation support based on the “five As” framework. Descriptive statistics were computed, and predictors of HCPs giving patients advice to stop smoking were explored using logistic regression analysis. Results All employees (N = 3998) in the hospital received a survey link; 1645 (41.1%) HCPs with daily patient contact completed the survey. Smoking cessation support in the hospital setting was limited with regard to assessment of smoking; providing information and advice; planning and referral for further support; and follow-up on smoking cessation attempts. Almost half (44.8%) of participating HCPs with daily patient contact never or rarely advise their patients to stop smoking. Physicians were more likely than nurses to advice patients to stop smoking, and HCPs in outpatient clinics were more likely to give advice than inpatient clinic HCPs. Conclusion Smoking cessation support is very limited in the hospital-based healthcare setting. This is problematic, as hospital visits can be windows of opportunity to help patients change their health behaviour. An intensified focus on the implementation of hospital-based smoking cessation support is needed.

An ageing population, an estimated 47 million people currently living with dementia, and predictions of a threefold increase in people living with a diagnosis by 2050 have led the WHO to declare dementia a public health priority. Emerging research also suggests that dementia is linked to poor oral health and that oral health declines alongside cognitive decline. Drawing on Bourdieu's concepts of field and capital, this paper presents an analysis of interview data from participants with dementia, carers and carer/diagnosed dyads participating in a qualitative study of the mouth and oral health. We argue that Bourdieu's conceptual toolkit provides a way of contextualising experiences of oral health within dementia and un-picking the multi-layered impact of structure, institutions, biology, resource mobilisation and self in the context of a progressive disease which ultimately challenges knowledge of the self and the ability to interact with the world around us. [ABSTRACT FROM AUTHOR]

IntroductionBack and neck pain are the leading causes of disability worldwide. Doctors of chiropractic (DCs) are trained to manage these common conditions and can provide non-pharmacological treatment aligned with international clinical practice guidelines. Although DCs practice in over 90 countries, chiropractic care is rarely available within integrated healthcare delivery systems. A lack of DCs in private practice, particularly in low-income communities, may also limit access to chiropractic care. Improving collaboration between medical providers and community-based DCs, or embedding DCs in medical settings such as hospitals or community health centres, will improve access to evidence-based care for musculoskeletal conditions.Methods and analysesThis scoping review will map studies of DCs working with or within integrated healthcare delivery systems. We will use the recommended six-step approach for scoping reviews. We will search three electronic data bases including Medline, Embase and Web of Science. Two investigators will independently review all titles and abstracts to identify relevant records, screen the full-text articles of potentially admissible records, and systematically extract data from selected articles. We will include studies published in English from 1998 to 2020 describing medical settings that have established formal relationships with community-based DCs (eg, shared medical record) or where DCs practice in medical settings. Data extraction and reporting will be guided by the Proctor Conceptual Model for Implementation Research, which has three domains: clinical intervention, implementation strategies and outcome measurement. Stakeholders from diverse clinical fields will offer feedback on the implications of our findings via a web-based survey.Ethics and disseminationEthics approval will not be obtained for this review of published and publicly accessible data, but will be obtained for the web-based survey. Our results will be disseminated through conference presentations and a peer-reviewed publication. Our findings will inform implementation strategies that support the adoption of chiropractic care within integrated healthcare delivery systems.

Background: Hospital visits constitute a 'window of opportunity' for initiating smoking cessation attempts, and healthcare providers (HCPs) play an important role in supporting patients to stop smoking. Yet, the current practices of supporting smoking cessation in the hospital setting are largely unexplored. The aim of this study was to explore practices of smoking cessation support among hospital-based HCPs. Methods: HCPs working in a large hospital in the secondary care sector completed an online, cross-sectional survey, including sociodemographic and work-related factors as well as 21 questions assessing practices of smoking cessation support based on the "five As" framework. Descriptive statistics were computed, and predictors of HCPs giving patients advice to stop smoking were explored using logistic regression analysis. Results: All employees (N = 3998) in the hospital received a survey link; 1645 (41.1%) HCPs with daily patient contact completed the survey. Smoking cessation support in the hospital setting was limited with regard to assessment of smoking; providing information and advice; planning and referral for further support; and follow-up on smoking cessation attempts. Almost half (44.8%) of participating HCPs with daily patient contact never or rarely advise their patients to stop smoking. Physicians were more likely than nurses to advice patients to stop smoking, and HCPs in outpatient clinics were more likely to give advice than inpatient clinic HCPs. Conclusion: Smoking cessation support is very limited in the hospital-based healthcare setting. This is problematic, as hospital visits can be windows of opportunity to help patients change their health behaviour. An intensified focus on the implementation of hospital-based smoking cessation support is needed. [ABSTRACT FROM AUTHOR]

Objectives: Patient-centredness of care during wait time before surgery can be improved. In this study we aimed to assess (1) patients' experiences with and preferences regarding wait time before surgery; (2) the impact of wait time on quality of life (QoL) and (3) which factors influence patients' wait time experience., Design, Setting, Participants: We performed an exploratory sequential mixed-methods study among women with gynaecological cancer in two tertiary hospitals. We conducted semistructured interviews and identified aspects of QoL and factors that influenced wait time acceptability through thematic analysis. We developed a questionnaire from this thematic analysis which was completed by 97 women. Descriptive statistics and univariate and multivariate regression analyses were performed., Results: Average ideal wait time was 3.5 weeks (±1.7 weeks), minimum and maximum acceptable wait times were 2.2 and 5.6 weeks. Many patients scored above the threshold of the Hospital Anxiety and Depression Scale for anxiety (48%) or depression (34%), had sleeping problems (56%) or experienced pain (54%). A number of factors were more common in patients who indicated that their wait time had been too long: low education level (OR 7.4, 95% CI 0.5 to 5.0, p=0.007), time to surgery >4 weeks (OR 7.0, 95% CI 0.8 to 4.4, p=0.002) and experienced sleep disturbance (OR 3.27, 95% CI 0.0 to 3.1, p=0.05). If patients expectation of wait time was >4 weeks (OR 0.20, 95% CI -4.0 to -0.5 p=0008) or if patients experienced pain (OR 0.26, 95% CI -3.6 to -0.3, p=0.03), they less frequently indicated that wait time had been too long., Conclusion: To improve patient-centredness of care, healthcare providers should aim to reduce wait time to 3-4 weeks and ensure that patients are well informed about the length of wait time and are aware of high levels of anxiety, depression and pain during this time. Future studies should evaluate what interventions can improve QoL during wait time., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To describe a new co-design framework termed Evidence-informed, Experience-based Co-design (E2CD)., Background: Involving consumers and clinicians in planning, designing and implementing services results in the end-product being more likely to meet the needs of end-users and increases the likelihood of their uptake and sustainability. Different forms and definitions of co-design have been described in the literature and have had varying levels of success in health service redesign. However, many fall short of including people with lived experience in all aspects of the process, particularly in setting priorities for service (re)design. In addition, health services need to deliver evidence-based care as well as care that meets the needs of users, yet few ways of integrating research evidence into co-design processes are described. This paper describes a new framework to approach co-design which addresses these issues. We believe that it offers a roadmap to address some of healthcare's most wicked problems and potentially improve outcomes for some of the most vulnerable people in our society. We use improving services for people with high healthcare service utilisation as a working example of the Framework's application., Conclusion: Evidence-informed experience-based co-design has the potential to be used as a framework for co-design that integrates research evidence with lived experience and provides people with lived experience a central role in decision-making about prioritising and designing services to meet their needs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Increasingly, healthcare and public health strategists invite us to look at healthcare organisations as not just care providers but as anchor institutions (ie, large community-rooted organisations with significant impact in the local economy, social fabric and overall