BACKGROUND:At the end of 2024 over 3,500 women were living in prison in England, many of whom have experienced prior trauma and domestic abuse and are more likely than men in prison to self-harm. Compared to women living in the community, they also have higher levels of social care needs, yet little research has been conducted to explore social care provision for this population. METHODS:We conducted surveys of healthcare managers and governors in eleven women's prisons in England and their corresponding nine local authorities (LAs), to establish how they addressed their responsibilities for women with social care needs eight years on from the 2014 Care Act. Numerical and pre-coded data were analysed in Microsoft Excel using simple descriptive methods (e.g., frequencies, percentages). Descriptive qualitative analysis was used on free-text data. FINDINGS:The LA survey was completed by 9/9 LA staff; the prison governor survey by 8 staff (representing 10/11 prisons); and the healthcare manager survey by 7/11 staff. Considerable variation was found between establishments in Care Act assessment rates (1% to 36%). Some prisons relied on prison officers or peer supporters who had not received adequate training/supervision to identify social care needs, although all respondents agreed that social care provision had improved since the Care Act. There was less agreement regarding arrangements for transferring assessments between LAs on release. Qualitative analysis provided insight into this and other problems, including identifying women with social care needs; transferring information; gaining access into the prison; and resolving disputes/disagreements between LAs. Several proactive initiatives to improve identification/provision, and promote wellbeing, were described (e.g., regular drop-ins; scoping the use of telecare; linking with external agencies (e.g., neurodiversity and sensory services); an enablement/reablement pathway; and advocacy). CONCLUSION:This paper is the first to explore social care provision for women in prison in relation to the 2014 Care Act. Although provision has grown and improved since the implementation of the Act, it is patchy and often suboptimal or "gets forgotten". Potential ways forward include standardised, flexible screening processes; gender-specific adaptation of screening/assessment tools; and social care training and supervision for officers and peer supporters.

Prison peer support schemes can offer social care for people who require help with activities such as self-care, fetching meals, getting around safely, taking part in meaningful activities, and/or forming or maintaining relationships. Little is known about how best to deliver and monitor prison peer support schemes. Peer supporters do not always receive appropriate training or supervision, leaving them and the support recipient vulnerable to exploitation and/or distress or harm. We conducted a mixed studies review to co-develop guidance on peer support schemes for social care in prison and developed an initial programme theory and logic model. We synthesised findings/evidence from stakeholder workshops, six of our previous projects on social care in/on release from prison, and an umbrella review of the literature. The co-developed guidance provides structure for some aspects of the peer support process while allowing for flexibility. We make recommendations about recruitment, training, roles, support plans, and supervision of and support for peer supporters themselves. Better structured/formalised processes which espouse a peer-led approach would empower peer supporters to optimise their capacity to be the “eyes and ears on the ground” and to become recognised, respected and valued as integral to the running of the prison. In turn, this could provide individuals with a sense of purpose, self-efficacy, and self-confidence. The correct balance between risk-management and allowing some flexibility within the peer support role needs to be determined. Our guidance will be implemented and evaluated in at least one prison and disseminated across England and Wales.

ABSTRACT In England and Wales, approximately 8% of prisoners aged 50 and over are likely to have dementia/MCI, but they do not receive equivalent care to their counterparts in the community. We previously designed DECISION (Dementia and Mild Cognitive Impairment in prison), a care pathway and training/awareness package for use in prison. The aim of this article is to describe the development of an initial programme theory (IPT) and logic model for the DECISION care pathway. Development of the IPT and logic model was an iterative process involving: i) an umbrella review approach to synthesising information from seven systematic reviews of dementia in prison; ii) co‐design workshops with key stakeholders including experts by experience; and iii) reviewing our previous qualitative work. Key elements of the IPT and logic model include specialist training for and ongoing supervision of dementia care coordinators; ageing awareness training for all staff in prison; use of two cognitive screening tools; and release planning, including awareness‐raising among probation and third sector groups who work with people released from prison who have dementia/MCI. The IPT and logic model will provide stakeholders with a proposed framework for the innovation or further development of dementia care and support in prison.

