OBJECTIVES:This study aimed to evaluate the impact of a social prescribing intervention (the Central Locality Integrated Care Service (CLICS)) on unplanned hospital usage in the city of Bradford. DESIGN:A quasi-experimental study applying a dynamic staggered difference-in-differences (DID) analysis on a propensity matched cohort between 2019 and 2023, using data from the Connected Bradford dataset, a pseudonymised linked health dataset on the whole Bradford population. SETTING:CLICS was delivered within general practices in deprived and ethnically diverse inner-city areas of Bradford, Yorkshire, UK. PARTICIPANTS:In total, 1304 CLICS patients were matched to 5216 control patients on key characteristics including ethnicity, deprivation, age, gender and health conditions. INTERVENTIONS:A proactive social prescribing intervention that integrates clinical and non-clinical services, including an individualised approach to tailor support based on the patient's needs, both within primary care services and by linking them to appropriate community-based assets/services. PRIMARY AND SECONDARY OUTCOME MEASURES:The primary outcome was the rate of unplanned hospital admissions and the secondary outcome was unplanned accident and emergency (A&E) attendances. RESULTS:CLICS patients were 2.1% (95% CI -3.8% to -0.4%, p=0.013) less likely to have an unplanned hospital admission and 2.4% (95% CI -4.6% to -0.2%, p=0.03) less likely to have an unplanned A&E attendance compared with the matched control. The DID analysis demonstrated a gradual increase in the association over time. Subanalyses revealed heterogeneity by ethnicity, the reduction in unplanned hospital admissions was observed only in patients of the Pakistani group, whereas the reduction in A&E attendances was statistically significant only in the white British group. CONCLUSION:The CLICS intervention was associated with a reduction in unplanned hospital usage. Social prescribing may be a valuable component of strategies to reduce health inequalities in unplanned hospital usage.

Background: Delirium is common and distressing for hospice in-patients. Hospital-based research shows delirium may be prevented by targeting its risk factors. Many preventative strategies address patients’ fundamental care needs. However, there is little research regarding how interventions need to be tailored to the in-patient hospice setting. Aim: To explore the behaviours of hospice in-patient staff in relation to delirium prevention, and the influences that shape these behaviours. Design: Focused ethnography supported by behaviour change theory. Observation, semi-structured interviews and document review were conducted. Setting/participants: A total of 89 participants (multidisciplinary staff, volunteers, patients and relatives) at two UK in-patient hospice units. Results: Hospice clinicians engaged in many behaviours associated with prevention of delirium as part of person-centred fundamental care, without delirium prevention as an explicit aim. Carrying out essential care tasks was highly valued and supported by adequate staffing levels, multidisciplinary team engagement and role clarity. Patients’ reduced physical capability limited some delirium prevention behaviours, as did clinicians’ behavioural norms related to prioritising patient comfort. Delirium prevention was not embedded into routine assessment and care decision-making, despite its potential to reduce patient distress. Conclusions: The value placed on fundamental care in hospices supports delirium prevention behaviours but these require adaptation as patients become closer to death. There is a need to increase clinicians’ understanding of the potential for delirium prevention to reduce patient distress during illness progression; to support inclusion of delirium prevention in making decisions about care; and to embed routine review of delirium risk factors in practice.

Unplanned hospital admissions are costly and disproportionately affect people who are socioeconomically disadvantaged and from an ethnic minority group. A national primary care pay-for-performance scheme, the Quality and Outcomes Framework (QOF), was introduced in England in 2004 to financially incentivise general practices to meet a range of performance indicators, but the QOF’s impact on unplanned hospital admissions remains unclear. We examined the association between unplanned hospital admissions for cardiovascular disease (CVD), individual-level characteristics and achievement of key QOF indicators for CVD at the patients’ registered general practice. This study used the Connected Bradford dataset, which links individual-level primary and secondary care data. Our analytical sample included 508,977 patients registered with a Bradford District general practice from 2017 to 2019. Logistic regression was used to estimate associations between achievement of relevant QOF indicators and unplanned admissions for cardiovascular diseases, adjusting for individual-level differences in age, sex, ethnicity, socioeconomic status and pre-existing health conditions. Significantly reduced odds of unplanned CVD hospital admissions were associated with attending a practice with higher achievement rates for QOF indicators relating to atrial fibrillation management (OR 0.97, p < 0.001), diabetes management (OR 0.98, p = 0.002), and smoking cessation (OR 0.98, p = 0.038). Conversely, increased odds of unplanned admission were associated with higher achievement for QOF indicators relating to antiplatelet or anticoagulation medication (OR 1.06, p < 0.001) and blood pressure control for diabetic patients (OR 1.02, p = 0.03). Individual-level characteristics significantly associated with increased risk of unplanned admission included living in the most deprived fifth of neighbourhoods (OR 2.00, p < 0.001) and having Pakistani ethnicity (OR 1.65, p < 0.001). Primary care diagnoses of hypertension (OR 1.79, p < 0.001), diabetes (OR 1.56, p < 0.001), chronic cardiac disease (OR 2.79, p < 0.001), and stroke (OR 1.6, p < 0.001) were all statistically significant and associated with higher odds of unplanned admissions for CVD. We found mixed evidence for an association between practice-level QOF achievement and unplanned hospital admissions for CVD. There were large ethnic and socioeconomic inequalities in unplanned admissions for cardiovascular disease. Supporting general practices to appropriately improve their achievement of key cardiovascular disease related QOF indicators and reducing socioeconomic inequalities might likely reduce the number of unplanned hospital admissions.

