BackgroundHealth care accessibility in rural regions remains a critical global concern, shaped by the intersection of geographic isolation, economic precarity, infrastructural deficits, and socio-cultural constraints.Study AimThis study examines health care access in the remote villages of Akhal and Naranag in District Ganderbal, Jammu and Kashmir.MethodsThe study employed a qualitative research design grounded in an interpretive paradigm. Data were generated using semi-structured interviews and focus group discussions with 18 rural residents and 8 health care providers, and thematically analysed.ResultsThe findings reveal five interrelated dimensions of health care inaccessibility: (i) geographic and logistical barriers, where difficult terrain and poor connectivity delay or prevent timely care; (ii) resource and personnel shortages, resulting in inconsistent service delivery and eroded trust in public health systems; (iii) economic constraints, where high out-of-pocket expenditure and indirect costs compel households to defer or forgo treatment; (iv) cultural and social influences, including gender norms and reliance on traditional healing systems that shape health care-seeking behaviour; and (v) resilience and coping strategies, where communities and providers develop adaptive mechanisms such as informal transport networks, barter systems, and outreach practices to navigate systemic gaps. Drawing on critical sociology, the study conceptualizes health care inaccessibility as a product of unequal distribution of capital, embedded structural disadvantage, and constrained agency within rigid social structures.ConclusionThe findings demonstrate that health care inequities in rural Kashmir are not isolated service failures but manifestations of deeply entrenched structural and socio-cultural processes. By providing a context-specific and empirically grounded analysis, this study contributes to the limited body of literature on rural health care in geographically remote regions of India. It underscores the need for integrated policy interventions that combine infrastructural development, financial protection, and culturally responsive health care delivery, while also recognizing and strengthening community-based resilience.
ObjectivesStigma is a well-documented barrier to care for people with substance use disorders (SUDs), but little is known about how it affects individuals with SUDs who also experience multiple disadvantages such as homelessness, poverty and unmet health care needs. This article explores how stigma is experienced by service users, staff, and system-level stakeholders of outreach services tailored to this cohort, and how it shapes interactions with health care services, treatment engagement, and service implementation.MethodsNinety-eight semi-structured interviews were conducted with service users, staff, and stakeholders of three outreach-based services for people with SUDs and multiple disadvantages in England. Data were analysed using the iterative categorisation technique. The analysis was guided by a framework informed by a sociological model of stigma and a typology of stigma and discrimination in mental health.ResultsFour themes were identified: (1) stigmatising language and discriminatory practices in primary and acute health care encounters; (2) self-stigma and its impact on help-seeking behaviour; (3) the influence of stigma on the commissioning and sustainability of services tailored to this cohort; and (4) the key role of specialist services, such as outreach services and acute hospital alcohol care teams, in reducing stigma.ConclusionsStigma operates across interpersonal and structural levels, undermining equitable care for people with SUDs and multiple disadvantages. Addressing these barriers requires stigma-informed training for acute and primary health care providers, as well as advocacy skills for specialist services.
With increasing costs, and an aging population, it is inevitable that demand for health and social care exceeds the available resources. Policymakers seek to maximise value-for-money and, increasingly, use quantitative economic methods to guide such policy. Current characterisation of value is largely based upon health utility and may not align with societal preferences for attributes such as care processes, autonomy and dignity. The limited concept of value provided by quality adjusted life years (QALY), with other factors adding weight to the QALY or inflating thresholds, may distort funding decisions. This essay explores the limitations of current economic methods and argues that these prioritise cost utility calculations and lack appropriate measures for other attributes of health or social care. Many methods require assumptions and simplifications, such as the equivalence of chosen outcomes, leading to unintended or unconsidered consequences. The choice of perspective, handling of unrelated costs, and methodological choices may conceal implicit value judgements, and the values and preferences used may reflect the preferences of specific stakeholders but fail to represent the interests of those likely to bear the opportunity costs of policy decisions. Areas are identified in which there is the potential for improved alignment of decisions with societal values. Existing methods could be used more extensively to identify and quantify societal preferences in terms of monetary value or equivalent health utility. Changes to decision-making processes to favour a net benefit approach over the use of a variable willingness-to-pay threshold, may reduce the current primacy of cost per QALY calculations, and there is a need for a more rigorous approach to the consideration of opportunity costs. It is concluded that without such changes there is a danger that high-cost new technologies will displace more caring aspects of health and social care that are highly valued by society.