Objectives To identify/map the nature and extent of the literature on training for non-custodial staff (social workers, healthcare staff and/or their equivalent) working in prisons in England, with a specific focus on social care, to inform the training of individuals delivering the Empowered Together (coordinated social care in prison) intervention. Study design Systematic scoping review. Methods We conducted systematic searches across eight electronic databases. Pairs of reviewers independently screened articles meeting pre-specified criteria. We extracted the following into Excel spreadsheets: study characteristics; training development, content/delivery, evaluation; author recommendations. We tabulated study characteristics and provided narrative summaries. We also considered the grey literature. Results Of 512 records identified through database searches, two met our inclusion criteria. Both focused on training to support people living in prison with dementia. Each embraced stakeholder involvement as part of training development, targeted a range of staff (rather than solely social workers), and aimed to enhance knowledge among staff. However, only one covered practical skills and neither included evaluations of their training programmes. No relevant documents were found within the grey literature. Conclusions This is the first systematic scoping review of social care training in prison. Findings suggest a paucity of evidence regarding training for social workers working in prisons across England. Future training should ideally be co-designed with key stakeholders including people living and working in prison, and future research should focus on robust evaluation of training initiatives not only in terms of knowledge but also the impacts this has on people living in prison.

People in prison experience high rates of physical and mental health problems and although prison provides opportunities to improve health and wellbeing, they often experience worse health outcomes. This study aimed to explore the perspectives of staff and people in prison, considering their experiences of perceived avoidable healthcare-associated harm and the factors they felt influenced prevention of harm. Qualitative, semi-structured, interviews were conducted with 32 prison staff and commissioners and 23 people in prison across five prisons in England. Interviews were conducted between August 2022 and January 2024 and were analysed thematically. Problems with access to timely and appropriate healthcare were commonly raised by participants in relation to issues around medication management and access to healthcare. Prison policies and practice were highlighted by participants as factors that influenced the prevention of harm; interviewees referred to the impact of staffing capacity and the skillsets of staff in terms of trauma and mental health, the impact this had on relationships between staff and people in prison, as well as challenges related to communication and coordination between teams within the prison. Experiences of perceived avoidable healthcare-associated harm in prisons centred on medication management issues and difficulties with accessing healthcare. Recruiting and retaining skilled staff and systems lacking communication and coordination were considered important factors influential to harm prevention. A systems-based approach is needed to improve patient safety considering how integration and communication can be improved but this is needed alongside improved health literacy and interventions to increase autonomy that are led by people in prison.

Introduction Recent research indicates that around 8% of older people living in prison have signs or symptoms of dementia or mild cognitive impairment (MCI), yet the care they receive is not equivalent to care in the community and this means their needs may not be met. We co-developed an intervention specifically for older people living in prison with dementia/MCI (Dementia and Mild Cognitive Impairment in prison care pathway and training package-DECISION). To date, this has not been implemented or evaluated. This paper presents our protocol for a study to assess the feasibility and acceptability of DECISION.Methods This is a non-randomised, realist-informed mixed-methods feasibility study with integrated process evaluation, which will take place in two prisons in England. The intervention was codeveloped with experts with lived experience. Participants will include older people living in prison, staff working in prison and peer supporters. We will assess the feasibility and acceptability of the intervention (eg, numbers eligible; rates of recruitment and retention), and the evaluation design (eg, completion rates of standardised outcome measures). Methods will include semistructured, realist-informed interviews; an audit to assess implementation fidelity; focused ethnography; training questionnaires; and collection of resource use data. We will refine the DECISION programme theory using realist-informed methods to examine and refine how contexts and mechanisms interact to produce the intervention's outcomes.Ethics and dissemination This study received a favourable ethical opinion from the Wales REC 3 Research Ethics Committee in January 2025 (reference number 24/WA/0323). HMPPS National Research Committee approval was also granted in January 2025 (reference number 2024-1451). Findings will be disseminated through a range of avenues, including stakeholder engagement events, open-access papers, conference presentations, evidence briefings for commissioners, providers and practitioners, and newsletters for service users.

