Screening-to-intervention pathway for child anxiety problems alongside usual school practice versus usual school practice only (iCATSi2i): a cluster-randomised, controlled trial in primary schools in England.

In a context of growing democratic fragility, education is increasingly called upon to cultivate democratic participation, relational responsibility, and civic engagement. However, dominant approaches to education for democracy continue to privilege cognitive knowledge and procedural participation, often overlooking the embodied, affective, and relational dimensions through which democracy is first encountered and lived. This paper advances the concept of democracy-as-becoming to examine democratic learning in Early Years and Primary Education, where democratic relations are enacted through everyday pedagogical encounters rather than transmitted as abstract knowledge. The study draws on a transnational Participatory Action Research (PAR) programme conducted within the Aesthetic and Embodied Learning for Democracy-as-Becoming (AECED) project across multiple European contexts. Focusing on four cases in Portugal and Croatia, the paper presents a cross-case analytical synthesis of professional learning processes in which educators participated as co-researchers. These cases combined aesthetic, embodied, narrative, and digital pedagogical practices across online and face-to-face professional learning environments. Data included reflective writings, online discussions, observation notes, and visual and narrative artefacts generated through iterative PAR cycles. The analysis identifies three interrelated pedagogical ecologies—embodied, aesthetic–narrative, and digital/hybrid—through which democratic becoming is enabled, negotiated, and constrained. Across these ecologies, democratic learning emerged through relational grounding, co-creation, and embodied participation, while also being shaped by institutional conditions and perceptions of pedagogical risk. The paper contributes a data-informed conceptual model of democratic becoming grounded in cross-case analysis, highlighting how democratic sensibility develops through the interaction of relational, embodied, professional, and institutional dimensions. It concludes by discussing implications for teacher education, curriculum design, and research on democratic education, emphasising the need to recognise aesthetic and embodied pedagogies as core infrastructures of democratic life.

Testing nature-based biopsychosocial resilience theory: a research programme protocol.

The article provides a theoretical analysis of the role of methodological pluralism in contemporary science and substantiates its significance for the development of research competence of PhD students within the system of third-level higher education training in the specialty of Public Administration and Management. The relevance of the study is determined by the growing complexity of scientific knowledge, the interdisciplinary nature of modern research, and the need to develop researchers’ ability to navigate a variety of theoretical approaches and methodological strategies. It is shown that in contemporary philosophy of science methodological pluralism is considered an important characteristic of the development of scientific knowledge, reflecting the coexistence of different research programmes, theoretical models, and explanatory concepts. Recognition of the plurality of methodological approaches contributes to a deeper analysis of complex social phenomena and opens opportunities for integrating various research strategies and conceptual frameworks. Particular attention is paid to the significance of methodological pluralism in social and administrative research, where the objects of analysis are characterized by multidimensionality, dynamism, and interaction of different social institutions. In this context, the expediency of combining different methodological approaches and research methods is substantiated, which makes it possible to ensure a more comprehensive analysis of public administration processes. It is argued that the course “Philosophy of Science” plays an important role in developing the methodological culture of future researchers and constitutes an essential component of PhD training in higher education. The use of methodological pluralism principles in teaching this course contributes to the development of critical thinking, the ability for methodological reflection, and the conscious selection of research strategies. The study concludes that integrating the ideas of methodological pluralism into the content and teaching methodology of the Philosophy of Science course contributes to the development of research competence of PhD students, the formation of their methodological culture, and the improvement of the quality of scientific research in the field of public administration.

Joint probability framework for the development and validation of a prognostic model for the conditional outcome of quality of life: a retrospective study in historical European cohorts of survivors of head and neck cancer.