community well-being). In response, this study explores the mechanisms through which healthcare organisations can impact social determinants of health and communities in their local areas., Design: We conducted case studies with interviews and synthesised the findings using a realist approach to produce a set of explanations (programme theory) of how healthcare organisations can have a positive impact on the overall well-being of local communities by operating as anchor institutions., Setting: Secondary healthcare organisations in England, including mental health and community services., Participants: Staff from case study sites which were directly employed or actively engaged in the organisation's anchor institution strategy. Data collection took place from early June to the end of August 2023., Results: We found four building blocks for effective anchor activity including employment, spending, estates and sustainability. Healthcare organisations-as anchor institutions-can improve the social determinants of health for their local communities through enabling accessible paths for local community recruitment and career progression; empowering local businesses to join supply chains boosting income and wealth; transforming organisational spaces into community assets; and supporting local innovation and technology to achieve their sustainability goals. These blocks need to be integrated across organisations on the basis of a population health approach promoted by supportive leadership, and in collaboration with a diverse range of local partners., Conclusions: Healthcare organisations have the potential for a positive impact on the overall well-being of local communities. Policymakers should support healthcare organisations to leverage employment, spending, estates and sustainability to help address the unequal distribution of the social determinants of health., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Objective: In 2023, Australian government emergency medical services (EMS) responded to over 4 million consumers, of which over 56% were not classified as an 'emergency', at the cost of AU$5.5 billion. We explored the viewpoints of politicians, policymakers, clinicians and consumers on how these non-emergency requests should be managed., Design: A realist framework was adopted; a multidisciplinary team (including paramedicine, medicine and nursing) was formed; data were collected via semistructured focus groups or interviews, and thematic analysis was performed., Setting and Participants: 56 participants were selected purposefully and via open advertisement: national and state parliamentarians (n=3); government heads of healthcare disciplines (n=3); government policymakers (n=5); industry policymakers in emergency medicine, general practice and paramedicine (n=6); EMS chief executive officers, medical directors and managers (n=7); academics (n=8), frontline clinicians in medicine, nursing and paramedicine (n=8); and consumers (n=16)., Results: Three themes emerged: first, the reality of the EMS workload (theme titled 'facing reality'); second, perceptions of what direction policy should take to manage this ('no silver bullet') and finally, what the future role of EMS in society should be ('finding the right space'). Participants provided 16 policy suggestions, of which 10 were widely supported: increasing public health literacy, removing the Medical Priority Dispatch System, supporting multidisciplinary teams, increasing 24-hour virtual emergency departments, revising undergraduate paramedic university education to reflect the reality of the contemporary role, increasing use of management plans for frequent consumers, better paramedic integration with the healthcare system, empowering callers by providing estimated wait times, reducing ineffective media campaigns to 'save EMS for emergencies' and EMS moving away from hospital referrals and towards community care., Conclusions: There is a need to establish consensus on the role of EMS within society and, particularly, on whether the scope should continue expanding beyond emergency care. This research reports 16 possible ideas, each of which may warrant consideration, and maps them onto the standard patient journey., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Militaries have an important and inevitable role in global health and will interface with existing health systems on deployments. While the primary concern of militaries is not global health, there are clear, and increasingly frequent, circumstances when global health activities align with the interests of defence. Recognising this link between global health and security warrants thoughtful consideration and action where concerns affecting both intersect. In addition to providing medical support to military personnel on operations, advantageous effects can be achieved directly from military medical activities as part of Defence Engagement. While there are limitations and ethical boundaries to the role of militaries in global health, further training, research and conceptual development are warranted to optimise military medical activity at the intersection of security and global health to deliver advantageous effects. This paper forms part of a special issue of BMJ Military Health dedicated to Defence Engagement., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

The future operational demand for medical support in Western militaries will likely outstrip available resources, necessitating burden-sharing through medical interoperability with allies and partners. However, the current North Atlantic Treaty Organization (NATO) model of interoperability through standardisation, while achieving high levels of commonality and integration along the operational patient care pathway (OPCP), is high-cost and resource-intensive. We have termed this model assured interoperability. Assured interoperability, while applicable to well-established partnerships with high-resource nations, is unlikely to be feasible when working with resource-limited partners or, potentially, when in a sustained conflict with a near-peer adversary. In these circumstances, there will be a requirement to develop a far less resource-intensive model of medical interoperability with lower levels of commonality, assurance and standardisation than assured interoperability, but that provides a 'good enough' OPCP for the operational context. We have termed this pragmatic interoperability. By considering these two types of interoperability, the complete continuum of medical interoperability can be mapped with the full spectrum of partners demonstrating increasing levels of interoperability from pragmatic through to assured interoperability, integrateability and interchangeability, reducing the gap between demand and provision of medical support for operations, increasing operational resilience. This is a paper commissioned as a part of the Defence Engagement special issue of BMJ Military Health ., Competing Interests: Competing interests: TFH, CC and STH are serving officers in the UK Defence Medical Services. RW is a former officer in the US Army and is currently employed by the Henry Jackson Foundation for the Advancement of Military Medicine., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: There has not been a theoretical test run in Germany that compares different navigation systems with an industry solution (MapTrip112). The aim of this study was to compare navigation systems to elucidate whether the emergency response time (ERT) was reduced and, consequently, whether the adherence to the travel time improved., Design: Prospective, simulation study, cross-sectional study., Setting: Offices of the Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe University Frankfurt (60 590 Frankfurt am Main, Germany). The situation-adaptable industry navigation solution MapTrip112 was tested in its 'Lights and Siren(s) (L&S)' mode in comparison to the TomTom and Google Maps navigation systems. MapTrip112 was set to calculate a route that takes special emergency rights of way into account., Outcome Measures: All three navigation systems simultaneously calculated the distances and durations of fictitious routes. Three scenarios were tested: the University Hospital Frankfurt (60 596 Frankfurt am Main, Germany) and the Central Fire Station 1 (60435 Frankfurt am Main, Germany) served as the starting points for the urban routes, while the Odenwald Health Centre (64 711 Erbach, Germany) served as the starting point for rural routes. The routes' endpoints were arbitrarily chosen locations inside the customary operational radius. The routes were selected for short and long distances as well as for different periods, including weekdays, weekends and evening rush hour (4-7 pm), in the German cities of Frankfurt am Main and Odenwaldkreis (Southern Hesse)., Results: The time and distance were calculated for a total of 4650 trips. When comparing travel times and distances between rural and urban areas as well as between weekdays and weekends, statistically significant results were obtained (p<0.001). With time advantages ranging from 23.5 s to 300.5 s (4.75% to 50% of the travel time) on weekdays and weekends, MapTrip112 consistently outperformed both TomTom and Google Maps. For city missions, MapTrip112 achieved time gains of up to 50% over its competitors, with significant advantages during the rush hours and around specific locations such as the University Hospital Frankfurt and Fire Station 1., Conclusion: MapTrip112 always achieved the fastest routes although these were not always accompanied by a shortened distance. These findings underscore MapTrip112's superiority in providing efficient routing solutions across various scenarios. For this reason, the use of this software should be considered in practice and investigated in real-world conditions in further studies., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Transitioning patients from their paediatric centres to adulthood is an important subject for many of these patients living with