ABSTRACTThe mental health needs of older people in prison (OPiP) are considerable but remain overlooked. This review aimed to develop an Initial Programme Theory (IPT) to understand how the mental health needs of OPiP can be addressed and how mental health care for older people in the community could be adapted for the prison environment. A review and realist synthesis pertaining to the mental health needs of OPiP was conducted across three stages, including: (1) a systematic review of empirical work; (2) a scoping review of prison guidance documents; and (3) a scoping review of community mental health guidance documents. Synthesis of eligible literature and development of the IPT followed realist principles and was supplemented by a stakeholder workshop of experts by personal and occupational experience. Overall, 122 sources were included. The IPT suggested that prisons can address the mental health needs of OPiP via micro‐level mechanisms (i.e., screening, assessment, care planning, intervention, continuity of care/release), meso‐level mechanisms (i.e., accommodation, environment, activities, religion/spirituality, peer support, family support) and macro‐level mechanisms (i.e., staff training/education, governance). Each mechanism is underpinned by trauma‐informed, integrated and patient‐centered care principles and their implementation should be guided by a local assessment of prison‐specific needs. Our IPT provides a framework for how prisons can address the mental health needs of OPiP, informed by community care provision, via several mechanisms across different levels. Future research should build on this work to inform a full evaluation of its impact on meaningful outcomes to promote equivalency of care for OPiP and non‐discriminatory access to mental health support for those at risk of marginalization.

In England, local authorities are responsible for providing social care in prison in accordance with the Care Act (implemented in 2015), but little is known about ‘low-level’ needs that do not meet eligibility criteria. These ‘low-level’ social care needs can greatly affect individuals living in prison with limited autonomy. This scoping review aimed to describe the nature, extent, and conceptualisation of ‘low-level’ social care in UK prisons, including prevention and promotion of independence. We adopted the Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for Scoping Reviews checklist and Joanna Briggs Institute guidelines. Papers were screened by pairs of reviewers. In total, 31 papers were included. Findings are reported using descriptive techniques. Types of ‘low-level’ social care discussed included finances (n = 8 papers), feelings of safety (n = 8), and dignity (n = 8). Ten papers included prevention of social care needs and/or promoting independence in relation to social care needs. Evidence is limited, and further research is needed on ‘low-level’ support needs of people in prison. Consensus is needed on what constitutes ‘low-level’ social care needs; how they may vary depending on individual characteristics including age, gender, ethnicity, culture, and neurodiversity; and how individuals should be supported with these needs.

Context: Social care need in prisons is increasing in many countries. However, the delivery of social care in prisons has been (at best) inconsistent and there has been no previous review to inform provision for people on release. Objective: To identify and synthesise what is known about the social care needs of people on release from prison and how best to meet these. Method: A scoping review encompassing systematic searches of 26 electronic databases (January 2010–July 2021) included a wide range of literature. No exclusions were made on the basis of study design, method or quality. Findings were organised according to their contribution to the research questions. Findings: Forty-six documents met the review criteria of which 27 were from the UK. Just two focused specifically on the topic of interest and most of the extracted material was descriptive in nature. Almost no information was found on the number of people released from prison in need of social care. However, the challenges of providing care for this group appeared well understood. Although there were many examples of good practice and widespread consensus about its enablers, outcome information was lacking. Limitations: In keeping with the nature of the review, the quality of the literature was not formally assessed. Implications: The review identified several promising initiatives ranging from prison buddy schemes to pre-release training in everyday living skills and personalised pathway documents. Conclusions: Policy makers and researchers must now shift their attention to the effectiveness of particular interventions in improving social care outcomes.

Objectives The burden of cardiovascular disease (CVD) is increasing. Cardiac rehabilitation (CR) is a complex intervention offered to patients with CVD, following a heart event, diagnosis or intervention, and it aims to reduce mortality and morbidity. The objective of this within-trial economic evaluation was to compare the cost-effectiveness of metacognitive therapy (MCT) plus usual care (UC) to UC, from a health and social care perspective in the UK.Methods A multicentre, single-blind, randomised controlled trial (ISRCTN74643496) was conducted in the UK involving 332 patients with CR with elevated symptoms of anxiety and/or depression and compared group-based MCT with UC. The primary outcome of the cost-effectiveness analysis was quality-adjusted life-years (QALYs). The time horizon of the primary analysis was a 12-month follow-up. Missing data were imputed using multiple imputation. Uncertainty was explored by probabilistic bootstrapping. Sensitivity analyses tested the impact of the study design and assumptions on the incremental cost-effectiveness ratio.Results In the primary cost-effectiveness analysis, MCT intervention was dominant, with a cost-saving (net cost −£219; 95% CI −£1446, £1007) and QALY gains (net QALY 0.015; 95% CI −0.015, 0.045). However, there is a high level of uncertainty in the estimates. At a threshold of £30 000 per QALY, MCT intervention of around 76% was likely to be cost-effective.Conclusions Results suggest that intervention may be cost-saving and health-increasing; however, findings are uncertain and subject to limitations. Further research should aim to reduce the uncertainty in the findings (eg, with larger sample sizes) and explore potential longer-term economic benefits associated with MCT in this setting.