Abstract Introduction Legislative and regulatory frameworks governing the practice of community pharmacy public health services (CPPHS)—and the way in which the community pharmacy workforce (CPW) interacts with them—tend to focus on the role of the community pharmacist. This focus influences associated policies, guidance, evaluations and research. Team-based CPPHS activities, however, could optimise skill mix to provide timely and appropriate advice, support and interventions. An initial policy review for England, as part of this PhD research programme, suggested a systemic failure to fully recognise and articulate the potential of involving the wider CPW in CPPHS, and a lack of inclusive policy frameworks and educational strategies for non-pharmacist staff, despite their growing involvement in CPPHS delivery. Aim To examine the CPPHS literature to establish which members of the CPW are participants therein, the nuances of their roles, and reflections on education and training (E&T) required for CPPHS delivery. Methods JBI methodology[1] guided a scoping review (ScR) including the use of the PRISMA-ScR checklist. The Sample (S), Phenomena of Interest (P of I), Design (D), Evaluation (E) and Research (R) type SPIDER[2] search framework defined the inclusion criteria. Scopus, CINAHL Ultimate and MEDLINE databases were searched with specific keywords to identify articles published in English or French from 1st January 2008 to 14th February 2025 and conducted in the UK, USA, Australia, New Zealand or France. Searches were combined in the sequence of S + (P of I1 + P of I2) + (D or E) + R. The PhD researcher undertook the selection of included studies in three phases (title, abstract and full text). Data were charted into a Microsoft Excel spreadsheet using pre-defined parameters in line with the search strategy. Mixed method data analysis approaches (content and thematic analysis) were used, with study characteristics being analysed quantitatively and extracted data relevant to the ScR objectives being analysed qualitatively. Results Thirty-four studies were included from a yield of 579 articles, the majority of which came from England (n = 13). All studies referenced pharmacists, but they were only participants in thirty. Sixteen studies included at least one cohort of non-pharmacist participants, such as healthy living champions (HLCs) (n = 7), pharmacy technicians (n = 4) and/or pharmacy assistants (n = 4). Characterisation of non-pharmacist roles was predominantly missing, with studies focusing on overall service delivery as opposed to individual capabilities. In respect of E&T, an important finding in respect of non-pharmacist roles was that other healthcare professionals do not view CP support staff as having the same level of knowledge as their counterparts in GP practices, e.g. healthcare assistants. Conclusion A strength of this ScR is that it has exposed the gap in the literature relating to the PH role of the non-pharmacist CPW, which is consistent with the perpetual cycle of missed opportunities to create whole workforce, evidence-based policy in this field. Addressing this research gap will align well with government-stated need for a new team-based approach to CPPHS delivery. The ScR was limited by predominantly absent definitions for non-pharmacist workforce groups, making it difficult to compare roles across different countries.

Abstract Introduction The SYNERG-IE research programme aims to address the unmet needs of patients with Sjögren’s disease (SjD) and Sjögren’s associated with additional autoimmune rheumatic diseases (AIRDs), which are chronic, multisystemic conditions that frequently lead to significant morbidity and health service utilization.[1,2] Despite their clinical complexity, there is limited population-based evidence describing hospitalisation patterns among patients with AIRDs in Ireland. Understanding these trends is essential to inform service planning, identify changing patterns of disease burden, and optimise inpatient management strategies. Aim To examine trends and characteristics of hospitalisations related to autoimmune rheumatic diseases in Ireland by analysing the Hospital In-patient Enquiry (HIPE) database. Methods Data were obtained from the HIPE database and included all inpatient discharges with AIRDs listed as the principal diagnosis between 2015–2019 and 2022–2023. AIRDs were identified using the International Classification of Diseases (ICD)-10 codes and included Rheumatoid Arthritis (RA, M05/M06), Systemic Lupus Erythematosus (SLE, M32), SjD (M35.0), Systemic Sclerosis (SSc, M34), Myositis (including Polymyositis/Dermatomyositis, M33), and Mixed/Undifferentiated Connective Tissue Diseases (MCTD/UCTD, M35.1/M35.8/M35.9). Analyses focused on temporal trends in hospitalisations, and descriptive statistics were used to summarise patient characteristics, length of stay (mean, standard deviation), admission type, discharge status, and clinical specialty. Comorbidities (excluding AIRDs) were identified from additional diagnosis records to assess their frequency and distribution. Results Overall, 3942 inpatient hospitalisations were recorded, with RA (65.6%) being the commonest coded condition, followed by SLE (14.1%), and SSc (8.9%). Trend analyses showed overall number of hospitalisations per year remained relatively stable, with a decreasing trend in RA, more marked declines in SjD, and a slight upward trend in SSc, SLE, and myositis. Compared to RA, patients with other AIRDs had significantly longer hospitals stays (mean 5.4 vs 10.4 days), with the longest mean duration of admissions for myositis at 16 days. Prolonged hospitalisations (>90 days) were more commonly observed in patients with myositis and SjD. Patients with SLE and myositis were significantly more likely to have emergency admissions compared to their counterparts. SjD (24.7%) and SLE (27.7%) patients were significantly less likely to be admitted under a rheumatologist. Nephrology and orthopaedics were common specialties to care for hospitalised SLE (22.1%) and RA (21.9%) patients, respectively. We observed significantly higher rates of neurological admissions in SjD patients in comparison to all other AIRDs (24% vs 1.5%). Conclusion This study used comprehensive, national administrative dataset capturing all hospital discharges in Ireland for AIRDs, providing robust population-level estimates; however, the use of routinely coded data limits clinical detail and may be subject to coding variability. We observed a reduction in RA-related admissions over time potentially due to earlier diagnosis and access to advanced therapies. This was offset by increased rates of admission with SSc, SLE, and myositis, and patients with these AIRDs often required prolonged hospital stay. Access to new therapies for AIRD patients as they become available may improve outcomes. High rates of neurological admission in SjD patients warrant prospective evaluation.