different chronic pathologies. There are few studies that assess its effectiveness in paediatric surgical pathologies. The overall objective of this scoping review is to assess the extent of the literature describing transitional programmes dedicated to young patients living with surgical conditions. The primary question will look to assess what transitional programmes are available for young patients living with surgical conditions either operated or not., Methods and Analysis: The proposed scoping review will follow guidelines described by the Joanna Briggs Institute manual described by Peters et al in 2020. This protocol will employ the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols checklist. The concept that will be included in this review is the exposure of these patients to a transition of care pathway or care programmes. Patients between the ages of 16 and 30 with a surgical condition will be included. There will be no comparator. No specific outcomes will be assessed, however, the outcomes that will be found from the transition programmes will be reviewed. A knowledge synthesis librarian will search MEDLINE All (Ovid), Embase (Ovid), Web of Science Core Collection (Clarivate) and CINAHL Complete (EBSCOhost). The literature search will be limited to 2000 onwards publications. No language or age group limitation will be applied. The reference list of all included sources of evidence will be screened for additional studies. Screening of search results and data extraction from included studies will be completed in Covidence by two independent reviewers. We will also use the PAGER (Patterns, Advances, Gaps, Evidence for practice and Research recommendations) framework to report and summarise the results., Ethics and Dissemination: This review does not require ethics approval. Our dissemination strategy includes peer review publication, conference presentation, co-constructed guidelines with stakeholders and policymakers., Trial Registration: This review is registered on OSF., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To assess healthcare workers' (HCWs) confidence level in diagnosing and managing mpox disease and its associated factors in hospitals in the Amhara Region., Design: Institution-based cross-sectional study., Setting: Hospitals in the Amhara Region, Northwest Ethiopia., Participants: A total of 640 HCWs, with a response rate of 96.9%, participated from 1 October to 30 December 2022. A multistage stratified random sampling technique with proportional allocation was used to recruit study participants. Data were collected using the KoboCollect toolbox and exported to STATA V.17 for analysis. Descriptive statistics were used to describe data. Ordinal logistic regression analysis was used to identify predictors of confidence level to diagnose and manage mpox at p<0.05., Primary Outcome: HCWs' confidence level in diagnosing and managing mpox disease and its associated factors., Results: The overall proportion of HCWs who had high confidence level in diagnosing and managing mpox disease was found to be 31.5% (95% CI: 27.9%, 35.2%). Similarly, 26.8% (95% CI: 23.2%, 30.3%) and 41.8% (95% CI: 38.1%, 45.4%) of HCWs expressed medium and low confidence level to diagnose and manage the disease, respectively. The odds of higher confidence versus lower or medium confidence level in diagnosing and managing mpox were greater for HCWs who regularly visit amenable websites (adjusted OR (AOR)=1.59, 95% CI: 1.16, 2.2), were physicians (AOR=1.9, 95% CI: 1.32, 2.73), were aged 30-35 years old (AOR=1.64, 95% CI: 1.12, 2.39), had got public health emergency epidemic disease management training (AOR=2.8, 95% CI: 1.94, 4.04) and had positive attitudes (AOR=1.72, 95% CI: 1.26, 2.36) compared with their counterparts., Conclusion: The overall confidence level of HCWs in diagnosing and managing mpox disease in the study area was low. Therefore, the HCWs should be regularly updated about mpox disease through morning sessions and training in the diagnosis and clinical management of mpox disease including infection prevention and control., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: This study aimed to develop a patient-centred approach to the burden of acute type A aortic dissection (ATAAD) through modelling. The main objective was to identify potential improvements in managing this life-threatening cardiovascular condition and to provide evidence-based recommendations to optimise outcomes., Design: We developed a predictive model along patient pathways to estimate the burden of ATAAD through the years of life lost (YLLs) metric. The model was created based on a systematic review of the literature and was parameterised using demographic data from the German healthcare environment. The model was designed to allow interactive simulation of different scenarios resulting from changes in key impact factors., Setting: The study was conducted using data from the German healthcare environment and results from the literature review., Participants: The study included a comprehensive modelling of ATAAD cases in Germany but did not directly involve participants., Interventions: There were no specific interventions applied in this study based on the modelling design., Primary and Secondary Outcome Measures: The single outcome measure was the estimation of YLL due to ATAAD in Germany., Results: Our model estimated 102 791 YLL per year for ATAAD in Germany, with 62 432 and 40 359 YLL for men and women, respectively. Modelling an improved care setting yielded 93 191 YLL or 9.3% less YLL compared with the current standard while a worst-case scenario resulted in 113 023 or 10.0% more YLL. The model is accessible at https://acuteaorticdissection.com/ to estimate custom scenarios., Conclusions: Our study provides an evidence-based approach to estimating the burden of ATAAD and identifying potential improvements in the management of pathways. This approach can be used by healthcare decision-makers to inform policy changes aimed at optimising patient outcomes. By considering patient-centred approaches in any healthcare environment, the model has the potential to improve efficient care for patients suffering from ATAAD., Competing Interests: Competing interests: AM is a shareholder of x-cardiac and receives consulting fees from Edwards and Pfizer as well as travel grants from Abbott, Edwards, and Medtronic. All other authors declare no competing interests., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Climate change poses a major threat to our health, livelihoods and the planet. In 2020, the UK National Health Service (NHS) committed to reducing its Scope 1, 2 and 3 emissions to reach net zero by 2045. Although a net zero NHS would help to limit the consequences of climate change, little is known about the UK general public's values and preferences for the proposed service changes needed to reach net zero., Methods: This study will elicit the public's preferences for actions to help achieve net zero NHS in England and Scotland using a discrete choice experiment (DCE). The DCE attributes and levels describe actions that can be taken by the NHS across key areas: buildings and estates, outdoor space, travel and transport, provision of care, goods and services and food and catering. The survey was designed using online think-aloud interviews with 17 members of the public. Two versions of the survey will be administered to a sample of up to 2200 respondents. One will include a payment vehicle as income tax increases. We will estimate the relative importance of each attribute and, for the former survey, the monetary trade-offs which individuals are willing to make between attributes. Where possible, we will match both samples to gauge preference robustness with the inclusion of the monetary payment. We will test whether respondents' preferences differ based on their socioeconomic circumstances and attitudes toward the NHS and climate change., Ethics and Dissemination: The University of Aberdeen's School of Medicine, Medical Sciences and Nutrition Ethics Research Board has approved the study (reference: SERB/690090). All participants will provide informed consent. Results will be submitted to peer-reviewed publications and presented at relevant conferences and seminars. A lay summary of the research will be published on the Health Economics Research Unit website., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Veterans are not a demographically homogenous group, yet minority groups continue to be under-represented in research and report feeling less able to access clinical services to seek support. While veteran-specific healthcare has responded to the needs of the majority, the success of veteran mental health services is contingent on serving the whole veteran population. Key to the personalisation of healthcare is the question of access and a need to address specific inequalities and barriers to help-seeking behaviour. In this paper, we explore the issues of access to veteran healthcare at three levels: those barriers common to all veterans; those common to all minority groups of veterans; and those relevant to specific minority groups of veterans. Stigma, military attitudes and culture (eg, stoicism), and access to services and professionals with veteran-specific knowledge are universal barriers across veteran groups. Minority groups report a heightening of these barriers, alongside being 'othered' in veteran care settings, a lack of representation of them or their experiences in service descriptions and advertising, a lack of professional cultural competencies on specific issue, and the veteran environment potentially being retraumatising. Finally, barriers specific to individual groups are discussed. Attending to these is essential in developing holistic approaches to personalised healthcare that meets the needs of all veterans., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: The perspective of general practitioners' (GPs) on retirement and the factors influencing their attitude towards retirement have been