The key role of medical workforce well-being in the delivery of excellent and equitable care is recognised internationally. However, doctors are known to experience significant mental ill health and erosion of their well-being due to challenging demands and pressurised work environments. Existing workplace support strategies often have limited effect and do not consider the multiple factors contributing to poor well-being in doctors (e.g. individual, organisational and social), nor whether interventions have been implemented effectively. To work with, and learn from, diverse hospital settings to understand how to optimise strategies to improve doctors' workplace well-being and reduce negative impacts on the workforce and patient care. Three inter-related sequential phases of research activity: Phase 1: a typology of interventions and mapping tool to improve hospital doctors' workplace well-being based on iterative cycles of analysis of published and in-practice interventions and informed by relevant theories and frameworks and engagement with stakeholders. Phase 2: realist evaluation consistent with Realist And MEta-narrative Evidence Syntheses: Evolving Standards quality standards of existing strategies to improve hospital doctors' workplace well-being in eight purposively selected acute National Health Service trusts in England based on 124 interviews with doctors, well-being intervention implementers/practitioners and leaders. Phase 3: codeveloped implementation guidance for all National Health Service trusts to optimise their strategies to improve hospital doctors' workplace well-being - drawing on phases 1 and 2, and engagement with stakeholders in three online national workshops. Phase 1: although many sources did not clarify their underlying assumptions about causal pathways or the theoretical basis of interventions, we were able to develop a typology and mapping tool which can be used to conceptualise interventions by type (e.g. whether they are designed to be largely preventative or 'curative'). Phase 2: key findings from our realist interviews were that: (1) solutions needed to align with problems to support doctor's well-being and avoid harm to doctors; (2) involving doctors in creating solutions was important to address their well-being problems; (3) doctors often do not know what well-being support is available and (4) there were physical and psychological barriers to accessing well-being support. Phase 3: our 'Workplace well-being MythBuster's guide' provides constructive evidence-based implementation guidance, while authentically representing the predominantly negative experiences reported in phase 2. Although we sampled for diversity, the eight trusts we worked with may not be representative of all trusts in England. Misaligned well-being solutions can cause harm. It is paramount to prioritise improvements in working environments, instead of well-being 'add-on's, and to involve doctors and other relevant staff in identifying problems and in planning how to address these. Further research is required to tailor the findings to primary care, mental health and social care settings. Health economic studies of well-being interventions (ideally, at systems level) are urgently required, since small investments could have far-reaching positive impacts. 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 NIHR132931.

Women who use and/or are in treatment for using drugs during the perinatal period have complex health and social care needs. Substance use in the perinatal period is multifaceted, with many confounding factors that may impact the long-term health and well-being of both mothers and children. Evidence is needed to identify which psychosocial interventions are effective for women who use and/or are in treatment for drug use during the perinatal period. (1) Describe the range of psychosocial interventions available for women who use and/or are in treatment for drugs in the perinatal period; (2) to document evidence on the effectiveness of interventions and (3) identify interventions that women feel most meet their needs. A mixed-methods systematic review was conducted following a predetermined protocol and the Joanna Briggs Institute guidance for mixed-methods systematic reviews, adopting a segregated approach. Eight databases were searched for articles meeting the inclusion criteria on 7 April 2022, and updated searches were run on 5 February 2024. The search was limited to include peer-reviewed articles published after 1990 and available in English. In total, 15,655 articles were identified. Following screening by four reviewers by title and abstract and then full text, 197 articles were included in the review. A data extraction template was used to extract study characteristics and results. Quality was assessed using the mixed-methods Quality Appraisal Tool. Cohen's d was used to measure the effect size for quantitative data to understand if an intervention had a small (> 0.2), medium (> 0.5) or large effect (> 0.8). Effectiveness was measured through three outcomes: (1) improvements and engagement with and retention in substance use treatment services for women in the prenatal and postnatal period; (2) reductions in substance use by women in the perinatal period and (3) improvements in engagement with and retention in prenatal care. For qualitative data, articles were grouped by the intervention type and the authors' analytical themes and conclusions were thematically synthesised. The 197 included studies described 217 separate interventions. Most interventions (85.3%) were community-based, delivered in more than one way (49.3%), and delivered in single settings (50.6%), although some were colocated alongside other services (22.1%). No conclusive evidence for effectiveness was established for any type of intervention, although most interventions that improved retention in substance use services included practical support. The qualitative synthesis supported these findings and additionally suggested that women appreciated being able to access multiple services in one place: non-judgemental, trauma-informed services and peer-support models. There were wide discrepancies in the types of information reported related to the age of some studies, limiting our ability to evaluate the effectiveness through quantitative analysis. The qualitative analysis was similarly limited as not all the identified qualitative papers included the views of women about treatment received. Interventions that included practical support were found to be more effective in both the quantitative and qualitative findings. There is also some evidence for the effectiveness and feasibility of integrated, multidisciplinary interventions in both the quantitative and qualitative data. There is a need for up-to-date, high-quality research studies into interventions for pregnant women who use and/or are in treatment for drug use. It is additionally important that the voices of women are considered in future research. 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 NIHR130619.

