Simulation facilitators routinely invoke the ‘Socratic method’ when describing their questioning approach, yet this invocation often lacks philosophical grounding and practical specificity. Whilst Socratic questioning features prominently in debriefing standards, its application has become what scholars describe as "extraordinarily vague", with conflicting interpretations proliferating across the literature. Facilitators need clear guidance for important decisions: when to challenge versus support, when to profess ignorance versus share expertise, when to create discomfort versus maintain psychological safety. This article returns to Plato’s dialogues to construct a contemporary pedagogical framework through close textual analysis. We developed five distinct facilitation orientations drawn from specific passages in the original texts: the Gadfly (challenging assumptions through persistent questioning), the Professed Ignorant (modelling intellectual humility), the Midwife (facilitating emergence of tacit knowledge), the Stingray (inducing productive cognitive dissonance), and the Co-inquirer (fostering collaborative discovery). These orientations function as philosophical stances rather than algorithmic techniques, providing meta-level guidance that complements existing debriefing frameworks. Each orientation addresses different aspects of productive uncertainty, the deliberate cultivation of intellectual discomfort as a catalyst for deeper thinking. When facilitators position themselves as fellow learners, debriefing can shift from teaching learners what to think towards teaching them how to think. Engagement with Socratic principles expands facilitators’ repertoires for creating meaningful learning conversations. These orientations offer simulation educators a philosophically grounded alternative to vague appeals to ‘being Socratic’. They emerge from interpretive choices calibrated specifically to healthcare simulation contexts rather than claims of historical authenticity.

Simulation facilitators routinely invoke the ‘Socratic method’ when describing their questioning approach, yet this invocation often lacks philosophical grounding and practical specificity. Whilst Socratic questioning features prominently in debriefing standards, its application has become what scholars describe as "extraordinarily vague", with conflicting interpretations proliferating across the literature. Facilitators need clear guidance for important decisions: when to challenge versus support, when to profess ignorance versus share expertise, when to create discomfort versus maintain psychological safety. This article returns to Plato’s dialogues to construct a contemporary pedagogical framework through close textual analysis. We developed five distinct facilitation orientations drawn from specific passages in the original texts: the Gadfly (challenging assumptions through persistent questioning), the Professed Ignorant (modelling intellectual humility), the Midwife (facilitating emergence of tacit knowledge), the Stingray (inducing productive cognitive dissonance), and the Co-inquirer (fostering collaborative discovery). These orientations function as philosophical stances rather than algorithmic techniques, providing meta-level guidance that complements existing debriefing frameworks. Each orientation addresses different aspects of productive uncertainty, the deliberate cultivation of intellectual discomfort as a catalyst for deeper thinking. When facilitators position themselves as fellow learners, debriefing can shift from teaching learners what to think towards teaching them how to think. Engagement with Socratic principles expands facilitators’ repertoires for creating meaningful learning conversations. These orientations offer simulation educators a philosophically grounded alternative to vague appeals to ‘being Socratic’. They emerge from interpretive choices calibrated specifically to healthcare simulation contexts rather than claims of historical authenticity.

BACKGROUND:The 10-year health plan for England aims to shift care from hospitals to neighbourhoods, making the interface between primary-secondary care a critical determinant of quality, safety and efficiency. The primary-secondary care interface (PSI) represents a complex space of interconnected elements containing diverse, sub-systems of activity. Workforce sustainability is a core element of PSI function. AIM:To understand how and why the UK PSI works, for whom, and under what circumstances. DESIGN & SETTING:Using a realist review approach, we will build upon an existing programme theory (PT) about GP workforce sustainability. The search will focus on evidence from National Health Service (NHS) areas facing significant workforce and socioeconomic challenges. METHOD:Following Pawson's five steps :1) locating existing theories, 2) searching for evidence, 3) document selection and appraisal ,4) data extraction and organisation of evidence 5) data synthesis. We will analyse secondary and grey literature to refine PT. Collaboration with a content expert group of individuals using and working in the system will ensure analysis is grounded in real-world experience. RESULTS:Findings will be expressed as context, mechanism, outcome configurations (CMOCs). These will provide causal explanations for how the PSI influences workforce sustainability and equity of care. CONCLUSION:The review will examine components of the PSI that facilitate a sustainable workforce. It will explore in what circumstances mechanisms support effective and equitable interventions at the PSI such as referral management and patient access. Explanations will support developing system-wide improvements, tailored to the needs of staff and patients in under-served areas .

BACKGROUND:Infants born very preterm (<30 weeks' gestational age) are at increased risk of long-term developmental challenges. Monitoring health and development after discharge home is an essential aspect of neonatal follow-up care; however, there is limited understanding of how parents and carers experience this care with their child or how their own needs are addressed. METHODS:This study aimed to understand and evaluate parents' experiences of neonatal developmental follow-up. Participants were recruited purposively from three diverse National Health Service providers in England. Semi-structured qualitative interviews were conducted, and data were generated and analysed using a Constructivist Grounded Theory approach. Data collection and analysis occurred concurrently, supported by memoing, reflexivity and peer debriefing. Initial and focused coding led to the iterative development of categories. RESULTS:Between January 2023 and October 2024, 24 interviews were conducted with parents of infants born before 30 weeks of gestation. Three categories were generated from the data analysis: parent support needs, disintegrated care and healthcare professional (HCP) experience and behaviours. CONCLUSION:Parents highlighted that their psychological support needs were unmet during their child's neonatal developmental follow-up, and they found navigating healthcare services after discharge home challenging. Changes to care priorities are required, emphasising the development of integrated systems across service providers and geographical areas, and training for universal healthcare providers.

