The National Health Service in England is piloting an extension of access to its Digital Weight Management Programme, a digital service to support behavioural and lifestyle changes for weight loss. Access is being piloted to include referrals for patients with a body mass index above a threshold level set by the National Health Service England and who either have a diagnosis of osteoarthritis of the knee or hip (musculoskeletal referrals - 11 pilot sites) or are on elective surgical care waiting lists (elective care referrals - 10 pilot sites). There is a marked variation across sites in the number of patients referred. To understand reasons for variation (local implementation, barriers and facilitators) and experiences of the implementation and functioning of referral pathways for musculoskeletal and elective surgical care patients into the National Health Service Digital Weight Management Programme. A comparative case study (n = 7 sites) methodology was used, employing a mixed-methods approach following a sequential explanatory design: descriptive analysis of quantitative referral data from National Health Service England; staff (n = 25) and patient (n = 18) interviews and online workshops. Thematic analysis was conducted. Osteoarthritis treatment and elective surgery providers in the National Health Service in England. Interviews: staff and patients at three musculoskeletal and four elective care pilot sites. Workshops: staff at all pilot sites. Referral of osteoarthritis and elective surgery patients to the National Health Service Digital Weight Management Programme. Patients' and staff's views. Sites that created referral processes that optimised clinical staff time (e.g. automation and use of administrative staff) and involved ways to capture body mass index if missing from patient records were more likely to have a higher number of referrals. Despite generally positive attitudes towards the Programme, many staff felt they had insufficient information to describe it accurately to patients, which may impact both offering and acceptance of referrals. Strong leadership and personal staff motivation arealso likely to impact referral offers. Similarly, patients were more likely to accept a referral if it aligned with their attitudes towards weight management and was offered at a time where they felt they could engage with the Programme. Data were available on numbers of patients referred but not on numbers of eligible patients not referred. All patients interviewed had accepted referral to the Programme: we were unsuccessful in our attempts to recruit patients who had declined referral. No patients from minority ethnic groups volunteered to be interviewed. There is a considerable variation between case study sites in the details of how they have implemented new pathways for referring patients to the National Health Service Digital Weight Management Programme. These differences likely reflect varying local contexts. No single best model for the referral pathways has been identified. It would be desirable to capture the experiences of patients from diverse ethnic backgrounds and from patients who declined referral. Larger, longitudinal and observational studies could help understand the specifics of referral conversations as well as the effectiveness and cost-effectiveness of these referral pathways against other pathways to the Programme to aid decision-making and development of support materials for staff. This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR167932.

Women who use drugs during the perinatal period often have complex health and social care needs. Their infants can experience developmental and health problems. Despite United Kingdom's guidelines and policies on the care of pregnant women and mothers who use drugs, there is little evidence of the services that are available in the United Kingdom and whether they meet the needs of women and their infants. This study sought evidence of (1) best practice models for care that have the potential to interrupt the transmission of adversity across generations and (2) the views and experiences of women and staff on different models of care and how services could be improved. The study involved systematic reviews, longitudinal qualitative research and coproduction. There were three phases. In phase 1, an Expert Advisory and CoProduction Group was established to guide the research and to develop a theory of change for improved service models. The group comprised multidisciplinary stakeholders from health and social care and peer advisers. Two reviews were undertaken: A scoping review of UK guidance for perinatal care for women who use drugs included 111 documents, recommending integrated multidisciplinary working. A mixed-methods systematic review of evidence of integrated models of perinatal care for women who use drugs and their babies reviewed 197 studies. Qualitative findings suggest that women appreciate collocated services that are easy to access. Quantitative findings found evidence that integrated programmes at the point of delivery decrease substance use during the perinatal period. Phase 2 involved a qualitative longitudinal study in four sites, two in England and two in Scotland, that aimed to explore perinatal care pathways. Up to five interviews were conducted with 36 women, from early pregnancy up to 18 months post natal (131 interviews). Many women experienced stigma and were anxious about social services' involvement. Access to residential treatment and mental health support was uneven. Support for women who had lost care of their babies was poor. Focus group interviews (79 staff) and individual interviews (21 staff) were conducted with health and social care practitioners. Staff reported that high caseloads, staff turnover and training gaps contributed to difficulties in providing care to this challenging group. In phase 3, the Expert Advisory and CoProduction Group worked with the research team to develop a theory of change for recommendations for an optimised service model. The theory of change identified eight key recommendations and emphasised that a whole-system approach is required to meet the complex needs of this population. For the quantitative findings of the mixed-methods systematic review, the diversity of study types made it difficult to draw firm conclusions on the effectiveness of different approaches. Not all women recruited to the qualitative longitudinal study took part in all the anticipated interviews. There is a need for high-quality research studies into effective interventions for pregnant women who use drugs. Implementation research is required to test and implement the theory of change for optimum services for women who use drugs in the perinatal period. This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR130619.

