The COVID-19 pandemic continues to impact the daily lives of people and communities. The physical and mental health, financial and social effects of the pandemic, and the subsequent cost-of-living crisis has furthered existing inequalities. The pre-pandemic precarity of finances and social capital among the most vulnerable communities, has led to an exacerbation of poorer health and greater anxiety. The aim of this study was to explore how individuals, voluntary organisations and employers experienced the pandemic, and how they adapted to the changing situation and their potential relevance to challenges that have persisted since. This study is part of the COVID-LIV research programme. Semi-structured interviews were conducted with 49 participants from three societal strands: individuals/households (n = 27), community and voluntary organisations (n = 19), and employers (n = 6) within the Liverpool City Region. Data were analysed using thematic analysis underpinned by symbolic interactionism. Three overarching themes emerged from the analysis: (1) Impacts of the COVID-19 pandemic; (2) Adapting to challenges: socio-economic and personal impact; and (3) Capacity for resilience: the pandemic and its legacy. COVID-19 and the period since have presented challenges. Closure of social spaces, changes to routine and restricted movement impacted mental and physical health. However, it was not felt equally by communities from different demographic and socio-economic backgrounds. While remote working and volunteering offered benefits, digital exclusion and burnout were challenges. Community organisations were more dynamic in meeting emerging needs, but system-wide limitations and funding constraints impacted the support available. Findings highlight the enduring nature of pandemic-related inequalities and the compounded effects of socio-economic shocks. Structural and individual-level interventions are essential to strengthen resilience and reduce disparities. Collaborative, community-driven solutions and equitable policy measures can mitigate future crises. Lessons from adaptive responses during COVID-19 provide valuable insights for enhancing preparedness and resilience in public health emergencies.

The Covid-19 pandemic profoundly disrupted societal systems, prompting community groups, voluntary organizations and employers to adapt rapidly to emerging needs. Here we present findings of a study conducted in the North West of England, exploring how groups and organisations adapted and responded to local needs at this time. We conducted semi-structured interviews with ‘key informants’ within local community voluntary, charity, faith or social enterprise (VCFSE) sector groups and organisations (n = 19) and large/ medium employers within any sector (n = 6). Interview transcripts were analysed thematically by a team of academic researchers and ‘Public Advisers’ with knowledge of local communities. Our findings reveal that community-based VCFSE groups and organisations played a critical role in addressing immediate needs such as food insecurity, isolation, and health vulnerabilities. This response was motivated by a strong sense of responsibility for the wellbeing of the clients and communities they served, and was enabled by their strong community networks, local knowledge, and ability to increase system capacity through collaboration. However, in a context of increased wellbeing needs later in the pandemic, many struggled to restart their core business, constrained by depleted resources and difficulties in interpreting and applying government ‘Covid-secure’ legislation and guidance. The study underscores the importance of local resilience, highlighting the VCFSE sector’s central role in addressing inequalities exacerbated by crises. It calls for substantial long-term investment to sustain this vital infrastructure, which is critical not only for recovery but also for preparedness for future societal shocks.

Community empowerment is prominent in global and national policies that aim to increase social and health equity. This paper describes the pathways through which community empowerment could in theory contribute to greater equity and highlights concerns about the potential for current initiatives to deliver positive impacts. Understanding and addressing imbalances in power, valuing knowledge people acquire from their experience of inequalities and supporting people to build alliances beyond the boundaries of their own communities can all contribute to addressing some of the limitations of contemporary empowerment initiatives.An initiative in nine disadvantaged neighbourhoods in NW England sought to address these concerns, through a Community Research and Engagement Network (COREN). The initiative aimed to enhance and direct collective capabilities at action on social inequalities driving health inequalities. The COREN model explicitly considered how local power dynamics could be shifted to enable residents to operate as equals alongside other actors and how their experiential knowledge could be valued as equal to that of professionals and academics. An evaluation highlighted how the COREN had contributed to positive impacts including perceived influence, social connections and feeling valued, alongside cultural, economic, environmental and governance impacts. However, local empowerment initiatives can only be part of the solution to social and health inequalities, as the root causes of these inequalities lie outside the control of people living and working in disadvantaged areas.

