Health Research Programme Research Articles

Routine outcomes to investigate differences between ethnic minorities and White British people presenting to emergency services for injury: the stakeholder consultation.

Research has found differences in processes and outcomes of care between people in ethnic minorities and White British populations in some clinical conditions, although findings have been mixed. The Building an understanding of Ethnic minority people's Service Use Relating to Emergency care for injuries study is investigating differences in presentation, experience and health outcomes between people from ethnic minorities and White British people who seek emergency health care for injury. Our aim was to consult with stakeholders to define measurable outcomes available in routine ambulance and emergency department data; to assess the appropriateness of existing outcome measures for ethnic minorities and White British people; and to identify any gaps. Clinicians, public contributors, researchers, people from the third sector, public health, healthcare inclusion were invited to join an online workshop to discuss routine outcomes. Twenty participants attended the stakeholder consultation, with only one being a public contributor, a limitation. Eleven were from a minority ethnic background and seven were female. The integrated list of outcomes included 25 items, combining routine outcomes from the Building an understanding of Ethnic minority people's Service Use Relating to Emergency care for injuries protocol and literature (n = 17) with additional outcomes (n = 8). Notably, the initial list lacked provisions for safeguarding referrals and cases of treatment refusal, which were new additions. Safety concerns arose due to the lack of safeguarding referrals, treatment refusal and self-discharge. Factors such as pre-existing health conditions, injury location and experiences of discrimination were identified as possible influences on care quality and waiting times for ethnic minority patients. Although the number of stakeholders taking part in our consultation was low, their participation identified outcomes not found in routine data, supporting the adoption of a mixed-methods approach to answer our research questions. A future consultation could look to include more public members and wider range of clinicians including those who work in safeguarding and rehabilitation services. 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 NIHR132744.

School-level variation in children's moderate to vigorous intensity physical activity before and after COVID-19: a multilevel model analysis.

Schools play a crucial role in facilitating physical activity among children, but the COVID-19 pandemic has affected both children's physical activity and the school environment. It is essential to understand between-school differences in children's physical activity post lockdown, to determine if and how the role of schools has changed. Active-6 is a natural experiment comparing postlockdown accelerometer-estimated physical activity to a pre-COVID-19 comparator group. Accelerometer and individual data were collected on 1296 children aged 10-11 pre-COVID-19 (2017-8), with school characteristics collected from the 50 schools they attended. Post lockdown, we collected accelerometer, individual and school data from 393 children in 23 of the same schools and 436 children in 27 of the same schools in 2021 (Wave 1) and 2022 (Wave 2), respectively. Sources of variation (between-school, between-pupil and within-pupil) in child weekday moderate to vigorous physical activity at each wave were modelled using linear mixed-effects models with school-level wave random coefficients. We extended the model to estimate the proportion of between-school variation explained by school policy, curriculum and physical environment factors and school-aggregated pupil characteristics. We also explored the extent to which postlockdown differences in moderate to vigorous physical activity were mediated by individual or school factors. Between-school variation comprised 13% of the total variation pre-COVID-19, 7% in Wave 1 and 13% in Wave 2. School factors associated with moderate to vigorous physical activity were the following: whether physical education was compromised due to space (often: 9 minutes lower moderate to vigorous physical activity; sometimes: 5.4 minutes lower); high after-school club attendance (7 minutes higher moderate to vigorous physical activity for each additional club attended on average in the school); cycle training policy (4 minutes higher moderate to vigorous physical activity); and higher prevalence of active travel (1 minute higher moderate to vigorous physical activity for each 10% point increase in prevalence). These factors explained 22% of the between-school variation pre-COVID-19, and 72% at Wave 2. The relative importance changed, with cycle training policy and active travel being the most important pre-COVID-19 and cycle training policy, active after-school clubs and compromised physical education space most important in Wave 2. No factors were found to mediate the postlockdown differences in moderate to vigorous physical activity, except compromised physical education space, which had a suppressor effect in Wave 2. Only 27 of the initial 50 schools participated post lockdown, limiting our ability to make comparisons across waves. Sample sizes were additionally affected by missing data for some variables. While schools continue to play an important role in facilitating children's physical activity, the factors that contribute to this have changed post-COVID-19, with cycle training, active after-school clubs and ensuring physical education is prioritised even when space is limited now explaining nearly three-quarters of the between-school variation in children's moderate to vigorous physical activity. School-level interventions that focus on these areas, and policies that support them, may offer the potential to increase children's physical activity. This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR131847.

What happens between first symptoms and first acute exacerbation of COPD - observational study of routine data and patient survey.

