Background: Effective and cost-effective treatments are not always optimally implemented. The benefit forgone due to sub-optimal implementation is often not considered or estimated. We use the economic concept of ‘incremental net monetary benefit’ (INMB) to demonstrate how this can be valued. This approach can inform decision-making when used to estimate the value for money of potential future quality improvement (QI) programmes. We illustrate these analyses using the case of antenatal magnesium sulphate (MgSO4), a cost-effective treatment for the prevention of cerebral palsy in preterm births. We estimate the optimal implementation of MgSO4, the INMB lost due to sub-optimal implementation, and the value of future implementation initiatives to increase the use of MgSO4. Methods: We estimated MgSO4 treatment implementation for babies under 32 weeks’ gestation using routine data on its uptake between 2014 and 2022 in England, Scotland, and Wales. The optimal uptake level of MgSO4 was estimated using clinical judgment. The societal lifetime INMB of MgSO4 for the prevention of cerebral palsy in preterm births was obtained from the literature. The INMB of sub-optimal implementation over time was estimated as the difference between optimal and actual uptake over time in each country. We estimated the cost-effectiveness of a hypothetical future QI programme based on different scenarios of implementation effectiveness and costs. Results: The optimal uptake of MgSO4 was 95%. The INMB forgone associated with sub-optimal MgSO4 uptake has reduced over time, as uptake has increased. However, in 2022, the societal lifetime INMB forgone was still £18.2m in England, £3.7m in Scotland, and £1.0m in Wales. A future QI programme across all three countries achieving a 5% increase in MgSO4 uptake over one year, and costing £987,500 to implement, would be cost-effective; generating £7.5m in INMB. Future implementation initiatives are likely to be cost-effective within a range of different implementation effectiveness and costs. Conclusions: The case of MgSO4 treatment for preterm birth illustrates how sub-optimal implementation of evidence-based interventions can be associated with high opportunity costs measured as INMB forgone. This approach provides valuable quantification of the value for money of future QI programmes to improve the implementation of these interventions.

Background Following the 2019 NHS Long Term Plan, link workers have been employed across primary care in England to deliver social prescribing. Aim To understand and explain how the link worker role is being implemented in primary care in England. Design and setting This was a realist evaluation undertaken in England, focusing on link workers based in primary care. Method The study used focused ethnographies around seven link workers from different parts of England. As part of this, we interviewed 61 patients and 93 professionals from health care and the voluntary, community, and social enterprise sector. We reinterviewed 41 patients, seven link workers, and a link worker manager 9-12 months after their first interview. Results We developed four concepts from the codes developed during the project on the topic around how link workers are integrated (or not) within primary care: (or not) within primary care: centralising or diffusing power; forging an identity in general practice; demonstrating effect; and building a facilitative infrastructure. These concepts informed the development of a programme theory around a continuum of integration of link workers into primary care - from being 'bolted on' to existing provision, without much consideration, to 'fitting in', shaping what is delivered to be accommodating, through to 'belonging', whereby they are accepted as a legitimate source of support, making a valued contribution to patients' broader wellbeing. Conclusion Social prescribing was introduced into primary care to promote greater attention to the full range of factors affecting patients' health and wellbeing, beyond biomedicine. For that to happen, our analysis highlights the need for a whole-system approach to defining, delivering, and maintaining this new part of practice.

