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.

Background:General practices are facing challenges such as rising patient demand and difficulties recruiting and retaining general practitioners. Greater use of digital technology has been advocated as a way of mitigating some of these challenges and improving patient access. This includes Digital First Primary Care, when a patient's first contact with primary care is through a digital route, either through a laptop or smartphone. The use of Digital First Primary Care has been expedited since COVID-19. There is little evidence of staff experiences of using Digital First Primary Care with more complex patients, such as those with multiple long-term conditions. Objective:To understand the experiences of those with multiple long-term conditions of Digital First Primary Care from the perspectives of healthcare professionals and stakeholders. Design:This was a qualitative evaluation, comprised of four distinct work packages: Work package 1: Locating the study within the wider context, engaging with literature, and co-designing the study approach and research questions with patients. Work package 2: Interviews with health professionals working across general practice and key expert topic stakeholders, including academics and policy-makers. Work package 3: Analysis of data and generation of themes, and testing findings with patients. Work package 4: Synthesis, reporting and dissemination. Results:The study commenced in January 2021 and in total 28 interviews were conducted with 14 health professionals and 15 stakeholders between January and August 2022. From the perspective of health professionals, Digital First Primary Care approaches could enable patients to speak with a clinician more quickly than traditional approaches. Those with multiple long-term conditions could submit healthcare readings from home, though health professionals felt patients may struggle navigating digital systems not designed to capture the nuances associated with living with multiple conditions. Clinicians expressed preferences for seeing patients face-to-face, particularly those with multiple long-term conditions, to identify non-verbal cues about a patient's health. Digital First Primary Care approaches provided an opportunity for clinicians to engage with the carers of patients living with multiple long-term conditions, yet there were concerns around obtaining consent and confidentiality. There remain debates among stakeholders about the nature and extent to which Digital First Primary Care impacts on staff workload. Limitations:At the time of data collection, general practices were facing considerable pressure to deliver care and respond to the COVID-19 pandemic. While it was originally intended that the study would include interviews with patients with multiple long-term conditions and their carers, none of the general practices that took part in the study were willing and/or able to recruit patients and carers in the time available. Conclusions:The rapid implementation of Digital First Primary Care, at a time of immense pressures, meant there has been little time for considering the impact on patients, including those with multiple long-term conditions. The impacts on care continuity depended largely on how surgeries implemented their approaches. Staff and stakeholders felt that Digital First Primary Care, as an additional route for accessing primary care, could be useful for patients with multiple long-term conditions but not at the expense of face-to-face consultations. Future work:Future research obtaining patient and carer views of digital-first approaches, understanding the impacts on carers and how approaches are designed with patients with more complex conditions in mind, is essential. Funding:This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 16/138/31) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 21. See the NIHR Funding and Awards website for further award information.

Although research has demonstrated that transport infrastructure development can have positive and negative health-related impacts, most of this research has not considered mental health and wellbeing separately from physical health. There is also limited understanding of whether and how any effects might be experienced differently across population groups, whether this differs according to the stage of development (e.g. planning, construction), and how changes to planned infrastructure may affect mental health and wellbeing. This paper presents a protocol for the Wellbeing Impact Study of HS2 (WISH2), which seeks to address these questions using a high-speed rail development in the UK as an applied example. WISH2 is a 10-year, integrated, longitudinal, mixed-methods project using general practices (primary medical care providers in the UK) as an avenue for participant recruitment and for providing a geographically defined population for which aggregated data on mental health indicators are available. The research comprises: (i) a combined longitudinal and repeated cross-sectional cohort study involving multiple waves of survey data collection and data from medical records; (ii) longitudinal, semi-structured interviews and focus groups with residents and community stakeholders from exposed areas; (iii) analysis of administrative data aggregated at the general practice population level; and (iv) health economic analysis of mental health and wellbeing impacts. The study findings will support the development of strategies to reduce negative impacts and/or enhance positive mental health and wellbeing impacts of high-speed rail developments and other large-scale infrastructure projects.