Dementia education programmes for formal caregivers of people with intellectual disability are limited. This study was not designed or powered to evaluate effectiveness, but to assess the feasibility, acceptability, and appropriateness of outcome measures for a co-produced dementia education programme within intellectual disability services. A mixed-methods, quasi-experimental feasibility study was conducted with 40 formal caregivers recruited from supported living and residential providers across four NHS Trusts in the Northwest of England. The programme comprised interactive modules, case studies, group discussion, and practical tools to support the management of dementia-related behaviours and promote person-centred care. Feasibility outcomes included recruitment, retention, acceptability, and completion of outcome measures. The dementia education programme was feasible and acceptable with only minor modifications. Recruitment and retention were good, with 100% completion of follow-up outcome measures, supporting the suitability of the programme and study procedures for future research.

Research and policy initiatives for type 1 diabetes (T1D) across European countries demonstrate an emergent, critical shift towards universal paediatric screening. National adaptations of screening, however, remain under-researched. The current study, as part of the EU-funded EDENT1FI programme, aimed to examine the psychosocial impact and acceptability of screening according to local contexts and regions. The EDENT1FI screening research programme includes 27 partners involved in implementing screening across eight European countries-four countries already implementing national or local research screening programmes and four countries that are new adopters. The study consists of four sub-studies with assessments performed at five timepoints, from screening baseline to insulin-requiring T1D: (1) we examine the screening-specific psychological impact on families using a novel questionnaire for parents of screened children; (2) we further measure the psychological wellbeing of parents by administering validated questionnaires; (3) we explore parental acceptability through semi-structured interviews and (4) we explore professional stakeholder acceptability via semi-structured interviews. Data analysis will integrate questionnaire responses and thematic analysis for the interviews. Findings should provide a deeper understanding of the psychosocial aspects of universal paediatric screening measured longitudinally. The experience of implementation context across countries will be harmonised with the attitudes towards and practices of screening to inform best practice for scaling up universal screening. The study will provide essential insights into how best a general population screening program for T1D can be integrated into existing European health systems.

Patient and public involvement and engagement (PPIE) has many benefits for the design, delivery and dissemination of health research, but this can be difficult to achieve. Systematic reporting and evaluation of PPIE in multi-year, multisite and complex clinical trials is very limited. This evaluation presents a multi-perspective description and evaluation of patient and public involvement within a large-scale, multisite, longitudinal research programme focused on developing and evaluating a vocational rehabilitation and clinical psychology intervention for individuals recovering from traumatic injury. Conducted as part of the NIHR-funded ROWTATE research programme (2019-2026), the evaluation explores the scope, impact, and lived experiences of PPIE group members across all phases of the study, from development of the intervention, feasibility study and trial design to intervention delivery, data collection, analysis and dissemination. Employing multiple methods, including open-ended surveys with PPIE group members and researchers, a 'You Said, We Did' activity log, and minute taking, the study identifies key patterns related to PPIE group members' motivations, contributions, personal impact and barriers and facilitators to engagement. Findings highlight the significant value of PPIE in enhancing study relevance, improving data collection and communication strategies, informing rehabilitation, clinical psychology and health economics components, and shaping intervention delivery. PPIE group members reported a strong sense of purpose and intellectual engagement, despite challenges including communication gaps and role clarity. Researchers valued PPIE contribution to the research, and the positive and enriching experience of working with PPIE group members. Both groups reflected on the barriers and facilitators to PPIE. The evaluation highlights the importance of inclusive, well-supported, and transparent PPIE practices and contributes novel insights into the PPIE role in under-researched domains such as clinical psychology and health economics. Traumatic injury survivors were involved in all processes of this evaluation. This includes research design, funding acquisition, data collection, data analysis and interpretation and the write-up of this manuscript. Five traumatic injury survivors are co-authors of this manuscript.