Chronic obstructive pulmonary disease affects nearly 400 million worldwide - over a million in the United Kingdom - and is the third leading cause of death. However, there is limited understanding of what prompts a diagnosis, how long this takes from symptom onset and the different approaches to clinical management by primary care professionals. Map out the clinical management and National Health Service contacts from symptom presentation to chronic obstructive pulmonary disease diagnosis and first acute exacerbation of chronic obstructive pulmonary disease in three time periods; construct risk prediction for first acute exacerbation of chronic obstructive pulmonary disease. Retrospective cohort study and cross-sectional survey. Primary care. Patients with incident chronic obstructive pulmonary disease aged > 35 years in England. None. First acute exacerbation of chronic obstructive pulmonary disease. Clinical Practice Research Datalink Aurum; new online survey. Forty thousand five hundred and seventy-seven patients were diagnosed between April 2006 and March 2007 (cohort 1), 48,249 between April 2016 and March 2017 (cohort 2) and 4752 between March and August 2020 (cohort 3). The mean (standard deviation) age was 68.3 years (12.0); 47.3% were female. Around three-quarters were diagnosed in primary care, with a slight fall in cohort 3. Compliance with National Institute for Health and Care Excellence diagnostic guidelines was slightly higher in cohorts 2 and 3 for all patients; 35.8% (10.0% in the year before diagnosis) had all four elements met for all cohorts combined. Multilevel modelling showed considerable between-practice variation in spirometry. The survey on the charity website had 156 responses by chronic obstructive pulmonary disease patients. Many respondents had not heard of the condition, hoped the symptoms would go away and identified various healthcare-related barriers to earlier diagnosis. Clinical Practice Research Datalink analysis showed notable changes in post-diagnosis prescribing from cohort 1 to 2, such as increases in long-acting muscarinic antagonist (21.7-46.3%). Triple therapy rose from 2.9% in cohort 2 to 11.1% in cohort 3. Documented pulmonary rehabilitation rose from just 0.8% in cohort 1 to 13.7% in cohort 2 and 20.9% in cohort 3. For all patients combined, the median time to first acute exacerbation of chronic obstructive pulmonary disease in patients who had one was 1.4 years in cohorts 1 and 2. Acute exacerbation of chronic obstructive pulmonary disease prediction models identified some consistent predictors, such as age, deprivation, severity, comorbidities, post-diagnosis spirometry and annual review. Models without post-diagnosis general practitioner actions had a c-statistic of around 0.70; the highest c-statistic was 0.81, for cohort 2 with post-diagnosis general practitioner actions and 6-month follow-up. All models had good calibration. The three most important predictors in terms of their population attributable risks were being a current smoker and offered smoking cessation advice (32.8%), disease severity (30.6%) and deprivation (15.4%). The highest population attributable risks for variables with adjusted hazard ratios < 1 were chronic obstructive pulmonary disease review (-27.3%) and flu vaccination (-26.6%). Symptom recording and chronic obstructive pulmonary disease diagnosis vary between practice; predicted forced expiratory volume in 1 second had many missing values. There has been some improvement over time in chronic obstructive pulmonary disease diagnosis and management, with large changes in prescribing, though patient and system barriers to further improvement exist. Data available to general practitioners cannot generate risk prediction models with sufficient accuracy. It will be important to expand the COVID-era cohort with longer follow-up and augment general practitioner data for better prediction. This study is registered as Researchregistry.com: researchregistry4762. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/99/72) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 43. See the NIHR Funding and Awards website for further award information.

Ceftazidime with avibactam for treating severe aerobic Gram-negative bacterial infections: technology evaluation to inform a novel subscription-style payment model.

To limit the use of antimicrobials without disincentivising the development of novel antimicrobials, there is interest in establishing innovative models that fund antimicrobials based on an evaluation of their value as opposed to the volumes used. The aim of this project was to evaluate the population-level health benefit of ceftazidime-avibactam in the NHS in England, for the treatment of severe aerobic Gram-negative bacterial infections when used within its licensed indications. The results were used to inform National Institute for Health and Care Excellence guidance in support of commercial discussions regarding contract value between the manufacturer and NHS England. The health benefit of ceftazidime-avibactam was first derived for a series of high-value clinical scenarios. These represented uses that were expected to have a significant impact on patients' mortality risks and health-related quality of life. Patient-level costs and health-related quality of life of ceftazidime-avibactam under various usage scenarios compared with alternative management strategies in the high-value clinical scenarios were quantified using decision modelling. Results were reported as incremental net health effects expressed in quality-adjusted life-years, which were scaled to 20-year population in quality-adjusted life-years using infection number forecasts based on data from Public Health England. The outcomes estimated for the high-value clinical scenarios were extrapolated to other expected uses for ceftazidime-avibactam. The clinical effectiveness of ceftazidime-avibactam relative to its comparators was estimated by synthesising evidence on susceptibility of the pathogens of interest to the antimicrobials in a network meta-analysis. In the base case, ceftazidime-avibactam was associated with a statistically significantly higher susceptibility relative to colistin (odds ratio 7.24, 95% credible interval 2.58 to 20.94). The remainder of the treatments were associated with lower susceptibility than colistin (odds ratio < 1). The results were sensitive to the definition of resistance and the studies included in the analysis. In the base case, patient-level benefit of ceftazidime-avibactam was between 0.08 and 0.16 quality-adjusted life-years, depending on the site of infection and the usage scenario. There was a high degree of uncertainty surrounding the benefits of ceftazidime-avibactam across all subgroups, and the results were sensitive to assumptions in the meta-analysis used to estimate susceptibility. There was substantial uncertainty in the number of infections that are suitable for treatment with ceftazidime-avibactam, so population-level results are presented for a range of scenarios for the current infection numbers, the expected increases in infections over time, and rates of emergence of resistance. The population-level benefit varied substantially across the scenarios, from 531 to 2342 quality-adjusted life-years over 20 years. This work has provided quantitative estimates of the value of ceftazidime-avibactam within its areas of expected usage within the NHS. Given existing evidence, the estimates of the value of ceftazidime-avibactam are highly uncertain. Future evaluations of antimicrobials would benefit from improvements to NHS data linkages, research to support appropriate synthesis of susceptibility studies, and application of routine data and decision modelling to assess enablement value. No registration of this study was undertaken. This award was funded by the National Institute for Health and Care Research (NIHR) Policy Research Programme (NIHR award ref: NIHR135592), conducted through the Policy Research Unit in Economic Methods of Evaluation in Health and Social Care Interventions, PR-PRU-1217-20401, and is published in full in Health Technology Assessment; Vol. 28, No. 73. See the NIHR Funding and Awards website for further award information.

Impact of frailty in older people on health care demand: simulation modelling of population dynamics to inform service planning.