Establishing Research Ecosystems in Local Government: Ten lessons from the front line of the first year of the NIHR Health Determinants Research Collaborations (HDRCs). Newbury-Birch D1, Harbin, K2. Adamson A3, Asthana S4, Batey C5, Buffardi A6, Curley J7, Dezateux C8, Divers A1, Fitzsimmons E9, Forbes L10, Frossell S11, Goyder E12, Hampshaw S13, Humphreys E14, O'Malley E15, Maiden H16, Marks D17, Murchie M18, Paranjothy S19,20, Ramsay SE3, Sheldon T8, Shore R21, Simpson A16,22, Speight A16, Wallace G9, Whelan M23, Whiting D10,24, Woolfe I25,26, Ferguson B27. On behalf of the 13 NIHR PHR Health Determinants Research Collaborations funded in 2022/2023. 1. School of Social Sciences, Humanities and Law, Teesside University (HDRC South Tees) 2. HDRC South Tees, Middlesbrough Council 3. Population Health Sciences Institute, Newcastle University (HDRC Gateshead and HDRC Newcastle) 4. Centre for Health Technology, University of Plymouth (HDRC Plymouth) 5. HDRC Newcastle, Newcastle City Council 6. HDRC Islington, Public Health Department, London Borough of Islington 7. HDRC Lambeth, Public Health, London Borough of Lambeth 8. Wolfson Institute of Population Health, Queen Mary University of London (HDRC Tower Hamlets) 9. HDRC Plymouth, Plymouth City Council 10. Centre for Health Services Studies, University of Kent (HDRC Medway) 11. HDRC Coventry, People Directorate, Coventry City Council 12. Sheffield Centre for Health and Related Research, Division of Population Health, University of Sheffield (HDRC Doncaster) 13. HDRC Doncaster, City of Doncaster Council 14. HDRC Tower Hamlets, Health & Adult Social Care Directorate, London Borough of Tower Hamlets 15. HDRC Gateshead, Public Health & Wellbeing, Gateshead Council 16. HDRC Blackpool, Blackpool Council 17. Department of Public Health, Environments & Society, London School of Hygiene and Tropical Medicine (HDRC Islington) 18. HDRC Aberdeen, Aberdeen City Council 19. NHS Grampian (HDRC Aberdeen) 20. Institute of Applied Health Sciences, University of Aberdeen (HDRC Aberdeen) 21. HDRC Bradford, City of Bradford Metropolitan District Council 22. Lancaster University (HDRC Blackpool) 23. Coventry University (HDRC Coventry) 24. HDRC Medway, Public Health, Medway Council 25. Department of Women's and Children's Health, King's College London (HDRC Lambeth) 26. Evelina London Children's Hospital (HDRC Lambeth) 27. Department of Health Sciences, University of York Health inequalities are where we see differences in health across the population, and between different groups in society, that are systematic, unfair and avoidable (1). They need a long-term systemic response to support people to value their health and wellbeing (2). These social, economic environmental, cultural and commercial factors, known as the wider determinants of health, are unequally distributed across the UK population (3). This is despite numerous attempts to address them at a local, national and internationally (4, 5). Both the Marmot review and the Dame Carol Black review highlighted the huge economic costs of failing to act on the wider determinants of health (4-6). Local public health leaders are in a strong position to develop a whole system approach to reducing health inequalities that puts communities at its heart (10). Thirteen Local Authorities (LAs) were awarded funding by the National Institute for Health and Care Research (NIHR) in October 2022 to develop HDRCs. Ten of them as full HDRCs (HDRC Tower Hamlets, HDRC Newcastle, HDRC Doncaster, HDRC Aberdeen, HDRC Bradford, HDRC Plymouth, HDRC Gateshead, HDRC Blackpool, HDRC Coventry and HDRC Lambeth). Three were given a further year to develop their plans and became full HDRCs in October 2023 (HDRC South Tees, HDRC Medway, HDRC Islington). Eleven more full HDRCs were announced in December 2023 and are due to start January 2024 (HDRC Ealing, HDRC Sandwell, HDRC Wakefield, HDRC Southampton, HDRC Rhondda Cynon Taf, HDRC Liverpool, HDRC Somerset, HDRC Cumberland, HDRC Cornwall, HDRC Essex, HDRC North Yorkshire). As in round one there were a number of areas given a year to develop their work further (HDRC Manchester, HDRC Portsmouth, HDRC Torfaen, HDRC Leicestershire, HDRC Glasgow, HDRC Surrey) (11). The aim of the HDRCs is to embed a culture of evidence-based decision-making within Local Government. The HDRCs will help to stimulate economic growth, particularly in some of the most deprived areas of the country and contribute to the Government's plans to act for the longer-term resilience of the health and wealth of the country (12). This article examines the key learning from the first year of the wave one HDRCs and give advice to new HDRCs starting their journeys in 2024. Between April and October 2023, the lead author asked