People with severe mental illness (e.g. bipolar disorder, psychosis) experience poor oral health compared to the general population. They are more likely to have decayed, missing or filled teeth, and periodontal disease, which can affect quality of life and functioning. It can add to the burden of living with severe mental illness. Dentists can prevent and treat oral health problems. However, people with severe mental illness experience profound and multifaceted barriers to attendance, including practical issues, financial difficulties and dental anxiety. Unfortunately, existing dental interventions have not addressed these issues. They have not helped people with severe mental illness to attend the dentist. This project aimed to develop and evaluate a link work intervention, delivered by mental health support workers, to enable dental access in people with severe mental illness. The intervention attempted to help people to navigate dental systems and bridge the gap between services. There were four work packages: Work package 1 involved 4 co-production workshops with patients, staff, and carers (7, 6, 8 and 12 attendees, respectively). We used this information to co-develop and refine the link work intervention and associated training materials. This step ensured that the intervention was relevant and helpful to people with mental health difficulties. Work package 2 was a realist review to understand the contexts and resultant mechanisms by which link work interventions affect access to community healthcare services. A search of empirical and grey literature identified 31 reports. The analysis resulted in nine context, mechanism, and outcome configurations within three theory areas, providing useful information on how and why link work interventions might be helpful. Work package 3 was a feasibility randomised controlled trial of a link work intervention to support dental access in people with severe mental illness who had not attended a routine dental appointment in the past 3 years. Seventy-nine out of the target 84 participants were randomised to receiving either treatment as usual or treatment as usual plus the link work intervention. The majority of the feasibility criteria were met and there was high engagement with the intervention. Uptake of an optional dental examination was low at follow-up (12.7%; 95% CI: 7.0% to 21.8%). There were no serious adverse events attributable to the intervention or trial procedures. Overall, the findings supported progression to a full trial. Work package 4 was an embedded qualitative evaluation of the link work intervention and trial. Narrative-informed interviews were carried out with 18 participants in the trial (13 in the intervention arm, 5 in the treatment as usual arm) and 3 link workers. The qualitative data suggested high levels of interest and engagement from stakeholders, and need for dental intervention. The link work intervention offered practical and emotional support at different stages of access to address barriers to dental visiting at the individual, relational and organisational level. Overall, the project successfully developed and evaluated a link work intervention to enable dental access in people with severe mental illness. The authors followed participants up after 9 months and the feasibility of longer-term retention is unknown. The next step is to explore the effectiveness and cost-effectiveness of the link work intervention through a full trial. This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR132853.

The North East is one of the most disadvantaged areas of England with end-of-life care needs shaped by high levels of disability, physical and mental ill health. This programme of work aimed to set the foundation for the development of a palliative and end-of-life care research community, equipped to meet local and national challenges. Develop a self-sustaining research culture in North East palliative and end-of-life care. Build research collaborations around older age, frailty, multiple long-term conditions and inequalities and submit at least one research proposal. Convene a diverse patient and public advisory group. To establish cross-institutional collaborations, we worked with patient and public partners and key stakeholders from local National Health Service trusts, hospices, social care, our National Institute for Health and Care Research infrastructure (Applied Research Collaboration North East and North Cumbria, Policy Research Unit Older People and Frailty, National Institute for Health and Care Research Innovation Observatory, Comprehensive Research Network, and Research Design Service). A series of events were hosted to foster a research culture, including establishing a monthly seminar programme, research sandpits, bespoke research training and dissemination events. A diverse community of patient and public involvement partners was established to support and shape the developing research. Multiple project and two fellowship applications were supported by the partnership. A qualitative study identified issues pertinent to local access to data that could support research. This work has been a catalyst for palliative and end-of-life care research and practice collaborations to develop. Funding success and ongoing research and training events should provide a platform for sustained research development in this area. This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR135278.

