OBJECTIVE:To assess the effect of a proactive, assets based, peer support infant feeding intervention in addition to usual care on breastfeeding rates, formula feeding practices, and other outcomes, compared with usual breastfeeding support alone. DESIGN:UK based, multicentre, parallel group, unblinded, randomised controlled trial. SETTING:17 localities in the UK that offered breastfeeding peer support as part of usual care between January 2022 and 30 April 2024. PARTICIPANTS:2475 nulliparous women between 20 and 35 weeks of gestation were randomised 1.43:1, to account for potential clustering by peer supporter: 1458 to the ABA-feed (Assets based feeding help Before and After birth-feed) peer support intervention and 1017 to usual care. INTERVENTIONS:The ABA-feed intervention comprised person centred proactive peer support for infant feeding underpinned by an assets based approach (focusing on the capabilities of, and resources available to, participants) and behaviour change theory delivered in person and remotely by text and telephone call. Usual care included universal care from midwives and health visitors and could also include services that provided reactive support such as peer supporters in breastfeeding groups, counselling, helplines, and social media support groups. MAIN OUTCOME MEASURES:The primary outcome was any breastfeeding at eight weeks after birth. Secondary outcomes at eight, 16, and 24 weeks after birth included breastfeeding initiation, any and exclusive breastfeeding, formula feeding practices, anxiety, social support, and healthcare utilisation. Analyses were based on the intention-to-treat principle. RESULTS:Rates of any breastfeeding at eight weeks did not differ between the intervention group (1013/1452; 69.8%) and usual care group (698/1015; 68.8%); adjusted risk difference 0.01, 95% confidence interval -0.03 to 0.04. Preplanned subgroup analyses showed no interactions between the intervention and age, prespecified feeding intentions, mother's education, index of multiple deprivation fifth, or relationship status. Breastfeeding initiation rates were high (intervention 94.2%; usual care 92.5%). At eight weeks the intervention group reported higher social support, but this was not sustained at 16 weeks. No differences were observed in other secondary outcomes. CONCLUSION:The ABA-feed peer support intervention did not improve breastfeeding rates compared with usual breastfeeding support in a UK context. TRIAL REGISTRATION:ISRCTN Registry ISRCTN17395671.

OBJECTIVE:The objective of this study is to co-produce a care bundle for women with multiple long-term health conditions (MLTC) that could be pilot tested and implemented in UK maternity services. DESIGN:Online co-production workshops each attended by 20-30 key interest holders. SETTING:United Kingdom, October 2023-February 2024. POPULATION:Women with experience of pregnancy with MLTC, healthcare professionals and other interest holders involved in commissioning, planning and delivering care for pregnant women with MLTC. METHODS:This study followed a three-step process: (1) a consolidated list of key components of care for pregnant women with MLTC was created through secondary analysis of prior collected qualitative data; (2) the list of care components was explored during four co-production workshops; and (3) findings from (1) and (2) were synthesised to develop a maternity care bundle of 4-5 key care components for pregnant women with MLTC. MAIN OUTCOME MEASURES:A maternity care bundle of five key care components for pregnant women with MLTC. RESULTS:A list of 25 care components was refined to develop a proposed care bundle of five components. These were provisions of early and reliable medication advice and decision support; creation of a 'goals of care summary' accessible to women and the care team; provision of continuity of midwifery care throughout pregnancy and postnatal care; provision of a named care coordinator; and a formal postnatal handover of care from the multidisciplinary care team to the General Practitioner (GP) and secondary care team involving the woman. CONCLUSIONS:This study coproduced an evidence-based care bundle for pregnant women with MLTC to enhance communication and ensure individualised care and support. Further collaborative work with women and professionals is required to refine, implement and evaluate its impact on outcomes.

PROBLEM:Infant readmissions within the first 28 days of life have risen significantly over the past decade. BACKGROUND:Postnatal care is often described as under-resourced, with many women reporting a lack of sufficient support after birth. OBJECTIVE:To explore parents' experiences in the lead-up to infant readmission within the first four weeks of life. METHODS:Twenty-eight parents of 18 infants unexpectedly admitted to a large urban paediatric referral hospital in England within four weeks of birth were interviewed face to face. Data were analysed using thematic analysis. FINDINGS:Parents valued being united in their role as protectors. Mothers struggling with breastfeeding often felt intense responsibility, being their baby's sole source of nutrition. When concerns arose, some parents were unsure who to contact. Seeking advice from family sometimes delayed professional help. Others felt dismissed by health professionals offering false reassurance. Many were comforted upon arriving at the hospital and receiving a diagnosis, which validated their concerns and reinforced their protective instincts. DISCUSSION:This study highlights parents' need to be together post-birth, their decision-making when their baby became unwell, and their interactions with health professionals during readmission. CONCLUSION:Services should support shared caregiving early on by improving partner access to postnatal wards and enhancing community support for families returning home. The care pathway for unwell infants is often unclear and should be made more accessible to avoid unnecessary emergency visits. Health professionals must prioritise women's emotional wellbeing, especially during breastfeeding challenges, and respond seriously to parental concerns with clear escalation routes.