BACKGROUND:Health and social care services increasingly recognise the value of involving people with lived experience in service design and delivery. For people who have experienced multiple disadvantage (combinations of homelessness, mental ill health, addiction, involvement with the criminal justice systems or domestic violence/abuse), participating in professional settings may be challenging and can risk re-traumatisation and greater disillusionment. However, gaining confidence and competency to do this offers opportunities for personal and professional development, contributing to meaningful change. It is necessary that individuals with lived experience can engage safely and effectively in these settings. This study analyses how an organisation of people who have experienced multiple disadvantage, Independent Futures (IF), enabled co-production within services and systems, to understand how people can be best supported and how involvement impacts them. METHODS:Sixteen IF members and three IF staff participated in semi-structured interviews. A staff survey, at two time points, investigated how employees from Changing Futures partner organisations perceived their ability to embed co-production within services, with 147 responses. Internal documentation was analysed to illustrate the diversity of co-production work that IF contributed to. RESULTS:Putting trauma-informed principles into practice facilitated personal growth, improved confidence and some work skills for IF members, who contributed to 65 different workstreams. However, embedding co-production into wider services and systems proved challenging. Staff survey comments highlighted obstacles related to resources, time and hierarchical cultures. CONCLUSION:Lived experience organisations can model trauma-informed practice and influence systems. Embedding trauma-informed principles requires flexibility, openness and willingness that is sustainable only when everyone adopts and commits to these principles. Any evidence of tokenism destroys trust and undermines the endeavour. PUBLIC CONTRIBUTION STATEMENT:This study was co-produced with people with lived experience of multiple disadvantage and staff participants. Two lived experience IF members were involved in: developing the funding bid, designing the research including designing the staff survey, developing interview topic guides, commenting on information sheets and developing interview arrangements to ensure comfort and safety of IF members. Four lived experience IF members and three members of staff contributed to writing the paper, including reviewing key literature, refining the analysis and developing the discussion and conclusion.

OBJECTIVES:To codevelop (with children and young people with diabetes (CYPD)) an intervention to improve diabetes control and future health outcomes of CYPD from 'underserved' groups, to reduce treatment outcome inequalities between different socioeconomic and ethnic groups. To follow Medical Research Council guidance for complex interventions and the COM-B (Capability, Opportunity, Motivation, Behaviour) model for behaviour change intervention development. DESIGN:In phase 1 (previously reported), we established the evidence base, conducted literature reviews and analysed data from semistructured interviews with CYPD and their carers. In phase 2 (this report), we applied the COM-B framework to identify intervention components; in phase 3 (this report), we evaluated these components, including focus groups with CYPD, their carers' and healthcare practitioner (HCP) surveys, using the Acceptability, Practicability, Effectiveness, Affordability, Spill-Over Effects, Equity criteria. SETTING:Secondary care; children, young people and their carers' were approached from two large paediatric diabetes services in England, both with socioeconomically and ethnically diverse underserved populations; paediatric diabetes HCPs were surveyed across four English regions. PARTICIPANTS:N=69 underserved CYPD (aged 5-19 years) and/or family members took part in interviews; N=48 paediatric diabetes HCP survey respondents (survey 1); N=34 paediatric diabetes HCP survey respondents (survey 2); N=3 young people's advisory group participants; N=17 underserved CYPD/carers focus group participants; N=9 wider stakeholder participants. RESULTS:The codevelopment process and integration of COM-B established four elements for an intervention package: (1) an enhanced peer support/mentoring programme; (2) provision of a health and well-being coach to CYPD/families; (3) family/community support to address social and community issues and (4) training for HCPs, including cultural competence, poverty proofing and to emphasise the need for increased sensitivity and better supported communication in work with CYPD from underserved groups. CONCLUSIONS:The Diversity in Diabetes codevelopment work informed an intervention to improve diabetes care in underserved groups, reflecting sociocultural contexts and plausible support options at the individual, community and clinical levels. The 'Diversity in Diabetes' programme will next test feasibility and further refine the intervention package in two more paediatric diabetes centres in England.

Poor behaviour in UK secondary schools is considered a significant problem. While the Department for Education recommends disciplinary behaviour management strategies (DBMS), their impact on pupil mental health and wellbeing, as well as their effectiveness in addressing poor behaviour, remains unclear. Young people aged 13-18 years were recruited to a study using peer-led semi-structured interviews, analysed using the Framework Method. Fifteen interviews were conducted and analysis showed that participants found DBMS to be confusing, unfair, harsh and inconsistent. They were seen as ineffective for addressing poor behaviour and as negatively affecting pupil mental health and wellbeing, and academic and social outcomes. Participants viewed DBMS, especially the use of isolation, as ineffective and potentially harmful. They suggested that school leaders should review their behaviour management policies and consider the adoption of approaches that build relationships and seek to understand the reasons for poor behaviour.