Inequalities exist in hospitalisation rates, which are undesirable and costly for health systems; with higher rates in populations with lower levels of income, education or residing in socioeconomically marginalised neighbourhoods where ill-health is more prevalent and preventive care is more limited. Objectives:To understand which interventions reduce, maintain or increase socioeconomic inequalities in hospitalisations or readmissions to aid efforts of policymakers and practitioners working to improve health equity and reduce hospital pressures. Design:Systematic review. Eligibility criteria:Intervention studies in any Organisation for Economic Co-operation and Development (OECD) country, involving individuals of any age, published in any language which reported the differential impact across socioeconomic group (any classification) for three categories of intervention (population-level, health service or integrative interventions) on hospitalisation or readmission outcomes (all cause or condition specific). Data extraction and synthesis:An electronic search of MEDLINE, Embase, CINAHL, Cochrane CENTRAL and Web of Knowledge was conducted covering 24 years (from 1 January 2000 to 1 April 2024), supplemented with full citation searches of included studies, website searches and expert consultation. Risk of bias was assessed using the EHPP tool, direction of effect classified and narrative synthesis conducted. Results:From 25 618 records screened, 36 studies met the inclusion criteria, conducted in eight countries with 42% of these published in the past 5 years. Studies employed a range of study designs and 88% were rated as either moderate or strong quality. A range of equity impacts of interventions on hospitalisations and readmissions were observed; 6 interventions increased inequalities, 7 maintained, 10 had mixed or inconclusive impacts, and 13 studies reported effective interventions for reducing inequalities. Interventions successful at reducing inequalities were those implemented and enforced across entire populations and systems and supportive interventions tailored to the varied needs and contexts of people from different socioeconomic groups. Conclusions:Socioeconomic disadvantage was variously measured making comparison of equity impacts across studies complex. Policymakers and practitioners cannot assume that interventions implemented to reduce hospitalisations or readmissions will necessarily reduce prevailing and costly healthcare inequalities; it is imperative that the equity impacts of interventions are consistently monitored. To improve equity of hospital outcomes, investment in population health and integrative activity addressing the social determinants of health, alongside health service interventions, is required. PROSPERO registration number:CRD42019153666.

To assess the clinical service provision of neonatal follow-up services in the UK in line with UK National Institute for Health and Care Excellence (NICE) guideline NG72, ‘Developmental follow-up of children and young people born preterm’. Design: Online survey. Setting: Neonatal units in England, Scotland and Wales (n = 187) in July– September 2022. Participants: Lead neonatal clinicians for neurodevelopmental follow-up. Responses were received from 154 neonatal units, representing 82 What this study hopes to add. How this study might affect research, practice, or policy.

Objectives:Socioeconomic disadvantage increases the risk of acute illnesses and injuries requiring hospital admission, some of which are avoidable. This systematic review aimed to identify the impact of interventions on hospital admissions in socioeconomically disadvantaged populations and identify knowledge gaps. Design:Systematic review (PROSPERO, CRD42019153666). Data sources:We searched MEDLINE (OVID), Embase (OVID), CINAHL (EBSCO), Cochrane CENTRAL (Wiley) and the Web of Knowledge platforms. Eligibility criteria:Studies published between 1 January 2000 and 1 April 2024. We included quantitative studies that included a socioeconomically disadvantaged population, conducted studies in countries members of the Organisation for Economic Co-operation and Development (OECD) with universal healthcare and reported on hospital admission or readmissions. Data extraction and synthesis:We assessed study quality using the Effective Public Health Practice Project tool. We summarised studies using a narrative synthesis approach and present findings using vote counting as a measure of effect. Results:We included 20 studies of interventions targeted towards socioeconomically disadvantaged populations. Their impacts on hospitalisations of interventions, grouped under three domains-(1) population level health and social policy, (2) health and care service-based interventions and (3) integrative interventions-were mixed. Through vote counting, we found some evidence that social policy interventions targeting socioeconomically disadvantaged groups have an important impact on hospitalisations, especially those focused on improved housing and income. Conclusions:While ongoing efforts to ensure that healthcare interventions improve the equity of access, experience and outcome are warranted, social policy interventions that address the wider determinants of health, such as housing, income and education, hold promise for controlling rates of hospital admissions in socioeconomically disadvantaged groups. This underscores the value of multi-sectoral action to reduce inequalities. Future studies should explore the long-term outcomes of interventions, particularly integrative ones, which may bring benefits in the long term but not so much in the short term. PROSPERO registration number:CRD42019153666.