INTRODUCTION:Social prescribing has become an important feature of the UK primary care offer. However, there remains limited evidence on how best to implement and deliver social prescribing programmes to maximise effectiveness and long-term sustainability.AIM:To explore social prescribing practices and experience of implementing social prescribing programmes across National Institute for Health and Social Care Research (NIHR) Collaborative Leadership for Applied Health and Care Research (CLAHRC) North West Coast (NWC) and NIHR Applied Research Collaboration (ARC) NWC region to identify key learning points that can be applied to other settings.METHOD:We held a learning exchange workshop attended by practitioners and Public Advisors who had been involved in implementing and evaluating eight different social prescribing programmes with the support of NIHR CLAHRC NWC. We followed this with an online survey of social prescribing practice and priorities within the NIHR ARC NWC area. We used the findings from the workshop and survey to develop an initial model of the elements needed to successfully implement and sustain a working social prescribing programme.FINDINGS:We identified three core essential elements for a successful social prescribing programme: a personalised approach; meaningful service-user and community involvement; and whole systems working. These core elements need to be supported with adequate resources in the form of continuity of funding and adequate community resources to refer people to, capacity building and appropriate evaluation.CONCLUSION:We were able to use a learning exchange workshop to both facilitate learning between practitioners and begin the process of identifying the ingredients needed for a successful social prescribing programme, which may be built on with further research.

BackgroundSocial distancing restrictions to manage the COVID-19 pandemic were put in place from March 2020 in the United Kingdom (UK), with those classed as "highly clinically vulnerable" advised to shield entirely and remain at home. However, personal risk perception has been shown to comprise of various elements beyond those outlined in the national pandemic guidance. It is unclear whether those deemed COVID-19 vulnerable identified as high-risk to COVID-19 and thus complied with the relevant advice. The aim of this research is to explore the perception of risk in catching and spreading COVID-19, amongst individuals from individual households, and vulnerable groups in a region of the UK.MethodsTwo individual, semi-structured interviews were conducted, four-weeks apart, with adults living in households in the Liverpool City Region. At the follow-up interview, participants were given the option of using photo-elicitation to guide the discussion. Reflexive thematic analysis was employed to conceptualise themes. The qualitative analysis was underpinned with symbolic interactionism.ResultsTwenty-seven participants (13:14 males:females, and 20 with a vulnerable risk factor to COVID-19) completed a baseline interview, and 15 of these completed a follow-up interview four-weeks later. Following thematic analysis, two overarching themes were conceptualised, with subthemes discussed: theme 1) Confusion and trust in the risk prevention guidance; and theme 2) Navigating risk: compliance and non-compliance with public health guidance.ConclusionParticipants developed their own understanding of COVID-19 risk perception through personal experience and comparison with others around them, irrespective of vulnerability status. COVID-19 guidance was not complied with as intended by the government, and at times even rejected due to lack of trust. The format in which future pandemic guidance is conveyed must be carefully considered, and take into account individuals' experiences that may lead to non-compliance. The findings from our study can inform future public health policy and interventions for COVID-19 and future pandemics.