Mother and Baby Units are specialised psychiatric facilities for women during and after pregnancy. In the United Kingdom, efforts have been made to expand the Mother and Baby Unit availability and establish care guidelines. However, the accessibility of these services for ethnic minority women remains relatively unexplored despite well-documented disparities. To explore patient pathways to Mother and Baby Units in three UK localities, with a focus on variations in pathways between services and among ethnic groups. This is a three-site, longitudinal retrospective service evaluation conducted in Birmingham, London and Nottingham during a 12-month period (1 January-31 December 2019). Electronic records were accessed to extract data on the type of admission, the referral process and the type of pathway (simple or complex). The simple pathway entailed contact with one clinician/service prior to admission to the Mother and Baby Unit, while the complex pathway involved interactions with two or more clinicians/services before Mother and Baby Unit admission. Data were collected using the adapted World Health Organization Encounter form and were analysed using uni- and multivariable analyses. Electronic records from 198 patients were analysed, with participants distributed proportionally across three sites: Birmingham (n = 70, 35.4%), London (n = 62, 31.3%) and Nottingham (n = 66, 33.3%). All Mother and Baby Units were nationally commissioned and received referrals from across England. Most patients were in the post partum period, admitted for the first time through emergency, informal and complex pathways. The average length of admission was 6 weeks. Significant differences in admission characteristics were observed between services. Patients of Asian ethnicity had more emergency admissions compared to those of Black and White ethnicities. Ethnicity was the only significant factor associated with the simple/complex care pathway. After controlling for pathway-level and patient-level factors, Black patients were 6.24 times less likely to experience a complex care pathway than White patients. No evidence was found that patients from the Black ethnic background are detained more often than White patients. The heterogeneity among categorised ethnic groups, data extracted solely from electronic records without validation through patients' personal accounts of their care pathways, unanalysed declined referrals and the utilisation of pre-COVID-19 pandemic data. The ethnic composition of the study sample matched that of the UK maternity population in the Nottingham subsample, but Black and Asian populations were over-represented in the Birmingham and London subsamples. The study provides valuable insights into patient journeys to Mother and Baby Units, highlighting significant differences between services. It also emphasises the role of ethnicity in care pathways. For example, Black patients were less likely to encounter more than two services before Mother and Baby Unit admission, suggesting either more direct access to specialist care or insufficient community-based interventions. This dual interpretation calls for future research to explore whether pathway differences among ethnic groups result from optimal clinical decision-making or gaps in care provision. Should further examine the role of ethnicity in shaping care pathways; explore the link between care pathway types and treatment outcomes; investigate if simple or complex pathways result from optimal clinical decisions or gaps in the healthcare system and explore admissions to general wards versus Mother and Baby Units and transitions between these units. 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 17/105/14.