Story telling is a fundamental part of human nature. Yet in health care education, there is often a focus on students learning to condense a person's rich, sometimes messy story about their life, into a flat, aseptic, clinical account of a patient's symptoms.1 While this approach may help learners handle the complexity of symptomatology, it risks losing sight of the story's central character, as the person is transmogrified into 'the patient'. Excessive focus on fact-gathering diminishes the ability to communicate,2 and adopting this mind-set risks shifting the emphasis of a consultation from relationship to transaction. Engraining a transactional approach to patient interaction may underpin the attrition in empathy seen during undergraduate medical programmes.3 Stories, be they written, visual or spoken, are a powerful way to learn. Rita Charon, general internist, literary scholar and originator of the field of narrative medicine,4 described it as 'a commitment to understanding patients' lives, caring for the caregivers and giving voice to the suffering'.5 The purpose of narrative medicine is threefold: it can reveal patients' perspectives, facilitate self-reflection among learners and provide emotional support to learners.6 We contend that narrative medicine can be a particularly potent catalyst for meaningful learning about underserved populations and health inequality, be it racism, ageism, gender bias and sexism, hetero-normism, colonialism or stigmatised medical conditions. We believe that narrative medicine can add value to the education of all health care professionals—this is of particular relevance when considering underserved communities, since a multidisciplinary approach is recognised as being central to good care for these groups.7 In this toolbox article, we outline relevant educational theory, offer a structure for teaching using narratives, signpost and showcase recommended resources, outline potential barriers to implementation and offer strategies to mitigate against these. Narrative medicine can be a particularly potent catalyst for meaningful learning about underserved populations and health inequality Humans are story telling animals who were teaching and learning through stories long before there was any concept of educational theory—despite this it is useful to consider how this activity can be theorised. Our intention and experience with narrative medicine is that it can foster 'light-bulb moments', in which the learner's perspective can be expanded irrevocably. This aligns with TL theory which we will now consider. TL has been defined by Mezirow, as 'the process by which we transform our taken-for-granted frames of reference to make them more inclusive, discriminating, open, emotionally capable of change …'8 p.8. TL recognises that we all carry preconceptions and assumptions (frames of reference) that influence how we perceive and act within the world. TL seeks to go beyond teaching for knowledge and skills acquisition and instead aspires to challenge and ultimately change these frames of reference. As Kumagai eloquently writes, 'In transformative learning, it is not just what one knows that changes; rather, it is how one knows something, how one sees oneself and others, and how one exists and acts in the world'9 p.650. The events that provide the potential stimulus to change are termed disorientating dilemmas and are traditionally events that stir emotions.10 As an example, we signpost readers to novel work by Thompson et al.11 that describes a course for medical students that aimed to develop their awareness of disability. Students spent 1 week at sea on a tall ship, working alongside a 'buddy' with a disability, in a challenging maritime environment. Such an experience prompts learners to reflect critically on their established frames of reference, yet this alone does not guarantee that transformation will occur. TL contends that transformation is a collective, rather than an individual, experience. The opportunity to discuss, debate and share perspectives with peers, within the setting of a challenging, yet supportive group, provides the climate needed for transformation to occur. The opportunity to discuss, debate and share perspectives with peers provides the climate needed for transformation to occur. Milota et al.12 conducted a systematic review of narrative medicine as a medical education tool. They identified that the majority of included articles (22 of 36) employed a pedagogic process that consisted of three-steps. In Figure 1, we present a synthesis of this three-step approach, which we commend to educators planning to teach using narratives, along with a worked example of how this might be implemented in practice. Integrated into Figure 1 are links to the key tenets of TL theory described above. There is also a reference to the concept of 'close reading' within step 2 of Figure 1. Close reading has been described as the signature method of narrative medicine and involves training learners to 'search for aspects of a written text—like sensory detail, perspective, genre, time, voice, metaphor, and plot—that may harbor meaning for both writer and reader'13 p.348. There are a variety of different types of narratives that can be employed in such teaching; these include patients' narratives, relatives' or care-giver's narratives, clinician's narratives or fictional narratives. There is also great potential variety in the medium through which the narratives are presented to learners—written media (books, magazines, newspapers, poetry), visual media (film, video, television, theatre, art) and audio content (music, podcasts, interviews). Powley and Higson2 p.25 describe how narratives 'engage the imagination to release perceptive and creative responses'. We would encourage clinical teachers to embrace this sentiment and to employ similar imagination and creativity when selecting resources to use within teaching using narrative approaches. For the purposes of this article, we have organised the suggested resources into three categories—so-called 'big picture' stories, multimedia resources and 'local' resources. We acknowledge that there is overlap between these groups but contend that this categorisation may help clinical teachers to identify potential resources and to plan delivery of sessions. We consider 'big picture' stories to be those of global significance. Some of these may be widely known, others may not, but the essence of these 'big picture' stories is that they carry headline messages that may be shocking, challenging or disrupting to one's understanding or world view. The global context of these stories is important, as they offer a vehicle to help normalise diversity, to embed concepts of social justice and accountability within curricula and to produce graduates who are culturally competent and better able to understand and serve the needs of the diverse populations they serve.14 Furthermore, it is recognised that teaching using narrative medicine can 'reveal worlds that are otherwise closed to us'15 p.818. In Table 1 below, we present five suggested stories. For each, we outline the story, the context and the topics that could be taught using the narrative. Henrietta Lacks was an African American woman who died of cervical cancer in 1951. Unbeknownst to her, cancerous cells obtained while treating her condition were taken for research. The cells proved to have an incredible capacity for survival in a laboratory. The cell line, so-called HeLa, has since been used widely in medical research and underpins many modern medical discoveries, including most recently, research into vaccines for COVID-19. John E Fryer was an American psychiatrist and gay rights activist. At the 1972 American