ObjectivesReducing unnecessary exposure to antimicrobials and minimising preventable deaths from sepsis are in persistent tension in clinical work. Guidance documents are central to shaping clinical and organisational practice, yet there is a gap in understanding how these documents conceptualise the organisational system conditions that influence their use in practice.MethodsUsing content analysis, this qualitative document review analysed 40 national, regional, and local documents from six hospitals systems across England to examine how guidance conceptualises system conditions that influence antimicrobial use in cases of suspected or confirmed sepsis.ResultsWe identified six themes: (1) symbolic use of human factors, (2) an unclear understanding of the end user, (3) an ambiguous fit between national, regional, and local documents, (4) harmony in what is stated, (5) harmony in what is not stated, and (6) a lack of focus on management's role.ConclusionsSystem conditions within organisations will mediate how these documents are enacted in practice. Therefore, future development should consider how documents can guide a coherent fit between clinical, operational, and leadership structures via an effective operating model and the role management plays in achieving this coherence in different settings.
ObjectiveTo explore women's experiences with health and social care during voluntary termination of pregnancy (i.e., abortion) in Spain and to identify areas for improvement in the quality of care provided throughout the process.MethodsA qualitative study was conducted using semi-structured interviews with 30 adult women who underwent a voluntary termination of pregnancy in Spain between 2013 and 2023. Participants were selected to ensure diversity in age, educational level, and geographical region. Interviews were analysed in Atlas.ti using a two-phase deductive-inductive approach, whereby an initial coding framework informed by the literature was refined through the inductive identification of emergent codes and themes from the data.ResultsWomen's experiences were strongly influenced by the quality of care received throughout the abortion process. During the pre-abortion stage, participants reported inadequate information and guidance, insufficient sensitivity and empathy from professionals, non-consensual practices, stigmatizing attitudes, attempts to dissuade them from abortion, and barriers to access from conscientious objection and uneven service provision. During the abortion procedure, women described insufficient information about the intervention, inadequate pain management, denial or improper administration of anaesthesia, and impersonal or unsympathetic treatment during recovery. In the post-abortion stage, deficiencies included inadequate medical follow-up, pressure to adopt contraceptive methods, and limited access to psychological support. Overall, participants' accounts revealed a pattern of shortcomings that negatively affected their emotional well-being and experiences across all stages of the process.ConclusionThe findings highlight systemic deficiencies in health and social care during voluntary termination of pregnancy. Improving abortion care requires person-centred, non-judgemental, and evidence-based services that guarantee adequate information, respectful treatment, timely access, informed decision-making, effective follow-up, and psychological support. Strengthening professional training and implementing mechanisms to monitor and improve quality of care are essential to safeguarding women's sexual and reproductive rights and enhancing their experiences throughout the abortion process.
ObjectiveTo evaluate patient experiences with a remote Colon Capsule Endoscopy (CCE) service delivered through the 5G-SUCCEEDS initiative, utilizing the InteliGI Smartbox for home-based diagnostics with remote clinical supervision.MethodsThis mixed-methods service evaluation involved 25 patients referred from primary care with low-to-intermediate colorectal cancer risk, or under post-polypectomy surveillance. Patients received a Smartbox with CCE equipment, including a capsule, receiver belt, and a tablet for remote videoconferencing with clinical staff. Data on patient experience, confidence, and satisfaction were collected through surveys and semi-structured interviews. Twenty-two participants returned the questionnaire, and eight completed semi-structured interviews. The Nonadoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework was used for thematic analysis.ResultsAnalysis of the technology showed that most patients rated the Smartbox as user-friendly, with bowel preparation noted as the most challenging aspect. Analysis of the value proposition of the innovation showed that most patients expressed satisfaction with remote CCE. Videoconferencing was essential for ensuring correct equipment setup and providing patient reassurance. Patients valued the convenience of performing the procedure at home, with most able to continue their daily activities. Analysis of the adopter system found that most patients reported that they did not need any assistance from a family member or a nurse while doing the procedure.ConclusionThis study indicates the patient acceptance of home-delivered CCE through the 5G-SUCCEEDS initiative. The results suggest that remote CCE, supported by 5G technology and the InteliGI Smartbox (or alternative), offers a viable and patient-centred alternative to in-clinic colonscopy procedures.