BACKGROUND:We report on a study of a facilitated interactive group learning approach, through Collaborative Implementation Groups (CIGs), established to enhance capacity for equity-sensitive evaluation of healthcare services to inform local decision-making: (1) What was the experience of participants of the CIGs? (2) How was knowledge mobilisation achieved? (3) What are the key elements that enhance the process of coproducing equity-sensitive evaluations? METHODS:A thematic analysis of qualitative data obtained from focus group (FG) discussions and semistructured interviews exploring the experiences of participants. All FGs included representation of participants from different projects across the programme. Interviews were conducted with a member from each of the teams participating in the first cohort after their final workshop. RESULTS:We identified four themes to illustrate how the approach to delivering intensive and facilitated training supported equity-sensitive evaluations of local healthcare services: (1) Creating the setting for coproduction and knowledge mobilisation; (2) establishing a common purpose, meaning and language for reducing health inequalities; (3) making connections and brokering relationships and (4) challenging and transforming the role of evaluation. CONCLUSION:We report on the implementation of a practical example of engaged scholarship, where teams of healthcare staff were supported with resources, interactive training and methodological advice to evaluate their own services, enabling organisations to assemble timely practical and relevant evidence that could feed directly into local decision-making. By encouraging mixed teams of practitioners, commissioners, patients, the public and researchers to work together to coproduce their evaluations, the programme also aimed to systematise health equity into service change. The findings of our study illustrate that the approach to delivering training gave participants the tools and confidence to address their organisation's stated aims of reducing health inequalities, coproduce evaluations of their local services and mobilise knowledge from a range of stakeholders. PATIENT OR PUBLIC CONTRIBUTION:The research question was developed collaboratively with researchers, partner organisations and public advisers (PAs). PAs were involved in meetings to agree on the focus of this research and to plan the analysis. N. T. is a PA and coauthor, contributing to the interpretation of findings and drafting of the paper.

The Health Inequalities Assessment Toolkit (HIAT) was developed to support those involved in health research to integrate a focus on health inequalities. Our study focuses on bringing together the concepts of boundary objects (BO) and brokers-as-bricoleurs to explain the implementation of the HIAT within a research capacity building programme. Exploring the extent to which (i) the HIAT operated as a BO and (ii) the ideal conditions to nurture and enhance its effectiveness during knowledge mobilisation. We employed a qualitative approach to analyse: semi-structured focus groups and telephone interviews; secondary data from an evaluation of the wider research programme within which the capacity building was situated. Data was thematically analysed incorporating the properties of a BO: meaningfulness, convergence, resonance and authenticity. Four main themes identified: (1) Generating convergence through creating a focus (2) Reconciling differences to create a common language (3) Workshop facilitators: boundary brokers-as-bricoleurs, (4) Thoughts into action. The HIAT operated as a BO, enabling individuals across the different project teams to galvanise around the issue of health inequalities, explore collaboratively and incorporate equity within service evaluations. Highlighting the importance of involving brokers with an ability to improvise and mobilise around the HIAT, using their expertise to translate and interpret across boundaries and emphasise shared goals. Reflecting on this, a modified tool with additional resources beyond socio-economic causes has been launched as a forum to consider health inequalities from diverse perspectives for use beyond UK health and social care research.

Background and aimDespite the significant mental health challenges the COVID-19 pandemic and its associated government measures have presented, research has shown that the majority of people have adapted and coped well. The aim of this study was i) to determine the proportion of people with mental stability and volatility during the pandemic in a North West England city region sample and ii) to establish group differences in psychosocial variables. Mental stability and volatility refer to the extent to which individuals reported change in levels of common mental health symptoms over the course of 12 weeks. No change in mental health over the 12 weeks reflected mental stability whilst change in mental health reflected mental volatility.MethodA two-wave-online survey (N = 163) was used to explore the psychological and social impact of the pandemic on relatively disadvantaged neighbourhoods within the region. The data collected represents 12 weeks of individual pandemic experience between mid-June and mid-December 2020. A three-level composite common mental health change variable was created combining self-reported anxiety and depression to group stable, volatile, and very volatile individuals in terms of the changeability of their mental health. Kruskal-Wallis with post-hoc tests were used to determine how people with mental stability and volatility differed on factors categorised within an ecological framework of resilience (individual, community, societal, and COVID-19 specific).ResultsIndividuals categorised as 'stable' in terms of mental health symptoms (63.6%) had better mental and physical health; were more tolerant of uncertainty; and reported higher levels of resilience and wellbeing compared to 'very volatile' people (19.8%). These individuals also reported feeling less socially isolated, experienced a greater sense of belonging to their community which was more likely to fulfil their needs, and were more likely to have access to green space nearby for their recommended daily exercise. 'Stable' individuals did not report worrying any more during the pandemic than usual and tolerated uncertainty better compared to those in the 'volatile' group.ImplicationsThe majority of participants in this sample were mentally stable and coping well with the challenges presented by the pandemic. The resilience of these individuals was related to key place-based factors such as a strong sense of community and useable local assets. The data showcase the role of place-based social determinants in supporting resilience and thereby highlight key preventative measures for public mental health during times of international crisis.