In England and Wales, the primary treatments for individuals convicted of sexual offences are psychological. However, medication to manage problematic sexual arousal (MMPSA) is gaining importance as an alternative. This article reviews the current evidence surrounding the MMPSA approach. This paper synthesises challenges encountered, advancements achieved and learnings accumulated over 16years of the MMPSA treatment pathway from 2009 to 2025 in England and Wales. Drawing on a programme of mixed-methods research, including cohort studies, case studies, qualitative interviews with patients and professionals and implementation evaluations, this paper seeks to bring together key findings to present a consolidated picture of the research on the MMPSA pathway to date. The focus is on synthesising findings and identifying implications for service delivery. Evaluations of treatment outcomes showed promising results regarding the effectiveness of the MMPSA service. Qualitative analyses and case studies provided insightful details regarding patient and staff concerns that may hinder the efficiency and reach of the treatment pathway. Research with community clinicians highlighted issues regarding the 'off-label' use of medication for this purpose. The MMPSA treatment service is available in a limited number of prisons in England and Wales. Supported by promising service evaluations and existing literature, a larger population could benefit from MMPSA treatment. Furthermore, the MMPSA service would benefit from improvements to create smoother transitions for individuals leaving prison and entering the community, and it should ideally be expanded to ensure that those in the community can also access the MMPSA service.

Domestic abuse and suicidal ideation are highly prevalent in the United Kingdom, often co-occurring. Numerous practical and psychosocial barriers inhibit help-seeking. This study explored whether community pharmacy could offer an accessible setting for a domestic abuse and suicidal ideation response service. The design was a randomised cluster feasibility trial. Twelve pharmacies were recruited from one pharmacy organisation, randomised into eight intervention pharmacies and four controls. Thirty-seven pharmacy staff were trained to deliver the Lifeguard Pharmacy intervention, which involved providing a consultation and structured referral or signposting to customers identified as experiencing domestic abuse and/or suicidal ideation. Staff learning from the training was evaluated using the validated Continuing Professional Development reaction questionnaire, analysed using a paired t-test. The intervention ran from January to July 2023 and was accompanied by a nested process evaluation consisting of staff focus groups and a multistakeholder final evaluation workshop with a mix of lay, pharmacy staff and representatives from referral organisations. Data were collected on number and category of client contacts from intervention and control pharmacies; descriptive analyses were performed. After intervention training, pharmacy staff showed statistically significant improvements in their levels of perceived ability, ease and confidence in responding to and referring people in need of help for domestic abuse and suicidal ideation with increased confidence in the ability of other pharmacy staff to support domestic abuse and suicidal ideation. During the intervention period, staff responded to 24 cases in intervention pharmacies: 8 for suicidal ideation, 9 for domestic abuse and 7 for both domestic abuse and suicidal ideation. Of these, 22 were staff-initiated and 2 were client-initiated. Two cases (one suicidal ideation and one domestic abuse) were identified in control pharmacies. Staff participants had a positive perception of the service and its impact on them and their clients. The multistakeholder workshop findings confirmed the feasibility of a staff-initiated response service for both domestic abuse and suicidal ideation in a community pharmacy setting. However, there were challenges marketing and delivering a client-initiated service, and the study was not able to collect all of the information required to inform a future trial. There were challenges to collecting data and obtaining informed consent from Lifeguard Pharmacy clients, especially when distressed or time-pressured. Consequently, full data sets were only collected from 4 of the 24 people who used the service. All 12 participating pharmacies were located in 1 region of England, hence a future study would need to test implementation across a broader range of settings. It is feasible to implement a staff-initiated response service for domestic abuse and/or suicidal ideation in selected pharmacies. The combination of staff training, consultation guide, referral tool and client support resources and organisational support empowered staff to proactively identify people experiencing domestic abuse and/or suicidal ideation. Further development work would be needed before a client-initiated service could be delivered, and a future implementation study is contingent on finding ways to safely consent and collect data from clients. Some preliminary health economic work was conducted but a full health economic analysis would be needed as part of a future study. 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 NIHR133132.