Many people are living in prison with a range of social care needs, for example, requiring support with washing, eating, getting around safely, and/or maintaining relationships. However, social care for this vulnerable group is generally inadequate. There is uncertainty and confusion about who is legally responsible for this and how it can best be provided, and a lack of integration with healthcare. We used realist-informed approaches to develop an initial programme theory (IPT) for identifying/assessing social care needs of, and providing care to, male adults in prison and on release. IPT development was an iterative process involving (a) an initial scoping of the international prison literature; (b) scoping prison and community social care policy documents and guidelines; (c) full systematic search of the international prison social care literature; (d) insights from the community social care literature; (e) stakeholder workshops. Information from 189 documents/sources and stakeholder feedback informed the IPT, which recommended that models of prison social care should be: trauma-informed; well integrated with health, criminal justice, third-sector services and families; and person-centred involving service-users in all aspects including co-production of care plans, goals, and staff training/awareness programmes. Our IPT provides an initial gold standard model for social care provision for people in prison and on release. The model, named Empowered Together, will be evaluated in a future trial and will be of interest to those working in the criminal justice system, care providers and commissioners, local authorities, housing authorities, voluntary groups, and service-users and their families.

eview question / Objective The overall aim of this realist-informed scoping review is to explore the nature and extent of the literature on lower-level social care needs of adults on entry to male prisons, identify any gaps in the prison literature, and explore conceptualisations and definitions of social care used.Adopting a realist-informed approach, we will use the information gathered from the scoping review to d e v e l o p a s e t o f ' c o n t e x t -m e c h a n i s moutcome' (CMO) configurations, and seek to address the following research question: 'What works in addressing the lower-level social care needs of adults on entry to male prisons, how, why, for whom, and in what circumstances?' Note: We anticipate that there will be knowledge gaps in the prison literature.Therefore, in line with our realist-informed approach, we will also explore the broader community literature on lower-level social care after completing the prison-specific search and analysis.This aspect of the review will be exploratory and iterative in nature.Background A significant number of people living in prisons have, or are at risk of developing, social care needs.Examples include needing help with getting washed/dressed, toileting, mobility, building/maintaining positive relationships, or participating in purposeful activity.In England local a u t h o r i t i e s ( e .g ., c o u n t y c o u n c i l s ) h a v e responsibility, under the Care Act 2014, for assessing and providing for certain social care needs of people in prison, for prevention of social c a r e n e e d s , a n d f o r t h e p r o m o t i o n o f independence relating to social care.However, there are specific eligibility criteria, leaving many people with lower-level needs excluded from formal support and in some cases receiving inappropriate informal support (for example, INPLASY

To synthesize evidence on the ability of specialist care home support services to prevent hospital admission of older care home residents, including at end of life. Systematic review, without meta-analysis, with vote counting based on direction of effect. Fourteen electronic databases were searched from January 2010 to January 2019. Reference lists of identified reviews, study protocols and included documents were scrutinized for further studies. Papers on the provision of specialist care home support that addressed older, long-term care home residents’ physical health needs and provided comparative data on hospital admissions were included. Two reviewers undertook study selection and quality appraisal independently. Vote counting by direction of effect and binomial tests determined service effectiveness. Electronic searches identified 79 relevant references. Combined with 19 citations from an earlier review, this gave 98 individual references relating to 92 studies. Most were from the UK (22), USA (22) and Australia (19). Twenty studies were randomized controlled trials and six clinical controlled trials. The review suggested interventions addressing residents’ general health needs ( p  < .001), assessment and management services ( p  < .0001) and non-training initiatives involving medical staff ( p  < .0001) can reduce hospital admissions, while there was also promising evidence for services targeting residents at imminent risk of hospital entry or post-hospital discharge and training-only initiatives. End-of-life care services may enable residents to remain in the home at end of life ( p  < .001), but the high number of weak-rated studies undermined confidence in this result. This review suggests specialist care home support services can reduce hospital admissions. More robust studies of services for residents at end of life are urgently needed. The review addressed the policy imperative to reduce the avoidable hospital admission of older care home residents and provides important evidence to inform service design. The findings are of relevance to commissioners, providers and residents.