The administration of magnesium sulphate (MgSO4) in preterm labour is an evidence-based intervention recommended by the United Kingdom’s National Institute for Health and Care Excellence (NICE) to prevent neurological damage to the infant. However, uptake varies across UK maternity units. We used findings from three studies in England, Scotland and Wales investigating implementation of guidance on MgSO4 as neuroprotectant in preterm-labour to understand how knowledge mobilisation can drive scaling and spread of improvement. Remote semi-structured interviews were carried out as part of an evaluation of (1) the PReCePT (Preventing Cerebral Palsy in Pre-Term Labour) National Programme, and (2) the PReCePT cRCT study, and as part of a qualitative study investigating MgSO4 guidance implementation in Scotland and Wales. Normalisation Process Theory informed data collection and analysis. Data were analysed using the framework method. Interviews with 86 strategic and clinical leads and implementers from the three nations suggested that despite evidence being necessary and important for policy decision-making and clinical buy-in, improvement interventions were motivated by audit data and benchmarking. Scaling of improvement was driven by knowledge sharing, diffusion of innovation, and capacity building through relational structures (e.g. networks, communities) spanning the perinatal ecosystem. Local champions operating in multiple communities and networks as boundary-spanners connected national and regional leadership, patient group representatives, implementers i.e. clinical leads and champions, and perinatal clinical teams to enable knowledge mobilisation. Their work relied on backfill funding and protected time, and social-cognitive and social-structural resources in their settings. Sense-making, cognitive participation, collective action and reflexive monitoring work took place iteratively and dynamically within and across these structures on each level of the system. QI interventions driven by knowledge mobilisation can drive scaling and spreading of improvement, but require knowledge sharing and an infrastructure within the system to support improvement capacity building. Strong leadership with the ability to address power imbalances between co-actors, and secure protected funding for local champions is also required.

Introduction The PRIME-UK randomised controlled trial (RCT) aims to establish whether a model of care that seeks to be proactive, integrated and empower participants, caregivers and healthcare professionals can improve outcomes in people with parkinsonism. Given that this intervention is novel and complex, understanding whether and how the intervention will be acceptable, implementable, cost-effective and scalable across contexts are key questions beyond that of whether ‘it works’. We describe an embedded process evaluation to answer these questions, which aims to support interpretation of the trial results, refinement of the intervention and support future scaling of the PRIME-Parkinson model of care.Methods and analysis A mixed-methods approach will be used to collect data across four process evaluation domains: implementation, mechanism of change, acceptability and context. Quantitative data will be collected prospectively from all participants and analysed descriptively with exploratory tests of relationships as power allows. Qualitative data will be collected through semistructured interviews with a purposively sampled subpopulation of participants, caregivers and staff members as well as case studies where relevant. Interview transcripts will be analysed thematically using interpretive qualitative analysis. Synthesis of quantitative and qualitative data will also be performed to draw conclusions.Ethics and dissemination The quantitative data will be collected as part of the main PRIME-UK RCT which was been granted NHS REC approval (21/LO/0387) on 27 July 2021. The qualitative data will be collected as part of a substudy, ‘PRIME-Qual’, which was granted NHS REC approval (21/LO/0388) on 14 July 2021. The mixed-methods process evaluation will be published after the conclusion of the trial in addition to the main trial findings.Trial registration number NCT05127057.