No evidence-based support for young people who have experienced technology-assisted sexual abuse exists. The project's aims were to develop a digital intervention that improves mentalisation (the ability to understand the minds of oneself and others that underlies behaviour) to reduce the risk for revictimisation and future harm and improve young people's resilience. To co-design a mentalisation-based digital intervention; determine its feasibility, acceptability, safety and usability; and determine how to best integrate this into practice. A mixed-methods, non-randomised study in young people aged 12-18 years exposed to technology-assisted sexual abuse across two United Kingdom sites. We adapted an existing mentalisation-based therapy manual and co-designed a digital health intervention (app) using participatory methods. Recommendations from our pre-trial qualitative work with healthcare professionals supporting young people with technology-assisted sexual abuse and lived experience consultation informed app development and trial procedures. The primary outcome was the feasibility and acceptability of delivering the digital intervention measured against relevant fields of the Consolidated Standards of Reporting Trials statement for feasibility studies. Intervention safety was reported against an adverse events procedure. Usability was guided by the framework for analysing and measuring usage and engagement data in digital interventions. Acceptability was examined using qualitative methods. The planned sample size of the feasibility clinicaltrial was 60 young people. Between May 2022 and March 2023, 147 young people were screened for eligibility for the feasibility clinicaltrial; 72 referrals were made and 43 young people were allocated to receive the intervention. We found that it was possible to recruit and retain participants to this trial. Quantitative and qualitative data showed that the i-Minds app was safe, acceptable and associated with promising signals of efficacy on valuable outcomes post treatment, including technology-assisted-sexual-abuse-related post-traumatic symptoms, resilience, internalising symptoms and reflective functioning. Most participants accessed or completed app modules. User feedback indicated that participants had a positive experience using the app, positively increasing their knowledge/understanding of their own mental health and their motivation to address their mental health difficulties. Practitioners identified the barriers to implementing i-Minds into routine practice as not being involved in its design at the outset, possible impact on workload and whether digital health interventions might replace routine care. Facilitators included the distinct nature and specificity of the i-Minds app for the target group and its ability to support young people on service waiting lists. There was limited ethnic diversity in the samples, reflecting potential selection bias at the referral point. Sexual orientation is not reported in the trial. The trial lacked randomisation and a control group, limiting interpretation of post-treatment improvements. A mentalisation-based digital intervention is feasible, acceptable and safe. A larger-scale evaluation appears warranted. Further service improvements are required for routine assessment and support for young people experiencing technology-assisted sexual abuse. Further questions could be explored, including evaluating training materials for online harms, developing guidelines assessing for and responding to online harms, validated measures to assess for online harms, understanding further where digital health interventions fit along the clinical care pathway, recruiting a more diverse sample, and further differentiating the forms of online harms and their consequences. 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 NIHR131848.

Centralising specialised healthcare services into high-volume centres is proposed to improve patient outcomes and efficiency. Most reviews focus on relatively few conditions and a limited range of outcomes. To review the evidence on centralisation of a range of specialised acute services, to analyse (1) how centralisations are defined; (2) how centralisations are organised and delivered; and (3) the relationship between centralisation and several key outcomes. Scoping review, conducted in November 2020. Specialised acute healthcare services. Centralisation of services into a reduced number of high-volume units. We included 93 papers covering specialised emergency and elective acute healthcare services, published to November 2020. Definitions of centralisation commonly lacked detail, but, where available, covered centralisation's form, objectives, mechanisms and drivers. We proposed a typology of four forms of centralisation, reflecting the number and functions of specialist units (centralisation of whole pathway, centralisation of pathway components, hierarchy of specialist units, partial centralisation). For most outcomes, the majority of papers suggested a positive impact of centralisation: mortality (33/55 papers), survival (19/25), morbidity (17/27), quality of life (6/7), quality of care (22/30), length of stay (17/26), cost-effectiveness (3/3) and patient experience (3/3). Centralisation was associated with increased patient travel (9/12); 3/5 papers suggested no impact on inequalities. This review was conducted in November 2020 and did not include grey literature or studies that did not analyse outcomes, so more recent and further evidence - for example, on types of centralisation model and how centralisation was implemented - may exist. As this was a scoping review, we did not conduct a quality assessment, which may reduce the confidence with which we may view the presented impacts of centralisation. Centralisation is commonly associated with improved care and outcomes. However, research seldom describes centralised services in sufficient detail, rarely compares different service models and tends to focus on a narrow range of outcomes. Therefore, understanding the extent and nature of centralisation's impact - and the mechanisms by which it is achieved - remains elusive. By addressing these gaps, future research may of greater use to all stakeholders with an interest in centralisation. Should provide clearer descriptions of centralisations, compare different centralisation models and study a wider range of important outcomes, including patient experience and cost-effectiveness. 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 NIHR133613.