INTRODUCTION:Pregnant women who use specialist perinatal mental health services are more likely to be smokers at the time of birth than those without mental illness. This study explored health professionals' experiences of providing smoking cessation support to pregnant women with complex and severe mental illness. METHODS:Online video semi-structured interviews were conducted in England October 2023 - October 2024 with 20 National Health Service (NHS) healthcare professionals whose role included discussing smoking cessation with pregnant women with mental illness. Using job descriptions, participants were categorised 'signposters' (n= 11) or 'stop smoking practitioners (SSP)' (n=9). Interview topic guides and data analysis were guided by the Theoretical Domains Framework. RESULTS:Reported barriers to effective provision of smoking cessation support included prioritising mental health over smoking cessation and being cautious about communicating harms of smoking in case it caused women's mental health to deteriorate. Health professionals also lacked confidence that pregnant women with mental illness could quit. Lacking knowledge about the relationship between mental health and smoking was a barrier specifically for many 'signposters'. Facilitators included having capacity for health professionals to be responsive to women's needs, offering flexibility and effective integration of smoking cessation services within maternity and mental health care settings. CONCLUSIONS:Barriers to effective smoking cessation support included prioritising mental illness over smoking cessation advice and a pessimistic view that pregnant women with mental illness would struggle to quit smoking. Facilitators included full integration of services and adapting to women's needs by offering flexible timing and delivery of smoking cessation support.ImplicationsThis study shows multiple areas which may be impacting on the effectiveness of smoking cessation support available to pregnant women with mental illness. Future research could address some of the barriers identified in the study including prioritising mental health over smoking cessation, addressing health professionals' beliefs that pregnant women with mental illness are unlikely to quit smoking, training on communicating harms of smoking and improving knowledge on effect of smoking on mental health. Future research could also focus on sharing good practice including appointment flexibility and full integration of smoking cessation services within maternity and perinatal mental health services.

INTRODUCTION:One in five women enters pregnancy with multiple long-term health conditions, which is associated with increased risks of adverse maternal and child outcomes. There is a lack of research exploring individuals' experiences of preconception care for these women, which is also reflected in existing guidelines that predominantly focus on single health conditions. This study aimed to explore experiences of preconception care and support among women with multiple long-term health conditions and health professionals. METHODS:This is a secondary analysis of qualitative data collected by the MuM-PreDiCT consortium. The primary study involved semi-structured interviews between March 2022 and May 2023 with pregnant (> 28 weeks) and postnatal (< 2 years) women with multiple long-term physical and/or mental health conditions in the United Kingdom, and healthcare professionals involved in their care. Data captured within the preconception coding reports were analysed thematically. RESULTS:Fifty-seven women and 51 healthcare professionals were interviewed. Six themes were identified from the thematic analysis. Women and professionals described the importance of tailored preconception care and support, incorporating condition-focused counselling (sub-theme 1) and medication planning (sub-theme 2). Sensitive and realistic care and support were considered essential, but women had mixed experiences of involvement and empathy from different professionals. The significance of optimising antenatal care by making every preconception contact count was emphasised by both women and professionals, who valued early referrals, specialist input and integration of services. Although professionals viewed the preconception period as an opportunity to empower women, many women felt they had to self-advocate and seek information due to gaps in professional awareness, knowledge and education. Professionals reported differing views on who, within the care team, should take responsibility for care delivery. Some believed that women should play an active role in managing their health, including initiating conversations around pregnancy intentions. The delivery of preconception care was complicated by a range of challenges, including a lack of service integration, availability, time and funding. CONCLUSION:Women with long-term health conditions can experience substantial gaps in preconception care, characterised by inconsistent guidance and limited access to tailored, reliable support, which frequently leads to feelings of isolation and the need to seek additional information when preparing for pregnancy. These results will inform the co-development of a care bundle for affected women. PATIENT OR PUBLIC CONTRIBUTION:Our Patient and Public Involvement group was involved in the design of the study and the analysis and interpretation of the data, and two public study investigators are part of the author group.

BACKGROUND:Neonatal jaundice affects 60-80% of newborns, with bilirubin testing recommended for suspected jaundice. In the UK, detection largely falls to community midwifery services. Challenges in neonatal jaundice pathways have been identified but are not well understood. AIM:Explore and understand community neonatal jaundice pathways in the UK and identify improvement opportunities. METHODS:A mixed-methods study of community midwifery jaundice pathways in three UK NHS trusts in a diverse urban area including: (1) pathway mapping workshops, (2) cross-sectional analysis of detection, testing and admission in term infants, (3) time-motion exploration of serum bilirubin testing activity. Local data was triangulated with (4) a national survey of Heads of Midwifery. FINDINGS:Pathways and practice varied and deviated from NICE guidance locally and nationally, with many challenges identified. Among 16,760 eligible infants, 27% were assessed as jaundiced, of which 77% were not tested within 6 hours. Black infants were significantly less likely to be assessed or tested. 64% of infants re-admitted were not tested in the community. While there was variation in local testing rates, readmission rates were similar. No subsequent kernicterus was detected. DISCUSSION:Community pathways were inconsistent and deviated from guidance, with under-testing and ethnic inequalities. It was not clear whether testing variation impacted clinical outcomes. Future research should compare and evaluate efficacy, costs and implementation of neonatal jaundice interventions and pathways, including the impact on disparities and new testing technologies. CONCLUSION:Community jaundice pathways require further exploration, particularly access and inequalities to testing, and impact of new technologies.