Background The present evaluation explored young people's, parents/carers, and healthcare professionals' perceptions of the Youth Information, Advice and Counselling (YIAC) model operated by a voluntary sector organisation in North West England. With an aim to understand the key components that contribute to enhancing the success of the YIAC model. Method Semi-structured interviews and focus groups with young people, parents/carers, and healthcare professionals were conducted. Data were analysed using thematic analysis. Results Five main themes were identified from the data: 1) Accessibility and flexibility; 2) Non-clinical model and environment; 3) Staff; 4) Partnership working; and 5) Promotion of positive mental health and wellbeing. Conclusion Findings highlight the importance of non-clinical, community-based, 'one-stop-shop' hubs for young people in disadvantaged areas. The key components highlighted as facilitating access and engagement include: opportunity to self-refer, choice of location, timely provision of support, non-clinical environment, age appropriate services, a non-hierarchical workforce, inclusive support for family and carers, a focus on wider, often social, issues, and collaboration with partner organisations. These findings suggest that early support hubs for young people's mental health should have consistent, long-term funding and should exist in every local area.

Introduction People from Minority Ethnic backgrounds living in the UK are at greater risk of not only contracting COVID-19, but also experiencing serious consequences of the virus. These emerging health inequalities mirror those already evident in UK society. Aim The aim of this study was to understand how COVID-19 and the associated imposed restrictions affected the lives of people from the Muslim community living in the North West of England. Method Twenty-five in-depth qualitative interviews and four focus groups ( n = 22) explored individual experiences of COVID-19 and imposed restrictions. Data were analysed thematically. Findings The virus and associated imposed restrictions had negative impacts on the psychological wellbeing of participants, their families and the wider community. Worry and low mood were particular features of participant’s pandemic stories. Main concerns were those of contracting and transmitting the virus to others and employment-related difficulties. Low mood was particularly linked to the impact of restrictions on fundamental interactions embedded within cultural and religious practices. These practices are central to feelings of belonging and connectedness within the Muslim community. Religious beliefs were important in helping to mitigate psychological distress for some participants. Conclusion Psychological distress was associated with COVID-19 virus and impact of COVID-19 restrictions on livelihoods and fundamental human interactions. Better provision of culturally appropriate information, improving local channels of communication and practical support are important during times of pandemic when usual support systems may be disrupted.

The widening range of treatment options for epilepsy, and their potential outcomes, mean decisions about treatment for people with epilepsy (PWE) are often complex. While antiepileptic drugs (AEDs) represent the mainstay of treatment, other potential nondrug interventions are gaining in importance. These treatments all have the potential for harming those using them, as well as bringing benefits. This study examined the views and experiences of PWE about a range of treatment options. We used both qualitative and quantitative approaches - a series of depth-narrative interviews, followed by a large-scale survey. Treatment options and healthcare priorities deemed important by at least 10% of interview participants were then addressed as a series of statements in the follow-on survey questionnaire. Quantitative responses supported healthcare priorities identified through the qualitative interviews. The key goal of treatment among study participants was to be able to live 'a normal life'. Important physical, psychological, and life benefits of treatment were identified - most being the direct consequence of improved seizure control. One psychological benefit, reduced worry, was also identified as an important treatment goal. All participants viewed AEDs as appropriate first-line treatment; and since adverse effects of AEDs had implications for individual levels of daily function and wellbeing, their appropriate management was considered important. In contrast, surgery was almost always regarded as the treatment of last resort. Despite lack of research evidence supporting their use, participants were interested in complementary therapies as adjunctive treatment and a means of coping with having epilepsy, with yoga and meditation of particular interest. An important finding was the desire for targeted services to help with memory problems, as was the call to increase availability of psychological/counseling services. Our findings emphasize the importance of providing treatment responsive to the life context of individual patients. They highlight not only the level of demand for specific treatment options, but also the need for high-quality evidence to support future investment in their provision.