Objectives To establish principles informing a new scoring system for the UK's Clinical Impact Awards and pilot a system based on those principles. Design A three-round online Delphi process was used to generate consensus from experts on principles a scoring system should follow. We conducted a shadow scoring exercise of 20 anonymised, historic applications using a new scoring system incorporating those principles. Setting Assessment of clinical excellence awards for senior doctors and dentists in England and Wales. Participants The Delphi panel comprised 45 members including clinical excellence award assessors and representatives of professional bodies. The shadow scoring exercise was completed by 24 current clinical excellence award assessors. Main outcome measures The Delphi panel rated the appropriateness of a series of items. In the shadow scoring exercise, a novel scoring system was used with each of five domains rated on a 0–10 scale. Results Consensus was achieved around principles that could underpin a future scoring system; in particular, a 0–10 scale with the lowest point on the scale reflecting someone operating below the expectations of their job plan was agreed as appropriate. The shadow scoring exercise showed similar levels of reliability between the novel scoring system and that used historically, but with potentially better distinguishing performance at higher levels of performance. Conclusions Clinical excellence awards represent substantial public spending and thus far the deployment of these funds has lacked a strong evidence base. We have developed a new scoring system in a robust manner which shows improvements over current arrangements.

Many organisations struggle to keep pace with public health evidence due to the volume of published literature and length of time it takes to conduct literature reviews. New technologies that help automate parts of the evidence synthesis process can help conduct reviews more quickly and efficiently to better provide up-to-date evidence for public health decision making. To date, automated approaches have seldom been used in public health due to significant barriers to their adoption. In this Perspective, we reflect on the findings of a study exploring experiences of adopting automated technologies to conduct evidence reviews within the public health sector. The study, funded by the European Centre for Disease Prevention and Control, consisted of a literature review and qualitative data collection from public health organisations and researchers in the field. We specifically focus on outlining the challenges associated with the adoption of automated approaches and potential solutions and actions that can be taken to mitigate these. We explore these in relation to actions that can be taken by tool developers (e.g. improving tool performance and transparency), public health organisations (e.g. developing staff skills, encouraging collaboration) and funding bodies/the wider research system (e.g. researchers, funding bodies, academic publishers and scholarly journals).

Background:The Children and Young People's Mental Health Trailblazer programme is funding the creation of new mental health support teams to work in schools and further education colleges. Mental health support teams directly support children and young people with 'mild to moderate' mental health problems and work with school and college staff to promote well-being for all. A new workforce of education mental health practitioners is being trained for the teams.Objective(s):The National Institute for Health and Care Research Birmingham, RAND and Cambridge Evaluation Rapid Evaluation Centre and Policy Innovation and Evaluation Research Unit undertook an early evaluation of the Trailblazer programme to examine the development, implementation and early progress of mental health support teams in the programme's first 25 'Trailblazer' sites.Design:A mixed-methods evaluation, comprising three work packages: 1. Establishing the baseline and understanding the development and early impacts of the Trailblazer sites, including two rounds of surveys with key informants and participating education settings in all 25 sites. 2. More detailed research in five purposively selected Trailblazer sites, including interviews with a range of stakeholders and focus groups with children and young people. 3. Scoping and developing options for a longer-term assessment of the programme's outcomes and impacts. Fieldwork was undertaken between November 2020 and February 2022. The University of Birmingham Institute for Mental Health Youth Advisory Group was involved throughout the study, including co-producing the focus groups with children and young people.Results:Substantial progress had been made implementing the programme, in challenging circumstances, and there was optimism about what it had the potential to achieve. The education mental health practitioner role had proven popular, but sites reported challenges in retaining education mental health practitioners, and turnover left mental health support teams short-staffed and needing to re-recruit. Education settings welcomed additional mental health support and reported positive early outcomes, including staff feeling more confident and having faster access to advice about mental health issues. At the same time, there were concerns about children who had mental health problems that were more serious than 'mild to moderate' but not serious enough to be accepted for specialist help, and that the interventions offered were not working well for some young people. Mental health support teams were generally spending more time supporting children with mental health problems than working with education settings to develop 'whole school' approaches to mental health and well-being, and service models in some sites appeared to be more clinically oriented, with a strong focus on mental health support teams' therapeutic functions.Limitations:Despite efforts to maximise participation, survey response rates were relatively low and some groups were less well represented than others. We were not able to gather sufficiently detailed data to develop a typology of Trailblazer sites, as was planned.Conclusions:Key lessons for future programme implementation include: - Whether mental health support teams should expand support to children and young people with more complex and serious mental health problems. - How to keep the twin aims of prevention and early intervention in balance. - How to retain education mental health practitioners once trained.Future work:The findings have important implications for the design of a longer-term impact evaluation of the programme, which is due to commence in summer 2023.Study registration:Ethical approval from the University of Birmingham (ERN_19-1400 - RG_19-190) and London School of Hygiene and Tropical Medicine (Ref: 18040) and Health Research Authority approval (IRAS 270760).Funding:The Birmingham, RAND and Cambridge Evaluation Rapid Evaluation Centre is funded by the National Institute for Health and Care Research Health Services and Delivery Research programme (HSDR 16/138/31). The Policy Innovation and Evaluation Research Unit is funded by the NIHR Policy Research Programme (PR-PRU-1217-20602).