Smoking during pregnancy is the leading preventable cause of maternal and infant morbidity and mortality in high income countries, disproportionately affecting women with mental illness. While behavioural smoking cessation interventions are effective for pregnant women and non-pregnant people with mental illness separately, evidence for specific smoking cessation interventions for pregnant women with mental illness is lacking. This review aimed to identify and map BCTs from effective general mental health smoking cessation trials to determine which may be helpful for pregnant women experiencing mental illness. A systematic review identified effective smoking cessation RCTs among people with mental illness. MEDLINE, EMBASE, PsycINFO, CINAHL, HMIC and CENTRAL databases were searched through April 2026. BCTs were coded using BCT Taxonomy; those in at least two effective interventions classified as ‘promising’ and compared against BCTs identified within National Centre for Smoking Cessation Training Standard Treatment Programme for pregnant women. Of 12,403 records, 195 full texts were screened and 16 RCTs met the inclusion criteria. Most interventions combined psychosocial and pharmacological components; motivational interviewing was the most common. Of 39 distinct BCTs identified, 26 were ‘promising’. Frequent BCTs included goal setting (1.1), problem solving (1.2), action planning (1.4), social support (unspecified) (3.1), instruction on how to perform the behaviour (4.1) and pharmacological support (11.1). High overlap exists; most promising BCTs for mental health populations are already embedded within the standard UK pregnancy care pathway. This study shows that behavioural components of effective smoking cessation interventions for people experiencing mental illness align with what is available women accessing NHS smoking in pregnancy cessation services. However, persistently high smoking rates in pregnant women with mental illness suggest that the presence of these techniques alone is insufficient. These findings imply that service improvements should prioritise adapting the delivery of existing BCTs, such as goal setting and problem-solving, to address specific psychological barriers and social contexts of this group to improve engagement and clinical outcomes.

When care homes close, social care leaders and managers must oversee the process of helping people to find new homes and take action to mitigate the detrimental impact on residents, families and staff. Everyone involved may be angry and distressed, and there can be significant political, media and/or legal controversy. However, there is scant research exploring local leaders’ experiences, little knowledge of local closure policies and arguably insufficient support for leaders as they undertake such important and sensitive work. In response, this article reports findings from a national survey of social care leaders (Directors of Adult Social Services or their nominees) in England, exploring their experiences of managing care home closures (with a particular focus on those involving older people and their families). Leaders from 38 of 152 English Councils participated (a 25% response rate), 19 of whom also shared a copy of their closure policy for analysis. Given the sensitive nature of these issues, the significant workload pressures faced by Directors and previous response rates to national surveys, this was a strong response, providing important insights. Respondents suggested that care home closures can be a challenging and often contested experience, leading to concerns raised by older people and families, local campaigns, and difficult media and political issues. Despite the importance of these issues, there was wide variation in local practice and written protocols, and a number of potential gaps in coverage. Most policies seemed to have been generated locally/bottom up, sometimes drawing on previous guidance (produced by the current research team in a particular policy context and some significant time ago), and with little evidence of more recent/current guidance or of a consistent approach across Councils. Overall, there seems scope for clearer, more definitive and national guidance to support Directors in such a complex and important task.

This project was carried out to understand what needs to change in maternity care in Coventry and Warwickshire to improve the experiences of women from Black African, Caribbean and mixed‑Black heritage backgrounds. Between May and June 2025, we held community workshops with Black African, Caribbean and mixed‑Black heritage women, online workshops with healthcare professionals (HCPs), local authority members and voluntary, community and social enterprise (VCSE) staff, and a final joint workshop where everyone reviewed and ranked the suggested solutions.