Background:Social prescribing link workers formed part of the Additional Roles Reimbursement Scheme introduced into primary care in England from 2019. Link workers assist patients experiencing issues affecting their health and well-being that are 'non-medical' (e.g. lack of social connections, financial difficulties and housing problems). They give patients space to consider these non-medical issues and, when relevant, connect them to support, often within the voluntary-community-social-enterprise sector. We conducted an earlier realist review on the link worker role in primary care. We then carried out a realist evaluation, described in this report, to address the question: When implementing link workers in primary care to sustain outcomes - what works, for whom, why and in what circumstances? Aim:To develop evidence-based recommendations to optimise the implementation of link workers in primary care and to enable patients to receive the best support possible. Design:A realist evaluation, involving two work packages. Setting:Data were collected around seven link workers in different parts of England. Methods:For work package 1, researchers spent 3 weeks with each link worker - going to meetings with them, watching them interact with patients, with healthcare professionals and with voluntary-community-social-enterprise staff. During this time, researchers had a daily debrief with the link worker, inviting them to reflect on their working day, and they collected relevant documents (e.g. job descriptions and information on social prescribing given to patients). They also conducted interviews with 93 primary care/voluntary-community-social-enterprise staff and 61 patients. As part of this work package, data on patient contact with a general practitioner before and after being referred to a link worker were collected. Work package 2 consisted of follow-up interviews (9-12 months later) with patients; 41 were reinterviewed. In addition, link workers were reinterviewed. A realist logic of analysis was used to test (confirm, refute or refine) the programme theory we developed from our realist review. Analysis explored connections between contexts, mechanisms and outcomes to explain how, why and in what circumstances the implementation of link workers might be beneficial (or not) to patients and/or healthcare delivery. Results:We produced three papers from the research - one on link workers 'holding' patients, one on the role of discretion in their job, and another exploring patient-focused data and readiness to engage in social prescribing. Data from these papers were considered in relation to Normalisation Process Theory - a framework for conceptualising the implementation of new interventions into practice (e.g. link workers into primary care). By doing so, we identified infrastructural factors required to help link workers to: (1) offer person-centred care; (2) develop patients' self-confidence, sense of hope and social capital; (3) facilitate appropriate general practitioner use; (4) foster job satisfaction among those delivering social prescribing. Discussion:Our research highlighted the importance of a supportive infrastructure (including supervision, training, leadership/management, clarity about the role, link workers' ability to use existing skills and knowledge and having capacity to connect with providers in the voluntary-community-social-enterprise sector) in order to produce person-centred care, to nurture hope, self-confidence and social capital among patients, to ensure they receive the right support (medical or non-medical), and to promote link workers' job satisfaction. Data showed how link workers can contribute to the offer of holistic care beyond a purely medical lens of health and illness. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR130247.

People from Black and other minoritized ethnic communities are known to experience health and social care inequities, including barriers to accessing bereavement support. However, bereavement experiences and support needs in different population groups are poorly understood. This qualitative, co-produced study aimed to explore experiences of grief and bereavement among people of Black British and Black Caribbean heritage in England. Through community conversations and interviews with 35 participants, the study illuminates how structural inequities, cultural norms, and systemic racism intersect to shape grief experiences. Participants highlighted the importance of extended family and community in grief, which often clashed with the individualistic norms of white British society. Cultural customs that discouraged emotional expression made grieving harder, while rituals like Nine-Night and storytelling provided crucial communal support. Findings inform evidence-based recommendations for systemic reforms and community-level action to help improve experiences among Black British and Black Caribbean bereaved people in England.

To reduce the risk of COVID-19 infection, transmission and illness during the pandemic, the Department for Education (DfE) issued guidance to schools. However, research on how the school community perceives the impact of the COVID-19 mitigation measures outlined remains limited. This qualitative study aims to explore the effects of school closures and in-school mitigation measures on daily school life, as well as their impact on mental health and wellbeing from the perspective of English secondary school staff and students. Participants were purposively sampled from English secondary schools serving diverse communities participating in the COVID-19 Mapping and Mitigation in Schools study (CoMMinS). Selection ensured representation of staff roles and student demographics. Semi-structured interviews were conducted remotely, and data analysed thematically. Interviews took place between January and August 2021 with participants from five secondary schools (20 staff and 25 students). Both staff and students reported significant disruption to school life, with four themes identified: (1) teaching and learning impact, (2) social impact, (3) safeguarding impact, and (4) and mental health and wellbeing impact. Findings highlight widespread negative effects across every aspect of school life, for both staff and students. This study suggests that COVID-19 mitigation measures in UK secondary schools led to a sense of loss and uncertainty as well as increased self-reported stress among both staff and students.