Genomic technologies including next-generation sequencing (NGS) and arrays for cytogenetic anomalies are now standard of care in England for the diagnostic evaluation of patients with suspected haematological malignancies. Challenges remain in the management of potential germline findings as a result of NGS panels and copy number variant analyses in haemato-oncology pathways. The first national consensus meeting in April 2022 organised by the UK Cancer Genetics Group (UKCGGG), in collaboration with the CanGene-CanVar research programme and the NHS England haemato-oncology working group led to published best practice recommendations on laboratory and clinical pathways where there was potential to identify germline predisposition to haematological malignancies. On 3 and 4 April 2025, a second national meeting was held to address further challenges in these pathways and review updates in the national landscape subsequent to the 2022 recommendations. The meeting specifically focussed on TP53, DDX41, myeloproliferative neoplasm driver genes, non-single nucleotide variation and identification of gene carriers for addition to the National Inherited Cancer Predisposition Register (NICPR) through the National Disease Registration Service (NDRS). Using the format of a pre-workshop survey followed by structured discussion and in-meeting polling, high-level consensus was achieved for UK best practice across these areas.

Regional economic disparities in the United Kingdom lead to large differences in health. Previous attempts to address this issue have had limited success. Community Wealth Building is an economic strategy that aims to address these inequalities by redirecting wealth back into the local economy and increasing community control over the economy. The City of Preston initiated a Community Wealth Building strategy in 2012. We investigate the health impact of this approach in Preston up to 2019, a period during which their strategy largely focused on progressive procurement and the adoption of the Living Wage by employers within Preston. We estimate the impact of Community Wealth Building in Preston on mental health problems as measured by the Small Area Mental Health Index and its constituent components (antidepressants, depression diagnoses and mental health-related hospital attendances), self-reported life satisfaction, wages, employment and the number of non-profit enterprises. We use matching and difference-in-differences analysis to compare changes in outcomes in Preston before and after the intervention with changes in the outcomes in comparison areas. We use data on invoices and contracts issued by local authorities to compare procurement by Preston City Council with other similar local authorities, assessing the impact of local procurement on employment, wages and the cost of contracts. Finally, we use a combination of interviews and workshops to understand the process of change that has taken place in Preston and what has helped or hindered this. We found that, in Preston, the introduction of Community Wealth Building was associated with a reduction in mental health problems (-0.11 reduction in Small Area Mental Health Index, 95% confidence interval -0.16 to -0.06) alongside improvements in life satisfaction (0.06, 95% confidence interval 0.01 to 1.3), wages (£38 per week, 95% confidence interval £6.8 to £62.1), employment (4.1%, 95% confidence interval 2.3% to 5.8%) and a growth in non-profit enterprises (additional 20 enterprises 95% confidence interval 6 to 50). These economic improvements tended to be greatest among more disadvantaged groups, reducing inequalities. Preston City Council was much more likely to procure services from local suppliers compared to other similar local authorities, and this practice is likely to have contributed to these economic benefits. We found no evidence that procuring locally increased costs. Stakeholders in Preston highlighted that economic pathways to health impact were the most developed particularly in relation to procurement policy, while the community pathways to impact were less developed. Lack of widespread public involvement and engagement with smaller Voluntary, Community, Faith and Social Enterprise organisations in Preston had arguably limited the potential impact of Community Wealth Building in Preston. Despite this, appreciation for the approach and its aims remains strong. Community Wealth Building in Preston has led to economic gains that disproportionately benefited less advantaged groups, and this led to improvements in mental health and well-being. This seems to have been largely driven by changes in procurement practices of anchor institutions alongside policies to improve working conditions - such as the Living Wage. Future development should aim to shift the balance toward bottom-up civic engagement, which will help enhance sustainability of the approach. This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR130808.