IntroductionArriving at a C. difficile infection (CDI) diagnosis, treating patients and dealing with recurrences is not straightforward, but a comprehensive and well-rounded understanding of what is needed to improve patient care is lacking. This manuscript addresses the paucity of multidisciplinary perspectives that consider clinical practice related and healthcare system-related challenges to optimizing care delivery.MethodsWe draw on narrative review, consultations with clinical experts and patient representatives, and a survey of 95 clinical and microbiology experts from the UK, France, Italy, Australia and Canada, adding novel multi-method evidence to the knowledge base.Results and discussionWe examine the patient pathway and variations in clinical practice and identify, synthesize insights on and discuss associated challenges. Examples of key challenges include the need to conduct multiple tests for a conclusive diagnosis, treatment side-effects, the cost of some antibiotics and barriers to access of fecal microbiota transplantation, difficulties in distinguishing recurrence from new infection, workforce capacity constraints to effective monitoring of patients on treatment and of recurrence, and ascertaining whether a patient has been cured. We also identify key opportunities and priorities for improving patient care that target both clinical practice and the wider healthcare system. While there is some variety across surveyed countries’ healthcare systems, there is also strong agreement on some priorities. Key improvement actions seen as priorities by at least half of survey respondents in at least three of the five surveyed countries include: developing innovative products for both preventing (Canada, Australia, UK, Italy, and France) and treating (Canada, Australia, and Italy) recurrences; facilitating more multidisciplinary patient care (UK, Australia, and France); updating diagnosis and treatment guidelines (Australia, Canada, and UK); and educating and supporting professionals in primary care (Italy, UK, Canada, and Australia) and those in secondary care who are not CDI experts (Italy, Australia, and France) on identifying symptoms and managing patients. Finally, we discuss key evidence gaps for a future research agenda.

Digital technology is expected to improve care and address significant service pressures within the National Health Service and social care though evidence on how their implementation might be optimised is lacking. This study explores how one such example, home-based sensors with artificial intelligence capabilities, was implemented in English social care to identify changes in behaviour that indicate the onset of potentially more serious issues. Its focus was staff perspectives on decision-making processes and implementation, to inform recommendations for others exploring the potential of new and emerging technology. Qualitative data were collected from 18 semistructured interviews conducted across three sites delivering social care, with senior decision makers, operational leads, and care staff. We identified several issues with the selection process and implementation of AI-based technology in social care, including a lack of consensus around what success would look like, problems identifying and evaluating alternatives, and technical challenges to implementation, as well as obstacles to developing a longer-term, more preventative approach in a system experienced as focused on responding to acute needs. Ultimately, the research confirmed a number of recognised implementation challenges associated with training, resource, and acceptability to staff and patients. It added particular insights around the anxieties experienced by frontline staff and the cultural shift required of preventative interventions in a system geared to meeting acute crises. That many barriers are familiar suggests a particular need to focus on helping policymakers/local leaders avoid similar pitfalls in the future.