for at least one person from each of the LAs and one academic/other partner involved in HDRCs to complete a small survey with open ended questions which took about ten-minutes to complete. The survey was conducted using Jisc online surveys. Data was downloaded and open-ended questions were coded by DNB and KH. All data was downloaded and analysed using an inductive approach (13). Twenty-seven people responded with representation from all the 13 HDRCs. Below we identify ten key things to consider when starting the journey. Recruit to posts early Recruitment was a colossal problem for both LAs and universities. Bureaucratic hold ups and slow HR processes hindering progress were apparent as well as issues recruiting staff with the right skills, appropriate expertise and at the right time. The precarious financial climate of Local Government also needed to be navigated with care, with jobs being created for the HDRCs against job losses elsewhere. "£5 million funding creating 10+ new jobs has arrived against the backdrop of recent job cuts. We have to be cognisant of this. Developing relationships with teams within the council with similar objectives to HDRC, against the backdrop of funding pressures and job insecurity" (LA) Think about capacity Capacity proved to be significantly stretched during the first year. Academic colleagues reported working well beyond their intended HDRC costed time to counterbalance the time constraints felt by LAs in recruiting staff. These pressures saw a slowing of momentum, research culture change, relationship building and "buy in". "We found that the extent to which LA Finance and HR systems struggle to accept and contract out funding, difficulties in back filling people's time" (LA) Consider priorities The main thing is to expect a slow start and don't underestimate the size of the task at hand. Treat recruitment as a priority and think about job descriptions straight away. Build a cohesive team with strong leadership whose sole focus is on the HDRC, helping to get through the early legal and bureaucratic hassles. Take time to get to know key staff across all sectors and the community, utilising and nurturing relationships. Leadership is vital Ensure that you have good leadership at both the LA and University. Project management is essential. "Appoint a competent project manager to help get through legal and bureaucratic hassles; give researchers time to bed in and understand cultures of both LA and University" (University) Create a plan Create a clear plan, giving individuals time to bed in and understand the diverse cultures of both LAs and Universities. Use the plan to quickly establish priority areas, costing LA and academic staff appropriately. Fully think through each milestone and any potential barriers ensuring to collect baseline data as soon as objectives are set and have robust monitoring processes throughout. But be prepared for fast-paced learning and a constant change of the plan. Be flexible and change your bid/plan as needed. Don't underestimate the size of the job to align organisations Aligning the needs and motivations of the HDRC within LAs was shown to be a delicate process. Managing expectations was a major task for the first year. Being realistic with timelines whilst also harnessing the motivation and excitement to get going. "We use the analogy of doing the groundwork on a building site - there is a lot happening that nobody can see at the moment, but soon there will be something that staff, residents and local academics can really see and engage with" (LA) Culture Change Changing the research culture within LAs was seen to be paramount to the success of HDRCs. It is important to understand current approaches in the LAs. Getting some 'early wins' in terms of research funding is a good thing for staff to see what success looks like and means. It is important to identify "champions" within the LAs to help champion the work. "It has reinforced my knowledge and the organisational and professional gap between LA officers and researchers, different ways of working and thinking. But I am learning to tackle this" (University) It's not a competition Some HDRCs are ahead of others in some things and behind in others. Keep to your project plan and enjoy successes whether they are big or small. "Recognise there is a start-up period and manage expectations" (LA) Community involvement is everything Ensure that you work with your community partners and that they are part of the team from as early as possible. "Recruitment of Co-Researchers with lived experience to the project should be the very first thing you do. Think very strongly about how you will make the community members feel valued for their contribution to the project" (LA) Support is imperative Finally, HDRCs found having other HDRCS to get support from was extremely valuable "It is a new and challenging concept and way of working for many of us - the peer support has been invaluable". NIHR have also been supportive and flexible in a number of ways which has been helpful" (University) This study/project is funded by the NIHR PHR, Health Determinants Research Collaborations. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. References 1. NICE. NICE and health inequalities London [Available from: https://www.nice.org.uk/about/what-we-do/nice-and-health-inequalities. 2. Director of Public Health. Live Well South Tees. Redcar and Cleveland: Public Health South Tees; 2018. 3. Such E. Framing the wider determinants of health and health inequalities: local stakeholder views in England. Evidence & Policy. 2023;19(4):513-35. 4. Marmot M, Allen J, Boyce T, Goldblatt P, Morrison J. Health Equity in England: The Marmot review 10 years on. London: Institute of Health Equity; 2020. 5. Marmot M. Fair Society, Health Lives: Strategic Review of Health Inequalities in England Post-2010. London: The Marmot Review; 2010. 6. Black C. Working for a Healthier Tomorrow: Dame Carol Black's Review of the health of Britain's working age population. London: TSO; 2008. 7. Michie S, Fixsen D, Grimshaw J, Eccles M. Specifying and reporting complex behaviour change interventions: the need for a scientific method. Implementation Science. 2009;4(1):40. 8. Glasgow RE, Lichtenstein E, Marcus AC. Why don't we see more translation of health promotion research to practice? Rethinking the efficacy-to-effectiveness transition. AJPH. 2003;93(8):1261-7. 9. Ferrer RL. Social Determinants of Health. In: Daaleman TP, Helton MR, editors. Chronic Illness Care: Principles and Practice. Cham: Springer International Publishing; 2023. p. 527-45. 10. Stansfield J, South J, Mapplethorpe T. What are the elements of a whole system approach to community-centred public health? A qualitative study with public health leaders in England's local authority areas. BMJ Open. 2020;10(8):e036044. 11. National Institute for Health and Care Research. NIHR invests a further £55m to tackle health inequalities through local government research: NIHR; 2023 [Available from: www.nihr.ac.uk/news/nihr-invests-a-further-55m-to-tackle-health-inequalities-through-local-government-research/34972. 12. National Institute for Health and Care Research. £50 million awarded to local government to tackle interventions for health inequalities through research 2022 [Available from: https://www.nihr.ac.uk/news/50-million-awarded-to-local-government-to-tackle-interventions-for-health-inequalities-through-research/31654 13. Azungah T. Qualitative research: deductive and inductive approaches to data analysis. Qualitative Research Journal. 2018;18(4):383-400.

BACKGROUND:Delirium is a distressing condition often experienced by hospice in-patients. Increased understanding of current multidisciplinary care of delirium is needed to develop interventions in this setting. AIM(S):To explore hospice staff and volunteers' practice, its influences and what may need to change to improve hospice delirium care. DESIGN:Qualitative interview study using behaviour change theory from a critical realist stance. SETTING/PARTICIPANTS:Thirty-seven staff, including different professional groups and roles, and volunteers were purposively sampled from two in-patient hospices. RESULTS:We found that participants' practice focus was on managing hyperactive symptoms of delirium, through medication use and non-pharmacological strategies. Delirium prevention, early recognition and hypoactive delirium received less attention. Our theoretically-informed analysis identified this focus was influenced by staff and volunteers' emotional responses to the distress associated with hyperactive symptoms of delirium as well as understanding of delirium prevention, recognition and care, which varied between staff groups. Non-pharmacological delirium management was supported by adequate staffing levels, supportive team working and a culture of person-centred and family-centred care, although behaviours that disrupted the calm hospice environment challenged this. CONCLUSIONS:Our findings can inform hospice-tailored behaviour change interventions that develop a shared team understanding and engage staff's emotional responses to improve delirium care. Reflective learning opportunities are needed that increase understanding of the potential to reduce patient distress through prevention and early recognition of delirium, as well as person-centred management. Organisational support for adequate, flexible staffing levels and supportive team working is required to support person-centred delirium care.