ObjectivesAsthma is a prevalent chronic condition that affects approximately 300 million people worldwide, posing a significant health and economic burden. Effective management is often hindered by barriers to in-person care. Telehealth has emerged as a potential solution to enhance access to asthma care, yet its economic implications remain unclear. This review synthesizes evidence on the cost-effectiveness of synchronous telehealth compared to standard asthma care.MethodsA systematic search of eight electronic databases (MEDLINE, EMBASE, Web of Science, CINAHL, Cochrane Library, Tufts Cost-Effectiveness Analysis Registry, NHS Economic Evaluations Database, and EconLit) was conducted from January 2000 to June 2024, with searches repeated in January 2026, for economic evaluations of telehealth interventions in asthma care. The reporting quality was assessed using the CHEERS checklist, and results were synthesized narratively.ResultsFour studies (published between 2005 and 2008) from high-income countries (UK and Australia) assessed telephone-based telehealth over periods ranging from 3 to 12 months compared to in-person care. Telehealth interventions resulted in higher asthma review rates, shorter visit durations, and lower costs per consultation but showed no consistent improvements in asthma control or quality of life.ConclusionsSynchronous telehealth appears to be a cost-effective approach for increasing asthma review rates. However, evidence of its impact on quality of life and symptom control remains limited. Further recent studies with improved reporting are required to assess the long-term health economic value of telehealth in asthma care.
IntroductionThis systematic review aimed to synthesize evidence on the key findings of evaluations of implementation of models of care in rehabilitation and describe facilitators and barriers to implementing new models of care.MethodSix electronic databases were searched. Abstracts and full texts were screened and critically appraised. Facilitators and barriers were classified using the Consolidated Framework for Implementation Research version 2.0.ResultsOf the 64 studies identified, 52 (81%) were new care models implemented in a hospital and 12 (19%) were situated in a home or community-based setting. Common implementation evaluation metrics reported included fidelity (n = 15), adherence (n = 16), feasibility (n = 14), and acceptability (n = 12). Facilitator domains were innovation source (e.g., uncomplicated models), outer setting (e.g., positive attitude), inner setting (e.g., teamwork or motivation), individuals (e.g., skill) and implementation (e.g., planning according to need and context). Barrier domains were innovation source (e.g., model complexity), outer setting (e.g. .organisational culture), inner setting (e.g., staff turnover, training, or resources,), individuals (e.g., no champions) and implementation (e.g., lack of planning).ConclusionsThe review highlights the importance of planning before implementing new models of care in rehabilitation settings to address potential facilitators and barriers in a real-world environment.
Background The disruption of health services by the COVID-19 pandemic prompted the WHO to advocate for rapid adaptation of healthcare. Little is known about the specific rapid adaptation strategies deployed in first contact physiotherapy services (FCPS) and how they were experienced by providers and patients. Study Aim To explore views and experiences of physiotherapists and key stakeholders on the rapid adaptation of FCPS during the COVID-19 pandemic in the UK and Australia. Methods A multiple case study design was employed across four case sites; UK (n = 2), Australia (n = 2), involving online semi-structured interviews with 22 participants in 2024 and document review. A case-based approach using framework analysis was applied, drawing on the public health emergency framework of readiness, responsiveness, and sustainability, alongside the consolidated framework for implementation research (CFIR). Results Gaps in readiness for adaptation, particularly in terms of planning and resources, were evident across FCPS in both countries. However, the findings highlight FCPS as an adaptable service, with strategies implemented within the first three to six months following the declaration of COVID-19 as a pandemic. The most notable adaptation variation was in telehealth, where alignment with service contexts influenced implementation and ongoing sustainability. New challenges not fully captured within CFIR constructs emerged, including the initial lack of acceptability, particularly related to telehealth, and the unpredictable nature of the pandemic. Conclusion To strengthen FCPS preparedness for the future, policies should proactively equip services with the resources and capabilities required to manage emergencies and associated contingencies, while accounting for contextual variations. Such forward planning would support an effective response and the long-term integration of beneficial adaptations, thereby strengthening service resilience.