previously investigated. However, while the number of GPs has been declining for many years in France, leading to the emergence of medical deserts, the impact on their patients remains to be explored. The aim of this study was to understand patients' perceptions of their GP's retirement., Design: A semistructured interview-based qualitative study was conducted, using Interpretative Phenomenological Analysis., Setting: Interviews were conducted in two general practices located in Essonne, Ile-de-France, France, between January and April 2014., Participants: Thirteen women and five men, aged 21-94 years, were included in this study. Exclusion criteria were the non-declaration of the physician as the declared doctor and being under 18 years of age., Results: The GP-patient relationship is a link that is built up over time, over the course of several consultations. Patients choose their GP based on qualities or skills they value. In this way, the physician chosen is unique for their patients; this choice reflects a certain loyalty to their physician. The interaction with the family sphere reinforces this relationship through the multiple links created during care. When a GP retires, this link is broken. Patients' reactions can range from indifference to real grief., Conclusion: This study confirms the importance of the link between the GPs and their patients and highlights the need to prepare patients for their GP's retirement., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Interhospital patient transfers have become routine. Known drivers are access to specialty care and non-clinical reasons, such as limited capacity. While emergency medical services (EMS) providers act as main patient transfer operators, the impact of interhospital transfers on EMS service demand and fleet management remains understudied. This study aims to identify patterns in regional interhospital patient transfer volumes and their spatial distribution, and to discuss their potential implications for EMS service demand and fleet management., Design: A retrospective study was performed analysing EMS transport data from the province of Drenthe in the Netherlands between 2013 and 2019 and public hospital listings. Yearly volume changes in urgent and planned interhospital transfers were quantified. Further network analysis, including geomapping, was used to study how transfer volumes and their spatial distribution relate to hospital specialisation, and servicing multihospital systems. Organisational data were considered for relating transfer patterns to fleet changes., Setting: EMS in the province of Drenthe, the Netherlands, 492 167 inhabitants., Participants: Analyses are based on routinely collected patient data from EMS records, entailing all 248 114 transports (137 168 patients) of the Drenthe EMS provider (2013-2019). From these interhospital transports were selected (24 311 transports)., Results: Interhospital transfers represented a considerable (9.8%) and increasing share of transports (from 8.6% in 2013 to 11.3% in 2019). Most transfers were related to multihospital systems (47.3%, 11 509 transports), resulting in a considerable growth of planned EMS transports (from 2093 in 2013 to 3511 in 2019). Geomapping suggests increasing transfer distances and diminishing resource efficiencies due to lacking follow-up rides. Organisational data clarify how EMS fleets were adjusted by expanding resources and reorganising fleet operation., Conclusions: Emerging interhospital network transfers play an important role in EMS service demand. Increased interhospital transport volumes and geographical spread require a redesign of current EMS fleets and management along regional lines., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: An organisation's ability to learn and adapt is key to its long-term performance and success. Although calls to improve learning within and across health organisations and systems have increased in recent years, global health is lagging behind other sectors in attention to learning, and applications of conceptual models for organisational learning to this field are needed. LEVERAGING THE 4I FRAMEWORK: This article proposes modifications to the 4I framework for organisational learning (which outlines the processes of intuition, interpretation, integration and institutionalisation) to guide the creation, retention and exchange of knowledge within and across global health organisations., Proposed Expansions: Two expansions are added to the framework to account for interorganisational learning in the highly interconnected field: (1) learning pathways across organisations via formal or informal partnerships and communities of practice and (2) learning pathways to and from macro-level 'coordinating bodies' (eg, WHO). Two additional processes are proposed by which interorganisational learning occurs: interaction across partnerships and communities of practice, and incorporation linking global health organisations to coordinating bodies. Organisational politics across partnerships, communities of practice and coordinating bodies play an important role in determining why some insights are institutionalised while others are not; as such, the roles of the episodic influence and systemic domination forms of power are considered in the proposed additional organisational learning processes., Discussion: When lessons are not shared across partnerships, communities of practice or the research community more broadly, funding may continue to support global health studies and programmes that have already been proven ineffective, squandering research and healthcare resources that could have been invested elsewhere. The '6I' framework provides a basis for assessing and implementing organisational learning approaches in global health programming, and in health systems more broadly., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: There are not enough general practitioners (GPs) in the UK National Health Service. This problem is worse in areas of the country where poverty and underinvestment in health and social care mean patients experience poorer health compared with wealthier regions. Encouraging more doctors to choose and continue in a GP career is a government priority. This review will examine which aspects of the healthcare system affect GP workforce sustainability, how, why and for whom., Methods and Analysis: A realist review is a theory-driven interpretive approach to evidence synthesis, that brings together qualitative, quantitative, mixed-methods research and grey literature. We will use a realist approach to synthesise data from the available published literature to refine an evidence-based programme theory that will identify the important contextual factors and underlying mechanisms that underpin observed outcomes relating to GP workforce sustainability. Our review will follow Pawson's five iterative stages: (1) finding existing theories, (2) searching for evidence, (3) article selection, (4) data extraction and (5) synthesising evidence and drawing conclusions. We will work closely with key stakeholders and embed patient and public involvement throughout the review process to refine the focus of the review and enhance the impact and relevance of our research., Ethics and Dissemination: This review does not require formal ethical approval as it draws on secondary data from published articles and grey literature. Findings will be disseminated through multiple channels, including publication in peer-reviewed journals, at national and international conferences, and other digital scholarly communication tools such as video summaries, X and blog posts., Prospero Registration Number: CRD42023395583., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Models of care (MoCs) describe evidence-informed healthcare that should be delivered to patients. Several MoCs have been implemented for low back pain (LBP) to reduce evidence-to-practice gaps and increase the effectiveness and sustainability of healthcare services., Objective: To synthesise research evidence regarding core characteristics and key common elements of MoCs implemented in primary healthcare for the management of LBP., Design: Scoping review., Data Sources: Searches on MEDLINE (PubMed), EMBASE, Cochrane Central Register of Controlled Trials, PEDro, Scopus, Web of Science and grey literature databases were conducted., Eligibility Criteria: Eligible records included MoCs implemented for adult LBP patients in primary healthcare settings., Data Extraction and Synthesis: Data extraction was carried out independently by two researchers and included a summary of the studies, the identification of the MoCs and respective key elements, concerning levels of care, settings, health professionals involved, type of care delivered and core components of the interventions. Findings were investigated through a descriptive qualitative content analysis using a deductive approach., Results: 29 studies reporting 11 MoCs were included. All MoCs were implemented in high-income countries and had clear objectives. Ten MoCs included a stratified care approach. The assessment of LBP patients typically occurred in primary healthcare while care delivery usually took place in community-based settings or outpatient clinics. Care provided by general practitioners and physiotherapists was reported in all MoCs. Education (n=10) and exercise (n=9) were the most common health interventions. However, intervention content, follow-ups and discharge criteria were not fully reported., Conclusions: This study examines the features of MoCs for LBP, highlighting that research is in its early stages and stressing the need for better reporting to fill gaps in care delivery and implementation. This knowledge is crucial for researchers, clinicians and decision-makers in assessing the applicability and transferability of MoCs to primary healthcare settings., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Understanding flexibility and adaptive capacities in complex healthcare systems is a cornerstone of resilient