Background:Digital technology is a focus within the NHS and social care as a way to improve care and address pressures. Sensor-based technology with artificial intelligence capabilities is one type of technology that may be useful, although there are gaps in evidence that need to be addressed.Objective:This study evaluates how one example of a technology using home-based sensors with artificial intelligence capabilities (pseudonymised as 'IndependencePlus') was implemented in three case study sites across England. The focus of this study was on decision-making processes and implementation.Design:Stage 1 consisted of a rapid literature review, nine interviews and three project design groups. Stage 2 involved qualitative data collection from three social care sites (20 interviews), and three interviews with technology providers and regulators.Results:• It was expected that the technology would improve care planning and reduce costs for the social care system, aid in prevention and responding to needs, support independent living and provide reassurance for those who draw on care and their carers. • The sensors were not able to collect the necessary data to create anticipated benefits. Several technological aspects of the system reduced its flexibility and were complex for staff to use. • There appeared to be no systematic decision-making process in deciding whether to adopt artificial intelligence. In its absence, a number of contextual factors influenced procurement decisions. • Incorporating artificial intelligence-based technology into existing models of social care provision requires alterations to existing funding models and care pathways, as well as workforce training. • Technology-enabled care solutions require robust digital infrastructure, which is lacking for many of those who draw on care and support. • Short-term service pressures and a sense of crisis management are not conducive to the culture that is needed to reap the potential longer-term benefits of artificial intelligence.Limitations:Significant recruitment challenges (especially regarding people who draw on care and carers) were faced, particularly in relation to pressures from COVID-19.Conclusions:This study confirmed a number of common implementation challenges, and adds insight around the specific decision-making processes for a technology that has been implemented in social care. We have also identified issues related to managing and analysing data, and introducing a technology focused on prevention into an environment which is focused on dealing with crises. This has helped to fill gaps in the literature and share practical lessons with commissioners, social care providers, technology providers and policy-makers.Future work:We have highlighted the implications of our findings for future practice and shared these with case study sites. We have also developed a toolkit for others implementing new technology into adult social care based on our findings (https://www.birmingham.ac.uk/documents/college-social-sciences/social-policy/brace/ai-and-social-care-booklet-final-digital-accessible.pdf). As our findings mirror the previous literature on common implementation challenges and a tendency of some technology to 'over-promise and under-deliver', more work is needed to embed findings in policy and practice.Study registration:Ethical approval from the University of Birmingham Research Ethics Committee (ERN_13-1085AP41, ERN_21-0541 and ERN_21-0541A).Funding:This project was funded by the National Institute of Health and Care Research (NIHR) Health Services and Delivery Research programme (HSDR 16/138/31 - Birmingham, RAND and Cambridge Evaluation Centre).

BACKGROUND:Between 2018 and 2025, a national implementation programme is funding more than 500 new mental health support teams (MHSTs) in England, to work in education settings to deliver evidence-based interventions to children with mild to moderate mental health problems and support emotional wellbeing for all pupils. A new role, education mental health practitioner (EMHP), has been created for the programme. AIMS:A national evaluation explored the development, implementation and early progress of 58 MHSTs in the programme's first 25 'Trailblazer' sites. This paper reports the views and experiences of people involved in MHST design, implementation and service delivery at a local, regional and national level. METHODS:Data are reported from in-depth interviews with staff in five Trailblazer sites (n = 71), and the programme's regional (n = 52) and national leads (n = 21). RESULTS:Interviewees universally welcomed the creation of MHSTs, but there was a lack of clarity about their purpose, concerns that the standardised CBT interventions being offered were not working well for some children, and challenges retaining EMHPs. CONCLUSIONS:This study raises questions about MHSTs' service scope, what role they should play in addressing remaining gaps in mental health provision, and how EMHPs can develop the skills to work effectively with diverse groups.