Regulatory decisions may be enhanced by incorporating patient preferences for drug benefit and harms. This study demonstrates a method of weighting clinical evidence by patients’ benefit–risk preferences. Preference weights, derived from discrete choice experiments, were applied to clinical trial data to estimate the expected utility of alternative drugs. In a case study, the rank ordering of antiepileptic drugs ( AED s), as indicated from clinical studies, was compared with ordering based on weighting clinical evidence by patients’ preferences. A statistically significant change in rank ordering of AED s was observed for women of childbearing potential who were prescribed monotherapy for generalized or unclassified epilepsy. Rank ordering inferred from trial data, valproate > topiramate > lamotrigine, was reversed. Modeling the expected utility of drugs might address the need to use more systematic, methodologically sound approaches to collect patient input that can further inform regulatory decision making.

We conducted a systematic review of observational evidence on the health impacts of women's low control/autonomy in the living environment in societies with profound gender discrimination and gender bias. Thirty observational studies of varying methodological quality were included. Overall, the evidence suggests that women's lower control or autonomy (for example lack of freedom of movement outside the home, lack of authority to access healthcare for sick children) was associated with poorer mental and physical health for women and higher morbidity and mortality for their children, after adjusting for their socioeconomic circumstances. Further studies are needed to disentangle and understand the pathways between low control and health outcomes in contexts of profound gender discrimination. This systematic review has highlighted the general low quality of the evidence base on this research question. It identifies the pressing need for high quality, longitudinal studies in the future.

Objectives To identify preferences for outcomes of antiepileptic drugs (AEDs) that patients consider important and, to investigate the impact of patient preferences on the ranking of AEDs, as indicated by a clinical trial. Methods Adult patients with epilepsy completed a web-based questionnaire containing a discrete choice experiment. Patients made choices between hypothetical pairs of AEDs described by varying levels of clinical efficacy and treatment-related adverse events (AEs). Data were analysed using a random effects logit model. Women with the potential to become pregnant were analysed separately. Utility and probability of uptake for existing AEDs were derived using preference weights and published clinical event data. Results Patients (n=414) had stronger preferences for reducing the risk of AEs than improving treatment benefit. In return for a 1% improvement in 12 month remission, the maximum acceptable risk of adverse events was: depression 0.31%, memory problems 0.30%, aggression 0.25%; and for women with the potential to become pregnant: depression 0.56%, memory problems 0.34%, and foetal abnormality 0.20%. The rank ordering of AEDs differed when patient preferences were considered. Conclusion Exploring what patients consider important in measuring AED effectiveness will assist in supporting adherence, and ensure clinical services are focused on patient-defined needs.