healthcare. Health systems provide structures in the form of standards, rules and regulation to healthcare providers in defined settings such as hospitals. There is little knowledge of how hospital teams are affected by the rules and regulations imposed by multiple governmental bodies, and how health system factors influence adaptive capacity in hospital teams. The aim of this study is to explore the extent to which health system factors enable or constrain adaptive capacity in hospital teams., Design: A qualitative multiple case study using observation and semistructured interviews was conducted between November 2020 and June 2021. Data were analysed through qualitative content analysis with a combined inductive and deductive approach., Setting: Two hospitals situated in the same health region in Norway., Participants: Members from 8 different hospital teams were observed during their workday (115 hours) and were subsequently interviewed about their work (n=30). The teams were categorised as structural, hybrid, coordinating and responsive teams., Results: Two main health system factors were found to enable adaptive capacity in the teams: (1) organisation according to regulatory requirements to ensure adaptive capacity, and (2) negotiation of various resources provided by the governing authorities to ensure adaptive capacity. Our results show that aligning to local context of these health system factors affected the team's adaptive capacity., Conclusions: Health system factors should create conditions for careful and safe care to emerge and provide conditions that allow for teams to develop both their professional expertise and systems and guidelines that are robust yet sufficiently flexible to fit their everyday work context., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The COVID-19 pandemic has significantly impacted frontline health workers. However, a neglected dimension of this discourse was the extent to which the pandemic impacted frontline healthcare workers providing non-communicable diseases (NCDs) care. This study aims to understand the experiences of healthcare workers with no prior exposure to pandemics who provided care to people living with NCDs (PLWNCDs)., Methods: A qualitative study design was employed, using a face-to-face in-depth interviews. Interviews were conducted in primary healthcare facilities in three administrative regions of Ghana, representing the Northern, Southern and Middle Belts. Only frontline health workers with roles in providing care for PLWNCDs were included. Purposive snowballing and convenience sampling methods were employed to select frontline health workers. An open-ended interview guide was used to facilitate data collection, and thematic content analysis was used to analyse the data., Results: A total of 47 frontline health workers were interviewed. Overall, these workers experienced diverse patient-driven and organisational challenges. Patient-level challenges included a decline in healthcare utilisation, non-adherence to treatment, a lack of continuity, fear and stigma. At the organisational levels, there was a lack of medical logistics, increased infection of workers and absenteeism, increased workload and burnout, limited motivational packages and inadequate guidelines and protocols. Workers coped and responded to the pandemic by postponing reviews and consultations, reducing inpatient and outpatient visits, changing their prescription practices, using teleconsultation and moving to long-shift systems., Conclusion: This study has brought to the fore the experiences that adversely affected frontline health workers and, in many ways, affected the care provided to PLWNCDs. Policymakers and health managers should take these experiences into account in plans to mitigate the impact of future pandemics., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Given the demand for net-zero healthcare, the carbon footprint (CF) of healthcare systems has attracted increasing interest in research in recent years. This systematic review investigates the results and methodological transparency of CF calculations of healthcare systems. The methodological emphasis lies specifically on input-output based calculations., Design: Systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline., Data Sources: PubMed, Web of Science, EconBiz, Scopus and Google Scholar were initially searched on 25 November 2019. Search updates in PubMed and Web of Science were considered until December 2023. The search was complemented by reference tracking within all the included studies., Eligibility Criteria: We included original studies that calculated and reported the CF of one or more healthcare systems. Studies were excluded if the specific systems were not named or no information on the calculation method was provided., Data Extraction and Synthesis: Within the initial search, two independent reviewers searched, screened and extracted information from the included studies. A checklist was developed to extract information on results and methodology and assess the included studies' transparency., Results: 15 studies were included. The mean ratio of healthcare system emissions to total national emissions was 4.9% (minimum 1.5%; maximum 9.8%), and CFs were growing in most countries. Hospital care led to the largest relative share of the total CF. At least 71% of the methodological items were reported by each study., Conclusions: The results of this review show that healthcare systems contribute substantially to national carbon emissions, and hospitals are one of the main contributors in this regard. They also show that mitigation measures can help reduce emissions over time. The checklist developed here can serve as a reference point to help make methodological decisions in future research reports as well as report homogeneous results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: To date, little is known on how social care data could be used to inform performance-based governance to accelerate progress towards integrated health and social care., Objectives and Design: This study aims to perform a descriptive evaluation of available social care data in the Netherlands and its fitness for integrated health and social care service governance. An exploratory mixed-method qualitative study was undertaken based on desktop research (41 included indicators), semi-structured expert interviews (13 interviews including 18 experts) and a reflection session (10 experts)., Setting: The Netherlands; social care is care provided in accordance with the Social Support Act, the Participation Law and the Law for Municipal debt-counselling., Results: This study found six current uses for social care data: (a) communication and accountability, (b) monitoring social care policy, (c) early warning systems, (d) controls and fraud detection, (e) outreaching efforts and (f) prioritisation. Further optimisation should be sought through: standardisation, management of data exchange across domains, awareness of the link between registration and financing, strengthening the overall trust in data sharing. The study found five ways the enhanced social care data could be used to improve the governance of integrated health and social care services: (a) cross-domain learning and cooperation (eg, through benchmarks), (b) preventative measures and early warning systems, (c) give insight regarding the quality and effectivity of social care in a broader perspective, (d) clearer accountability of social care towards contracting parties and policy, (e) enable cross-sector data-driven governance model., Conclusion: Although there are several innovative initiatives for the optimisation of the use of social care data in the Netherlands, the current social care data landscape and management is not yet fit to support the new policy initiatives to strengthen integrated health and social care service governance. Directions for addressing the shortcomings are provided., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Major reforms to the organisation of the National Health Service (NHS) in England established 42 integrated care systems (ICSs) to plan and coordinate local services. The changes are based on the idea that cross-sector collaboration is needed to improve health and reduce health inequalities-and similar policy changes are happening elsewhere in the UK and internationally. We explored local interpretations of national policy objectives on reducing health inequalities among senior leaders working in three ICSs., Design: We carried out qualitative research based on semistructured interviews with NHS, public health, social care and other leaders in three ICSs in England., Setting and Participants: We selected three ICSs with varied characteristics all experiencing high levels of socioeconomic deprivation. We conducted 32 in-depth interviews with senior leaders of NHS, local government and other organisations involved in the ICS's work on health inequalities. Our interviewees comprised 17 leaders from NHS organisations and 15 leaders from other sectors., Results: Local interpretations of national policy objectives on health inequalities varied, and local leaders had contrasting-sometimes conflicting-perceptions of the boundaries of ICS action on reducing health inequalities. Translating national objectives into local priorities was often a challenge, and clarity from national policy-makers was frequently perceived as limited or lacking. Across the three ICSs, local leaders worried that objectives on tackling health inequalities were being crowded out by other short-term policy priorities, such as reducing pressures on NHS hospitals. The behaviour of national policy-makers appeared to undermine their stated priorities to reduce health inequalities., Conclusions: Varied and vague interpretations of NHS policy on health inequalities are not new, but lack of clarity among local health leaders brings major risks-including interventions being poorly targeted or inadvertently widening inequalities. Greater conceptual clarity is likely needed to guide ICS action in future., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Decompensating patients require expeditious and focused care at the bedside. This can be particularly challenging when there are multiple layers of providers, each with differing specialisation, experience and autonomy. We examined the impact of our intensivist-driven hospital-wide rapid response team (RRT) at our 1171-bed quaternary care centre.Design: Single-centre retrospective cohort study.Methods: RRT service was implemented to assess, manage and triage acutely ill patients outside the intensive care unit (ICU). Criteria for consultation and workflow were established. The 24/7 team was led by an intensivist and included nurse practitioners and respiratory therapists. Over 3 years, we reviewed the impact of the RRT on patient outcomes and critical care support beyond the ICU.Results: Over 3 years, the RRT received 31 392 consults for 12 122 individual patients averaging 30 consults over 24 hours. 