OBJECTIVES:The National Clinical Excellence Awards (NCEAs) in England and Wales were designed, as a form of performance-related pay, to reward high-performing senior doctors and dentists. To inform future scoring of applications and subsequent schemes, we sought to understand how current assessors and other stakeholders would define excellence, differentiate between levels of excellence and ensure unbiased definitions and scoring.DESIGN:Semistructured qualitative interview study.PARTICIPANTS:25 key informants were identified from Advisory Committee on Clinical Excellence Awards subcommittees, and relevant professional organisations in England and Wales. Informants were purposively sampled to achieve variety in gender and ethnicity.FINDINGS:Participants reported that NCEAs had a role in incentivising doctors to strive for excellence. They were consistent in identifying 'clinical excellence' as involving making an exceptional difference to patients and the National Health Service, and in going over and above the expectations associated with the doctor's job plan. Informants who were assessors reported: encountering challenges with the current scoring scheme when seeking to ensure a fair assessment; recognising tendencies to score more or less leniently; and the potential for conscious or unconscious bias in assessments. Particular groups of doctors, including women, doctors in some specialties and settings, doctors from minority ethnic groups, and doctors who work less than full time, were described as being less likely to self-nominate, lacking support in making applications or lacking motivation to apply on account of a perceived likelihood of not being successful. Practical suggestions were made for improving support and training for applicants and assessors.CONCLUSIONS:Participants in this qualitative study identified specific concerns in respect of the current approaches adopted in applying for and in assessing NCEAs, pointing to the importance of equity of opportunity to apply, the need for regular training for assessors, and to improved support for applicants and potential applicants.

Respiratory syncytial virus (RSV) is a common respiratory virus that affects large numbers, mainly of children younger than five. The burden of RSV includes not only ill health for the children with the virus, which in severe cases results in hospitalisation, intensive care and even death; but also the emotional and practical burden on the affected families and carers; and the impact that has on productivity in the economy; alongside the costs of providing healthcare. We reviewed recent literature and published data relevant to the UK and used this information to model the costs to the healthcare system and to the wider UK economy in terms of productivity losses of parents/carers. We found healthcare costs and productivity losses in the UK resulting from RSV in children younger than five total approximately £80 million annually. These costs are the consequence, in part, of an estimated 467,000 GP visits per year in the UK for children aged under five with RSV and 34,000 hospitalisations. Our study also presents additional material, identified in the literature review, on the health impacts on affected children and the nature of the burden on parents and families of caring for a young child with RSV. The consequences of RSV are short-term for the majority of cases, but for some there are long term sequelae including poorer respiratory health in later life. RSV is also responsible for the deaths each year in the UK of an estimated 33 children under five.

BACKGROUND:There is growing interest in faecal microbiota transplantation (FMT) as a treatment for recurrent Clostridioides difficile infection (CDI), but evidence on the diverse requirements for safe, effective and accessible services is fragmented and limited.AIMS:To identify key components of FMT provision relating to the patient care pathway, stool donor pathway and wider healthcare system, and to explore variation in practice METHODS: We conducted a narrative review of the literature and consultations with key clinical experts in the field. Evidence is drawn from high-income country contexts, with an emphasis on Australia, Canada, Italy and the United Kingdom as case example countries.RESULTS:We identify and discuss key challenges to do with healthcare capacity (workforce, FMT and stool banking facilities), donors and donations, patient access and choice of FMT delivery routes, regulation, costs and reimbursement. We also identify improvement opportunities to increase awareness of FMT and referral processes, physician training, maintaining patient registries and outcome monitoring metrics, in-country regulatory harmonisation and tackling reimbursement challenges and discuss future research needs.CONCLUSION:Effectively bringing FMT to patients in a healthcare system requires much more than just the existence of a clinically effective procedure. With FMT being a potentially effective treatment option for recurrent CDI for many patients, a well-rounded understanding of how appropriate FMT capacity can be built and nurtured is important for both healthcare providers and policymakers seeking to improve patient care.