As populations age, frailty and the associated demand for health care increase. Evidence needed to inform planning and commissioning of services for older people living with frailty is scarce. Accurate information on incidence and prevalence of different levels of frailty and the consequences for health outcomes, service use and costs at population level is needed. To explore the incidence, prevalence, progression and impact of frailty within an ageing general practice population and model the dynamics of frailty-related healthcare demand, outcomes and costs, to inform the development of guidelines and tools to facilitate commissioning and service development. A retrospective observational study with statistical modelling to inform simulation (system dynamics) modelling using routine data from primary and secondary health care in England and Wales. Modelling was informed by stakeholder engagement events conducted in Hampshire, England. Data sources included the Royal College of General Practitioners Research and Surveillance Centre databank, and the Secure Anonymised Information Linkage Databank. Population prevalence, incidence and progression of frailty within an ageing cohort were estimated using the electronic Frailty Index tool, and associated service use and costs were calculated. Association of frailty with outcomes, service use and costs was explored with multistate and generalised linear models. Results informed development of a prototype system dynamics simulation model, exploring population impact of frailty and future scenarios over a 10-year time frame. Simulation model population projections were externally validated against retrospective data from Secure Anonymised Information Linkage. The Royal College of General Practitioners Research and Surveillance Centre sample comprised an open cohort of the primary care population aged 50 + between 2006 and 2017 (approx. 2.1 million people). Data were linked to Hospital Episode Statistics data and Office for National Statistics death data. A comparable validation data set from Secure Anonymised Information Linkage was generated. Electronic Frailty Index score calculated annually and stratified into Fit, Mild, Moderate and Severe frailty categories. Other variables included age, sex, Index of Multiple Deprivation score, ethnicity and Urban/rural. Frailty transitions, mortality, hospitalisations, emergency department attendances, general practitioner visits and costs. Frailty is already present in people aged 50-64. Frailty incidence was 47 cases per 1000 person-years. Frailty prevalence increased from 26.5% (2006) to 38.9% (2017). Older age, higher deprivation, female sex, Asian ethnicity and urban location independently predict frailty onset and progression; 4.8% of 'fit' people aged 50-64 years experienced a transition to a higher frailty state in a year, compared to 21.4% aged 75-84. Individual healthcare use rises with frailty severity, but Mild and Moderate frailty groups have higher overall costs due to larger population numbers. Simulation projections indicate frailty will increase by 7.1%, from 41.5% to 48.7% between 2017 and 2027, and associated costs will rise by £5.8 billion (in England) over an 11-year period. Simulation modelling indicates that frailty prevalence and associated service use and costs will continue to rise in the future. Scenario analysis indicates reduction of incidence and slowing of progression, particularly before the age of 65, has potential to substantially reduce future service use and costs, but reducing unplanned admissions in frail older people has a more modest impact. Study outputs will be collated into a commissioning toolkit, comprising guidance on drivers of frailty-related demand and simulation model outputs. This study is registered as NCT04139278 www.clinicaltrials.gov. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 16/116/43) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 44. See the NIHR Funding and Awards website for further award information.

Pathways to specialist community perinatal mental health services: a two-site longitudinal retrospective service evaluation.

During pregnancy and the postpartum period, women's mental health can deteriorate quickly. Timely and easy access to services is critically important; however, little is known about the pathways women take to access services. Previous research has shown that women from ethnic minority groups in the United Kingdom experience more access issues compared to the White British women. To describe pathways taken to specialist community perinatal mental health services and explore how they vary across services and ethnic groups. This is a two-site, longitudinal retrospective service evaluation conducted in Birmingham and London during 6 months (1 July-31 December 2019). Electronic records of 228 women were accessed and data were extracted on help-seeking behaviour, referral process and the type of pathway (i.e. simple or complex). Data were collected using the adapted World Health Organization encounter form and analysed using uni- and multivariable analyses. The median time from the start of perinatal mental illness to contact with perinatal mental health services was 20 weeks. The majority of patients accessed perinatal mental health services through primary care (69%) and their pathway was simple, that is they saw one service before perinatal mental health services (63%). The simple pathway was used as a proxy for accessible services. In Birmingham, compared to London, more referrals came from secondary care, more women were experiencing current deterioration in mental health, and more women followed a complex pathway. Despite differences between ethnic groups regarding type of pathway and duration of patient journey, there was no evidence of difference when models controlled for confounders such as clinical presentation, general characteristics and location. The service's location was the strongest predictor of the type of pathway and duration of patient journey. The heterogeneity among categorised ethnic groups; data extracted from available electronic records and not validated with patient's own accounts of their pathways to care; unanalysed declined referrals; the study was conducted before the COVID-19 pandemic and pathways may be different in the post-COVID-19 period. The study provides important insights into how patients find their way to community perinatal mental health services. It shows that there is a great degree of variability in the time taken to get into these services, and the pathway taken. This variation does not come from different needs of patients or different clinical presentations but rather from service-level factors. The studied community perinatal mental health services in the United Kingdom operate with a significant degree of variability in the types and characteristics of patient pathways. Future research should explore these issues on the national and international levels. Additionally, future research should explore the reasons for the different pathways taken and the outcomes and risks associated with them. 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.

Health and wellbeing of survivors of sexual violence and abuse attending sexual assault referral centres in England: the MESARCH mixed-methods evaluation.

One million people in England and Wales experience sexual violence and abuse each year, with nearly half experiencing serious sexual offences; around 30,000 survivors access sexual assault referral centres. This research was commissioned by National Institute for Health and Care Research to evaluate access, interventions and care pathways for survivors, especially those provided through sexual assault referral centres. The sexual assault referral centres care pathway was investigated through six sub-studies. There were two Cochrane Reviews (4274 participants). Seventy-two providers and 5 survivors were interviewed at eight sites; the children and young people study involved 12 participants from two sexual assault referral centres. A cohort study involving three-wave data collection over 1 year (21 sites; 2602 service users screened, 337 recruited) used a multilevel modelling framework to explore risk factors for burden of post-traumatic stress disorder symptoms at baseline and change at 1 year. We analysed costs and outcomes and conducted a narrative analysis (41 survivors). We worked closely with survivors and prioritised the safety/welfare of participants and researchers. Cochrane Reviews identified large effects from psychosocial interventions for post-traumatic stress disorder and depression. Sexual assault referral centres delivered a high-quality frontline service for survivors but groups experiencing domestic abuse and some ethnic and cultural minorities were under-represented. The qualitative research emphasised inter-agency collaboration for survivor benefit. The cohort study identified a risk 'triad' of adverse childhood experiences, poor mental health and economic deprivation, which was associated with baseline trauma burden. There were important improvements in trauma symptoms a year later. These improvements were unrelated to different sexual assault referral centre models. Costs and other outcomes were also similar across models. Harmful policing and justice practices/procedures were identified by 25% of participants. In this context, trauma-competent interviewing techniques, regular/timely updates and conveying case decisions with care signalled good practice. The cohort study lacked a comparison group, reducing confidence in the finding that access to sexual assault referral centres explained the reduction observed in post-traumatic stress disorder. Barriers to access call for concerted efforts to implement trauma-informed universal health services. The risk 'triad' underscores the value of holistic approaches to care at sexual assault referral centres and timely follow-on care. Poor mental health was the main barrier to service access beyond sexual assault referral centres. The persistence of trauma symptoms a year after accessing sexual assault referral centres signals urgent need for tackling counselling wait-lists, expanding support options and commitment to lifelong care. Multidisciplinary evaluation of sexual assault referral centres for better health provides a foundation for advancing trauma-informed practices in the context of sexual violence and abuse. This study is registered as ISRCTN30846825 https://doi.org/10.1186/ISRCTN30846825. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 16/117/04) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 35. See the NIHR Funding and Awards website for further award information.