Evidence suggests that centralising specialist healthcare services can improve outcomes for patients but increase travel distances and times. Traditionally, people requiring specialist health care were cared for by a single specialist, with mental and physical health care delivered by separate services. Recent trends involve greater collaboration between specialists. Integrated care is the highest level of collaboration, including shared access to medical records and multidisciplinary care. To investigate how centralisation of specialised healthcare services can be characterised. To examine the proposed integration between physical and mental health services in the care of children and young people with eating disorders and functional symptom disorders in one region of England. Mixed-methods study comprising: a scoping review (conducted in November 2020) of four databases to characterise centralisation of specialised healthcare services; a systematic literature review (conducted in August 2022, updated in July 2024) of three databases to evaluate integration of physical and mental health services for children and young people with eating disorders and functional symptom disorders; an interview study of parents (n = 10 participants), healthcare professionals (n = 14 participants) and a project lead (n = 1 participants) to understand perspectives on integration, which analysed data in themes organised within the Consolidated Framework for Implementation Research; and two discrete choice experiments of preferences using online surveys (n = 400 participants). The scoping review (n = 93 studies) found that definitions of centralisation commonly lacked detail but, where available, covered centralisation's form, objectives, mechanisms and drivers. Limited evidence suggests centralisation could be linked to better outcomes, but many important outcomes were rarely examined. The systematic review of integration found one low-quality (uncontrolled) pre-post study of eating disorders in Australia. Findings from the interviews suggest that service redesign should ensure the concept of 'integration' has shared meaning among professionals, and that agreement is reached over roles and responsibilities. From the discrete choice experiments, the main things that mattered to parents when thinking about integration were days missed from school in the case of eating disorders and time to diagnosis for functional symptom disorders. Limited, poor-quality literature in the reviews; small numbers of interview participants; difficulties engaging parents, carers and healthcare professionals for the discrete choice experiment. There is a lack of evidence around integrated care for children and young people affected by eating disorders and functional symptom disorders. Implementation of integrated services needs to address concerns regarding roles, responsibilities and leadership. Future evaluations should measure impact in terms of the factors found to matter most to participants in this study. Mixed-methods studies to evaluate integrated pathways. This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR133613.

The COVID-19 pandemic interrupted and, in some cases, transformed the way health visiting teams work, the way they interact with families and children and with the wider community and other service providers. Health visiting services are organised, delivered and experienced differently in different places, with little evidence to suggest what works best, for whom and in what contexts. To synthesise the evidence on changes during the pandemic to identify the potential for improving health visiting services and their delivery in the United Kingdom. This realist review engaged professional stakeholders (N = 28) and those caring for babies during the pandemic (N = 6) throughout the process. We searched five electronic databases for publications on health visiting during the COVID-19 pandemic from October 2022 to April 2023. This was followed by citation searching and review of organisational websites. Programme theory was iteratively refined through discussions with the team, professional stakeholders and people with lived experience and was translated into key findings and recommendations. One hundred and eighteen documents informed this review; most focused on health visiting in England (56%) or the United Kingdom (34%), with relatively few from Wales (6%), Scotland (3%) and Northern Ireland (1%). Documents highlighted the widespread, uneven and lasting impact of the COVID-19 pandemic on babies and families. Findings revealed significant concerns expressed by both families and practitioners and corresponding actions taken by health visiting services. These concerns and responses emphasised the flexibility and resourcefulness of health visitors, the vital role of trusting relationships between health visitors and families and the importance of holistic assessments for early intervention. Changes in service delivery were varied and were not always evaluated or sustainable. While the data illuminated some of the hidden complexities of health visiting practice, limited evidence was found on decision-making at organisational and managerial levels during the pandemic response. Included papers were predominantly from an advocacy or practitioner perspective, and few focused on health visiting in Scotland, Wales and Northern Ireland. Our focus on the universal health visiting pathways meant that documents pertaining to additional support received by the most vulnerable families might have been excluded. Experiences of Black, Asian and minority ethnic families and staff were illustrated in several papers. The COVID-19 pandemic highlighted the essential role of health visitors in safeguarding child and family well-being in the United Kingdom. While digital adaptations provide necessary continuity, face-to-face interactions remain essential for effective health visiting. The crisis exposed pre-existing workforce pressures and inconsistencies in service provision, emphasising the need for adequate support and funding. Policy-makers must recognise the complexity of health visiting and ensure sustained investment in universal home visiting services. Future resilience requires a realistic understanding of health visitors' work, integration into broader child health policies and enhanced interagency collaboration to address inequalities and improve long-term public health outcomes. Our implications for policy-makers will be translated into reflexive questions to prompt critical thinking about health visiting services in local areas. The small number of documents from countries outside England highlights this as a key area for future research. This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR134986.