Predictive genetic testing provides individuals with information about their future risk of developing health conditions. Theoretically, predictive genetic tests could have positive or negative impacts on the insurance industry. If genetic test results stimulate actions to reduce health risks, they may reduce costs to insurers. If disclosed to insurers, such information may allow them to better understand individual- and population-level risks and make insurance more affordable. However, if individuals who know they are at high genetic risk of becoming ill or dying are more likely to apply for insurance than those not at high risk, this may lead to an unanticipated increase in claims. It may be exacerbated if people at low genetic risk are less likely to apply for insurance compared to the general population. If this happened on a large scale it could make the insurance market unsustainable. Determining whether a genetic test could affect the insurance industry is complex and needs to be evaluated on a per-test basis. The Cambridge Centre for Health Services Research, a collaboration between RAND Europe and the University of Cambridge, developed a framework for evaluating the potential impacts on the UK insurance industry arising from predictive genetic tests. It considers the characteristics of genetic tests and behavioural aspects that influence their uptake. It is intended to provide a transparent approach for evaluating whether a specific condition for which a test is available could impact the insurance industry, currently or in the future, and understanding the key factors that influence this.

Background Reducing avoidable harm in maternity services is a priority globally. As well as learning from mistakes, it is important to produce rigorous descriptions of ‘what good looks like’. Objective We aimed to characterise features of safety in maternity units and to generate a plain language framework that could be used to guide learning and improvement. Methods We conducted a multisite ethnography involving 401 hours of non-participant observations 33 semistructured interviews with staff across six maternity units, and a stakeholder consultation involving 65 semistructured telephone interviews and one focus group. Results We identified seven features of safety in maternity units and summarised them into a framework, named For Us (For Unit Safety). The features include: (1) commitment to safety and improvement at all levels, with everyone involved; (2) technical competence, supported by formal training and informal learning; (3) teamwork, cooperation and positive working relationships; (4) constant reinforcing of safe, ethical and respectful behaviours; (5) multiple problem-sensing systems, used as basis of action; (6) systems and processes designed for safety, and regularly reviewed and optimised; (7) effective coordination and ability to mobilise quickly. These features appear to have a synergistic character, such that each feature is necessary but not sufficient on its own: the features operate in concert through multiple forms of feedback and amplification. Conclusions This large qualitative study has enabled the generation of a new plain language framework—For Us—that identifies the behaviours and practices that appear to be features of safe care in hospital-based maternity units.

96% of the veterinary profession agrees that Quality Improvement (QI) improves veterinary care. While clinical governance is an RCVS professional requirement, over the last year only 60% spent up to 3 days on the Quality Improvement activities which allow clinical governance to take place. 11% spent no time on it at all. A lack of time, know-how and organisational support were among the barriers preventing its adoption in practice. Rather than being an individual reaction to a problem, Quality Improvement is a formal approach to embedding a set of recognised practices, including clinical audit, significant event audit, guidelines and protocols, benchmarking and checklists. This framework should be applied within a just culture where errors are redefined as learning opportunities, and precedence is given to communication, team-work and team-morale, patient safety, and distributed leadership. Addressing this gap will require evolution – rather than a revolution. Persistent packages, given enough time and addressing the whole flow of the patient journey, trump one-off ‘heroic’ and narrowly-focused interventions. Creating a rhythm of learning alongside stability of practice allows lessons to be absorbed and improvements routinised. Doing good things well is better than doing perfect things sporadically and helps address the widespread concern that there is insufficient time for QI by making the time commitment more predictable and manageable. The research provides a robust, evidence-based, roadmap for the entire sector including professional organisations, educators, those in management positions and care providers.