BACKGROUND:People facing multiple disadvantage have often experienced extensive trauma. Changing Futures Bristol was part of a national programme to improve outcomes for people who face multiple disadvantage, such as combinations of homelessness, substance misuse, mental ill-health, domestic violence and abuse or contact with the criminal justice system. Aims were to understand how services could be improved, with more trauma-informed approaches at individual, service and system levels. An in-depth mixed method evaluation of Changing Futures Bristol examined how trauma-informed approaches were implemented and linked across services supporting people experiencing multiple disadvantage. METHODS:The study followed a participatory action research approach, involving research conducted in collaboration with people who have experienced multiple disadvantage, and staff partners. Collaborators actively contributed to securing funding, research design, data analysis, and write-up. A staff survey was conducted using existing measures and some tailored questions, to assess perceptions of trauma-informed approaches, equality, diversity and inclusion, and co-production. One hundred and seventeen staff responded, with 30 staff completing the survey again after one year to track any changes. Twenty-three staff members were interviewed. Qualitative data were analysed thematically, guided by trauma-informed principles and implementation domains. RESULTS:Movement toward more trauma-informed approaches was detected, although these changes were not found to be statistically significant after one year. Barriers included short-term funding and commissioning cycles and difficulties in staff retention, due to short-term contracts, vicarious trauma, stress and pressures of the job. Managers had to hold contradicting drivers to deliver targets and manage finances whilst creating space for relational support and trauma-informed practice. To create psychological safety, staff needed to feel trust and transparency. 73% of staff reported lived experience of at least one domain of multiple disadvantage or trauma. Support for staff is needed at all levels of the organisation. CONCLUSIONS:A long-term, collaborative, and trauma-informed approach is needed at all levels, including leaders, managers, policymakers, and central government. Government and public service reforms that focus on cross-sector collaboration and devolution of power will support trauma-informed practices. Stable, long-term funding and planning will help create a motivated, skilled workforce that can build on existing good practice.

In England, the national Government was responsible for balancing the risks of COVID-19 infection, transmission and illness against the known risks of school closures. The Department for Education (DfE) issued guidance to schools, however, there is limited empirical evidence on the experiences of staff and pupils affected by the guidance and accompanying COVID-19 mitigation measures. This qualitative study explored secondary school staff and pupils’ views and experiences of COVID-19 guidance and mitigation measures. There were two main objectives: (i) to examine implementation effectiveness, and (ii) to explore their effectiveness at promoting safety. Participants were purposively sampled from English schools serving diverse communities participating in the CoMMinS (COVID-19 Mapping and Mitigation in Schools) study. Semi-structured interviews were conducted remotely, and data were analysed thematically. Interviews took place between January and August 2021 with participants from five secondary schools (20 staff and 25 pupils); staff represented a range of roles within the school and pupil demographics varied. Main themes were: (i) negative views of the DfE guidance; (ii) negative experiences of the DfE guidance; (iii) ineffectiveness of the DfE guidance and school mitigation measures at promoting safety and reducing risk; (iv) ineffective implementation of the mitigation measures due to poor adherence and acceptability (with sub-themes for Lateral Flow Testing (LFT), face coverings, physical distancing and ventilation); and (v) positive perceptions (with sub-themes for hygiene measures, and approaches that facilitated implementation and safety which included staff enforcing compliance, having an ethos of co-operation, addressing inconsistencies, and minimising change). Insights from this research will help understand effectiveness of the measures in the ‘real-world school setting’. Understanding the experiences of staff and pupils will help to support policymakers and school leaders in future pandemic decision-making. This research identified challenges with the guidance and measures, minimal impact on perceived safety, and a negative impact on wellbeing. These challenges should be considered when assessing the benefit of the measures in keeping schools safe.

Social prescribing link workers are recently introduced roles in English primary care. One of their intended functions is to support patients with conditions influenced by the wider, social determinants of health. Their main purpose is to connect people to community resources to meet their nonmedical needs. However, our research reveals that link workers provide not only connections but also what we have described as "holding" for individuals with complex needs, who lack informal networks of support or who are waiting to access services. We explore the concept of holding, its meaning and significance in this context, and consider its consequences. As part of a realist evaluation, we observed seven link workers in GP practices in England during focussed ethnographies over a 3-week period. We took field notes and interviewed 61 patients and 93 healthcare and voluntary sector professionals. Nine to twelve months later, we carried out follow-up interviews with forty-one patients, seven link workers, and a link worker manager. We identified four functions of holding: supporting patients waiting for services, sustaining patients as they prepare for change, reducing the emotional burden of primary healthcare professionals, and bearing witness to patients' distress. Holding appears to be a vital but often overlooked aspect of social prescribing. Patients benefit from having a reliable and consistent person to support their emotional needs. However, similar to the impact of holding on other primary care professionals, there are unintended consequences: some link workers exceed their capacity, become overburdened, experience burnout, and leave their job. Recognizing the importance of holding and understanding its role in link workers' primary care responsibilities are critical. If holding work is accepted as a role for link workers, providing training and support to them should be prioritised to ensure successful implementation and positive outcomes for patients, link workers, and primary healthcare staff.