58.9% of the calls received were for sepsis alerts/risk of decompensation and 41.1% of the consults were for reasons of acute decompensation. Among patients that were seen by the RRT, over the course of their hospital stay, 14% were upgraded to a step-down unit, 18% were upgraded to the ICU and 68% completed care without requiring any escalation. The average mortality rate for patients seen by the RRT service during their hospital stay was 11.3% with an average 30-day readmission rate of 16.5% and average hospital length of stay 16 days without significant variation between the 3 years.Conclusions: Intensivist-led RRT ensured consistent high value care. Early intervention and consistent supervision enabled timely and efficient delivery of critical care services. [ABSTRACT FROM AUTHOR]

Introduction: Using health facility types as a measure of service availability is a common approach in international standards for health system policy and planning. However, this proxy may not accurately reflect the actual availability of specific health services., Objective: This study aims to evaluate the reliability of health facility typology as an indicator of specific health service availability and explore whether certain facility types consistently provide particular services., Design: We analysed a comprehensive dataset containing information from 1725 health facilities in Mali. To uncover and visualise patterns within the dataset, we used two analytical techniques: Multiple Correspondence Analysis and Between-Class Analysis. These analyses allowed us to quantitatively measure the influence of health facility types on the variation in health service provisioning. Additionally, we developed and calculated a Consistency Index, which assesses the consistency of a health facility type in providing specific health services. By examining various health facilities and services, we sought to determine the accuracy of facility types as indicators of service availability., Setting: The study focused on the health system in Mali as a case study., Results: Our findings indicate that using health facility types as a proxy for service availability in Mali is not an accurate representation. We observed that most of the variation in service provision does not stem from differences between facility types but rather within facility types. This suggests that relying solely on health facility typology may lead to an incomplete understanding of health service availability., Conclusions: These results have significant implications for health policy and planning. The reliance on health facility types as indicators for health system policy and planning should be reconsidered. A more nuanced and evidence-based understanding of health service availability is crucial for effective health policy and planning, as well as for the assessment and monitoring of health systems., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Countries with universal health coverage (UHC) strive for equal access for equal needs without users getting into financial distress. However, differences in healthcare utilisation (HCU) between socioeconomic groups have been reported in countries with UHC. This systematic review provides an overview individual-level, community-level, and system-level factors contributing to socioeconomic status-related differences in HCU (SES differences in HCU)., Design: Systematic review following the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) guidelines. The review protocol was published in advance., Data Sources: Embase, PubMed, Web of Science, Scopus, Econlit, and PsycInfo were searched on 9 March 2021 and 9 November 2022., Eligibility Criteria: Studies that quantified the contribution of one or more factors to SES difference in HCU in OECD countries with UHC., Data Extraction and Synthesis: Studies were screened for eligibility by two independent reviewers. Data were extracted using a predeveloped data-extraction form. Risk of bias (ROB) was assessed using a tailored version of Hoy's ROB-tool. Findings were categorised according to level and a framework describing the pathway of HCU., Results: Of the 7172 articles screened, 314 were included in the review. 64% of the studies adjusted for differences in health needs between socioeconomic groups. The contribution of sex (53%), age (48%), financial situation (25%), and education (22%) to SES differences in HCU were studied most frequently. For most factors, mixed results were found regarding the direction of the contribution to SES differences in HCU., Conclusions: SES differences in HCU extensively correlated to factors besides health needs, suggesting that equal access for equal needs is not consistently accomplished. The contribution of factors seemed highly context dependent as no unequivocal patterns were found of how they contributed to SES differences in HCU. Most studies examined the contribution of individual-level factors to SES differences in HCU, leaving the influence of healthcare system-level characteristics relatively unexplored., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: There are substantial variations in entry criteria for heart failure (HF) clinics, leading to variations in whom providers refer for these life-saving services. This study investigated actual versus ideal HF clinic inclusion or exclusion criteria and how that related to referring providers' perspectives of ideal criteria., Design, Setting and Participants: Two cross-sectional surveys were administered via research electronic data capture to clinic providers and referrers (eg, cardiologists, family physicians and nurse practitioners) across Canada., Measures: Twenty-seven criteria selected based on the literature and HF guidelines were tested. Respondents were asked to list any additional criteria. The degree of agreement was assessed (eg, Kappa)., Results: Responses were received from providers at 48 clinics (37.5% response rate). The most common actual inclusion criteria were newly diagnosed HF with reduced or preserved ejection fraction, New York Heart Association class IIIB/IV and recent hospitalisation (each endorsed by >74% of respondents). Exclusion criteria included congenital aetiology, intravenous inotropes, a lack of specialists, some non-cardiac comorbidities and logistical factors (eg, rurality and technology access). There was the greatest discordance between actual and ideal criteria for the following: inpatient at the same institution (κ=0.14), congenital heart disease, pulmonary hypertension or genetic cardiomyopathies (all κ=0.36). One-third (n=16) of clinics had changed criteria, often for non-clinical reasons. Seventy-three referring providers completed the survey. Criteria endorsed more by referrers than clinics included low blood pressure with a high heart rate, recurrent defibrillator shocks and intravenous inotropes-criteria also consistent with guidelines., Conclusions: There is considerable agreement on the main clinic entry criteria, but given some discordance, two levels of clinics may be warranted. Publicising evidence-based criteria and applying them systematically at referral sources could support improved HF patient care journeys and outcomes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Mental health and well-being of healthcare staff were majorly impacted by the COVID-19 pandemic. Little attention has been devoted to the role employers could choose to play in mitigating long-term negative consequences and how effective organisational measures taken were perceived by the individual healthcare workers. This study aims to investigate (1) whether and how healthcare professionals' mental health has changed from the second to the third pandemic year, (2) whether differences between professional groups (physicians, nurses, paramedics) identified in previous studies persisted and (3) how job demands and resources, for example, work culture and employers' measures, impacted this situation., Design: The study employs an observational, cross-sectional design, using an online survey., Setting and Participants: The study was conducted online from mid-June to mid-August 2022 among healthcare staff in state-run and private healthcare facilities, such as doctor's practices, hospitals and paramedic organisations, in Germany and Austria (n=421)., Outcome Measures: We measured psychological strain using an ICD-10-based symptom checklist, as well as subjective strain and importance of stressors using self-report questions. The ICD-10 was the 10th version of the International Statistical Classification of Diseases and Related Health Problems, a widely used standardized diagnostic manual., Results: Psychological strain stayed relatively consistent, with nursing staff suffering the most. While the job demands participants felt most affected by were structural issues (eg, staff shortages), employers were far more likely to be perceived as taking action against pandemic-specific job demands (eg, lack of protective gear). Psychological strain was lowest when staff perceived employers' actions