BackgroundOpioid use disorder (OUD) among pregnant and parenting individuals in the U.S. is a major public health concern. Current policies and procedures are not conducive to effective management of OUD in perinatal patients, who require multidisciplinary approaches. These approaches can challenge rigid healthcare structures, protocols, and staff beliefs. A formative evaluation was conducted of an integrated model of care, introduced as a first step in a system change process to provide comprehensive care to patients with perinatal OUD.MethodsRapid qualitative analysis was conducted of interviews with hospital staff (n = 19), staff at local organizations serving the population (n = 15), and patients (n = 5). Using the PRISM implementation framework, we evaluated current resources, gaps in care, treatment priorities, and feasibility, acceptability, and appropriateness of proposed changes.ResultsThere is a need for a centralized, long-term, healthcare system-linked space where pregnant and parenting women can obtain evidence-based, culturally- and life-stage-competent OUD treatment. Changing governmental policies is not enough to effect change; champions within the system are needed to advocate for changes in organizational policies and staff training. System-level changes must reduce departmental silos, improve integration with community and public health resources, and address the culture of stigma to create psychological safety for patients. Patients need to feel safe and supported throughout the healthcare system.ConclusionThe proposed integrated model of care was acceptable and appropriate; hospital employees provided clear guidance to ensure feasibility. Developing a multidisciplinary care team with coordinated care pathways, data reporting infrastructure, and staff education to reduce stigma are next steps.
ObjectivesThis study aims to explore the impediments to diabetes management among older women living in rural areas of Meghalaya, a northeastern state in India.MethodsThe study adopted a narrative inquiry approach. In-depth interviews were conducted with 29 older women (aged 60 and above), selected purposively. Findings were analyzed thematically using the open or inductive coding approach in NVivo 12.0.ResultsSeven key themes emerged from the study. These were: (i) negative impacts of physiological changes on diabetes management for the participants, (ii) weak social support which hindered diabetes care, (iii) experiences of ill-treatment by relatives and a sense of helplessness, (iv) caregiving roles as barriers to care, (v) difficulties in accessing treatment due to geographical barriers, (vi) expensive treatment due to comorbidities, and (vii) feelings of guilt due to financial dependency.ConclusionsOur study found a confluence of structural and individual-level barriers that hindered diabetes management among older women in rural Meghalaya. These barriers were linked not only to age and disease but also to gendered social roles, systemic health care gaps, and economic insecurity. This study emphasises the need to reinforce current healthcare policies and programmes targeting older women and to advocate for a comprehensive, multisectoral approach to address these issues effectively.
ObjectivesTo examine the role of state language access policies and state agency communications practices in facilitating access to vaccine information for Limited English Proficient (LEP) populations in the U.S.MethodsState language access policy data were linked to audit study field experiment data documenting the experiences (n = 455) of individuals of differing racial/ethnic identities and language use interacting with state health agencies to access COVID-19 vaccinations in the 50 states and District of Columbia. Regression analyses investigate whether state language access policies are associated with these outcomes: access to translation or interpretation, state health agency use of recommended communication practices, and receipt of information on how to access the vaccine.ResultsGovernment agency requirements for language access were associated with 17% higher availability of translation and interpretation services and greater use of recommended communications practices by state agencies. The use of nudges and absence of racialized or judgmental language in communications increased receipt of vaccine information by 13-26%. Interpretation was lacking in more than 40% of Spanish-language speaker phone encounters with state agencies.ConclusionsLEP populations are among the least likely to be vaccinated and disproportionately experienced negative consequences of the COVID-19 pandemic. Enacting state language access requirements and instituting training programs for health agency employees involved in vaccine distribution could help to increase vaccine access and avert some of the harmful, racialized impacts of future pandemics.
BackgroundRegulation by an independent state authority is a common means by which governments seek to safeguard service users and ensure good quality health and social care services. Inspectors play a key role in this process as they work at the interface between regulator and regulatee. Our aim was to investigate the role played by inspectors in the implementation of care regulations in residential disability services in Ireland.MethodsWe conducted focus groups with inspectors of residential disability services in Ireland. Participant recruitment was facilitated with the permission of the regulator. Twenty-two people participated over five online focus groups. Thematic analysis was carried out on the interview data.ResultsFour parent themes were identified: overall views on the regulatory system; the importance of skill and strategy for the role of inspector; impediments to effective regulation and inspection; and, positive effects of regulation. While not directly responsible for implementing regulations in services, inspectors played a role by calling attention to poor practices, apportioning accountability at the appropriate level in regulated organisations, and behaving in a consultant-like fashion in support of managers. There were barriers that complicated and inhibited their work such as resource constraints and bureaucracy. Their observation of improvements in service quality led them to conclude that regulation was an effective intervention, despite some flaws.ConclusionInspectors had a clear sense of the part they played in terms of aiding the implementation effort in services. They shared the goals of managers: trying to improve the quality of services and the lives of those that use services. While there were barriers that impacted on the effectiveness of their work, most inspectors regarded regulation as a positive intervention and had first-hand experience of its impact.