The National Institute of Health and Care Research (NIHR), funds, enables and delivers world-leading health and social care research to improve people’s health and wellbeing. To achieve this aim, effective knowledge sharing (two-way knowledge sharing between researchers and stakeholders to create new knowledge and enable change in policy and practice) is needed. To date, it is not known which knowledge sharing techniques and approaches are used or how effective these are in creating new knowledge that can lead to changes in policy and practice in NIHR funded studies. In this restricted systematic review, electronic databases [MEDLINE, The Health Management Information Consortium (including the Department of Health’s Library and Information Services and King’s Fund Information and Library Services)] were searched for published NIHR funded studies that described knowledge sharing between researchers and other stakeholders. One researcher performed title and abstract, full paper screening and quality assessment (Critical Appraisal Skills Programme qualitative checklist) with a 20

Background:Social prescribing link workers have become part of primary health care in recent years. They help patients to recognise non-medical factors affecting their health and identify sources of support, often in the voluntary, community and social enterprise sector. They form part of wider work to strengthen person-centred care, which actively seeks to engage individuals in decision-making about their health, taking into account their medical, social, psychological, financial and spiritual circumstances. Objective:To understand how buy-in to social prescribing and the link worker role is established for a patient, and how this relates to person-centred care. Design:A realist evaluation. Setting:Patients engaging with link workers in seven different parts of England were involved. Methods:As part of data collection, we observed link workers interacting with 35 patients. We also interviewed 61 patients and re-interviewed 41 of them 9-12 months later. Data were coded and developed into context-mechanism-outcome configurations, which were used to produce a programme theory. Results:Data highlighted how patients might be uncertain about the link worker role but agree to a referral as they sought assistance with their non-medical issues. Patients talked about experiencing a sense of hope through the trust they developed in a link worker. This trust was established through the communication skills and knowledge demonstrated by a link worker, and by their ability to act as an anchor point when required - a reliable, consistent source of support to whom patients could offload. The link worker role also involved connecting patients to external support, which called for sensitivity around how ready someone was to move forward; this was shaped by a patient's motivation but also their capacity to make changes given other demands in their life. Connecting patients to external support could be affected by structural factors outside the link workers' control (e.g. housing options or employment opportunities). Limitations:We did not interview patients who had rejected the offer of social prescribing, and most had a positive view of meeting with a link worker. Conclusions:Person-centred care is engendered by link workers through their skills, knowledge and ability to respond to the individual readiness of patients to engage with external support. It can be curtailed by structural factors outside link workers' sphere of control, such as access to housing or caring responsibilities of patients. This can hinder patients' ability to 'connect to', leaving link workers to continue 'connecting with' patients as they act as an anchor point. Future work:Exploration is required of factors affecting patients who interact with a link worker but do not access external support. Longitudinal work with a cohort of patients, speaking to them on a regular basis, may provide further understanding in this respect. Funding:This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR130247.

Background The administration of magnesium sulphate (MgSO4) in preterm labour is an evidence-based intervention recommended by the United Kingdom’s National Institute for Health and Care Excellence (NICE) to prevent neurological damage to the infant. However, uptake varies across UK maternity units. We used findings from implementation research in England, Scotland and Wales to explore knowledge mobilisation as a mechanism for improving adherence to clinical guidance. Methods Data were collected using semi-structured interviews for a process evaluation of the PReCePT (Preventing Cerebral Palsy in Pre-Term Labour) National Programme, the PReCePT cRCT study, and a study investigating MgSO4 guidance implementation in Scotland and Wales. Normalisation Process Theory informed data collection and analysis. Data were analysed using the framework method. Results Interviews with 68 strategic and clinical leads and implementers from the three nations suggested that despite evidence being necessary and important for policy decision-making, clinical leadership intervention decisions were motivated by audit data and benchmarking. Implementation success was impaired by degrees of silo working and rigid role boundaries, alongside differences in implementers’ ability to mobilise social-cognitive (e.g. commitment by maternity, neonatal and obstetric teams), and social-structural resources such as staff capacity, articulated workflows, and culture. Cross-organisational, diverse and collaborative communities of practice (CoPs) rooted in distributed leadership created a nexus between national and regional leadership, patient group representatives, implementers i.e. clinical leads and champions, and perinatal clinical teams. They provided a platform for CoP participants to build relationships and share knowledge, and together negotiate meaning, co-design implementation plans, share operational enablers such as strategies and products, and assess progress. Where training opportunities were provided alongside mentoring and peer support, CoPs created implementation resource i.e. capacity and capability within the perinatal system. Backfill funding for champions and protected time away from clinical duties were required to enable participation, especially for champions in resource-poor settings. Conclusions Opportunities to participate in collaborative, diverse, cross-organisational CoPs where knowledge and innovation can be co-created, shared, and spread across the perinatal ecosystem, can help address disparities in clinical teams’ ability to implement evidence-based interventions. Participation relies on backfill funding for champions, and a system-wide commitment to improvement.