Psychiatric Association annual conference, wearing a mask and assuming the pseudonym Dr Henry Anonymous, he gave a speech about his sexuality. At the time, homosexuality was listed as a mental illness within the Diagnostic and Statistical Manual of Mental Disorders (DSM). His speech and the ensuing protests were a key factor in the removal of homosexuality from the DSM. In this section, we provide an assortment of potential resources that could be drawn on to teach using narratives. These suggested resources are presented in Table 2 below, where they are categorised by resource type. There is increasing recognition that medical schools ought to engage with, partner with and respond to the needs of their communities.17 Through this process, the hope is that graduates will qualify with a more nuanced appreciation of the health needs of their local population. Narrative medicine has the potential to be used as a vehicle to achieve this. Stories from the geographical areas within which students are training offer a potentially rich resource for learning. Such narratives may be unique to a particular region and, when used judiciously, may open a window into a person's life that allows a student, from a differing background, to better understand the psycho-social context that underpins that person's lived experience. To illustrate the power of such local narratives, we present two examples from our own clinical experiences. Stories from the geographical areas within which students are training offer a potentially rich resource for learning. The first example is drawn from the author RT's local practice in Ashington, a town in the North East England. Image 1 shows 'Bedside', a painting produced by George Maclean, one of the 'Pitmen Painters'. 'George Maclean was a member of the Ashington Group, which began in the early 1930s, as an evening class of Northumbrian pitmen keen to learn about art. Within weeks they were producing their own work and within a few years their paintings amounted to a complete record of life in a mining community: clocking in, work at the coalface, the pithead baths, Saturday night at the Club etc. Their paintings ring true, transcending the usual limitations of amateur art. I came to Ashington as a physician in 2000, more than a decade after the last pit had closed. It is a close-knit, robust but warm-hearted and generous community that suffered immense post-industrial deprivation. This painting captures bereavement, emptiness, a lonely future; it resonates with the struggles I have witnessed in widowed miners. We sense the physical legacy of hard and dangerous work, strong hands and stooped frame, but also the hopelessness that comes with loss of companionship and role. I worry how this man fared and how his health needs were met'. The second example is drawn from the author NM's local practice in Fife, Scotland, and links with Image 2, Homeless life by Franco Folini. 'One story told by students rotating to Fife is that there is a lot of 'great pathology'. 'Great pathology' is often a symptom of poverty and associated issues such as addiction. My story begins with 'John', a 42-year-old man who attended hospital with pain from leg ulceration at a previous heroin injection site. It had been present for a year but had become increasingly painful over a few weeks. On reviewing John's medical notes, I created a story even before setting eyes on him. My body tensed up. I have noticed when looking after patients with addiction that sometimes I practise from a place of prejudice and thus consultations are short and subsequently lacking compassion. Admitting this brings feelings of shame, particularly because I am aware that occasionally people approach 'people like me' (a woman of African heritage) in the same way. However, I met John at a point in my life when health equity and social justice were at the forefront of my mind. So, I got respectfully curious. 'Why don't you see your practice nurse for regular sterile dressings?' I asked. 'Well, I use toilet paper for that because I don't have a GP. I'm homeless so I can't register'. John's story expanded my narrative, and I use these 'bedside stories' to reflect on bigger topics such as what it means for the NHS to be 'free at the point of access'; the difference between equality and equity in practice; how we challenge our own prejudices and use our privileges to advocate daily'. We acknowledge that while it is not yet clear whether narrative medicine can produce a long-term positive impact on patient care, it is proven to help learners develop more nuanced understanding of patients' perspectives and to enhance their capacity to self-reflect.12 For the educator seeking to evaluate the impact of their session, we would suggest employing methods that enable learners to demonstrate the extent to which they have achieved these goals. Established evaluation methods that are congruent with both TL and narrative medicine include personal reflective essays or other forms of creative reflection such as art. Narrative medicine is proven to help learners develop more nuanced understanding of patients' perspectives and to enhance their capacity to self-reflect. We recognise that for a multitude of reasons, educators may be reticent to trial this method of teaching in their institution. Informed by our own teaching experiences, which include many missteps and some successes, we provide within Table 3 further discussion of the potential barriers to teaching using narratives, along with strategies to mitigate against these. Lastly, we contend that successful implementation of narrative medicine requires a deliberate faculty development strategy. Educators will need to grasp the theory that underlies this approach to teaching and understands the types of resources likely to prompt a disorientating dilemma. Peer discussion forms an important part of TL and narrative medicine, and thus, small-group teaching (SGT), where learner–learner interaction is the goal, naturally aligns. Yet SGT is challenging to deliver; for example, the tendency for teachers to talk too much within SGT is well-recognised, particularly for less experienced educators.18 Thus, faculty development initiatives that allow educators to hone their facilitatory skills19 are crucial to successful implementation of narrative medicine. Successful implementation of narrative medicine requires a deliberate faculty development strategy We offer this toolbox in the hope that it will aid teachers and students in developing what Charon terms 'narrative competence': the competence to use, absorb, interpret and respond to stories.4 By working from the global to the local, we aim to foster a sense of comfort in the hearing of, and responding to, narratives from the public domain, such that we are sensitised to the narratives that surround us in our clinical practice, including our personal stories. Through offering suggestions, we aim to encourage an imaginative search for teaching resources with the power to engender collaborative learning. We encourage teachers to find fresh, richer approaches to learning from patients, connecting teacher, learners and patients in anathema to the 'detached concern' commended to us in the past.20 James Fisher: Conceptualization; writing—original draft; writing—review and editing; resources. Nony G. Mordi: Conceptualization; writing—original draft; writing—review and editing; resources. Richard Thomson: Conceptualization; writing— original draft; writing—review and editing; resources. We would like to thank the Ashington Group Trustees, Woodhorn Museum, Ashington, U.K. for granting permission to reproduce 'Bedside' by George Maclean. The authors have no conflict of interest to disclose. Not required.