Self-neglect can have serious consequences for individuals' self-care, health and well-being, and requires collaboration between many practitioners, from adult social care, health, fire and rescue, environmental protection and other organisations. Yet practice reviews highlight repeated failings in working together. This National Institute for Health and Care Research-funded study aimed to identify what problems arise in interagency and interprofessional practice with self-neglect within relevant contexts, and develop realist theory describing how they might be addressed. A realist review of 41 international research publications, 273 Safeguarding Adults Reviews (local statutory reviews of interagency safeguarding practice cases where it is felt there are 'lessons to be learnt') from England, and 85 Safeguarding Adults Board policies and procedures was undertaken to map evidence on collaborative working with self-neglect. Interviews were undertaken with 69 practitioners and managers from relevant agencies, 16 people with lived experience of self-neglect and 2 family carers about their experiences of collaborative working. A selection of 100 Safeguarding Adults Reviews featuring self-neglect was analysed as a set of case studies to estimate the use of services, and costs to agencies of support. Three focus groups were held with seven practitioners to coproduce research translation for use by services from the findings. Four workshops took place to pilot this research translation with practitioners; 73 participants responded to a post-workshop survey. Follow-up interviews with nine practitioners took place to further validate the study's conclusions. The study proposes four principal programme theories of interagency dynamics with self-neglect: policies, procedures and interfaces; mutual interagency understanding of roles and task; keeping a collective focus on the person experiencing self-neglect; and management support and monitoring. Practically oriented policies and procedures are needed to support a common understanding and coherent response to self-neglect among different agencies. Mutual interagency understanding of roles and the self-neglect task should be supported through shared spaces for consultation, better understanding of each other's legal powers, careful monitoring of mismatched expectations over referral, and expectations of interprofessional 'devil's advocacy' (presenting an opposing viewpoint, whether or not held with conviction, to ensure that all objections are considered). Where mutual understanding is lacking, communication and co-operation between services is impaired. Keeping a collective focus on the person experiencing self-neglect becomes harder to do when practitioners' attention is absorbed by interagency processes and barriers. Practitioner networks need to achieve a shared approach, informed by a trauma-aware perspective, if they are not to undermine each other's work. Management support and monitoring is needed to provide the time and flexibility that self-neglect support often needs. Professional curiosity in safeguarding must be complemented by greater 'interprofessional curiosity', supported structurally, procedurally and managerially, if interagency working is to fulfil its potential contribution to improving the lives of people experiencing self-neglect. 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 NIHR133885.

Emergency Department (ED) care of people injured in violence is increasingly seen as an opportunity to address patients' psychosocial vulnerabilities as well as their treatment. These vulnerabilities include alcohol, drug use, mental health and social vulnerabilities that are also associated with high levels of unplanned ED attendances for reasons other than violent injury. Since evidence of the effectiveness of interventions designed to reduce these risks is weak, we evaluated the impact of nurse-led Hospital Violence Intervention Programmes (HVIPs) across two sites in Wales, United Kingdom, on subsequent unplanned ED attendance. We used anonymised country-wide electronic health and administrative data to identify a cohort of patients, from 2019 to 2024, injured in violence who attended EDs in Wales, United Kingdom. We matched the characteristics of patients who engaged with the HVIP to control patients in the same cohort. We estimated the unadjusted hazard ratio (HR) for subsequent unplanned ED attendances for patients, and adjusted HRs to determine HVIP effectiveness overall and for sub-groups based on age and gender. This study is registered with ISRCTN (68945844). For patients who engaged with the intervention (n = 2068; representing 3580 attendances), the frequency of subsequent ED attendances was lower than control patients (n = 6196; 12,174 attendances; HR = 0.95, 95% CI 0.91-0.99). The intervention was more effective for female patients (HR = 0.86, 95% CI 0.80-0.92) and those aged 11-17 (HR = 0.88, 95% CI 0.82-0.92) and 18 to 30 (HR = 0.86, 95% CI 0.80-0.92) years of age. If risk factors associated with violence related injury are identified and addressed as part of ED care, ED attendances can be reduced. This study is funded by the National Institute for Health and Care Research, Public Health Research Programme (NIHR134055).