Older medical inpatients have complex biopsychosocial problems, which often lead to prolonged hospital stays. Proactive Integrated Consultation-Liaison Psychiatry was designed to help ward teams manage biopsychosocial complexity and thereby reduce the time that older medical inpatients spend in hospital. To assess the experience, effectiveness and cost-effectiveness of enhancing medical care with Proactive Integrated Consultation-Liaison Psychiatry in The HOME Study. A parallel-group, multicentre, individually randomised controlled trial with process and economic evaluations in 24 medical wards of three National Health Service hospitals. Patients aged ≥ 65 years, admitted in an emergency and expected to remain in hospital for at least 2 days from the time of enrolment. Proactive Integrated Consultation-Liaison Psychiatry clinicians (consultation-liaison psychiatrists supported by assisting clinicians) made proactive biopsychosocial assessments of patients' problems, then delivered discharge-focused care as integrated members of ward teams. Usual care was provided by ward teams. Observations on training Proactive Integrated Consultation-Liaison Psychiatry clinicians and the care they provided; Proactive Integrated Consultation-Liaison Psychiatry clinicians' experiences of working in the new service model; patients' and ward staff members' experiences of Proactive Integrated Consultation-Liaison Psychiatry. Time spent as an inpatient (during the index admission and any emergency re-admissions) in the 30 days post randomisation. Rate of discharge for the total length of the index admission; discharge destination; length of the index admission post randomisation truncated at 30 days; number of emergency re-admissions, number of days in hospital and rate of death in the year post randomisation; the patient's experience of the hospital stay and view on its length; anxiety; depression; cognitive function; independent functioning; health-related quality of life; overall quality of life. Cost-effectiveness of Proactive Integrated Consultation-Liaison Psychiatry over 1, 3 and 12 months from a hospital perspective. Two thousand seven hundred and forty-four participants were enrolled (1399 male, 1345 female; mean age 82.3 years; 2565 White; 1373 Proactive Integrated Consultation-Liaison Psychiatry, 1371 usual care). Proactive Integrated Consultation-Liaison Psychiatry was experienced positively by patients (43 interviews) and ward staff (54 interviews). The mean time spent in hospital in the 30 days post randomisation was 11.37 days (standard deviation 8.74) with Proactive Integrated Consultation-Liaison Psychiatry and was 11.85 days (standard deviation 9.00) with usual care; adjusted mean difference -0.45 (95% confidence interval -1.11 to 0.21; p = 0.18). The only statistically and clinically significant difference in secondary outcomes was the rate of discharge, which was 8.5% higher [rate ratio 1.09 (95% confidence interval 1.00 to 1.17); p = 0.042] with Proactive Integrated Consultation-Liaison Psychiatry - a difference most apparent in patients who stayed for >2 weeks. Compared with usual care, Proactive Integrated Consultation-Liaison Psychiatry was estimated to be modestly cost saving and cost-effective over 1 and 3, but not 12, months. Uncertain generalisability to other populations, hospitals and healthcare systems. This is the first randomised controlled trial of Proactive Integrated Consultation-Liaison Psychiatry. Proactive Integrated Consultation-Liaison Psychiatry is experienced by older medical inpatients and ward staff as enhancing medical care. It is also likely to be cost saving in the short term. Although the trial does not provide strong evidence that Proactive Integrated Consultation-Liaison Psychiatry reduces time in hospital, it does support and inform its future development and evaluation. Effectiveness of different forms of Proactive Integrated Consultation-Liaison Psychiatry; predictors of long hospital stays; barriers to and facilitators of the implementation of biopsychosocial medical care. This study is registered as Current Controlled Trials ISRCTN86120296. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/11/16) and is published in full in Health and Social Care Delivery Research; Vol. 13, No. 41. See the NIHR Funding and Awards website for further award information.