BACKGROUND:Online question banks are the most widely used education resource amongst medical students. Despite this there is an absence of literature outlining how and why they are used by students. Drawing on Deci and Ryan's self-determination theory, our study aimed to explore why and how early-stage medical students use question banks in their learning and revision strategies.METHODS:The study was conducted at Newcastle University Medical School (United Kingdom and Malaysia). Purposive, convenience and snowball sampling of year two students were employed. Ten interviews were conducted. Thematic analysis was undertaken iteratively, enabling exploration of nascent themes. Data collection ceased when no new perspectives were identified.RESULTS:Students' motivation to use question banks was predominantly driven by extrinsic motivators, with high-stakes exams and fear of failure being central. Their convenience and perceived efficiency promoted autonomy and thus motivation. Rapid feedback cycles and design features consistent with gamification were deterrents to intrinsic motivation. Potentially detrimental patterns of question bank use were evident: cueing, avoidance and memorising. Scepticism regarding veracity of question bank content was absent.CONCLUSIONS:We call on educators to provide students with guidance about potential pitfalls associated with question banks and to reflect on potential inequity of access to these resources.

Background Arising in blood and lymph-forming tissues, haematological malignancies (leukaemias, lymphomas and myelomas) are the fifth most common group of cancers. Around 60% are currently incurable and follow a chronic, remitting–relapsing pathway often initially managed by ‘watch & wait’. This involves hospital-based monitoring, followed by treatment if the cancer progresses (which not all do) and then further observation, in a process that may continually repeat. New treatments are constantly emerging, survival is improving and prevalence is rising, but population-based data documenting entire care pathway are sparse. Hence, empirically-based incidence and prevalence estimates about various treatment states (watch and wait, first-line treatment, observation, second-line treatment, etc.) and patterns of healthcare activity are lacking. Likewise, despite complex trajectories, anxiety-provoking watch and wait, and therapies that impede quality of life and incur marked healthcare costs, evidence about patient preferences for information sharing and treatment decisions is scant. Objectives Primary – to generate high-quality, evidence-based information about the care pathways of the general population of patients with chronic haematological malignancies. Secondary – to produce information resources suitable for testing in routine National Health Service practice. Design Population-based cohort of ≈ 8000 patients with chronic haematological malignancies, incorporating five nested work packages, each with its own individual design: (1) exploration of patient experiences: information and treatment decisions; (2) population-based analyses; (3) health economics; (4) development of information resources to support decision-making; and (5) patient well-being and decision-making survey. Setting This programme is predicated on the infrastructure of the United Kingdom’s Haematological Malignancy Research Network (www.hmrn.org); which provides ‘real-world’, robust, generalisable data to inform research and clinical practice, nationally and internationally. Set in Yorkshire and Humberside, the Haematological Malignancy Research Network’s catchment population of ≈ 4 million has a comparable sex, age, urban/rural, and area-based deprivation (Index of Multiple Deprivation, income domain) distribution to the United Kingdom as a whole; and in terms of ethnic diversity the region is centrally ranked, with around 80% of residents identifying as White British, 9% as Asian and 2% as black. Within the Haematological Malignancy Research Network, clinical practice adheres to national guidelines, and all patients with blood cancers are centrally diagnosed (≈ 2500 each year), tracked through their treatment pathways and linked to national databases (deaths, cancer registrations and Hospital Episode Statistics). Linked to the same national databases, the Haematological Malignancy Research Network also contains an age- and sex-matched general-population cohort. Participants Patients aged ≥ 18 years, resident in the study region, and diagnosed with chronic lymphocytic leukaemia, follicular lymphoma or myeloma. Methods Core Haematological Malignancy Research Network data were used to compare the hospital activity of patients with chronic lymphocytic leukaemia, follicular lymphoma and myeloma with that of the general population. Following additional linkages to genetic and clinical data, follicular lymphoma prognostic factors were examined. Two self-administered questionnaires addressing (1) quality of life and well-being and (2) decision-making were iteratively developed, piloted and deployed. Linkage to quality of life, clinical information and Hospital Episode Statistics enabled economic (myeloma) model development. In-depth interviews were conducted with 35 patients (10 alongside relatives). Results Trajectories of ≈ 8000 patients were mapped, and patient-pathway visualisations summarising individual and aggregate information were developed. As expected, patients with chronic blood cancers experienced higher levels of hospital activity than their general population counterparts, the largest effects being for myeloma. Following survey deployment, 3153 patients were recruited across 14 hospitals, 1282 with chronic lymphocytic leukaemia, follicular lymphoma or myeloma. Over half of the questionnaires were completed by patients on watch and wait; the remainder were completed during treatment or post-chemotherapy monitoring. Information gathered, coupled with in-depth interviews, demonstrated patients’ marked anxiety and fluctuating preferences for information sharing and decision-making, contingent on complex, inter-related factors. In turn, prognostic and microsimulation economic models were used to predict individual-level trajectories across multiple treatment lines, examining associated overall survival, costs and quality-adjusted life-years. Limitations Survey mapping to individual care pathways could not be completed because the COVID-19 pandemic delayed clinical data collection. Patients who attended clinics and participated in the survey were more likely than non-attenders to have had first-line chemotherapy, be slightly younger and live in more affluent areas. Conclusions This programme collated high-quality, population-based evidence. Previously lacking, this, coupled with new findings on preferences for information sharing and treatment decisions, provides the foundation for future research. Future work The translation of information accrued into resources suitable for testing in routine NHS practice is key. In this regard, COVID-19 has changed the communication landscape. The visualisations developed by this programme require further refinement/testing using participatory co-design with stakeholder groups. Underpinned by a suitable protocol applied within a single multidisciplinary team setting, prior to further evaluation within/outside the region, such outputs require testing in a cluster-randomised trial. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme (NIHR award ref: RP-PG-0613-20002) and is published in full in Programme Grants for Applied Research ; Vol. 12, No. 5. See the NIHR Funding and Awards website for further award information.