Building research capacity and capability to enhance the quality of living and dying addressing advancing frailty through integrated care: the ALLIANCE partnership.

Frailty affects around 10% of people aged over 65 years, increasing to 65% of those over 90 years. This number is increasing. Older people with frailty are projected to become the largest future users of care services as they near end of life. Living with frailty increases vulnerability to sudden deterioration, fluctuating capacity and mortality risk. This leads to complex needs, requiring integrated care, and an approach orientated towards living with, as well as dying from, advancing frailty. However, accessing care in a timely manner can be difficult. To develop a sustainable, cross-sectoral partnership to: identify priorities to improve integrated care delivery, and care transitions, for older people with advancing frailty develop organisations in which to conduct research submit study proposal(s) for funding. To establish Partnership infrastructure and identify key contacts across palliative and end-of-life care. To understand the strengths, weaknesses, barriers and enablers of research readiness and clinical services for people with advancing frailty. To support provider services to become research ready. To establish Partnership-wide research questions and develop research proposals. The Partnership brought together experts, by profession or experience (n = 244), across specialist palliative and geriatric care and local government, to improve the delivery of integrated care for older people with advancing frailty as they near end of life. Members included older people with frailty, unpaid carers, health, social and voluntary care professionals and academics, across the East Midlands, South East England and South West London. A survey of key contacts (n = 76) mapped and scoped the Partnership's strengths, weaknesses, barriers and enablers of services for people with advancing frailty, and service providers' research readiness. Forty-six key contacts responded. Most worked in the East Midlands (59%), in health care (70%) and in the community (58%). Survey findings were used to develop a service framework and to create a short list of potential research questions. Questions were refined and prioritised through coproduction with frail older people (n = 21), unpaid carer representatives (n = 7), health, social and voluntary care professionals (n = 11) and care home representatives (n = 3). The question chosen for bid development focused on ensuring what matters most to older people with frailty informs service development. This bid is currently being written. Partnership members were also supported to develop research readiness and enhance meaningful patient and public involvement by the development and curation of multiple resources. This work was challenging. The Partnership enabled the collaboration of diverse stakeholders and fostered opportunities to improve end-of-life care for older people with advancing frailty. However, the fluidity of the workforce, lack of finance to buy-out key contacts' time, limited service integration across sectors, lack of common language and concepts across sectors, need to build research understanding and readiness, and minimal evidence of engaging frail older people approaching end of life in determining service provision and research, made achieving the initial goals overly ambitious. Nevertheless, the Partnership developed a service framework for older people living and dying with advancing frailty, and is currently coproducing a clinically applied, translational research proposal. This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR135262.

National stakeholder consultation on how to measure care home residents' quality of life.

The Developing research resources And minimum data set for Care Homes' Adoption and use or DACHA study aims to create a prototype minimum data set combining residents' information recorded by care homes with their data held in health and social care data sets. The DACHA minimum data set will contain information on quality of life. Internationally and in the UK, there is no consensus on collecting information on quality of life in a standardised format equivalent to the consensus for health measures. This paper describes an online consultation with stakeholder representatives about how to measure the quality of life of residents in UK older-adult care homes, for inclusion in the DACHA minimum data set. We drew on principles of the Delphi technique, identifying participants knowledgeable about living, working in and visiting care homes, and preference scoring. We used a bespoke online research engagement platform (Thiscovery, www.thiscovery.org, Cambridge, UK) to engage the participants. Participants included care home staff and managers, old age specialists (clinical/research), commissioners/providers/regulators, primary care professionals, relatives/family carers of care home residents. The consultation is complementary to DACHA's research and patient and public involvement and engagement activities, which have involved people living in care homes; thus, care home residents were not included in this consultation. The first round asked 30 participants to rank the most important principles and domains to consider when measuring quality of life in care homes. Responses to round 1 informed the selection of quality of life measures that round 2 (September 2022) participants were asked to report their familiarity with and confidence in a range of outcome measures all of which met the criteria identified as important in round 1. Recruitment was extended in round 2, and 72 individuals participated. Based on the rankings and the qualitative feedback in round 2, we included four of the shortlisted quality of life outcome measures in DACHA's prototype minimum data set for care homes. The qualitative feedback suggested a shared understanding across the different representative groups about the strengths and limitations of the selected measures. This work makes an important contribution, understanding the opportunities that quality of life measures pose for different stakeholder groups as regular users of care home resident data. In future DACHA work, interviews and focus groups will collect further data about the perceptions of care home staff who completed measures during the pilot study and about the usefulness of the data collected via these measures. The quality-of-life section of the DACHA minimum data set can contribute to informing similar care home data sets internationally. 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 NIHR127234.

Quality of life, capability well-being, financial strain and physical activity in the short- and medium-term COVID-19 post-lockdown phases in the UK: a repeated cross-sectional study.