Background When care homes close, it can be detrimental to older people’s well-being. However, there is little formal evidence to guide services when undertaking such important work. Objectives This study explores what happens when homes close, how best to minimise negative outcomes for older people and families, and key lessons for councils as they manage future closures. Methods Background literature review, national survey of Director(s) of Adult Social Services and analysis of national Care Quality Commission data. Interviews with older people, families, care staff, social workers and broader managers/partners in four case study sites, together with outcomes data (EQ-5D, ICEpop CAPability measure for Older people and outcomes from the literature on what older people value about care services) at initial assessment, 28 days’ review and 1 year. Survey of care staff (Professional Quality of Life survey) before and after closures, supplemented with individual interviews; interviews with commissioners and service providers. Preliminary model-based economic evaluation comparing the costs and consequences of care home closures. Distillation of key messages into a national policy guide, an accessible guide for older people/families and a guide/free training video for care staff. Findings People assume that a care home is a home for life – but this is sadly not always the case. Care homes can close for all kinds of reasons (e.g. to do with funding, buildings, care quality, etc., but also due to broader factors beyond the control of the care sector). There can be significant differences between emergency closures (which can be especially traumatic) and more planned closures (when at least in principle there is more time to work at the pace of individual residents). Local policies vary significantly, and there may be scope for a more evidence-informed, consistent approach. Closures can be extremely difficult for everyone involved – and should perhaps only ever be a last resort. Closures are particularly traumatic for residents, who are losing their home and valued relationships. For some people, this may be similar to a bereavement. The needs of care staff – in terms of meaningful information, emotional and financial well-being and employment support – are often overlooked. This leaves people unsupported and might also reduce their ability to support others. Councils seeking to shape local care markets often lack the levers to be able to do this effectively. Care home closures can create financial pressures on the public sector, costing around £1500 per resident, while families and staff may face varying expenses, such as top-up fees and travel costs. Unplanned and emergency closures are slightly more expensive, and result in poorer outcomes for residents. We have limited long-term data, but it may sometimes be possible to manage closures in a way that minimises negative outcomes for some (especially if existing services were less than optimal and where closures are well planned). Limitations Collecting data from older people, families and staff during care home closures, and in a challenging policy context, is complex, and the amount of data it is possible to collect in such circumstances is inevitably limited in a number of ways. In reflecting on this, we nonetheless draw attention to: The novel nature of the research, filling key gaps in knowledge around such a significant topic. The diverse and multifaceted perspectives which only a programme of research could hope to include. The importance of our policy and practice materials, given the significance of the issues at stake and the lack of previous evidence on which to draw. Conclusions Care home closures can happen for many different reasons, and are always a logical possibility in a ‘care market’, which seeks to use choice and competition to keep costs down and promote quality. This study has identified a series of practical lessons and experiences shared by participants which might help others in future – made available to different audiences via a series of policy, practice and training materials. However, none of this should, in any way, minimise the distress experienced by residents, which can be very significant and may well be long lasting. Moving beyond the specific focus of this research, insights from interviews with local commissioners and providers may have broader implications for the extent to which local authorities have sufficient powers and practical tools to be able to deliver on their ‘market shaping’ responsibilities under the Care Act. Future research on care home closures could usefully focus on: The needs/experiences of people who may have additional or specific needs that might otherwise be overlooked, such as people living with dementia and people from minority ethnic communities or different faith groups. The knock-on effect that care home closures may have on partner agencies. More effective ways of managing emergency closures, and how best to support people after the closure with the trauma they may have experienced. Larger sample sizes might also generate additional insights around individual outcomes and around the implications of particular resident/staff characteristics or types of closure – but this may need to be balanced against the difficulty of conducting such research and the cost to funders of even larger studies. Study registration This study is registered as IRAS project ID: 297258. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research Programme (NIHR award ref: NIHR201585) and is published in full in Programme Grants for Applied Research; Vol. 14, No. 2. See the NIHR Funding and Awards website for further award information. Plain language summary We all want to be cared for with dignity when we are older, and we want the same for our families. Being looked after in a care home is expensive, and we have high expectations of the care that is given. But sometimes care homes close. This might be for a number of reasons, including financial problems, the state of the building or poor-quality care. This can affect the well-being of people in care homes, their families and the people who work there. Despite this, there is very little research to guide this important process. If care homes have to close, we want this to be well managed, so that older people are supported, families are reassured and care staff are helped to find new work and stay in care roles. To help with this, we: Asked Director(s) of Adult Social Services to tell us about what is happening across England and how they support older people at such potentially stressful times. Looked at some of the reasons why care homes might close from national data collected by an organisation called the Care Quality Commission. Worked in four different areas in England where homes are closing to ask older people, families, care staff and social workers about their experiences and how things could be improved. Looked at what impact closure has on older people’s health and well-being. Explored what happens to low-paid care staff after closures and the impact this has on them and the care they can give to others. Explored the cost implications for residents, family members, staff and wider society. We found that: People think that a care home is a home for life. Sadly, this is not always the case. Care homes can close for lots of different reasons. Planned closures can make it easier to support people well. Emergency closures, in particular, can be really upsetting. Local policies can be very different – perhaps there could be a more consistent national approach. Closures can be extremely difficult for everyone. They should only be a last resort. Closures are particularly traumatic for residents. For some people, this might be like a bereavement. The needs of care staff are often overlooked. It is difficult for councils to influence which homes open and close in their area. This might have broader implications for the role of councils beyond this particular topic. Closing a home costs councils money (about £1500 per resident). There can also be costs for residents and families. Even though moving to a new home can be very upsetting, some people settle and do well. We have written some guides to share what we have learnt with others. We have tried to focus on the things that people can do to make things better for residents – not on things they cannot change. There is a guide for older people and families being shared by a national charity called Age UK. Scientific summary Background We all want to be cared for with dignity when we are older, and we want the same for our families. Being looked after in a care home is expensive, and we have high expectations of the care that is given. Despite this, many care homes close every year, whether through an emergency (such as a fire/flood), councils making strategic choices to develop new service models, the cost of maintaining a dilapidated building, a private provider selling up/going bankrupt or a regulatory intervention following the discovery of poor care. In an era of austerity, care markets are increasingly fragile, and the very logic of a ‘market’ implies that the risk of failure has to be real for there to be sufficient incentives to deliver appropriate care at the right price. When care homes close, the received wisdom is that relocation can be detrimental to health and well-being. Despite this, there is little formal evidence to guide closure processes, with councils constantly ‘reinventing the wheel’. Objectives This study builds on a previous pilot in Birmingham in order to explore what happens to older people and care staff when care homes close, how best to manage closures in a way that minimises distress and negative outcomes for older people and families, and key lessons for councils as they seek to manage future closures. Our research questions are: What is the pattern of care home closures nationally? How are they undertaken in different councils, and what do councils consider to be best practice when supporting older people at such potentially stressful times? How do older people experience closures, what impact does closure have on health and quality of life, and how can any negative impacts be reduced? What impact do closures have on care staff and local care markets, and how can negative impacts be reduced? What are the costs and consequences of closures and the key data required to make this estimation? Can we develop a modelling framework to drive appropriate data collection for future home closure prediction to mitigate adverse outcomes? How can future closures be planned and conducted in a more evidence-based manner, so that outcomes for older people are improved and negative impacts reduced? Methods Work package 1 aimed to establish the pattern of care home closures nationally, how they are undertaken in different councils and what might constitute best practice when supporting older people. We carried out a cross-sectional survey targeted at social care leaders and an analysis of care home closure policy documents. All Director(s) of Adult Social Services in 152 councils in England were invited to participate. The survey explored leaders’ experiences of closures, policies, processes, perceived outcomes, challenges and any local evaluations. Participants were invited to share local care home closure policies for analysis. Descriptive statistics were analysed for quantitative survey data. Qualitative survey data and policy documents were analysed thematically. We also analysed routinely collected data from the Care Quality Commission (CQC) to understand the factors that influence care home closures. This combined individual care home characteristics from the CQC with information on council areas, taken from various sources, and data from the Social Care Collection. The CQC data provide us with information on 25,459 care homes between 2010 and 2021. These data are at the care home level and provide information on the type of care home (nursing/residential), the focus of the care home (older people, dementia, disability), size (measured by the number of beds), performance rating and indicators of whether the care home is located in an urban or rural area. The CQC data also provide us with the care home’s geographical location. This information allowed us to link data on other local characteristics (such as the proportion of the population who are over 65, deprivation, residential land prices and care home market competition). We also included variables collected as part of the Social Care Collection. This includes the proportion of self-funders, average daily rates of delayed transfers of care from hospital, total expenditure, satisfaction scores taken from the adult social care survey, proportion of individuals over 65 receiving long-term support and funds attached to carers support. The research used a multilevel logit regression model to study whether care homes close or stay open (a yes or no outcome). By using this approach, the study can account for differences between care homes within the same council, leading to more accurate results about how care home features, local factors, and social care spending affect the chances of a care home closing. Work package 2 explored the experiences of older people, families, care staff, social workers and broader stakeholders/local partners. We worked in four case study councils where homes were closing, including a mix of different locations across England, a mix of urban/rural settings and a mix in terms of socioeconomic/demographic factors. In each site, we undertook semi-structured qualitative interviews with 10–15 stakeholders/broader partners who had key roles in/perspectives on care home closures to explore the rationale for closure, key drivers, anticipated outcomes and impact on other services. We also undertook semi-structured interviews with 96 participants (older people, families, care staff and social workers) to explore the impact of closures, information/support provided, views on the process and areas for improvement. Interviews with older people took place in person with researchers based in the closing care homes (where COVID restrictions permitted). Where people were unable to consent to take part, a consultee was identified under the Mental Capacity Act. Interviews with families, care staff and assessors took place either in person or online, guided by their preference. We collected outcomes data for older people at initial review (before the closure), an early review (often 28 days after relocating) and at a longer-term review (1 year), before, during and after relocation. Twenty-two participants completed up to three paper-based questionnaires: EQ-5D, three-level version, ICEpop CAPability measure for Older people (ICECAP-O) and a 15-question, Likert scale questionnaire, based on a national review of the literature on what older people value about care services. Interviews were transcribed and analysed using the framework approach to identify key themes. Questionnaires were coded and analysed using Stata® (StataCorp LP, College Station, TX, USA). Work package 3 considered the impact of care home closures on care staff. Where access permitted, all care staff in closing homes in our four case study sites were invited to take part in interviews and to complete the Professional Quality of Life survey during and 6 months after closure. The interviews explored how care staff experienced the closure of the care home where they worked, how they prepared for closure, the impact upon themselves and current/future employment, and their insights into the closure process. All employed staff at a care home were given the opportunity to take part, including kitchen staff, cleaners and handypeople, as well as people providing direct care and those working in co-ordinating or care management capacities. In each of our four case study sites, we carried out semi-structured interviews with commissioners and providers (seeking up to eight of each per site). Participants included those in senior roles involved in decision-making or closely connected to care home functioning, as well as those who were indirectly or directly impacted by a care home closing. Interviews explored the relationship between commissioners and providers, the nature and impact of local authority strategy, the responsibilities of care homes and the local care market (including approaches to trying to shape the local market, to ensure stability and to contingency planning). Work package 4 focused on analysing the economic impacts of care home closures on residents, their families, care home staff and councils. Pathway costing employed both quantitative and qualitative methods, organised into three stages. Stage 1 involved analysing stakeholder interviews (from WP2) to identify economic themes related to care home closures. Stage 2 utilised these insights to develop closure pathways for stakeholders, including residents, families and care staff. Stage 3 conducted a full cost analysis to estimate closure costs, including using sensitivity analysis for different stakeholders. This stage involved identifying and quantifying resources needed at each pathway stage. Economic modelling focused on developing a decision tree model to analyse care home closures under three scenarios: planned, unplanned and emergency. This model was informed by interview data from WP2, specifically coded for WP4. The pathways developed in the previous pathway costing served as a foundation and were adapted to reflect the complexities of unplanned and emergency closures. Cost and resource use data were derived from the previous cost analysis, supplemented by literature and expert opinion, especially for unplanned and emergency scenarios. Probabilities within the model were informed by observations from case study sites, literature reviews, qualitative interviews and expert opinions. The analysis was conducted from a public sector perspective using a 12-month decision tree model. This model reports the cost per capability improvement by comparing unplanned and emergency scenarios to a reference case of planned closures. Outcomes were measured using ICECAP-O and EQ-5D data collected in WP2. In work package 5, we summarised findings in a national policy guide sent to all social care leaders in England, a free training video, a guide for older people/families and a guide for care staff. Results Key findings were that: People assume that a care home is a home for life – but this is sadly not always the case. Care homes can close for all kinds of reasons (e.g. to do with funding, buildings, care quality, etc., but also due to broader factors beyond the control of the care sector). There can be significant differences between emergency closures (which can be especially traumatic) and more planned closures (when at least in principle there is more time to work at the pace of individual residents). Local policies vary significantly, with scope for a more evidence-informed, consistent approach. Closures can be extremely difficult for everyone involved – and should perhaps only ever be a last resort. Closures are particularly traumatic for residents, who are losing their home and valued relationships. For some people, this may be similar to a bereavement. The needs of care staff – in terms of meaningful information, emotional and financial well-being and employment support – are often overlooked. This leaves people unsupported and might also reduce their ability to support others. Councils seeking to shape local care markets often lack the levers to be able to do this effectively. Care home closures can create financial pressures on the public sector, costing around £1500 per resident, while families and staff may face varying expenses, such as top-up fees and travel costs. Unplanned and emergency closures are slightly more expensive, and result in poorer outcomes for residents. We have limited long-term data, but it may sometimes be possible to manage closures in a way that minimises negative outcomes for some (especially if existing services were less than optimal and where closures are well planned). Conclusions Overall, we conclude that: Many people assume that moving into a care home means a home for life – but this is sadly not always the case. Homes can close for all kinds of reasons. This can be due to issues around funding, business decisions and/or the quality of care delivered – but can also be influenced by broader factors (such as changes in land values influencing people’s decisions about whether or not to exit the market). There can be very significant differences between emergency closures (which can be especially difficult and traumatic) and more planned closures (when at least in principle there is more time to plan, communicate and work at the pace of individual residents). There has previously been limited evidence to guide decision-makers and practitioners seeking to support and relocate older people. Local policies and protocols vary significantly, and there may be scope for a more evidence-informed, consistent approach (e.g. via a national or regional template). Closures can be extremely difficult and traumatic for everyone involved, from social care leaders and staff, to service providers and care staff, to older people and families – and should perhaps only ever be seen as a last resort. Closures are particularly traumatic for older people, who may be understandably angry, distressed and disorientated. People are losing their home and valued relationships with residents and staff, and the process may well be similar to that of a bereavement. The needs of care staff – in terms of meaningful information, practical details, emotional well-being and employment support – can often be overlooked. This should be a key focus in future, both to better support staff, and because care staff are so significant in terms of supporting older people. Local authorities have a duty to shape their local care markets, but often lack the levers, powers and tools to be able to do this effectively. Too often, they feel as if the ‘wrong’ homes are opening and closing in their areas. Care home closures can create financial pressures on the public sector, costing around £1500 per resident, while families and staff may face varying expenses, such as top-up fees and travel costs. Our findings indicate that unplanned and emergency closures are slightly more expensive and result in poorer outcomes for residents. Well-planned and supportive closures can potentially improve the health-related quality of life of residents over the longer-term period of a year (especially if people are unhappy with care in the original home) but are associated with a brief initial negative impact. Findings highlight the importance of careful preparation, planning and support to minimise disruption and improve overall outcomes. Recommendations for policy, practice and research Above all, there are a series of practical lessons and experiences shared by participants which might help others in future – made available to different audiences via a series of policy, practice and training materials. However, none of this should in any way minimise the distress experienced by residents, which can be very significant and may well be long lasting. We will also seek to work with regulators to learn lessons from one of our emergency closures, which happened at very short notice (hours) and was particularly traumatic for everyone involved. Moving beyond the specific focus of this research, insights from interviews with local commissioners and providers may have broader implications for the extent to which local authorities have sufficient powers and practical tools to be able to deliver on their ‘market shaping’ responsibilities under the Care Act. Future care home closures research could usefully focus on: The needs/experiences of people who may have additional or specific needs during closures that might otherwise be overlooked, such as people living with dementia and people from minority ethnic communities or different faith groups. The knock-on effect that care home closures may have on partner agencies. More effective ways of managing emergency closures and how best to support people after the closure with the trauma they may have experienced. Larger sample sizes might generate additional insights around individual outcomes and the implications of particular resident/staff characteristics or types of closure, but this may need to be balanced against the difficulty of conducting such research/the cost of even larger studies. Study registration This study is registered as IRAS project ID: 297258. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research Programme (NIHR award ref: NIHR201585) and is published in full in Programme Grants for Applied Research; Vol. 14, No. 2. See the NIHR Funding and Awards website for further award information.