BACKGROUND:Depression and debt are common in the UK. Debt Counselling for Depression in Primary Care: an adaptive randomised controlled pilot trial (DeCoDer) aimed to assess the clinical effectiveness and cost-effectiveness of the addition of a primary care debt counselling advice service to usual care for patients with depression and debt. However, the study was terminated early during the internal pilot trial phase because of recruitment delays. This report describes the rationale, methods and findings of the pilot study, and implications for future research. OBJECTIVES:The overarching aim of the internal pilot was to identify and resolve problems, thereby assessing the feasibility of the main trial. The specific objectives were to confirm methods for practice recruitment and the ability to recruit patients via the proposed approaches; to determine the acceptability of the study interventions and outcome measures; to assess contamination; to confirm the randomisation method for main trial and the level of participant attrition; and to check the robustness of data collection systems. DESIGN:An adaptive, parallel, two-group multicentre randomised controlled pilot trial with a nested mixed-methods process and economic evaluation. Both individual- and cluster (general practice)-level were was used in the pilot phase to assign participants to intervention or control groups. SETTING:General practices in England and Wales. PARTICIPANTS:Individuals were included who were aged ≥ 18 years, scored ≥ 14 on the Beck Depression Inventory II and self-identified as having debt worries. The main exclusion criteria were being actively suicidal or psychotic and/or severely depressed and unresponsive to treatment; having a severe addiction to alcohol/illicit drugs; being unable/unwilling to give written informed consent; currently participating in other research including follow-up phases; having received Citizens Advice Bureau (CAB) debt advice in the past year; and not wanting debt advice via a general practice. INTERVENTIONS:The participants in the intervention group were given debt advice provided by the CAB and shared biopsychosocial assessment, in addition to treatment as usual (TAU) and two debt advice leaflets. The participants in the control group were given advice leaflets provided by the general practitioner and TAU only. MAIN OUTCOME MEASURES:(1) Outcomes of the pilot trial - the proportion of eligible patients who consented, the number of participants recruited compared with target, assessment of contamination, and assessment of patient satisfaction with intervention and outcome measures. (2) Participant outcomes - primary - Beck Depression Inventory II; secondary - psychological well-being, health and social care utilisation, service satisfaction, substance misuse, record of priority/non-priority debts, life events and difficulties, and explanatory measures. Outcomes were assessed at baseline (pre-randomisation) and at 4 months post randomisation. Other data sources - qualitative interviews were conducted with participants, clinicians and CAB advisors. RESULTS:Of the 238 expressions of interest screened, 61 participants (26%) were recruited and randomised (32 in the intervention group and 29 in the control group). All participants provided baseline outcomes and 52 provided the primary outcome at 4 months' follow-up (14.7% dropout). Seventeen participants allocated to the intervention saw a CAB advisor. Descriptive statistics are reported for participants with complete outcomes at baseline and 4 months' follow-up. Our qualitative findings suggest that the relationship between debt and depression is complex, and the impact of each on the other is compounded by other psychological, social and contextual influences. CONCLUSIONS:As a result of low recruitment, this trial was terminated at the internal pilot phase and was too small for inferential statistical analysis. We recommend ways to reduce this risk when conducting complex trials among vulnerable populations recruited in community settings. These cover trial design, the design and delivery of interventions, recruitment strategies and support for sites. TRIAL REGISTRATION:Current Controlled Trials ISRCTN79705874. FUNDING:This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 35. See the NIHR Journals Library website for further project information. Mark Gabbay and Adele Ring are part-funded by NIHR Collaborations for Leadership in Applied Health Research and Care (CLAHRC) North West Coast and Richard Byng and Rod S Taylor, Vashti Berry and Elizabeth Shaw part-funded by NIHR CLAHRC South West Peninsula.

A significant body of research highlights negative impacts of epilepsy for individual quality of life (QOL). Poor seizure control is frequently associated with reporting of poor QOL and good seizure control with good QOL; however, this is not a universal finding. Evidence suggests that some people enjoy good QOL despite ongoing seizures while others report poor QOL despite good seizure control. Understanding the factors that influence QOL for people with epilepsy and the processes via which such factors exert their influence is central to the development of interventions to support people with epilepsy to experience the best possible QOL. We present findings of a qualitative investigation exploring influences and processes on QOL for people with epilepsy. We describe the clinical, psychological, and social factors contributing to QOL. In particular, we focus on the value of the concept of resilience for understanding quality of life in epilepsy. Based on our analysis, we propose a model of resilience wherein four key component sets of factors interact to determine QOL. This model reflects the fluid nature of resilience that, we suggest, is subject to change based on shifts within the individual components and the interactions between them. The model offers a representation of the complex influences that act and interact to either mitigate or further compound the negative impacts of epilepsy on individual QOL.