as effective. Only 60% of those with severe enough symptoms to require psychological help had intentions of seeking such help, which is in line with past studies. This help-seeking hesitancy was also dependent on different facets of perceived work culture., Conclusions: Healthcare staff and nursing staff in particular continue to suffer in the aftermath of the COVID-19 pandemic. However, while employers were perceived as taking action against pandemic-specific job demands, pre-existing job demands causing stress and psychological strain for staff have remained uncombatted., Competing Interests: Competing interests: The authors declare no conflicts of interest., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: This study measures the differences in inpatient performance after a points-counting payment policy based on diagnosis-related group (DRG) was implemented. The point value is dynamic; its change depends on the annual DRGs' cost settlements and points of the current year, which are calculated at the beginning of the following year., Design: A longitudinal study using a robust multiple interrupted time series model to evaluate service performance following policy implementation., Setting: Twenty-two public general hospitals (8 tertiary institutions and 14 secondary institutions) in Wenzhou, China., Intervention: The intervention was implemented in January 2020., Outcome Measures: The indicators were case mix index (CMI), cost per hospitalisation (CPH), average length of stay (ALOS), cost efficiency index (CEI) and time efficiency index (TEI). The study employed the means of these indicators., Results: The impact of COVID-19, which reached Zhejiang Province at the end of January 2020, was temporary given rapid containment following strict control measures. After the intervention, except for the ALOS mean, the change-points for the other outcomes (p<0.05) in tertiary and secondary institutions were inconsistent. The CMI mean turned to uptrend in tertiary (p<0.01) and secondary (p<0.0001) institutions compared with before. Although the slope of the CPH mean did not change (p>0.05), the uptrend of the CEI mean in tertiary institutions alleviated (p<0.05) and further increased (p<0.05) in secondary institutions. The slopes of the ALOS and TEI mean in secondary institutions changed (p<0.05), but not in tertiary institutions (p>0.05)., Conclusions: This study showed a positive effect of the DRG policy in Wenzhou, even during COVID-19. The policy can motivate public general hospitals to improve their comprehensive capacity and mitigate discrepancies in treatment expenses efficiency for similar diseases. Policymakers are interested in whether the reform successfully motivates hospitals to strengthen their internal impetus and improve their performance, and this is supported by this study., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: People in underserved groups have higher rates of tuberculosis (TB) and poorer treatment outcomes compared with people with no social risk factors., Objectives: This scoping review aimed to identify interventions that improve TB treatment adherence or completion rates., Eligibility Criteria: Studies of any design focusing on interventions to improve adherence or completion of TB treatment in underserved populations in low incidence countries., Sources of Evidence: MEDLINE, Embase and Cochrane CENTRAL were searched (January 2015 to December 2023)., Charting Methods: Piloted data extraction forms were used. Findings were tabulated and reported narratively. Formal risk of bias assessment or synthesis was not undertaken., Results: 47 studies were identified. There was substantial heterogeneity in study design, population, intervention components, usual care and definition of completion rates. Most studies were in migrants or refugees, with fewer in populations with other risk factors (eg, homelessness, imprisonment or substance abuse). Based on controlled studies, there was limited evidence to suggest that shorter treatment regimens, video-observed therapy (compared with directly observed therapy), directly observed therapy (compared with self-administered treatment) and approaches that include tailored health or social support beyond TB treatment may lead to improved outcomes. This evidence is mostly observational and subject to confounding. There were no studies in Gypsy, Roma and Traveller populations, or individuals with mental health disorders and only one in sex workers. Barriers to treatment adherence included a lack of knowledge around TB, lack of general health or social support and side effects. Facilitators included health education, trusted relationships between patients and healthcare staff, social support and reduced treatment duration., Conclusions: The evidence base is limited, and few controlled studies exist. Further high-quality research in well-defined underserved populations is needed to confirm the limited findings and inform policy and practice in TB management. Further qualitative research should include more people from underserved groups., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To examine the effectiveness of shared medical appointments (SMAs) compared with one-to-one appointments in primary care for improving health outcomes and reducing demand on healthcare services by people with one or more long-term conditions (LTCs)., Design: A systematic review of the published literature., Data Sources: Six databases, including MEDLINE and Web of Science, were searched 2013-2023. Relevant pre-2013 trials identified by forward and backward citation searches of the included trials were included., Eligibility Criteria: Randomised controlled trials of SMAs delivered in a primary care setting involving adults over 18 years with one or more LTCs. Studies were excluded if the SMA did not include one-to-one patient-clinician time. All countries were eligible for inclusion., Data Extraction and Synthesis: Data were extracted and outcomes narratively synthesised, meta-analysis was undertaken where possible., Results: Twenty-nine unique trials were included. SMA models varied in terms of components, mode of delivery and target population. Most trials recruited patients with a single LTC, most commonly diabetes (n=16). There was substantial heterogeneity in outcome measures. Meta-analysis showed that participants in SMA groups had lower diastolic blood pressure than those in usual care (d=-0.086, 95% CI=-0.16 to -0.02, n=10) (p=0.014). No statistically significant differences were found across other outcomes. Compared with usual care, SMAs had no significant effect on healthcare service use. For example, no difference between SMAs and usual care was found for admissions to emergency departments at follow-up (d=-0.094, 95% CI=-0.27 to 0.08, n=6, p=0.289)., Conclusions: There was a little difference in the effectiveness of SMAs compared with usual care in terms of health outcomes or healthcare service use in the short-term (range 12 weeks to 24 months). To strengthen the evidence base, future studies should include a wider array of LTCs, standardised outcome measures and more details on SMA components to help inform economic evaluation., Prospero Registration Number: CRD42020173084., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To assess greenhouse gas (GHG) emissions from a regional hospital laundry unit, and model ways in which these can be reduced., Design: A cradle to grave process-based attributional life-cycle assessment., Setting: A large hospital laundry unit supplying hospitals in Southwest England., Population: All laundry processed through the unit in 2020-21 and 2021-22 financial years., Primary Outcome Measure: The mean carbon footprint of processing one laundry item, expressed as in terms of the global warming potential over 100 years, as carbon dioxide equivalents (CO 2 e)., Results: Average annual laundry unit GHG emissions were 2947 t CO 2 e. Average GHG emissions were 0.225 kg CO 2 e per item-use and 0.5080 kg CO 2 e/kg of laundry. Natural gas use contributed 75.7% of on-site GHG emissions. Boiler electrification using national grid electricity for 2020-2022 would have increased GHG emissions by 9.1%, however by 2030 this would reduce annual emissions by 31.9% based on the national grid decarbonisation trend. Per-item transport-related GHG emissions reduce substantially when heavy goods vehicles are filled at ≥50% payload capacity. Single-use laundry item alternatives cause significantly higher per-use GHG emissions, even if reusable laundry were transported long distances and incinerated at the end of its lifetime., Conclusions: The laundry unit has a large carbon footprint, however the per-item GHG emissions are modest and significantly lower than using single-use alternatives. Future electrification of boilers and optimal delivery vehicle loading can reduce the GHG emissions per laundry item., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To assess the evidence for anti-racist interventions which aim to reduce ethnic disparities in healthcare, with a focus on implementation in the UK healthcare system., Design: Umbrella review., Data Sources: Embase, Medline, Social Policy and Practice, Social Care Online and Web of Science were searched for publications from the year 2000 up to November 2023., Eligibility Criteria: Only systematic and scoping reviews of anti-racist interventions reported in English were included. Reviews were excluded if no interventions were reported, no comparator interventions were reported or the study was primarily descriptive., Data Extraction and Synthesis: A narrative synthesis approach was used to integrate and categorise the evidence on anti-racist interventions for healthcare. Quality appraisal (including risk of bias) was assessed using the AMSTAR-2 tool., Results: A total of 29 reviews are included in the final review. 