Background Patient decision aids are interventions designed to support people making health decisions. At a minimum, patient decision aids make the decision explicit, provide evidence-based information about the options and associated benefits/harms, and help clarify personal values for features of options. This is an update of a Cochrane review that was first published in 2003 and last updated in 2017. Objectives To assess the effects of patient decision aids in adults considering treatment or screening decisions using an integrated knowledge translation approach. Search methods We conducted the updated search for the period of 2015 (last search date) to March 2022 in CENTRAL, MEDLINE, Embase, PsycINFO, EBSCO, and grey literature. The cumulative search covers database origins to March 2022. Selection criteria We included published randomized controlled trials comparing patient decision aids to usual care. Usual care was defined as general information, risk assessment, clinical practice guideline summaries for health consumers, placebo intervention (e.g. information on another topic), or no intervention. Data collection and analysis Two authors independently screened citations for inclusion, extracted intervention and outcome data, and assessed risk of bias using the Cochrane risk of bias tool. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made (informed values-based choice congruence) and the decision-making process, such as knowledge, accurate risk perceptions, feeling informed, clear values, participation in decision-making, and adverse events. Secondary outcomes were choice, confidence in decision-making, adherence to the chosen option, preference-linked health outcomes, and impact on the healthcare system (e.g. consultation length). We pooled results using mean differences (MDs) and risk ratios (RRs) with 95% confidence intervals (CIs), applying a random-effects model. We conducted a subgroup analysis of 105 studies that were included in the previous review version compared to those published since that update (n = 104 studies). We used Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to assess the certainty of the evidence. Main results This update added 104 new studies for a total of 209 studies involving 107,698 participants. The patient decision aids focused on 71 different decisions. The most common decisions were about cardiovascular treatments (n = 22 studies), cancer screening (n = 17 studies colorectal, 15 prostate, 12 breast), cancer treatments (e.g. 15 breast, 11 prostate), mental health treatments (n = 10 studies), and joint replacement surgery (n = 9 studies). When assessing risk of bias in the included studies, we rated two items as mostly unclear (selective reporting: 100 studies; blinding of participants/personnel: 161 studies), due to inadequate reporting. Of the 209 included studies, 34 had at least one item rated as high risk of bias. There was moderate-certainty evidence that patient decision aids probably increase the congruence between informed values and care choices compared to usual care (RR 1.75, 95% CI 1.44 to 2.13; 21 studies, 9377 participants). Regarding attributes related to the decision-making process and compared to usual care, there was high-certainty evidence that patient decision aids result in improved participants' knowledge (MD 11.90/100, 95% CI 10.60 to 13.19; 107 studies, 25,492 participants), accuracy of risk perceptions (RR 1.94, 95% CI 1.61 to 2.34; 25 studies, 7796 participants), and decreased decisional conflict related to feeling uninformed (MD -10.02, 95% CI -12.31 to -7.74; 58 studies, 12,104 participants), indecision about personal values (MD -7.86, 95% CI -9.69 to -6.02; 55 studies, 11,880 participants), and proportion of people who were passive in decision-making (clinician-controlled) (RR 0.72, 95% CI 0.59 to 0.88; 21 studies, 4348 participants). For adverse outcomes, there was high-certainty evidence that there was no difference in decision regret between the patient decision aid and usual care groups (MD -1.23, 95% CI -3.05 to 0.59; 22 studies, 3707 participants). Of note, there was no difference in the length of consultation when patient decision aids were used in preparation for the consultation (MD -2.97 minutes, 95% CI -7.84 to 1.90; 5 studies, 420 participants). When patient decision aids were used during the consultation with the clinician, the length of consultation was 1.5 minutes longer (MD 1.50 minutes, 95% CI 0.79 to 2.20; 8 studies, 2702 participants). We found the same direction of effect when we compared results for patient decision aid studies reported in the previous update compared to studies conducted since 2015. Authors' conclusions Compared to usual care, across a wide variety of decisions, patient decision aids probably helped more adults reach informed values-congruent choices. They led to large increases in knowledge, accurate risk perceptions, and an active role in decision-making. Our updated review also found that patient decision aids increased patients feeling informed and clear about their personal values. There was no difference in decision regret between people using decision aids versus those receiving usual care. Further studies are needed to assess the impact of patient decision aids on adherence and downstream effects on cost and resource use.