INTRODUCTION:Cardiac rehabilitation (CR) is offered to reduce the risk of further cardiac events and to improve patients' health and quality of life following a cardiac event. Psychological care is a common component of CR as symptoms of depression and/or anxiety are more prevalent in this population, however evidence for the cost-effectiveness of current interventions is limited. Metacognitive therapy (MCT), is a recent treatment development that is effective in treating anxiety and depression in mental health settings and is being evaluated in CR patients. This protocol describes the planned approach to the economic evaluation of MCT for CR patients. METHODS AND ANALYSIS:The economic evaluation work will consist of a within-trial analysis and an economic model. The PATHWAY Group MCT study has been prospectively designed to collect comprehensive self-reported resource use and health outcome data, including the EQ-5D, within a randomised controlled trial study design (UK Clinical Trials Gateway). A within-trial economic evaluation and economic model will compare the cost-effectiveness of MCT plus usual care (UC) to UC, from a health and social care perspective in the UK. The within-trial analysis will use intention-to-treat and estimate total costs and quality-adjusted life-years (QALYs) for the trial follow-up. Single imputation will be used to impute missing baseline variables. Multiple imputation will be used to impute values missing at follow-up. Items of resource use will be multiplied by published national healthcare costs. Regression analysis will be used to estimate net costs and net QALYs and these estimates will be bootstrapped to generate 10 000 net pairs of costs and QALYs to inform the probability of cost-effectiveness. A decision analytical economic model will be developed to synthesise trial data with the published literature over a longer time frame. Sensitivity analysis will explore uncertainty. Guidance of the methods for economic models will be followed and dissemination will adhere to reporting guidelines. ETHICS AND DISSEMINATION:The economic evaluation includes a within-trial analysis. The trial which included the collection of this data was reviewed and approved by Ethics. Ethics approval was obtained by the Preston Research Ethics Committee (project ID 156862). The modelling analysis is not applicable for Ethics as it will use data from the trial (secondary analysis) and the published literature. Results of the main trial and economic evaluation will be published in the peer-reviewed National Institute for Health Research (NIHR) journals library (Programme Grants for Applied Research), submitted to a peer-reviewed journal and presented at appropriate conferences. TRIAL REGISTRATION NUMBER:ISRCTN74643496; Pre-results.

Abstract Aims: To review existing evidence on effectiveness of community-based diversion programmes for Class A drug-using offenders. Methods: 31 databases were searched for studies published 1985–2012 (update search 2012–2016) involving community-based Criminal Justice System diversion of Class A drug users via voluntary or court-mandated treatment. Findings: 16 studies were initially included (US, 10; UK, 4; Canada, 1; Australia, 1). There was evidence for a small impact of diversion to treatment on drug use reduction (primary Class A drug use: OR 1.68, CI 1.12–2.53; other drug use: OR 2.60, 1.70–3.98). Class A drug users were less likely to complete treatment (OR 0.90, 0.87–0.94) than users of other drugs. There was uncertainty surrounding results for offending, which were not pooled due to lack of outcome measure comparability and heterogeneity. Individual studies pointed to a minor effect of diversion on offending. Findings remained unchanged following an update review (evidence up to March 2016: US, 3; Australia, 1). Conclusions: Treatment accessed via community-based diversion is effective at reducing drug use in Class A drug-using offenders. Evidence of a reduction in offending amongst this group as a result of diversion is uncertain. Poor methodological quality and data largely limited to US methamphetamine users limits available evidence.