ObjectiveInternational health systems had the opportunity to assess the resilience of core health services to severe disruption following the onset of the COVID-19 pandemic. This paper examines the resilience of a core health service to shocks from COVID-19. We compare outcomes following emergency admissions in England during the second (Winter 2020/21) and third (Winter 2021/22) major waves of COVID-19 with the first wave and historic admissions from 2016 to 2019.MethodsThis cohort study included adult emergency admissions for five common acute surgical conditions: appendicitis, symptomatic gallstone disease, intestinal obstruction, symptomatic diverticular disease, and abdominal wall hernia in 122 acute hospital Trusts in England. Participants were 647,367 admissions in the hospital episode statistics (HES) inpatient database including 34,560 in the second wave and 36,628 in the third wave. Outcome was all-cause mortality at 90 days.ResultsThere were 1308 deaths in wave two (3.8% of admissions) and 1235 (3.4%) in wave three compared with 3431 (3.4%) in the historic cohort and 577 (4.7%) in wave one. Compared with pre-COVID admissions, we found weak evidence of increased mortality in the second wave. There was no evidence of increased mortality in the third wave, compared to historic cohorts the case-mix adjusted odds ratios were: appendicitis 0.96 (95% CI 0.49-1.87); gallstone disease 1.27 (95% CI 0.94-1.72); diverticular disease 1.04 (95% CI 0.79-1.36); hernia 1.06 (95% CI 0.76-1.47); and intestinal obstruction 1.02 (95% CI 0.87-1.19).ConclusionsBy the end of wave three, outcomes for emergency admissions with five common acute conditions had returned to pre-pandemic levels. Lessons learnt during the disruption of the first wave of COVID-19 helped the NHS in England adapt emergency surgical services during subsequent waves. These findings emphasise the importance of maintaining, or quickly restoring core service capacity to help patient outcomes return to pre-pandemic levels.
ObjectivesTo present the findings from a national survey of senior leaders in NHS and independent hospitals in England concerning the effectiveness of shared arrangements for clinical governance. To provide a comprehensive overview of shared arrangements for the oversight of consultants' practice, processes for appraisal and revalidation, and the management of significant concerns. The results from this study will improve understanding of the practical functioning of clinical governance processes at the interface between the NHS and the independent sector.MethodsBetween December 2023 and April 2024, an online survey was distributed to senior leads with governance responsibilities in NHS and independent hospitals in England.Results320 responses were received (response rate 42%), 235 from individuals working in NHS trusts (response rate 40%) and 85 from individuals in independent hospitals (response rate 48%). Respondents reported that some clinical governance arrangements are established across both sectors, with some relationships characterised as positive and relatively strong. However, relationships often depended on goodwill, personal connections, and consultant probity, rather than the systematic implementation of recommended processes. Respondents expressed concerns regarding the non-mandatory and unregulated nature of processes for sharing concerns, believing this led to insufficient resources and challenges in verifying information. They called for improved data quality, better communication and information sharing and more robust and formalised processes.ConclusionsShared clinical governance arrangements between the NHS and independent sectors are in place in some but not all of the organisations where respondents' consultants worked. This raises concerns about progress towards implementing the Paterson inquiry recommendations, including access to consultants' whole practice information and sharing concerns about consultants working across different providers. The findings may also hold relevance for international audiences where medical staff work across multiple healthcare providers. Further empirical research is needed to compare clinical governance arrangements between the NHS and independent sectors, and suggest how shared clinical governance can be organised to assure the quality and safety of care.
ObjectivesMany different approaches are used to manage demand and reduce waiting lists in outpatient and community health settings. This systematic review aimed to synthesise evidence for models of care which are based on the principle of protecting capacity for new patients.MethodsWe conducted a systematic search of Medline (Ovid), Embase, PyscINFO and CINAHL from inception until April 2024. Eligible studies included use of a protected appointment model in an outpatient and community health service and compared data on measures of waiting. Two reviewers independently extracted data and assessed risk of bias. Methodological quality was assessed using the Downs and Black checklist. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework was used to evaluate evidence certainty for meta-analyses.ResultsA total of 26 studies were included in the review. Most studies described a specific, named model incorporating protected appointments, such as Open Access (n = 7), Advanced Access (n = 6), the Specific Timely Assessment and Triage Model (n = 6), and the Choice and Partnership Approach (n = 4). A single stepped wedge randomised controlled trial (n = 3,113) provided moderate certainty evidence of a large reduction in time from referral to first appointment (IRR -0.66, 95% CI -0.85 to -0.52), with a median reduction of 34%. Eight non-randomised studies of intervention (n = 43,655) provided moderate certainty evidence of a moderate to large reduction in waiting time (SMD = -0.66, 95% CI -0.95 to -0.36) with a weighted mean reduction of 81%. Studies that could not be included in the meta-analyses supported these findings. Five studies measured waiting list size and all reported reductions ranging from 44% to 98%. Other findings associated with interventions included increased service productivity and improved patient satisfaction.ConclusionsWaiting list reduction strategies incorporating protected appointments are associated with moderate to large reductions in waiting time in outpatient and community health services.