Background: Since 2020, the General Medical Services contract requires GP practices in England to offer women a GP appointment 6-8 weeks after birth: the '6-8 week postnatal check' or 'consultation'. Historically, provision of checks was variable, and women still frequently report poor experiences. Aim: To explore GPs' and women's perspectives of the 6-8 week postnatal check, including key components and timing. Design & setting: A mixed- methods study was undertaken with focus groups of GPs and women, and an online survey of GPs in England. Method: Focus groups explored GPs' and women's experiences of postnatal consultations. An online survey explored GPs' clinical approach, organisation, and improvement potential. Quantitative analysis examined associations between demographics and clinical approach. Thematic framework analysis was used for qualitative data. Results: In total, 18 women and 14 GPs participated in focus groups; 671 GPs completed the survey. Mental wellbeing and contraception were reported as important topics, although some women were not asked about mental health. GP survey responses indicated most recommendations from national guidance were 'always' or 'very often' covered by most, but not all GPs. Clinical coverage was higher for GPs who used clinical templates, had awareness of guidance, were female, or were a parent. Many GPs (n = 326/670, 49%) needed more time than they were allocated for the consultation (n = 524/670 [78%] allocated <= 15 minutes; n = 351/670 [52%] completed in <= 15 minutes). Conclusion: This study suggests GPs are allocated insufficient time for postnatal consultations, with substantial variation in practice. Specifying consultation duration and consideration of template usage in policy may improve care and outcomes for women.