OBJECTIVES:This review aims to assess the cost-effectiveness of psychological interventions for schizophrenia/bipolar disorder (BD), to determine the robustness of current evidence and identify gaps in the available evidence. METHODS:Electronic searches (PsycINFO, MEDLINE, Embase) identified economic evaluations relating incremental cost to outcomes in the form of an incremental cost-effectiveness ratio published in English since 2000. Searches were concluded in November 2018. Inclusion criteria were: adults with schizophrenia/BD; any psychological/psychosocial intervention (e.g., psychological therapy and integrated/collaborative care); probability of cost-effectiveness at explicitly defined thresholds reported. Comparators could be routine practice, no intervention, or alternative psychological therapies. Screening, data extraction, and critical appraisal were performed using pre-specified criteria and forms. Results were summarized qualitatively. The protocol was registered on the PROSPERO database (CRD42017056579). RESULTS:Of 3,864 studies identified, 12 met the criteria for data extraction. All were integrated clinical and economic randomized controlled trials. The most common intervention was cognitive behavioral therapy (CBT, 6/12 studies). The most common measure of health benefit was the quality-adjusted life-year (6/12). Follow-up ranged from 6 months to 5 years. Interventions were found to be cost-effective in most studies (9/12): the probability of cost-effectiveness ranged from 35-99.5 percent. All studies had limitations and demonstrated uncertainty (particularly related to incremental costs). CONCLUSIONS:Most studies concluded psychological interventions for schizophrenia/BD are cost-effective, including CBT, although there was notable uncertainty. Heterogeneity across studies makes it difficult to reach strong conclusions. There is a particular need for more evidence in the population with BD and for longer-term evidence across both populations.

Background Clozapine (clozaril, Mylan Products Ltd) is a first-choice treatment for people with schizophrenia who have a poor response to standard antipsychotic medication. However, a significant number of patients who trial clozapine have an inadequate response and experience persistent symptoms, called clozapine-resistant schizophrenia (CRS). There is little evidence regarding the clinical effectiveness of pharmacological or psychological interventions for this population. Objectives To evaluate the clinical effectiveness and cost-effectiveness of cognitive–behavioural therapy (CBT) for people with CRS and to identify factors predicting outcome. Design The Focusing on Clozapine Unresponsive Symptoms (FOCUS) trial was a parallel-group, randomised, outcome-blinded evaluation trial. Randomisation was undertaken using permuted blocks of random size via a web-based platform. Data were analysed on an intention-to-treat (ITT) basis, using random-effects regression adjusted for site, age, sex and baseline symptoms. Cost-effectiveness analyses were carried out to determine whether or not CBT was associated with a greater number of quality-adjusted life-years (QALYs) and higher costs than treatment as usual (TAU). Setting Secondary care mental health services in five cities in the UK. Participants People with CRS aged ≥ 16 years, with an International Classification of Diseases , Tenth Revision (ICD-10) schizophrenia spectrum diagnoses and who are experiencing psychotic symptoms. Interventions Individual CBT included up to 30 hours of therapy delivered over 9 months. The comparator was TAU, which included care co-ordination from secondary care mental health services. Main outcome measures The primary outcome was the Positive and Negative Syndrome Scale (PANSS) total score at 21 months and the primary secondary outcome was PANSS total score at the end of treatment (9 months post randomisation). The health benefit measure for the economic evaluation was the QALY, estimated from the EuroQol-5 Dimensions, five-level version (EQ-5D-5L), health status measure. Service use was measured to estimate costs. Results Participants were allocated to CBT ( n = 242) or TAU ( n = 245). There was no significant difference between groups on the prespecified primary outcome [PANSS total score at 21 months was 0.89 points lower in the CBT arm than in the TAU arm, 95% confidence interval (CI) –3.32 to 1.55 points; p = 0.475], although PANSS total score at the end of treatment (9 months) was significantly lower in the CBT arm (–2.40 points, 95% CI –4.79 to –0.02 points; p = 0.049). CBT was associated with a net cost of £5378 (95% CI –£13,010 to £23,766) and a net QALY gain of 0.052 (95% CI 0.003 to 0.103 QALYs) compared with TAU. The cost-effectiveness acceptability analysis indicated a low likelihood that CBT was cost-effective, in the primary and sensitivity analyses (probability < 50%). In the CBT arm, 107 participants reported at least one adverse event (AE), whereas 104 participants in the TAU arm reported at least one AE (odds ratio 1.09, 95% CI 0.81 to 1.46; p = 0.58). Conclusions Cognitive–behavioural therapy for CRS was not superior to TAU on the primary outcome of total PANSS symptoms at 21 months, but was superior on total PANSS symptoms at 9 months (end of treatment). CBT was not found to be cost-effective in comparison with TAU. There was no suggestion that the addition of CBT to TAU caused adverse effects. Future work could investigate whether or not specific therapeutic techniques of CBT have value for some CRS individuals, how to identify those who may benefit and how to ensure that effects on symptoms can be sustained. Trial registration Current Controlled Trials ISRCTN99672552. 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. 23, No. 7. See the NIHR Journals Library website for further project information.