People experiencing homelessness face up to 12 times higher mortality rates than the general population. People experiencing homelessness have multiple, unmet health and care needs, including poor physical and mental health, substance use disorder and lack of stable and safe housing, yet they do not find services accessible or tailored to their needs. The aim of this study was to assess the feasibility of conducting a larger, definitive trial evaluating an integrated clinical pharmacist/homeless third-sector support (Pharmacy Homeless Outreach Engagement Non-medical Independent prescribing Rx) for people experiencing homelessness, in a community pharmacy setting. Randomised, multicentre, open, parallel group external pilot trial with parallel economic and qualitative process evaluation. People experiencing homelessness ≥ 18 years were recruited from community pharmacies in Glasgow and Birmingham, United Kingdom. Participants were randomised 1 : 1 to receive Pharmacy Homeless Outreach Engagement Non-medical Independent prescribing Rx intervention in addition to usual care or usual care only. The Pharmacy Homeless Outreach Engagement Non-medical Independent prescribing Rx intervention is a collaboration between National Health Service pharmacist independent prescribers and third-sector homelessness charity workers offering weekly community pharmacy and/or outreach-based consultations for people experiencing homelessness to address health (e.g. health screening, treatment and prescribing), housing and social needs (e.g. welfare benefits, housing support). A range of health, social and care outcomes were evaluated at baseline, 3 and 6 months from both usual-care and intervention participants. The primary outcome was to evaluate the feasibility of a subsequent definitive randomised controlled trial according to pre-specified progression criteria classified as green (go ahead), amber (minor amendment in procedures required for definitive trial) and red (substantial changes needed). These related to recruitment; retention; intervention adherence; and collection of clinical and social outcomes data, including emergency department visits, rough sleeping and criminal justice encounters. Progression criteria were met (4 green and 1 amber) as follows: (1) recruitment (target 55% conversion rate): 100 people experiencing homelessness were recruited as planned from 5 community pharmacies, 100/183, that is, 55% eligible consented to participate - green; (2) retention (target 60%): 72 (72%) participants remained in the study at 6 months - green; (3) collection of routine healthcare utilisation data (target 60%): 91 (91%) had emergency department visit and mortality data available at 6 months - green; (4) completion of questionnaire booklet (target 60%): 72 (72%) completed the booklet at 6 months - green; (5) intervention adherence (target 60%). Twenty-six (53%) participants had over half of the planned weekly contacts with the Pharmacy Homeless Outreach Engagement Non-medical Independent prescribing Rx team - amber. Signals of improvements were observed, as there were fewer ambulance call-outs, fewer emergency department visits and hospitalisations; fewer nights slept rough; and improved health-related quality of life in Pharmacy Homeless Outreach Engagement Non-medical Independent prescribing Rx participants compared to the usual-care group at 6 months' follow-up. Qualitative interviews conducted with participants and stakeholders. Participants suggested the Pharmacy Homeless Outreach Engagement Non-medical Independent prescribing Rx intervention was characterised by holistic approach, comprehensiveness, consistency and care. Challenges identified included resource constraints, integration with existing services and concerns about long-term sustainability. Pharmacy Homeless Outreach Engagement Non-medical Independent prescribing Rx community pharmacy pilot randomised controlled trial successfully achieved key progression criteria. If found to be effective and cost-effective in a subsequent definitive randomised controlled trial, it offers promise as an adaptable (United Kingdom and internationally) model of integrated care provision for people experiencing homelessness. While small sample size limits generalisability of the, it fulfils the purpose of a pilot study. Temporary absence of intervention worker in one of the study settings constrained intervention delivery. Future trials should plan for contingency measures. Future research should seek to test and evaluate care models integrating health and voluntary sector care for people experiencing homelessness in various settings, including community pharmacy, street outreach and temporary accommodations. 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 NIHR133060.