Social prescribing link workers formed part of the Additional Roles Reimbursement Scheme introduced into primary care in England from 2019. Link workers assist patients experiencing issues affecting their health and well-being that are 'non-medical' (e.g. lack of social connections, financial difficulties and housing problems). They give patients space to consider these non-medical issues and, when relevant, connect them to support, often within the voluntary-community-social-enterprise sector. We conducted an earlier realist review on the link worker role in primary care. We then carried out a realist evaluation, described in this report, to address the question: When implementing link workers in primary care to sustain outcomes - what works, for whom, why and in what circumstances? To develop evidence-based recommendations to optimise the implementation of link workers in primary care and to enable patients to receive the best support possible. A realist evaluation, involving two work packages. Data were collected around seven link workers in different parts of England. For work package 1, researchers spent 3 weeks with each link worker - going to meetings with them, watching them interact with patients, with healthcare professionals and with voluntary-community-social-enterprise staff. During this time, researchers had a daily debrief with the link worker, inviting them to reflect on their working day, and they collected relevant documents (e.g. job descriptions and information on social prescribing given to patients). They also conducted interviews with 93 primary care/voluntary-community-social-enterprise staff and 61 patients. As part of this work package, data on patient contact with a general practitioner before and after being referred to a link worker were collected. Work package 2 consisted of follow-up interviews (9-12 months later) with patients; 41 were reinterviewed. In addition, link workers were reinterviewed. A realist logic of analysis was used to test (confirm, refute or refine) the programme theory we developed from our realist review. Analysis explored connections between contexts, mechanisms and outcomes to explain how, why and in what circumstances the implementation of link workers might be beneficial (or not) to patients and/or healthcare delivery. We produced three papers from the research - one on link workers 'holding' patients, one on the role of discretion in their job, and another exploring patient-focused data and readiness to engage in social prescribing. Data from these papers were considered in relation to Normalisation Process Theory - a framework for conceptualising the implementation of new interventions into practice (e.g. link workers into primary care). By doing so, we identified infrastructural factors required to help link workers to: (1) offer person-centred care; (2) develop patients' self-confidence, sense of hope and social capital; (3) facilitate appropriate general practitioner use; (4) foster job satisfaction among those delivering social prescribing. Our research highlighted the importance of a supportive infrastructure (including supervision, training, leadership/management, clarity about the role, link workers' ability to use existing skills and knowledge and having capacity to connect with providers in the voluntary-community-social-enterprise sector) in order to produce person-centred care, to nurture hope, self-confidence and social capital among patients, to ensure they receive the right support (medical or non-medical), and to promote link workers' job satisfaction. Data showed how link workers can contribute to the offer of holistic care beyond a purely medical lens of health and illness. 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 NIHR130247.

National Health Service England piloted a low-calorie diet programme, delivered through total diet replacement and behaviour change support via 1 : 1, group or digital delivery, to improve type 2 diabetes in adults with excess weight. To coproduce a qualitative and economic evaluation of the National Health Service low-calorie diet pilot, integrated with National Health Service data to provide an enhanced understanding of the long-term cost-effectiveness, implementation, equity and transferability across broad and diverse populations. What are the theoretical principles, behaviour change components, content and mode of delivery of the programme, and is it delivered with fidelity to National Health Service specifications? What are the service provider, user and National Health Service staff experiences of the programme? Do sociodemographics influence programme access, uptake, compliance and success? What aspects of the service work and what do not work, for whom, in what context and why? Can the programme be improved to enhance patient experience and address inequities? What are the programme delivery costs, and policy implications for wide-spread adoption? A mixed-methods study underpinned by a realist-informed approach was delivered across five work packages, involving: semistructured interviews with service users (n = 67), National Health Service staff (n = 55), service providers (n = 9); 13 service provider focus groups; and service user surveys (n = 719). Findings were triangulated with clinical data from the National Health Service England's first cohort analysis (n = 7540). Fifty-five per cent of service users who started total diet replacement completed the programme and lost an average of 10.3 kg; 32% of those with data available to measure remission achieved it. Examination of programme mobilisation identified barriers around referral equality and the impact of COVID-19, while effective cross-stakeholder working and communication were key facilitators. Service delivery and fidelity assessments identified a drift in implementation fidelity, alongside variation in the behaviour change content across providers. Perceived barriers to programme uptake and engagement aligned across service providers and users, resulting in key learning on: the importance of person-centred care, service user support needs, improvements to total diet replacement and the social and cultural impact of the programme. Early National Health Service quantitative analyses suggest some socioeconomic variation in programme uptake, completion and outcomes. Insights from the evaluation and National Health Service data were combined to develop the programme theory and underpinning context, mechanisms and outcomes. These were used to develop a list of recommendations to improve the cultural competency of programme delivery, total diet replacement delivery, peer support and address psychological support needs. Cost-effectiveness analyses using short-term follow-up data indicated there is potential for the programme to be cost-effective, but not cost saving. The National Health Service low-calorie diet can provide a clinically effective and potentially cost-effective programme to support weight loss and glycaemic control in adults with type 2 diabetes. However, this evaluation identified areas for improvement in referral equity, uptake and completion, and fidelity of delivery, which have informed the development of the programme, which has now been rolled out nationally. Ongoing programme monitoring and long-term follow-up are now required. The real-world setting limited some data collection and analysis. Future work will focus on the analysis of long-term clinical and cost-effectiveness, and addressing inequalities. 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 NIHR132075.