The COVID-19 lockdowns had negative effects on children's and adults' mental and physical health. There is, however, a paucity of research that explores differences in health-related quality of life (HRQL) and well-being over time after the COVID-19 lockdowns had been lifted. Furlough during lockdowns, increases in unemployment, and the emerging cost-of-living crisis all put pressure on family finances, which could have a detrimental effect on HRQL and well-being. This study, part of the wider Active-6 study, explored how HRQL, capability well-being and family financial strain changed after the lockdowns, the relationship between these outcomes, and whether physical activity had any mediating effect on differences in HRQL and capability well-being. Cross-sectional data were collected in May-December 2021 (Wave 1) and January-July 2022 (Wave 2). Children (aged 10-11) and their parent/carer were recruited from 23 to 27 schools in each wave, respectively, and completed validated questionnaires measuring HRQL (adults - EQ-5D-5L, children - CHU9D), capability well-being (adults - ICECAP-A) and family financial strain (adults - Family Economic Strain Scale, FESS). Children also completed questions on capability well-being. Weekday minutes of moderate-to-vigorous physical activity (MVPA) were measured using accelerometers. Mixed-effects regression models, adjusted for gender, age group (adults only), IMD and highest household education, were used to explore differences in HRQL and capability well-being between waves. In addition, the moderating effect of financial strain and the mediating effect of MVPA on HRQL and capability well-being were explored. Active-6 recruited 393 parent-child pairs in Wave 1 and 436 in Wave 2. There were no differences in HRQL (EQ-5D, CHU9D) and capability well-being (ICECAP-A) scores between waves, but financial strain was worse in Wave 2 compared to Wave 1 (FESS score difference 1.14 adjusted 95% CI 0.15 to 2.12). Increased financial strain was associated with lower (worse) EQ-5D-5L, CHU9D and ICECAP-A scores. There was no evidence of a mediating effect of MVPA. Pre-COVID-19 data on HRQL were not collected, so analysis was limited to post-lockdown only. Participating parents were predominantly female and participation was lower among lower socio-economic groups, limiting our ability to explore inequalities. Intervention planning to increase physical activity and health and well-being during the COVID-19 recovery should consider the financial strain families are experiencing and the negative implications of financial strain on HRQL. There were no differences in HRQL and capability well-being in children and adults after lockdowns lifted in 2021 and a year later in 2022. The results indicate increasing financial strain, which could reflect the UK's 'cost of living crisis'. This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR131847.

Vaccine Completion and Timeliness Among Children in the Military Health System: 2010-2019.

Few studies have evaluated pediatric vaccination coverage in the Military Health System, although some evidence suggests lower than ideal coverage. This study assessed vaccine completion and timeliness among military dependents through age 24 months. Children born at military hospitals from 2010 through 2019 were identified using Department of Defense Birth and Infant Health Research program data. Vaccine completion and timeliness were assessed for diphtheria, tetanus, and pertussis; polio; measles, mumps, and rubella; hepatitis B; Haemophilus influenzae type b; varicella; and pneumococcal conjugate individually and as a combined 7-vaccine series; rotavirus was assessed separately. Modified Poisson regression models were used to calculate risk ratios (RRs) and 95% confidence intervals (CIs) for noncompletion and delays, adjusting for demographic characteristics. Of 275 967 children, 74.4% completed the combined 7-vaccine series, and 36.2% of those who completed the series had delays. Completion peaked at 78.7% among children born in 2016 and 2017. Among all vaccines, completion was lowest for rotavirus (77.5%), diphtheria, tetanus, and pertussis (83.1%), Haemophilus influenzae type b (86.6%), and pneumococcal conjugate (88.4%). Risk for noncompletion was higher among children born to younger pregnant parents (adjusted RR = 1.33; 95% CI = 1.27-1.40) and with a well-child care location change (adjusted RR = 1.10; 95% CI = 1.09-1.12). Risk for delays paralleled that for noncompletion. Vaccine completion and timeliness generally improved among military children, but greater noncompletion of vaccine series with more versus fewer doses and disparities for younger and mobile service members suggest system barriers remain.

Role, function, and expectations of research funding committees: Perspectives from committee members

Research funding committees play an integral role in the research funding process, consisting of a range of skills, knowledge, and expertise (e.g., professional, and public contributors). Although there is some evidence that has explored the efficiency and effectiveness of funding committees in terms of the funding process, there is a lack of published evidence about the purpose, role, and function of funding committees, from the perspective of committee members. A subset of survey data from a cohort of six National Institute for Health and Care Research (NIHR) research programmes, exploring the purpose of a funding committee, and the expectations and role of a funding committee member between October 2020 to December 2021. All committee members were eligible to participate in the survey. Using an inductive approach, 50 completed responses (22.5% response rate) were analysed, focusing on the role of a funding committee member and the functions of a funding committee. Participants highlighted seven key areas for the purpose of a funding committee: prioritising and recommending what research to fund (n=36) and assessment of quality (n=24) being the most common responses. Four areas were considered important to the expectations and role of funding committee members, with reviewing, critically appraising, and discussing applications (n=44); and being fair, objective, and unbiased (n=27) being the most common responses. The findings offer a unique insight into committee members’ expectations about the role, purpose and function of a funding committee and their contribution to the funding recommendation process. There was high agreement that the purpose and role of committees and their members was to offer expert advice to make fair, impartial decisions on which research should be prioritised. Exploring the purpose, role, and function of funding committees has relevance and importance for funding organisations seeking to enhance and optimise the decision-making practice of funding committees.

Types and aspects of support that young carers need and value, and barriers and enablers to access: the REBIAS-YC qualitative study.

Many children and young people in England provide support to family members who are disabled, have mental or physical ill health, or misuse drugs or alcohol. Providing care can negatively impact children and young people's education, employment, health and social participation, with associated costs. Support is needed to prevent and reduce these negative impacts. The study sought to provide new knowledge and address prior research gaps regarding how best to support young carers from their perspective and that of the people they care for. To address the following questions: What types, components or features of services and other support are seen as helpful, valued, and acceptable to young people who look after someone at home and the people they support? Conversely, what is found to be less or unhelpful? What additional support is perceived as needed? What are the barriers experienced by young and young adult carers in seeking and accessing services for themselves or the person they support? What are the barriers and facilitators for practitioners in providing support and services perceived as valued, helpful and needed by young and young adult carers and the people they support? In-depth qualitative methodology using focus groups, in-depth semistructured interviews and workshops in four localities in England. One hundred and thirty-three carers aged 9-25 years with a range of caring and life circumstances and sociodemographic characteristics. Seventeen adult care recipients (parents) with a range of physical and/or mental healthcare and support needs. Nineteen practitioners from schools, colleges, young carers organisations, voluntary sector services, mental health services, the National Health Service, adult social care and local authority adult and children's social care commissioners. The types and aspects of support that young carers and their families need, and value when received, include: support that reduces or removes their practical and emotional caring responsibilities; support to mitigate the negative impacts of care and help with other life issues; information and advice about services and wider resources and support; someone trusted available to talk to; greater awareness, recognition and understanding; and choice, flexibility, and co-development of plans and solutions. We found a great deal of unmet need for support, and variation in type and quality of support received, including geographically. Potential limitations are that we were not able to engage with, or recruit, young carers from some intended subgroups, meaning some perspectives are missing. Partly because of COVID-19 measures during the study, we mainly recruited through young carers organisations and their family projects, although this was balanced by recruitment through schools and extensive outreach and engagement by the collaborating organisations prior to the project starting. Action is now needed to consistently and sustainably implement the types of support that young carers and the people they care for say they need and value. Future work should include more research from the perspectives of young carers and the people they care for, especially from particularly marginalised groups; and research to understand what works and how to improve implementation of the support needed and valued. This study is registered as Current Controlled Trials ISRCTN13478876. https://doi.org/10.1186/ISRCTN13478876. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR129645) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 36. See the NIHR Funding and Awards website for further award information.