BACKGROUND:Research suggests that a significant minority of hospital in-patients could be more appropriately supported in the community if enhanced services were available. However, little is known about these individuals or the services they require.AIMS:To identify which individuals require what services, at what cost.METHOD:A 'balance of care' (BoC) study was undertaken in northern England. Drawing on routine electronic data about 315 admissions categorised into patient groups, frontline practitioners identified patients whose needs could be met in alternative settings and specified the services they required, using a modified nominal group approach. Costing employed a public-sector approach.RESULTS:Community care was deemed appropriate for approximately a quarter of admissions including people with mild-moderate depression, an eating disorder or personality disorder, and some people with schizophrenia. Proposed community alternatives drew heavily on carer support services, community mental health teams and consultants, and there was widespread consensus on the need to increase out-of-hours community services. The costs of the proposed community care were relatively modest compared with hospital admission. On average social care costs increased by approximately £60 per week, but total costs fell by £1626 per week.CONCLUSIONS:The findings raise strategic issues for both national policymakers and local service planners. Patients who could be managed at home can be characterised by diagnosis. Although potential financial savings were identified, the reported cost differences do not directly equate to cost savings. It is not clear whether in-patient beds could be reduced. However, existing beds could be more efficiently used.DECLARATION OF INTEREST:None.

AIM To synthesize the evidence relating to the ability of specialist care home support services to prevent the hospital admission of older care home residents, including hospital admission at the end-of-life. DESIGN Systematic review and narrative synthesis. METHODS Ten electronic databases will be searched from 2010 - 31 December 2018 using predetermined search terms. All studies of specialist healthcare services to meet care home residents' physical healthcare needs which provide outcome data on hospital admission or place of death compared with usual care will be included. Two reviewers will independently assess studies' eligibility and methodological quality using the Effective Public Health Practice Project Quality Assessment Tool. Data will be extracted by one reviewer and checked by a second according to predetermined categories. Data will be synthesized in evidence tables and narrative. Funder: National Institute for Health Research School for Social Care Research, November 2016. DISCUSSION Care of older people in care home settings is a key aspect of nursing nationally and internationally. This review will increase understanding of the extent to which different models of specialist healthcare support for care homes are associated with key resident outcomes. IMPACT Standard healthcare support for care home residents is often inadequate, resulting in avoidable hospital admissions and lack of resident choice as to place of death. Although a range of specialist healthcare services are emerging, little is known about their relative effectiveness. This paper marshalls evidence of relevance to commissioners investing in healthcare provision to care homes to meet NHS targets.

Patients may be offered cardiac rehabilitation (CR), a supervised programme often including exercises, education and psychological care, following a cardiac event, with the aim of reducing morbidity and mortality. Cost-constrained healthcare systems require information about the best use of budget and resources to maximise patient benefit. We aimed to systematically review and critically appraise economic studies of CR and its components. In January 2016, validated electronic searches of the National Health Service Economic Evaluation Database (NHS EED), Health Technology Assessment, PsycINFO, MEDLINE and Embase databases were run to identify full economic evaluations published since 2001. Two levels of screening were used and explicit inclusion criteria were applied. Prespecified data extraction and critical appraisal were performed using the NHS EED handbook and Drummond checklist. The majority of studies concluded that CR was cost-effective versus no CR (incremental cost-effectiveness ratios (ICERs) ranged from $1065 to $71 755 per quality-adjusted life-year (QALY)). Evidence for specific interventions within CR was varied; psychological intervention ranged from dominant (cost saving and more effective) to $226 128 per QALY, telehealth ranged from dominant to $588 734 per QALY and while exercise was cost-effective across all relevant studies, results were subject to uncertainty. Key drivers of cost-effectiveness were risk of subsequent events and hospitalisation, hospitalisation and intervention costs, and utilities. This systematic review of studies evaluates the cost-effectiveness of CR in the modern era, providing a fresh evidence base for policy-makers. Evidence suggests that CR is cost-effective, especially with exercise as a component. However, research is needed to determine the most cost-effective design of CR.