ObjectivesDouble-checking medication administrations is one of the most frequently used strategies to prevent errors and associated harm. This practice is time-consuming, introduces repeated interruptions into the care process and lacks evidence of effectiveness. Double-checking is widespread in hospitals worldwide. In England, double-checking happens despite there being no regulatory requirement except for intravenous drugs and medicines that require complex calculations. Many hospital Trusts have assimilated double-checking over the past 25-30 years in response to recommendations from the investigation of medication administration errors. There is currently no national picture in England of the extent to which organisational policies stipulate double-checking, the variation in double-checking policy or how closely double-checking is perceived to be conducted in accordance with policies. This study set out to address these gaps in our understanding.MethodsAn online survey was distributed to a network of Medication Safety Officers (MSOs) and Freedom of Information requests were sent to 118 English NHS acute hospital Trusts for policies underpinning medicines administration. Data were analysed to address the research questions.ResultsPolicies were received from 94 acute NHS Trusts (80% response rate) and 48 MSOs submitted a survey response (39% response rate). Double-checking policies vary considerably between Trusts. MSOs perceived that it is common in practice for double-checking not to be conducted in accordance with policy. All reviewed Trust policies required double-checking for controlled drugs. Further to this, many required double-checking for specific medicines or in particular circumstances. Most commonly, these were intravenous medicines, medicines administered to children, medicines requiring complex calculations and cytotoxic or chemotherapeutic medicines. However, policies varied considerably around administration of injectable medicines and insulin to adults. A minority of policies specified that 'intravenous fluids' needed to be double-checked. Most policies neither emphasised nor explained the importance of the independent nature of double-checking. There was also a great deal of variation between Trust policies in the medicines exempt from double-checking requirements.ConclusionsThe variation between policies identified by the present study might reflect a lack of robust evidence underpinning the practice of double-checking. Research is needed to understand if double-checking is effective at preventing medication errors and, if it is, the exact circumstances in which it is effective, to facilitate the standardisation of double-checking policies. Identifying circumstances in which double-checking is ineffective may justify the removal of some existing policies and could reduce nurse workload to free up time for patient-focused care.
Objectives The NHS in England has introduced various innovations to keep up with the growing demand for elective care, one of which is patient-initiated follow-up (PIFU). This evaluation sought to understand staff experiences of implementing PIFU.Methods We conducted a rapid qualitative service evaluation between June 2022 and July 2023, based on semi-structured interviews (n = 36) with operational/managerial and clinical NHS staff from five English NHS Trusts, and an online workshop with 21 additional members of staff from the English NHS. We drew on the Non-adoption, Abandonment, Scale-up, Spread and Sustainability (NASSS) framework to structure qualitative data collection and analysis and to generate new insights into the adoption of the innovation of PIFU.Results We found that implementation of PIFU affected staff roles, workload, and job satisfaction. Levels of PIFU uptake, and experience with similar models, affected the extent to which participants experienced the impact of PIFU. How PIFU was implemented varied. Some staff saw changes in their role because of new administrative demands, safety-netting procedures (such as proactive measures by specialty teams to mitigate the risk of patients not initiating appointments when necessary), and selection of suitable patients. PIFU was felt by some staff to increase, and by others to decrease, workload. PIFU affected intensity of work, interrelated with other factors such as the size of waiting lists, and conditions experienced by patients. Whether staff were satisfied with PIFU related to its impact on their role and workload. Satisfaction was also affected by whether staff believed PIFU delivered benefits for patients, and by the aims they felt were driving rollout.Conclusion PIFU can significantly affect the experiences of staff and change staff roles and workload. However, the impact of PIFU is not uniform. Staff perspectives on PIFU from all parts of the health system should be better understood and considered during pathway design.