Interventions to minimise hospital winter pressures related to discharge planning and integrated care: a rapid mapping review of UK evidence.

Winter pressures are a familiar phenomenon within the National Health Service and represent the most extreme of many regular demands placed on health and social care service provision. This review focuses on a part of the pathway that is particularly problematic: the discharge process from hospital to social care and the community. Although studies of discharge are plentiful, we identified a need to focus on identifying interventions and initiatives that are a specific response to 'winter pressures'. This mapping review focuses on interventions or initiatives in relation to hospital winter pressures in the United Kingdom with either discharge planning to increase smart discharge (both a reduction in patients waiting to be discharged and patients being discharged to the most appropriate place) and/or integrated care. We conducted a mapping review of United Kingdom evidence published 2018-22. Initially, we searched MEDLINE, Health Management Information Consortium, Social Care Online, Social Sciences Citation Index and the King's Fund Library to find relevant interventions in conjunction with winter pressures. From these interventions we created a taxonomy of intervention types and a draft map. A second broader stage of searching was then undertaken for named candidate interventions on Google Scholar (Google Inc., Mountain View, CA, USA). For each taxonomy heading, we produced a table with definitions, findings from research studies, local initiatives and systematic reviews and evidence gaps. The taxonomy developed was split into structural, changing staff behaviour, changing community provision, integrated care, targeting carers, modelling and workforce planning. The last two categories were excluded from the scope. Within the different taxonomy sections we generated a total of 41 headings. These headings were further organised into the different stages of the patient pathway: hospital avoidance, alternative delivery site, facilitated discharge and cross-cutting. The evidence for each heading was summarised in tables and evidence gaps were identified. Few initiatives identified were specifically identified as a response to winter pressures. Discharge to assess and hospital at home interventions are heavily used and well supported by the evidence but other responses, while also heavily used, were based on limited evidence. There is a lack of studies considering patient, family and provider needs when developing interventions aimed at improving delayed discharge. Additionally, there is a shortage of studies that measure the longer-term impact of interventions. Hospital avoidance and discharge planning are whole-system approaches. Considering the whole health and social care system is imperative to ensure that implementing an initiative in one setting does not just move the problem to another setting. Time limitations for completing the review constrained the period available for additional searches. This may carry implications for the completeness of the evidence base identified. Further research to consider a realist review that views approaches across the different sectors within a whole system evaluation frame. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130588) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 31. See the NIHR Funding and Awards website for further award information.

The Resilience Hub approach for addressing mental health of health and social care workers during the COVID-19 pandemic: a mixed-methods evaluation.

Resilience Hubs provide mental health screening, facilitation of access and direct provision of psychosocial support for health and social care keyworkers in England affected by the coronavirus disease 2019 pandemic. To explore implementation of the Hubs, including characteristics of staff using the services, support accessed, costing data and a range of stakeholder perspectives on the barriers and enablers to Hub use and implementation of staff well-being support within the context of the pandemic. Mixed-methods evaluation. Four Resilience Hubs. Findings were integrated via mixed-method case studies, including: analyses of Hub mental health screening (N = 1973); follow-up questionnaire data (N = 299) on service use and health status of Hub clients; economic information provided by the Hubs; 63 interviews with Hub staff, wider stakeholders, Hub clients and keyworkers who did not use the Hubs. Findings were consistent across Hubs and workstreams. Most Hub clients were NHS staff. Under-represented groups included men, keyworkers from minority ethnic communities, care homes and emergency services staff. Clients reported comorbid mental health needs across multiple domains (anxiety; depression; post-traumatic stress; alcohol use; functioning). Their health status was lower than population norms and relevant pre-pandemic data. Several factors predicted higher needs, but having pre-pandemic emotional well-being concerns was one of the most robust predictors of higher need. Sixty per cent of participants who completed follow-up questionnaires reported receiving mental health support since Hub screening, most of which was directly or indirectly due to Hub support. High levels of satisfaction were reported. As in many services, staffing was the central component of Hub cost. Hubs were predominantly staffed by senior clinicians; this staffing model was consistent with the generally severe difficulties experienced by clients and the need for systemic/team-based working. Costs associated with health and social care use for Hub clients were low, which may be due to barriers to accessing support in general. Enablers to accessing Hubs included: a clear understanding of the Hubs, how to self-refer, and managerial support. Barriers included confusion between Hubs and other support; unhelpful beliefs about job roles, unsupportive managers, negative workplace cultures and difficulties caused by systemic issues. Some keyworkers highlighted a perceived need for further diversity and cultural competency training to improve reach to under-represented communities. Other barriers for these groups included prior negative experiences of services, structural inequalities and stigma. Some wider stakeholders had concerns around growing waiting times for Hub-provided therapy, and insufficient data on Hub usage and outcomes. Feedback was otherwise very positive. Main limitations included lack of comparative and pre-pandemic/baseline data, small numbers from under-represented groups limiting fine-grained analysis, and participant self-selection. Findings highlighted the value of the Hub model of outreach, screening, support navigation and provision of direct support during the coronavirus disease 2019 pandemic, and as a potential model to respond to future crises. The research provided recommendations to improve Hub promotion, equality/diversity/inclusion access issues, management of specialist resources and collection of relevant data on Hub outcomes and activities. Broader recommendations for the primary prevention of mental health difficulties across the health and care system are made, as individual support offers should be an adjunct to, not a replacement for, resolutions to systemic challenges. Research recommendations are made to conduct more robust evaluations of the clinical and cost-effectiveness of the Hubs, using larger data sets and comparative data. This study is registered as researchregistry6303. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR132269) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 29. See the NIHR Funding and Awards website for further award information.