Abstract Background Despite policy prominence and frameworks focusing on health inequalities, healthcare leaders do not feel they have the skills and knowledge to reduce health inequalities. This comparative case study explored four areas in England to examine how local health systems are addressing health inequalities and what ‘good’ practice might look like. Methods Interviews were held with 46 people working in health care services across the NHS, local authority or voluntary, community, social enterprise sectors. Key documents (n = ~ 10) in each of the four areas relating to reducing health inequalities were analysed using documentary analysis methods. Interviews and documents were coded and analysed independently before being integrated to synthesise findings. Analysis was conducted using a two-stage approach - firstly, an inductive analysis of emergent themes; secondly, to build knowledge on each case study’s’ system approach of reduction of health inequalities, principles of the Action Scales Model were used. Results Nineteen themes were identified across the four case studies; some themes were not apparent in all the case studies, nor in either the documentary analysis or interviews. These themes allowed us to compare between cases to explore what might be contributing to good practice. Themes identified included: understanding the local context; facilitators of how to tackle health inequalities and improve health and wellbeing; and future concerns. The secondary analysis highlighted potential levers for action from each case study; these included optimising retention and recruitment of workforce and allowing time and resources for longer-term planning. Two case study areas which appeared to have system resilience, demonstrated having a shared vision, strong partnerships, understanding of the system, and putting people and communities at the heart of decision making. Conclusion This comparative case study makes a unique contribution in the examination of how health systems are addressing health inequalities in their local areas. The combined interview and documentary analysis findings provide rich insights of local systems’ documented strategies, plans and what is happening ‘on the ground’.

IntroductionShared decision making (SDM) refers to patients and health care professionals working together to reach a decision about treatment/care. In abdominal aortic aneurysm (AAA) treatment options are influenced by patients' clinical characteristics, their preferences, and potential trade-offs between alternative interventions. This is a prime example of where SDM is essential to ensure the right decision is made for the right patient, yet we have little understanding of what happens in practice. This study explored patient experiences to understand SDM practice in AAA surgery.MethodsWe used a qualitative approach to describe, and identify improvements to, current treatment decision making in abdominal aortic aneurysm (AAA) surgery. Two groups of patients were interviewed: those at the point of discussing treatment options (with corresponding digitally recorded consultation data) and following surgical intervention from one hospital. Framework analysis was used.ResultsFifteen patients were interviewed, seven at the point of discussing treatment options and eight following surgical intervention. Timing, format and sources of information, verbal framing of interventions and level of patient engagement were key themes. Four areas for improvement were identified: earlier provision and more detailed written information along with signposting to quality on-line information; both intervention options, risks, benefits, and consequences, were not always discussed; some clinicians were somewhat directive in the decision-making process; and patients' treatment values/preferences were not explored-the only example was in one of the eight recorded consultations. Patients could feel overwhelmed by the information and decision and fearful of the impending surgery.ConclusionsMore emphasis should be placed on the provision of full information and the exploration of patient values and preferences for treatment. Clinician training and support for patients, including decision aids, could facilitate the decision-making process. Providing written information earlier and guidance on reliable on-line resources would benefits patients and their families.

Background Health systems are experiencing increasing compound pressures. Raising demand, underpinned by the ageing population and the rise in cost of living exacerbates these pressures further. We know that avoidable hospital admissions are a big healthcare costs. Across high-income countries we see increase numbers in avoidable admissions. Socio-economically disadvantage groups are at increased risk of avoidable hospital admissions. Initiatives are neded to reduce the number of avoidable hospital admissions. Methods This systematic review evaluates interventions aimed at socio-economically disadvantaged populations to reduce hospital admissions and identify any knowledge gaps. We searched MEDLINE, Embase, CINAHL, Cochrane CENTRAL and the Web of Knowledge platform for studies published between Jan 1 2000 and Feb 23 2022 (PROSPERO CRD42019153666). We incldued quantitative studies of socio-economically disadvantaged populations, conducted in an member country of the Organisation for Economic Co-operation and Development, with universal health care and reporting hospital admission or readmissions were included. We assessed study quality using the Effective Public Health Practice Project (EPHPP) tool. We summarised studies using a narrative synthesis approach. Results 28655 records were identified from the initial database search and 128 through additional methods. Titles and abstracts of 23496 studies were screened and 541 full texts were reviewed. 17 studies were included in the final review from thirteen countries. We present interventions across three domains of action – population health and cross sectoral policy, health and care system or integrative interventions. We found that interventions targeting socio-economically disadvantaged groups can reduce avoidable hospital admissions. Integrative approaches, especially those focused on empowerment of patients were effective in reducing avoidable admissions. No studies presented co-produced interventions, and across the literature pre-existing health inequalties were poorly described. Conclusion We found that integrative interventions, working across domains of action, were effective at reducing admission of socio-economically disadvantaged groups. Engagement with target groups to identify their health needs that lead to avoidable hospitalisation may be key in this work and should be reported and disseminated widely. Future health research should explore the absolute as well as the relative impact of health interventions describing the baseline characteritics and any differential impacts across the social gradient.