In the UK National Health Service, primary care organisation (PCO) managers have traditionally relied on the soft leadership of general practitioners based on professional self-regulation rather than direct managerial control. The 2004 general medical services contract (nGMS) represented a significant break from this arrangement by introducing new performance management mechanisms for PCO managers to measure and improve general practice work. This article examines the impact of nGMS on the governance of UK general practice by PCO managers through a qualitative analysis of data from an empirical study in four UK PCOs and eight general practices, drawing on Hood's four-part governance framework. Two hybrids emerged: (i) PCO managers emphasised a hybrid of oversight, competition (comptrol) and peer-based mutuality by granting increased support, guidance and autonomy to compliant practices; and (ii) practices emphasised a broad acceptance of increased PCO oversight of clinical work that incorporated a restratified elite of general practice clinical peers at both PCO and practice levels. Given the increased international focus on the quality, safety and efficiency in primary care, a key issue for PCOs and practices will be to achieve an effective, contextually appropriate balance between the counterposing governance mechanisms of peer-led mutuality and externally led comptrol.

AIM:Pharmacogenetic studies have identified the presence of the HLA-A*31:01 allele as a predictor of cutaneous adverse drugs reactions (ADRs) to carbamazepine. This study aimed to ascertain the preferences of patients and clinicians to inform carbamazepine pharmacogenetic testing services. METHODS:Attributes of importance to people with epilepsy and neurologists were identified through interviews and from published sources. Discrete choice experiments (DCEs) were conducted in 82 people with epilepsy and 83 neurologists. Random-effects logit regression models were used to determine the importance of the attributes and direction of effect. RESULTS:In the patient DCE, all attributes (seizure remission, reduction in seizure frequency, memory problems, skin rash and rare, severe ADRs) were significant. The estimated utility of testing was greater, at 0.52 (95% CI 0.19, 1.00) than not testing at 0.33 (95% CI -0.07, 0.81). In the physician DCE, cost, inclusion in the British National Formulary, coverage, negative predictive value (NPV) and positive predictive value (PPV) were significant. Marginal rates of substitution indicated that neurologists were willing to pay £5.87 for a 1 percentage point increase in NPV and £3.99 for a 1 percentage point increase in PPV. CONCLUSION:The inclusion of both patients' and clinicians' perspectives represents an important contribution to the understanding of preferences towards pharmacogenetic testing prior to initiating carbamazepine. Both groups identified different attributes but had generally consistent preferences. Patients' acceptance of a decrease in treatment benefit for a reduced chance of severe ADRs adds support for the implementation of HLA-A*31:01 testing in routine practice.

Sickness certification in primary care is increasingly the focus of new policies, practices and politics which are associated with keeping people in work rather than moving on to sickness absence. However, there are considerable tensions for practitioners from their role in sickness certification. The decision to issue a sicknote is influenced by a number of factors including the needs of their patient, their own attitudes towards work, and their responsibility to the state or employer. Some patients, such as those with Medically Unexplained Symptoms (MUS), are particularly challenging for Practitioners, as they do not fit the “sick role” and are difficult to negotiate with. We present the first taxonomy from actual sicknote consultations between General Medical Practitioners (GPs) and their patients, classifying the types of requests and the associated responses. Although, most sicknote requests do result in a sicknote, GPs do gather information about the patient’s social, occupational, and family circumstances, negotiate absences from work, impose terms and conditions upon the patient, and challenge patients’ illness constructions. Our findings suggest that, despite the tensions for GPs in managing these patients, sicknote consultations can be an important juncture for the clinicians and patients, particularly in light of the move from an illness deficit model towards a health capacity model, where work is considered health-giving, and not a barrier to illness recovery. This resonates with the switch in the UK to a “fitnote” approach from the previous “sicknote” one.