The National Health Service faces significant challenges in recruiting and retaining registered nurses. Recruiting unregistered staff is often adopted as a solution to the registered nurse shortage, but recent research found lower registered nurse staffing levels increase hospital mortality with no evidence that higher levels of assistant staff reduced risk. To estimate the consequences, costs and cost-effectiveness of variation in the size and composition of the staff on acute hospital wards in England. To determine if results are likely to be sensitive to staff groups such as doctors and therapists, who are not on ward rosters, associations between staffing and outcomes for multiple staff groups, including medical, are explored at hospital level. A national cross-sectional panel study and a patient-level longitudinal observational study using routine data. All English acute hospital Trusts and a subsample of four Trusts for the patient-level study. Naturally occurring variation in the size and composition of the workforce. Patients experiencing a hospital admission with an overnight stay and nursing staff providing care on inpatient wards. Death, patient and staff experience, length of stay, re-admission, adverse events, incidents (Datix), staff sickness, costs and quality-adjusted life-years. Publicly available records of hospital activity, staffing and outcomes (cross-sectional study) and hospital administrative systems (longitudinal study). In the cross-sectional study, lower staffing levels from doctors and allied health professionals were associated with increased risk of death. Higher nurse staffing levels were associated with better patient experience and staff well-being. In the longitudinal study, for adult inpatients, exposure to days with lower-than-expected registered nurses or nursing assistant staff was associated with increased hazard of death (adjusted hazard ratio 1.08/1.07, 95% confidence interval 1.07 to 1.09/1.06 to 1.08) and longer hospital stays. Low registered nurse staffing was also associated with increased hazard of re-admission (adjusted hazard ratio 1.01, 95% confidence interval 1.01 to 1.02). Eliminating low staffing cost £2778 per quality-adjusted life-years gained. Avoidance of registered nurse understaffing gave more benefits and was more cost-effective for highly acute patients. Although high bank or agency staffing was associated with increased hazard of death, avoiding low staffing using temporary staff still reduced mortality but was more costly and less effective than using permanent staff. If costs of avoided hospital stays are included, avoiding low staffing generates a net cost saving. Exploration of thresholds for low staffing indicated a greater beneficial effect from registered nurse staffing higher than current norms. This is an observational study. Causal inferences cannot be made from these results in isolation. Quality-adjusted life-years gains were estimated, although conclusions are not sensitive to assumptions or discount rates. We used current ward norms as reference for low staffing. Our results show the adverse effects of low nurse staffing but also show that medical and allied health professional staffing are important considerations for patient safety. Eliminating low registered nurse staffing gave more benefits than eliminating assistant staffing. Research is needed to validate methods to determine nurse staffing requirements, and the interaction between registered nurse and assistant staffing needs further exploration. This study is registered as Current Controlled Trials ClinicalTrials.gov NCT04374812. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128056) and is published in full in Health and Social Care Delivery Research; Vol. 13, No. 25. See the NIHR Funding and Awards website for further award information.