Background The experience of costly, unplanned care and hospitalisations is not equal across our society; populations living in socioeconomically disadvantaged circumstances where ill-health is more prevalent, experience higher rates. There is a policy, financial and moral imperative to act to address these inequalities and reduce mounting hospital pressures more broadly. Previous systematic reviews have only examined the average effect of healthcare interventions on avoidable hospitalisations, they have not looked at the differential impact of interventions across populations, nor taken a health systems approach and considered the impact of interventions beyond healthcare services on hospitalisations. We aimed to establish which interventions reduce, maintain or increase socioeconomic inequalities in hospitalisations and readmissions. Methods An electronic search of MEDLINE, Embase, CINAHL, Cochrane CENTRAL and Web of Knowledge was conducted January 1, 1999 to Feb 23, 2022, supplemented with full citation searches of included studies, website searches and expert consultation. Empirical studies involving individuals of any age, in Organisations for Economic Co-operation and Development countries, published in any language were included. Quantitative studies of interventions across any domain of activity (wider public-policy and population health, health and care service, and integrative interventions) were included provided they reported the differential impact of the intervention on either hospitalisations or readmissions across socioeconomic groups (individual or area-based measure of socio-economic status included). Risk of bias was assessed using the Effective Public Health Practice Project tool and narrative synthesis conducted with direction of effect plots. Results After removing duplicates, 23,496 titles and abstracts were screened, followed by 502 full texts. 37 studies met the inclusion criteria. Studies used a range of quantitative study designs and over half were from the US. Socioeconomic status was variously measured and reported, study quality was variable, and equity impacts mixed. Effective interventions for reducing socioeconomic inequalities were found across all domains of activity and were characterised as either requiring low personal agency to benefit (being legislative in nature and applied at a population or health system level) or for interventions implemented at an individual level, a vaccine programme or intervention focused on holistic integrative care. Conclusion Evaluating the equity impact of interventions should become more routine; interventions implemented to reduce hospitalisation rates may maintain or increase inequalities, but there are also promising examples of interventions which may reduce inequalities. Whole systems action and investment in non-healthcare activity alongside healthcare intervention is required to improve equity in health and care outcomes.

Background There is strategic objective to incorporate the principles and practice of co-design into routine service development and improvement. Aim The aim was to explore the concept and feasibility of service co-design with patients and health professionals with regards to the upper gastrointestinal (UGI) cancer care pathway. Methods and Results Qualitative telephone interviews and face-to-face focus groups in one region of England. Twenty patients completed interviews. Nine patients and ten professionals formed two focus groups. Patients were referred through the urgent (two week) GP referral route and were within six months of receiving their first treatment for an UGI cancer. Professionals were working as service planners and providers of the UGI cancer care pathway. Thematic analysis was undertaken. Six themes emerged: Responsibilities and expectations, Knowledge and understanding, Valuing patient input, Building relationships, Environment for co-design activities, Impact and effectiveness. Based on the themes a checklist has been created to provide practical suggestions for both professionals and patients on approaching co-design for service improvement. Conclusion This study offers policy and practice partners a clearer understanding of co-design and factors to consider when approaching co-design in real life settings.

BACKGROUND:The ability to provide person-centred care (PCC) is an essential skill for doctors and requires therapeutic empathy. We sought to evaluate a novel teaching approach to understand how medical students' personal reflections on an older person impact their views about PCC and frailty. APPROACH:We designed a teaching session where students prepared an image and story about an older person they knew. Given the innovative nature of this, we set it in the context of a Plan Do Study Act cycle to ensure evaluation and continuous improvement at each stage. Students' contributions were discussed in a supportive environment, weaving together stories about individuals with the impacts of ageing they experienced. We evaluated the teaching with a pre- and post-session 'frailty' word cloud and an online focus group. EVALUATION:Word cloud analysis showed a shift in the words students used when considering 'frailty', from words associated with illness and vulnerability to those associated with character and experience. Focus group themes supported these findings. Students expressed a change in their perception of frailty to consider 'the person behind the patient', which, unexpectedly, led to them also seeing 'the person behind the medical student'. The session stimulated student reflection on challenges that may impact on delivery of truly person-centred care. IMPLICATIONS:This flexible teaching technique was an effective stimulus for medical students to consider the person behind the patient. Future work could consider how to promote retention of empathy as medical students make the transition to working as a doctor.

Shared decision making has been on the policy agenda in the UK for at least twelve years, but it lacked a comprehensive approach to delivery. That has changed over the past five years, and we can now see significant progress across all aspects of a comprehensive approach, including leadership at policy, professional and patient levels; infrastructure developments, including the provision of training, tools and campaigns; and practice improvements, such as demonstrations, measurement and coordination. All these initiatives were necessary, but the last, central coordination, would appear to be key to success.