The assets-based feeding help before and after birth (ABA-feed) intervention aims to improve breastfeeding rates by offering proactive peer support to first-time mothers, regardless of feeding intention. Based on behaviour change theory and an assets-based approach, the intervention involved training existing peer supporters to become infant feeding helpers (IFHs). A train-the-trainer model was used, with coordinators delivering four 2-h training sessions to IFHs. Training covered a study overview, IFH role, role-play scenarios and signposting to local assets. Due to COVID-19, training was delivered online. Post-training questionnaires were completed by 22/30 (73.3%) coordinators and 119/193 (61.7%) IFHs, and qualitative interviews were conducted with 24 coordinators and 72 IFHs. Researchers observed training at five sites, assessing fidelity, engagement and delivery quality. Questionnaire data were analysed descriptively, and qualitative data were analysed using framework analysis. Findings indicated that coordinators valued the train-the-trainer model, particularly information on formula feeding and antenatal discussions. IFHs found training engaging and felt prepared, though some were apprehensive about formula feeding support. While online training was convenient, challenges included monitoring discussions and role-play in breakout rooms. Most participants favoured a hybrid approach, with in-person sessions for interactive activities. Observations showed high training fidelity, participant engagement and confidence in delivering intervention components. The ABA-feed training was acceptable to coordinators and IFHs and was delivered with fidelity. Future training should adopt a hybrid approach, incorporating diverse resources and prioritising in-person interactive components such as role-play. Trial Registration: ISRCTN17395671.