Background: Point of care testing (POCT) for infectious diseases is testing conducted near the patient. It allows clinicians to offer the most appropriate treatment more quickly. As POCT devices have increased in accuracy and become more cost-effective, their use has grown, but a systematic assessment of their use for clinical and public health management of infectious diseases in EU/EEA countries has not been previously undertaken. Methods: A scoping review of the literature on POCT in EU/ EEA countries as at November 2019, and a survey of key stakeholders. Results: 350 relevant articles were identified and 54 survey responses from 26 EU/EEA countries were analysed. POCT is available for a range of infectious diseases and in all countries responding to the survey (for at least one disease). POCT is commonly available for influenza, HIV/AIDS, Legionnaires' disease and malaria, where it is used in at least half of EU/EEA countries. While POCT has the potential to support many improvements to clinical care of infectious diseases (e.g., faster diagnosis, more appropriate use of antimicrobials), the results suggest POCT is infrequently used to support public health functions (e.g., disease surveillance and reporting). Conclusion: Although POCT is in use to some extent in all EU/EEA countries, the full benefits of POCT in wider public health functions have yet to be realised. Further research on barriers and facilitators to implementation is warranted.

Antimicrobial resistance (AMR) is one of the greatest public health threats at this time. While there is a good understanding of the impacts of AMR on infectious diseases, an area of less focus is the effects AMR may be having on non-communicable health conditions (such as cancer) and healthcare services (such as surgery). Therefore, this study aimed to explore what impact AMR is currently having on non-communicable health conditions, or areas of health services, where AMR could be a complicating factor impacting on the ability to treat the condition and/or health outcomes. To do this, a rapid evidence assessment of the literature was conducted, involving a systematic approach to searching and reviewing the evidence. In total, 101 studies were reviewed covering surgery, organ transplants, cancer, ICUs, diabetes, paediatric patients, immunodeficiency conditions, liver and kidney disease, and physical trauma. The results showed limited research in this area and studies often use a selective population, making the results difficult to generalize. However, the evidence showed that for all health conditions and healthcare service areas reviewed, at least one study demonstrated a higher risk of death for patients with resistant infections, compared with no or drug-susceptible infections. Poor health outcomes were also associated with resistant infections in some instances, such as severe sepsis and failure of treatments, as well as a greater need for invasive medical support. While there are gaps in the evidence base requiring further research, efforts are also needed within policy and practice to better understand and overcome these challenges.

Background Although problems that impair task completion — known as operational failures — are an important focus of concern in primary care, they have remained little studied. Aim To quantify the time GPs spend on different activities during clinical sessions; to identify the number of operational failures they encounter; and to characterise the nature of operational failures and their impact for GPs. Design and setting Mixed-method triangulation study with 61 GPs in 28 NHS general practices in England from December 2018 to December 2019. Method Time–motion methods, ethnographic observations, and interviews were used. Results Time–motion data on 7679 GP tasks during 238 hours of practice in 61 clinical sessions suggested that operational failures were responsible for around 5.0% (95% confidence interval [CI] = 4.5% to 5.4%) of all tasks undertaken by GPs and accounted for 3.9% (95% CI = 3.2% to 4.5%) of clinical time. However, qualitative data showed that time–motion methods, which depend on pre-programmed categories, substantially underestimated operational failures. Qualitative data also enabled further characterisation of operational failures, extending beyond those measured directly in the time–motion data (for example, interruptions, deficits in equipment/supplies, and technology) to include problems linked to GPs’ coordination role and weaknesses in work systems and processes. The impacts of operational failures were highly consequential for GPs’ experiences of work. Conclusion GPs experience frequent operational failures, disrupting patient care, impairing experiences of work, and imposing burden in an already pressurised system. This better understanding of the nature and impact of operational failures allows for identification of targets for improvement and indicates the need for coordinated action to support GPs.