Many countries use geographical funding formulae to distribute public funds for health care to local planning areas in proportion to need. In England, these aim to distribute resources in proportion to all healthcare needs regardless as to whether these are currently met or unmet. The National Health Service also has an additional objective to allocate resources to reduce health inequalities (i.e. differences in health between socioeconomic groups). Adjusting for unmet needs could help achieve this second objective, if a greater proportion of needs are unmet in disadvantaged socioeconomic groups with poorer health compared to more advantaged socioeconomic groups. Alternatively, if there are greater unmet needs for relatively expensive conditions that tend to affect older age groups (e.g. cancer), this could lead to a greater proportion of needs being unmet in more advantaged socioeconomic groups, who will tend to be older due to greater life expectancy. Adjusting for unmet needs would then lead to allocation of a greater share of resources to these more affluent populations with better health, potentially increasing health inequalities. It is, however, unclear how met and unmet healthcare needs should be measured in these formulae and how better accounting for unmet needs influences health inequalities. We outline a framework for estimating the relative need in geographical healthcare resource allocation and show how the distribution of needed resources between local health planning areas in England changes when accounting for unmet needs due to underdiagnosis for 11 long-term conditions. We derive a synthetic data set for all people aged ≥30 years in England, in 2018, including age, sex, socioeconomic deprivation, region, local health planning area and whether people have diagnosed or undiagnosed long-term conditions. We calculated the annual primary and secondary care costs for each condition using linked electronic healthcare record data, then estimated needed expenditure for each health planning area for two scenarios: (1) when only accounting for diagnosed cases and (2) including all cases (diagnosed and undiagnosed). We examine how the distribution of need between places changes between these scenarios and the consequences of this for health inequalities. Based on the estimates of underdiagnosis used, areas with the lowest overall needs tended to have a greater proportion of their needs unmet. Adjusting resource allocation by accounting for these unmet needs due to underdiagnosis would move resources from areas with the highest level of needs to areas with lower overall needs. Moving to this 'fair share distribution' would tend to benefit less deprived areas more than more deprived areas, potentially widening health inequalities. We show how accounting for unmet needs due to underdiagnosis in allocating resources could widen health differences between more and less deprived areas when underdiagnosis and treatment costs increase with age. Further research is needed to confirm our provisional estimates, but we provide a useful framework for improving assessments of relative need for healthcare resource allocation. Alternative approaches are likely to be needed where resource allocation policy additionally aims to reduce health 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 NIHR130258.

Cardiovascular-kidney-metabolic syndrome and atrial fibrillation: Insights from 2 real-world prospective registries across Europe and East Asia.

In addressing the many challenges that face them, some emergency departments are changing their staffing to include new roles, such as nurse practitioners and physician associates. Known collectively as non-medical practitioners, they work with varying levels of independence and supervision, which, evidence suggests, may influence outcomes. As part of a larger study investigating the impact of these staff skill-mix changes, we sought to measure quantitatively how such staff work independently or with supervision. To develop a prototype-structured observational tool for quantitative measurement of levels of independence and supervision of non-medical practitioners in emergency departments and urgent treatment centres in England. A multimethod study using an incremental and iterative process underpinned by theories suggesting autonomy can be measured by practice independence behaviour. We undertook three interconnected research activities in March 2021-April 2023: (1) literature review to clarify concepts, and identify classifications and tools associated with independence and supervision; (2) 12 ethnographic observations of non-medical practitioners and resident doctors to describe the enactment of independence and supervision, with data coded and thematically analysed; (3) collaborative prototype tool development incorporating three collaborative sessions with 28 clinicians, non-medical practitioners and patients, and three further stages of stakeholder feedback. Twenty-six articles were included in the literature review. Nine articles included concepts associated with independence and supervision, the main concepts being clinical decision-making, competence, responsibility and autonomy. These multifaceted concepts were found to be intertwined in complex ways with those of collaboration, teamwork and interdependence. Seventeen articles included classifications or tools to measure levels of independence or supervision. Shared decision-making was the most frequently measured concept. There were no tools or classifications identified for measuring levels of independence or supervision within a skill-mix team. Our clinical observations found that participant clinicians practised with varying levels of independence within an interdependent team. The extent of guidance, education and direction received in discussion with the clinician-in-charge varied widely. In addition to the clinician-in-charge structure, clinical discussion and advice seeking were often with colleagues known and trusted to have specific knowledge. Spatial, temporal and resource constraints also encouraged collaborative working. Patients played an important team role. During collaborative development of the prototype tool, key issues raised by stakeholders and addressed in the prototype included: concerns that an inappropriate binary might be perceived between independence as 'good' and supervision as 'bad'; clinicians practise interdependently with most episodes of care involving some interaction, consultation or advice seeking; and the importance of collecting contextual data. The literature review was limited by excluding non-English-language papers. Our clinician observations included two sites with self-selecting participants which may have introduced biases. Objectivity and validity of the tool were not tested. Our data led us to develop a prototype observational tool reflecting non-medical practitioners working within an interdependent skill-mix team. The tool discerns tasks and actions undertaken with varying levels of independence or supervision. Further testing of the tool is required. The prototype tool was designed for use in later stages of the larger study. 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 NIHR131356.