Women's Health Hubs: a rapid mixed-methods evaluation.

Women's sexual and reproductive health needs are complex and vary across the life course. They are met by a range of providers, professionals and venues. Provision is not well integrated, with inequalities in access. In some areas of the United Kingdom Women's Health Hubs have been established to improve provision, experience and outcomes for women, and to address inequalities and reduce costs. These models were established prior to the national implementation of Women's Health Hubs announced in the English 2022 Women's Health Strategy. To explore the 'current state of the art', mapping the United Kingdom landscape, and studying experiences of delivering and using Women's Health Hubs across England, defining key features and early markers of success to inform policy and practice. A mixed-methods evaluation, comprising three work packages: Mapping the Women's Health Hub landscape and context and developing a definition of Women's Health Hubs, informed by an online national survey of Women's Health Hub leaders, and interviews with regional stakeholders. In-depth evaluation in four hub sites, including interviews with staff and women, focus groups in local communities and documentary analysis. Interviews with national stakeholders and consolidation of findings from work packages 1 and 2. Fieldwork was undertaken from May 2022 to March 2023. The evaluation was initiated prior to the national scale-up of Women's Health Hubs announced in the 2022 Women's Health Strategy. Most areas of the United Kingdom did not have a Women's Health Hub. Seventeen active services were identified, established between 2001 and 2022. Women's Health Hubs were diverse, predominantly GP-led, with different perspectives of the role and definition of a hub. Women using hubs reported positive experiences, finding services caring and convenient. Implementation facilitators included committed, collaborative leaders working across boundaries, sufficient workforce capacity and a supportive policy context. Challenges included access to funding, commissioning, workforce issues, facilities and equipment, stakeholder engagement and wider system integration, priorities and pressures. Leaders were committed to addressing inequalities, but evidence of impact was still emerging. It was challenging to locate models; therefore, some may have been missed. Data availability limited assessment of impact, including inequalities. Some population groups were not represented in the data, and the evaluation was more provider-oriented. It was not possible to develop a typology of Women's Health Hubs as planned due to heterogeneity in models. Existing Women's Health Hub models were providing integrated approaches to meet local needs. Many were at an early stage of development. Evidence of system-level impact and costs was still emerging. Women's Health Hubs may widen inequalities if models are more accessible to advantaged groups. The important role of committed leaders in existing 'bottom-up' models may limit scalability and sustainability. Findings suggest that national scale-up will take time and requires funding and that it is necessary to design models according to local needs and resources. In 2023, the Department of Health and Social Care announced funding to establish a Women's Health Hub in every Integrated Care System in England. Future evaluation should consider system-level impact and costs, explore unintended consequences and test assumptions. This award was funded by the National Institute of Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR135589) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 30. See the NIHR Funding and Awards website for further award information.

Meeting social welfare legal needs in end-of-life care: co-creation of a system-wide research partnership.

Social welfare legal needs (matters of daily life, such as finances, housing and employment with legal rights, entitlements or protections) are prevalent towards end of life, creating significant difficulties for both patients and carers. Most people do not know where to go, although a range of services provide advice and support for addressing social welfare legal problems. Navigating this complex and fragmented system across health, social care and social welfare legal support is very challenging. Healthcare professionals are often the first contact for social welfare legal needs, although these are often overlooked and their impact on health and well-being unrecognised. Interprofessional learning can increase awareness of social welfare legal needs and build connections between service providers, offering a more holistic and cohesive multiagency response to the complex needs around end of life. The aim of the research was to co-create a robust foundation for cross-agency research investigating the impact of interprofessional learning on social welfare legal needs towards end of life in the North East England region. Convene a research partnership group across academics, multiagency service providers and members of the public with lived experience. Consider and agree key issues for successful place-based multiagency research in this area. Co-create a complexity-appropriate research proposal with interprofessional learning as an intervention. A series of research activities was implemented to convene a multiagency partnership group and consider the key issues for successful place-based multiagency research. Data were collected from two online workshops, an optional reflective workbook, and a modified Delphi technique. Initial participants were selectively recruited from our established stakeholder and patient and public involvement groups. Increasing diversity of the partnership continued throughout the project, using contacts provided by group members. Representation of services supporting underserved groups was a priority. All invited participants were recruited to the partnership, although contribution to research activities was variable. The partnership bridged knowledge gaps between services and united diverse perspectives, expertise and experience. A greater understanding of the barriers and opportunities for place-based multiagency working was generated, such as considering the importance of language in facilitating collaboration and responding to concerns around capacity. A non-hierarchical partnership was meaningful, with both personal and professional insights viewed as equally important. Facilitators to engagement with interprofessional learning were identified including the need for leadership endorsement. A non-traditional, mixed-method approach to interprofessional learning evaluation was favoured, with both qualitative and quantitative measures at three levels: patient and carer, professional learners and organisations. Important outcomes included raising awareness, connectedness and space to reflect. The partnership group expanded throughout the course of the project. While this extended diversity, variable participation hindered depth of discussion, with participants engaging at different points and with different understanding levels of the project. Supplementary materials provided some mitigation. Capacity and funding constraints limited engagement for some participants. Convening a multiagency partnership generated insights into the benefits, barriers and facilitators to research co-design and potential measures of success of interprofessional learning. Learning from this project has informed a complexity-appropriate research proposal to evaluate the impact of interprofessional learning as an intervention across different stakeholders. 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 NIHR135276.

Patient buy-in to social prescribing through link workers as part of person-centred care: a realist evaluation.