BACKGROUND:Since 2020, GP maternal postnatal consultations 6-8 weeks after birth have been mandatory under England's General Medical Services contract. Previously, provision and quality of these consultations was inconsistent, often inadequate. The impact of the mandate is unknown. AIM:To develop an understanding of facilitators and barriers to GPs providing high quality 6-8-week maternal postnatal checks through exploration of views and experiences of women and GPs. METHOD:Mixed methods study focus groups of GPs and women, and an online survey of GPs in England. Qualitative data collection was via focus groups exploring GPs' and women's experiences of postnatal consultations, and an online survey of GPs. Thematic framework analysis was used, with the Capability, Opportunity, Motivation - Behaviour (COM-B) model as an overarching thematic structure. Inductively developed subthemes were mapped to relevant constructs of the COM-B model. RESULTS:Focus groups included 18 women and 14 GPs, the GP survey received 671 responses. Twelve subthemes mapped to six domains of the COM-B model, comprising influences that could be facilitators or barriers to good care. Some influences related to both GPs and women. Some were specific to GPs, such as 'GPs' knowledge', or to women, such as 'Women's social context'. GPs' lived experience impacted their knowledge and motivation. CONCLUSION:GPs and women experienced barriers to good postnatal consultations. Organisational interventions could address; for example, adequate appointment duration, and improved information transfer. Application of the Behaviour Change Wheel to prioritise and develop interventions based on findings could improve women's experience and outcomes.