26 are from the healthcare sector and three are from education and criminal justice. The most promising interventions targeting individuals include group-based health education and providing culturally tailored interventions. On a community level, participation in all aspects of care pathway development that empowers ethnic minority communities may provide an effective approach to reducing ethnic health disparities. Interventions to improve quality of care for conditions with disproportionately worse outcomes in ethnic minority communities show promise. At a policy level, structural interventions including minimum wage policies and integrating non-medical interventions such as housing support in clinical care has some evidence for improving outcomes in ethnic minority communities., Conclusions: Many of the included studies were low or critically low quality due to methodological or reporting limitations. For programme delivery, different types of pathway integration, and providing a more person-centred approach with fewer steps for patients to navigate can contribute to reducing disparities. For organisations, there is an overemphasis on individual behaviour change and recommendations should include a shift in focus and resources to policies and practices that seek to dismantle institutional and systemic racism through a multilevel approach., Competing Interests: Competing interests: JLYY and KF are employed by the Department of Health and Social Care in England. The views expressed are those of the authors and not necessarily those of the Department of Health and Social Care. SP is funded by a National Institute for Health Research (NIHR) ; the views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or NHS; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Hip fractures are common injuries in older age with high mortality requiring multidisciplinary clinical care. Despite guidance, there is considerable variation in hip fracture services and patient outcomes; furthermore, little is known about how successful multidisciplinary working can be enabled. This study aimed to characterise professionals' views about the core components of multidisciplinary teamwork in hip fracture care., Design: The study comprised qualitative interviews with healthcare professionals delivering hip fracture care. Interviews were audio recorded, transcribed and analysed abductively: material was coded inductively and grouped into higher level concepts informed by theories and frameworks relating to teamwork., Setting: Four hospitals in England., Participants: Participants were 40 healthcare professionals including orthopaedic surgeons, orthogeriatricians, physiotherapists and service managers., Results: Results identified four components of successful multidisciplinary teamwork: (1) defined roles and responsibilities, (2) information transfer processes, (3) shared goals and (4) collaborative leadership. These were underpinned by a single concept: shared responsibility. Defined roles and responsibilities were promoted through formal care pathways, reinforced through induction and training with clear job plans outlining tasks. Information transfer processes facilitated timely information exchange to appropriate individuals. Well-defined common purpose was hindered by complex interdisciplinary professional relationships, particularly between orthogeriatric and orthopaedic staff, and encouraged through multidisciplinary team meetings and training. Clinical service leads were integral to bridging interdisciplinary boundaries. Mutual trust and respect were based on recognition of the value of different professional groups. Teamwork depended on formal clinical leads with facilitative and motivational roles, and on hospital leadership that created an environment supporting collaboration. Shared responsibility for patients was encouraged by joint orthopaedic and orthogeriatric care models. Staff shared responsibility by assisting colleagues when needed., Conclusions: Shared responsibility across the multidisciplinary team is fundamental to delivery of hip fracture care. Findings will inform development of clinical practice recommendations and training to build teamworking competencies., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Mental health conditions constitute a significant percentage of the global burden of disease. A shortfall of mental health specialists and a lack of integration of services in primary care in low-income and middle-income countries (LMICs) contribute towards a mental health treatment gap in excess of 70%. Organising and equipping non-specialist healthcare workers is, therefore, an important strategy for improving access to mental health services in LMICs. This scoping review aims to map literature that addresses the organisation of and support provided to health teams in primary care settings within the context of integrated mental healthcare and as it relates to detection, treatment and referral of mental health conditions. The review will be guided by the 'Innovative Care for Chronic Conditions' framework., Methods and Analysis: This review protocol will employ the methodological framework first developed by Arksey and O'Malley and later advanced by others and will follow the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping reviews guidelines. This process will entail identifying the research questions, locating relevant literature, choosing eligible reports and studies, extracting the data and summarising the results in English-language studies and reports from 2008 to 2023 will be sourced from PubMed, CINAHL, Cochrane Library, PsycARTICLES, Scopus, Web of Science, Academic Search Complete and the WHO website. A two-stage screening of titles and abstracts, followed by full-text literature will be done in duplicate with blinded authors. Data extraction will be based on predefined fields., Ethics and Dissemination: All literature accessed for this scoping review is in the public domain and thus, no approval from an ethics review board is required. The findings of the scoping review report will inform future mental health research in LMIC and will be disseminated to relevant stakeholders and published in a peer-reviewed journal., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: This study aimed to document lessons learnt and best practices for scaling up an innovative emergency transportation system, drawing insights from the m-mama programme implemented in Shinyanga, Tanzania. The m-mama pilot programme was implemented in phases from 2014 to 2016 in two districts and later scaled up to include all districts in Shinyanga region in 2017. The programme employed an emergency transportation system and technical and operational support of the health system to address the three delays leading to maternal and neonatal mortality., Design: Cross-sectional, qualitative research with key healthcare system stakeholders from the national, regional and district levels., Setting: The study was conducted in Kahama and Kishapu districts in Shinyanga, Tanzania. The two districts were selected purposefully to represent the programme implementation districts' rural and urban or semiurban settings., Participants: District, regional and national stakeholders involved in implementing the m-mama pilot programme in Shinyanga were interviewed between February and March 2022., Results: Lessons learnt from implementing the m-mama programme were grouped into four key themes: community engagement, emergency transportation system, government engagement, and challenges and constraints in technical implementation. Stakeholder engagement and collaboration at all levels, community involvement in implementation, adherence to local contexts and effective government partnerships were identified as key drivers for programme success. Coordination, supervision and infrastructure enhancement were crucial in implementing the emergency transportation system., Conclusions: Facilitating community involvement, understanding the local context and adapting to existing structures can enhance programme ownership and utilisation. The government serves as the central coordinator, overseeing resource mobilisation and distribution. A well-executed and coordinated emergency transportation system holds promise in addressing delays and curbing maternal and neonatal mortality. Collaborative knowledge-sharing among implementers is essential for identifying best practices and gaining insights into practical strategies for addressing anticipated challenges., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Osteoarthritis (OA) prevalence, severity and related comorbid conditions are greater among women compared with men, but women, particularly racialised women, are less likely than men to access OA care. We aimed to prioritise strategies needed to reduce inequities in OA management., Design: Delphi survey of 28 strategies derived from primary research retained if at least 80% of respondents rated 6 or 7 on a 7-point Likert scale., Setting: Online., Participants: 35 women of diverse ethno-cultural groups and 29 healthcare professionals of various specialties from across Canada., Results: Of the 28 initial and 3 newly suggested strategies, 27 achieved consensus to retain: 20 in round 1 and 7 in round 2. Respondents retained 7 patient-level, 7 clinician-level and 13 system-level strategies. Women and professionals agreed on all but one patient-level strategy (eg, consider patients' cultural needs and economic circumstances) and all clinician-level strategies (eg, inquire about OA management needs and preferences). Some discrepancies emerged for system-level strategies that were more highly rated by women (eg, implement OA-specific clinics). Comments revealed general support among professionals for system-level strategies provided that additional funding or expanded scope of practice was targeted to only formally trained professionals and did not reduce funding for professionals who already managed OA., Conclusions: We identified multilevel strategies that could be implemented by healthcare professionals, organisations or systems to mitigate inequities and improve OA care for diverse women., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)