Social prescribing link workers have become part of primary health care in recent years. They help patients to recognise non-medical factors affecting their health and identify sources of support, often in the voluntary, community and social enterprise sector. They form part of wider work to strengthen person-centred care, which actively seeks to engage individuals in decision-making about their health, taking into account their medical, social, psychological, financial and spiritual circumstances. To understand how buy-in to social prescribing and the link worker role is established for a patient, and how this relates to person-centred care. A realist evaluation. Patients engaging with link workers in seven different parts of England were involved. As part of data collection, we observed link workers interacting with 35 patients. We also interviewed 61 patients and re-interviewed 41 of them 9-12 months later. Data were coded and developed into context-mechanism-outcome configurations, which were used to produce a programme theory. Data highlighted how patients might be uncertain about the link worker role but agree to a referral as they sought assistance with their non-medical issues. Patients talked about experiencing a sense of hope through the trust they developed in a link worker. This trust was established through the communication skills and knowledge demonstrated by a link worker, and by their ability to act as an anchor point when required - a reliable, consistent source of support to whom patients could offload. The link worker role also involved connecting patients to external support, which called for sensitivity around how ready someone was to move forward; this was shaped by a patient's motivation but also their capacity to make changes given other demands in their life. Connecting patients to external support could be affected by structural factors outside the link workers' control (e.g. housing options or employment opportunities). We did not interview patients who had rejected the offer of social prescribing, and most had a positive view of meeting with a link worker. Person-centred care is engendered by link workers through their skills, knowledge and ability to respond to the individual readiness of patients to engage with external support. It can be curtailed by structural factors outside link workers' sphere of control, such as access to housing or caring responsibilities of patients. This can hinder patients' ability to 'connect to', leaving link workers to continue 'connecting with' patients as they act as an anchor point. Exploration is required of factors affecting patients who interact with a link worker but do not access external support. Longitudinal work with a cohort of patients, speaking to them on a regular basis, may provide further understanding in this respect. 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 NIHR130247.

Health visiting in the UK in light of the COVID-19 pandemic experience: (RReHOPE) findings from a realist review.

Child health programmes in the United Kingdom offer every child and their family an evidence-based programme to support child health and development. During the COVID-19 pandemic, health visiting services in many areas were reduced to a partial service, with significant variability between and within the four United Kingdom countries. This study investigated the impact of the pandemic on health visiting services and developed recommendations for policy and practice. Conduct a realist review of relevant literature. Engage with key stakeholders in policy, practice and research across the United Kingdom. Identify recommendations for improving the organisation and delivery of health visiting services, with a focus on services being equitable, effective and efficient. The realist review followed Pawson's five iterative steps and involved key stakeholder representatives at every step. We searched five electronic databases and references of included articles, as well as relevant organisational websites, to find quantitative, qualitative, mixed-methods and grey literature related to health visiting services in the United Kingdom during the COVID-19 pandemic. An assessment of their relevance to our initial programme theory determined inclusion in the review. Data were extracted, organised and presented as draft context, mechanism and outcome configurations. These were iteratively refined through meetings with 6 people with lived experience of caring for babies during the pandemic and 23 professional stakeholders. Context, mechanism and outcome configurations were then translated into findings and recommendations. One hundred and eighteen documents contributed to the review and collectively revealed the far-reaching, uneven and enduring impact of the COVID-19 pandemic on babies and families. Data uncovered significant concerns of families and practitioners amidst the pandemic, along with the service's corresponding actions. These concerns and responses underscored the critical importance of fostering and sustaining trusting relationships between health visitors and families, as well as conducting holistic assessments for early intervention. Although we found minimal evidence of decision-making within organisational/managerial levels, the data illustrated the diverse and complex nature of health visiting work and the need for flexibility and resourcefulness. The primary limitation of this review was a lack of specific evidence from the United Kingdom nations other than England. There was also a lack of data focusing on changes during the COVID-19 pandemic at a local management level. The needs of babies, children and families, and the delivery of services to support them, were not prioritised in the early phase of the pandemic response. Our data show that the health visiting service was concerned with maintaining visibility of all children, and especially supporting families with a new baby. Health visiting services adapted in numerous ways to respond to these concerns. Implications for policy and practice are presented, identified from our analysis and discussions with stakeholders. The RReHOPE study is part of a jigsaw of evidence, which will provide a much stronger evidence base for future policy and practice. This realist review presents several areas for future research, including how health visiting is organised at local management level; how to optimise limited resources; factors affecting differing uptake in different regions; and analysis of the effectiveness of health visiting using large cohort studies. This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme under award number NIHR134986.

The use of locum doctors in the NHS: understanding and improving the quality and safety of care.

The use of locum doctors in the National Health Service is widely believed to have increased, and there have been widespread and sustained concerns among policy-makers, healthcare providers, professional associations and professional regulators about the quality/safety, cost and effective use of locum doctors. To provide evidence on the extent, quality and safety of medical locum practice and the implications of medical locum working for health service organisation and delivery in primary and secondary care in the English National Health Service, to support policy and practice. Four interlinked work packages involving surveys of National Health Service trusts and of general practices in England; semistructured interviews and focus groups across 11 healthcare organisations in England; analysis of existing routine data sets on the medical workforce in primary care and in National Health Service trusts in England from National Health Service Digital and National Health Service Improvement; and analysis of data from the Clinical Practice Research Datalink in primary care and of electronic patient record data from two National Health Service hospitals in secondary care. In primary care, about 6% of general practice medical consultations were undertaken by locums in 2010 and this had risen slightly to about 7.1% in 2021. In National Health Service trusts (mostly secondary care and mental health), about 4.4% of medical staff full-time equivalent was provided by locum doctors. But those overall national rates of locum use hide a great deal of variation. In primary care, we found the National Health Service Digital workforce returns showed the rate of locum use by Clinical Commissioning Group varied from 1% to almost 31%. Among National Health Service trusts, the reported rate of locum use varied from < 1% to almost 16%. We found that there was poor awareness of and adherence to national guidance on locum working arrangements produced by National Health Service England. Our research showed that locum working can have adverse consequences for the quality and safety of care, but that such consequences were probably more likely to result from the organisational setting and the working arrangements than they were from the locum doctors themselves and their competence, clinical practice or behaviours. Our research was hampered in some respects by the COVID pandemic which both resulted in some delays and other challenges. Our efforts to use electronic patient record data in secondary care to explore locum doctor working were stymied by the problems of data access and quality. Locum doctors are a key component of the medical workforce in the National Health Service, and provide necessary flexibility and additional capacity for healthcare organisations and services. We found that the extent of reliance on locum doctors varied considerably, but that an over-reliance on locums for service provision was undesirable. Some differences in practice and performance between locum and permanent doctors were found, but these seemed often to arise from organisational characteristics. We found that patients were more concerned with the clinical expertise and skills of the doctor they saw than whether they were a locum or not. Organisational arrangements for locum working could be improved in many respects. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128349) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 37. See the NIHR Funding and Awards website for further award information.