Background Disciplinary behaviour management strategies are implemented in schools to manage pupil behaviour. There is limited evidence of their intended impact on behaviour but there is growing concern around the potential negative impacts on pupil wellbeing. Methods We carried out a systematic review to examine the impact of these strategies on psychosocial outcomes in pupils (PROSPERO Registration: CRD42021285427). We searched multiple sources and double-screened titles, abstracts, and full texts. Data extraction and risk of bias assessment were done by one reviewer and checked by another. Results were narratively synthesised. Results We included 14 studies, from 5375 citations, assessing temporary suspension (n=10), verbal reprimand (n=2), and mixed strategies (n=2). Depression was the most common outcome (n=7), followed by academic grades (n=4) and behaviour in class (n=4). All except one study were at high risk of bias. We found a recurring pattern in the evidence of disciplinary strategies associated with poor mental wellbeing and behaviour in pupils. The effect on academic attainment was unclear. Conclusions Disciplinary behaviour management strategies may have negative impact on pupil mental wellbeing and class behaviour. These important consequences should be assessed in better designed studies before these strategies are implemented.

Executive Summary: This study set out to evaluate the longer term sustainability, effectiveness, and cost effectiveness of the National PReCePT Programme (NPP) in England, and explore trends and MgSO4 guidance implementation practices in the devolved nations, Scotland and Wales. We found that the majority of improvement in MgSO4 use seemed to take place in the first year or two following the NPP. Benefits were largely sustained over the 4 years of follow-up, with an overall appearance of plateau in recent years. There was some indication of a slight declining trend in use coinciding with the COVID-19 pandemic, that continued to the end of 2022 (the end of the currently available data). Regional disparities in use of MgSO4 reduced since the NPP was launched. We estimated that the NPP was associated with around 597,000 GBP net monetary benefit (NMB) from a lifetime societal perspective, with an 89% probability of being cost-effective for babies with less than 30 weeks gestation. This NMB increased to 4.2M GBP when including babies up to 32 weeks gestation. By 2022, MgSO4 use in Wales had caught up with levels in England, with levels in Scotland not far behind. The NMB of implementing MgSO4 for babies up to 32 weeks gestation in the three nations has increased over time, generating approximately 125M GBP in England, 8M GPB in Scotland and 5M GBP in Wales in 2022. Consequently, the benefit forgone for not achieving optimal MgSO4 uptake has also reduced over time, although there remains considerable scope for improving performance in each nation. The improvements in implementing MgSO4 have generated health gains and cost savings associated with CP prevention. Investing additional resources in implementing MgSO4 further would be likely to be cost-effective in all three nations. Our analysis highlighted how devolved nation activities were (directly or indirectly) shaped by PReCePT methodology. Qualitative interviews with clinical leads involved in implementing MgSO4 in Scotland and Wales, where the NPP was not implemented, shed light on the separate but similar initiatives implemented there, explaining the increasing trends also observed in the devolved nations (e.g. the Maternity and Children Quality Improvement Collaborative (MCQIC) Preterm Perinatal Wellbeing Package (PPWP) in Scotland, improvement interventions mirroring PERIPrem in Wales, and British Association for Perinatal Medicine Toolkits in both nations). Challenges and enablers were linked to perinatal team relationships; local leadership with protected time and funding; access to national performance data; staff clarity and confidence on guidance and administration of treatment; opportunities for and commitment to co-creating meaning around the intervention; skills, competencies and resources available to adopters; and engagement in continuous improvement activities (e.g. audit and feedback, benchmarking and missed case reviews). Findings reiterate the need for local champions with backfill funding and protected time, and regional and national capacity building and support structures. These reflect findings from the corresponding interviews with English teams. The essential next step in this quality improvement journey is to better quantify, in this same population, the health and societal benefits associated with cases of cerebral palsy prevented from the improvements achieved in use of MgSO4. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study was jointly funded by The Health Foundation (funders reference 557668), the National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West, core NIHR infrastructure funded: NIHR200181), and Health Innovation West of England (formerly the West of England Academic Health Science Network). The views expressed are those of the authors and not necessarily those of NHS England, NHS Improvement, the NIHR or the Department of Health and Social Care. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The PReCePT Programme Evaluation was granted a favourable ethical opinion by the UK National Health Service Health Research Authority (HRA project ID: 260504) and the University of Bristol Faculty of Health Sciences Research Ethics Committee (FREC Ref: 84582). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Anonymised individual-level data for this study are from the NNRD. Our data sharing agreement with the NNRD prohibits sharing data extracts outside of the University of Bristol research team.