Background:Perinatal mental illness affects around 20% of women in pregnancy and the first postpartum year with little evidence regarding persistence and incidence in the second year. This study aimed to describe prevalence and incidence of moderate and severe mental illness in the second postpartum year to estimate the proportion of women who could benefit from extension of England's specialist perinatal mental health services to two years. Methods:A retrospective cohort study using United Kingdom primary care Clinical Practice Research Datalink GOLD. All women registered with a General Practitioner with third trimester, delivery code or postpartum medical record 1995-2020 were included. Secondary objectives were to investigate mental illness type and associated factors. Findings:2,132,754 pregnancies from 1,361,497 women were included. Prevalence of mental illness likely to need specialist PMH services in second postpartum year increased significantly from 3.1% (n = 2643/85,756) in 1995 to 7.4% (n = 2473/34,098) in 2018. Incident cases increased from 1.9% (n = 1630/85,756) in 1995 to 3.8% (n = 1285/34,098) in 2018 representing 56.6% (n = 69,926/123,510) of all cases in the second year. Adjusted analysis showed odds of mental illness in second year were higher: for women in most ages vs 30-34 yrs; for each additional pregnancy (OR: 1.16, 95% CI: 1.13, 1.19 two vs one); for preterm births (OR: 1.21, 95% CI: 1.15, 1.27), near term (OR: 1.21, 95% CI: 1.17, 1.25) or post-term (OR: 1.07, 95% CI: 1.04, 1.09) vs term; with history of mental illness (OR: 2.46, 95% CI: 2.41, 2.52), smoking (OR: 1.37, 95% CI: 1.35, 1.39), substance use disorder (OR: 1.54, 95% CI: 1.48, 1.60), and for each year vs 1995. Separate analysis using a subset of data showed odds of mental illness were higher for women in all quintiles vs least deprived and for women of white ethnicity vs all other ethnicities. Although severity could not be accurately measured, most recorded illnesses would require specialist perinatal mental health input. Interpretation:Extension of specialist perinatal mental health services to two years postpartum is justified. Funding:National Institute for Health and Care Research Applied Research Collaboration West Midlands (NIHR200165).

UK breastfeeding rates are low, with health inequalities in initiation and continuation. Breastfeeding peer support interventions are recommended in UK and global policy. The Assets-based feeding help Before and After birth (ABA-feed) trial tested the effectiveness of proactive, woman-centred support for infant feeding delivered by trained peer supporters (infant feeding helpers; IFHs) in addition to usual care at 17 UK sites. Using data from an embedded process evaluation, this paper reports the views and experiences of women receiving, and the IFHs and coordinators delivering, ABA-feed. Women (n = 2475) were recruited to the trial antenatally; 1458 were allocated to the intervention. Thirty women from five study sites took part in qualitative interviews between 9 and 23 weeks postnatal. IFHs (n = 72) and coordinators (n = 25) from across all sites participated in individual or group interviews towards the end of the intervention period. Interview transcripts were analysed alongside 1147 free-text responses from an 8-week postnatal follow-up survey using Framework Analysis. The ABA-feed intervention was highly acceptable to women, including younger women, those with less education, from diverse ethnic groups, single mothers, and those who intended to formula feed, as well as to IFHs and coordinators. Both remote and in-person support was acceptable. While women valued proactive daily contact during the first 14 days postpartum, some IFHs found this challenging, and some struggled with supporting women who chose formula feeding or were less engaged. This study highlights the value of flexible, proactive, woman-centred infant feeding support. TRIAL REGISTRATION: ISRCTN17395671.

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