In the United Kingdom, over 2.5 million health and social care professionals are registered by 13 statutory professional regulators. When professional conduct falls below standard, registered professionals may face an investigation into matters such as their conduct, health or competence via fitness to practise processes. Very serious cases are heard in public by an independent adjudication panel. The public, the largest source of concerns, may be asked by the regulator to be cross-examined in a hearing where their evidence may be crucial. Witness cross-examination is known to be distressing in the criminal context, where the victim is questioned about the harm they experienced and how they faced the alleged perpetrator. In fitness to practise, retelling stories could be similarly retraumatising. Our research focuses on the public (and colleagues) who raise concerns, including that they have been harmed by a professional, and examines their experience of engaging with fitness to practise processes. The study employed multiple qualitative methods. Public website materials were analysed using thematic content analysis, accessibility and readability algorithms and a useability survey about submitting a complaint (n = 11). The views of the public and those with personal experience of fitness to practise validated our analysis of the web content (n = 15). Sociolegal analysis was conducted of the United Kingdom's social work/social care regulators' conceptualisations of witness vulnerability and special measures. Twenty-seven registrants' employers were approached, and 25 were interviewed about organisational support for registrants, patients and service users. Data collection via regulators (n = 285) with small numbers via social media included surveys, (n = 64 in total) across 9 regulators, interviews (n = 47) across 10 regulators, ethnographic observation of hearings (n = 22) with 81 days of observation across 9 regulators, and documentary analysis of hearings determinations and witness statements across 13 regulators (n = 207). Project recommendations were coproduced through six formative workshops involving public members, legal, health and social care professionals, regulatory staff and lawyers and academics. Analytic methods included institutional ethnography, thematic analysis and narrative portraits. The website information for the public was often too much or too little, in inaccessible formats, and requiring high literacy and digital skills. The social care regulators' conceptions of vulnerability largely relied on inherent factors (e.g. disability), or misconduct categories, rather than being situationally sensitive to witnesses' diverse needs. The experience of those who had been harmed was found to be profoundly distressing for most participants at each stage of the fitness to practise process: having to retell their story, uncertainty about when and where they would need to respond, and taking part in a legalistic and adversarial process where their evidence, and credibility, were questioned. Findings informed 20 recommendations. Project resources are available for all stakeholders. This project provides globally unique evidence of the experiences of the public involved in health and care professional regulation. It recommends improvement of professional regulation through public-focused information, compassionate and trauma-informed communications and support, and for independent cross-regulator evaluation. Our research was informed throughout by people who had personal experience of fitness to practise, regulators, employers, lawyers and professional bodies. This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR131322.

Chronic obstructive pulmonary disease affects around 2% United Kingdom population. Timely identification of patients at risk of deterioration is crucial. Technology-enabled remote monitoring may help prevent deterioration, support chronic obstructive pulmonary disease patients at home and appropriate use of National Health Service services. Evidence on the adoption, use and experience of technology-enabled remote monitoring in the chronic obstructive pulmonary disease pathway is currently limited, impeding efforts to inform effective technology-enabled remote monitoring design and implementation. To understand what supports good practice in the implementation and use of technology-enabled remote monitoring in the chronic obstructive pulmonary disease care pathway and draw transferable lessons that can inform spread and scale up. Rapid evaluation, combining qualitative interviews, focused case studies and stakeholder workshops. Patient and public voices informed evaluation design, conduct and co-design of resources. Scoping interviews with a purposive sample of 29 national and regional stakeholders informed selection of four case study sites involved in delivering technology-enabled remote monitoring for chronic obstructive pulmonary disease. Case studies combined interviews with 19 staff and review of 18 documents. Analysis was informed by the non-adoption, abandonment and challenges to scale-up, spread and sustainability of technology framework. A stakeholder workshop (n = 23 participants) refined emerging findings. Interviews with respiratory patients and a co-design workshop informed development of patient-facing resources. Technology-enabled remote monitoring for chronic obstructive pulmonary disease occurs along a continuum of scope and scale. Technology-enabled care pathways have some common overarching features, but variation is seen across contexts and patient cohorts. Technology-enabled remote monitoring services influence care provision on a system level. Effective implementation is underpinned by service characteristics affecting its use, technology functionalities and organisational capabilities and capacities. Technology-enabled remote monitoring success also depends on defining the data-driven purpose and value proposition, ensuring buy-in, organising the workforce and workload in sustainable ways, data and IT platform interoperability, support for patients in using the service safely and appropriately, utilising existing resources, team buy-in, financial resourcing and clear policy incentives, and openness to ongoing learning. Patients value technology-enabled remote monitoring services that help them feel more connected to healthcare providers and provide timely information and support. Healthcare staff value high-quality patient care, services value affordability and sustainable workload impact. Small-scale qualitative evaluation conducted at pace. Technology can support remote monitoring but is only one aspect of an effective technology-enabled remote monitoring service. It needs to be embedded in the chronic obstructive pulmonary disease pathway and align with service needs and existing capacity in cost-effective ways and with proportionate oversight of quality and safety. Decision-makers need to consider which aspects of the technology are essential, how they can be effectively embedded and supported by an appropriately equipped workforce, and needs of different patient cohorts. There is a need for evidence on longer-term effectiveness and cost-effectiveness of technology-enabled remote monitoring for chronic obstructive pulmonary disease, impact on patient and staff experience, and issues of equity of access. Qualitative and quantitative approaches are needed to appreciate varied technology and evolving use in different settings/groups. This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR154231.