Background:Social prescribing addresses non-medical factors affecting health and well-being. Link workers are key to its delivery by connecting people to relevant support, often in the voluntary, community and social enterprise sector. Funding from the National Health Service means that link workers are becoming a common part of primary care in England. Objective:To explore and understand the implementation of link workers in primary care in England. Design:A realist evaluation addressed the question - When implementing link workers in primary care to sustain outcomes - what works, for whom, why and in what circumstances? Setting:Link workers and staff associated with seven primary care sites across England. Methods:Researchers spent 3 weeks with each link worker, going to meetings with them, watching them interact with patients, with healthcare staff and with voluntary, community and social enterprise organisations. In addition, interviews were conducted with 61 patients and 93 professionals (voluntary, community and social enterprise representatives and healthcare staff, including link workers). Follow-up interviews were conducted with 41 patients and with link workers 9-12 months later. Data were coded and developed into statements to identify how context around the link worker triggers mechanisms that lead to intended and unintended outcomes. Results:We found that link workers exercise micro-discretions in their role - actions and advice-giving based on personal judgement of a situation, which may not always reflect explicit guidance or protocols. Our analysis highlighted that micro-discretions engender positive connections (with patients, healthcare staff, the voluntary, community and social enterprise sector) and promote buy-in to the link worker role in primary care. Micro-discretions supported delivery of person-centred care and enhanced job satisfaction. Data also highlighted that lack of boundaries could place link workers at risk of overstepping their remit. Limitations:Our research focused on link workers attached to primary care; findings may not be applicable to those working in other settings. Data were collected around seven link worker cases, who were selected purposively for variation in terms of geographical spread and how/by whom link workers were employed. However, these link workers were predominately white females. Conclusions:Enabling link workers to exercise micro-discretions allows for responsiveness to individual patient needs but can result in uncertainty and to link workers feeling overstretched. Future work:Poor link worker retention may, in part, be associated with a lack of clarity around their role. Research to explore how this shapes intention to leave their job is being conducted by authors of this paper. Funding:This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR130247.

Background: Advance care planning can improve patient and family outcomes; however, minoritised ethnic communities experience access barriers. Co-production offers a way to design culturally appropriate information and support, but evidence is needed to understand its implementation in palliative care.Aim: To explore and describe how two charities used co-production to develop and deliver community-based advance care planning workshops for South Asian elders.Design: Workshops were co-produced by two charities. In parallel, a multi-component qualitative study was conducted comprising workshop observations, semi-structured interviews with charity staff and focus groups with workshop participants, facilitated by community co-researchers in English, Hindi, Urdu and Punjabi. Data were analysed using thematic analysis.Setting/participants: Four workshops were held in a London (UK) community setting (each with 5-30 participants); four interviews were conducted with charity staff members, and three focus groups with 16 workshop participants.Results: We describe three main themes: Co-production in action: organic origins and trusted foundations; Co-production processes embedded in equal partnership; and Impact of the workshops. Fundamental to co-production processes was the community-led approach of the local charity, the trust of the local South Asian community and the relationship between the charities, including transparent communication and mutual respect. The workshops were reported to be useful and enjoyable, engendering a sense of agency and connection and helped disseminate awareness and knowledge through the community, benefitting the wider system.Conclusions: Co-production can help widen access to advance care planning. Findings offer an in-depth example of co-production-in-action to inform intervention development and research.