INTRODUCTION:Living in an area with high levels of child poverty predisposes children to poorer mental and physical health. ActEarly is a 5-year research programme that comprises a large number of interventions (>20) with citizen science and co-production embedded. It aims to improve the health and well-being of children and families living in two areas of the UK with high levels of deprivation; Bradford in West Yorkshire, and the London Borough of Tower Hamlets. This protocol outlines the meta-evaluation (an evaluation of evaluations) of the ActEarly programme from a systems perspective, where individual interventions are viewed as events in the wider policy system across the two geographical areas. It includes investigating the programme's impact on early life health and well-being outcomes, interdisciplinary prevention research collaboration and capacity building, and local and national decision making. METHODS:The ActEarly meta-evaluation will follow and adapt the five iterative stages of the 'Evaluation of Programmes in Complex Adaptive Systems' (ENCOMPASS) framework for evaluation of public health programmes in complex adaptive systems. Theory-based and mixed-methods approaches will be used to investigate the fidelity of the ActEarly research programme, and whether, why and how ActEarly contributes to changes in the policy system, and whether alternative explanations can be ruled out. Ripple effects and systems mapping will be used to explore the relationships between interventions and their outcomes, and the degree to which the ActEarly programme encouraged interdisciplinary and prevention research collaboration as intended. A computer simulation model ("LifeSim") will also be used to evaluate the scale of the potential long-term benefits of cross-sectoral action to tackle the financial, educational and health disadvantages faced by children in Bradford and Tower Hamlets. Together, these approaches will be used to evaluate ActEarly's dynamic programme outputs at different system levels and measure the programme's system changes on early life health and well-being. DISCUSSION:This meta-evaluation protocol presents our plans for using and adapting the ENCOMPASS framework to evaluate the system-wide impact of the early life health and well-being programme, ActEarly. Due to the collaborative and non-linear nature of the work, we reserve the option to change and query some of our evaluation choices based on the feedback we receive from stakeholders to ensure that our evaluation remains relevant and fit for purpose.

Objectives To explore clinically important increases in depression/anxiety from before to during the first UK COVID-19 lockdown and factors related to this change, with a particular focus on ethnic differences. Design Pre-COVID-19 and lockdown surveys nested within two longitudinal Born in Bradford cohort studies. Participants 1860 mothers with a child aged 0–5 or 9–13, 48% Pakistani heritage. Main outcome measures ORs for a clinically important increase (5 points or more) in depression (eight item Patient Health Questionnaire (PHQ-8)) and anxiety (Generalised Anxiety Disorder Assessment (GAD-7)) in unadjusted regression analyses, repeated with exposures of interest separated by ethnicity to look for differences in magnitude of associations, and lived experience of mothers captured in open text questions. Results The number of women reporting clinically important depression/anxiety increased from 11% to 20% (95% CI 10%–13%; 18%–22%) and from 10% to 16% (95% CI 8%–11%; 15%–18%), respectively. Increases in depression/anxiety were associated with loneliness (OR=8.37, 95% CI 5.70 to 12.27; 8.50, 95% CI 5.71 to 12.65, respectively); financial (6.23, 95% CI 3.96 to 9.80; 6.03, 95% CI 3.82 to 9.51), food (3.33, 95% CI 2.09 to 5.28; 3.46, 95% CI 2.15 to 5.58) and housing insecurity (3.29, 95% CI 2.36 to 4.58; 3.0, 95% CI 2.11 to 4.25); a lack of physical activity (3.13, 95% CI 2.15 to 4.56; 2.55, 95% CI 1.72 to 3.78); and a poor partner relationship (3.6, 95% CI 2.44 to 5.43; 5.1, 95% CI 3.37 to 7.62). The magnitude of associations between key exposures and worsening mental health varied between ethnic groups. Responses to open text questions illustrated a complex interplay of challenges contributing to mental ill health including: acute health anxieties; the mental load of managing multiple responsibilities; loss of social support and coping strategies; pressures of financial and employment insecurity; and being unable to switch off from the pandemic. Conclusions Mental ill health has worsened for many during the COVID-19 lockdown, particularly in those who are lonely and economically insecure. The magnitude of associations between key exposures and worsening mental health varied between ethnic groups. Mental health problems may have longer term consequences for public health and interventions that address the potential causes are needed.

Background: Socio-economic, cultural and environmental conditions strongly affect health across the life course. Local government plays a key role in influencing these wider determinants of health and levels of inequality within their communities. However, they lack the research infrastructure and culture that would enable them to develop an evidence-based approach to tackling the complex drivers of those conditions. Methods: We undertook a scoping project using some research methods and some descriptive summaries to explore the potential for, and what would be needed to develop a local authority research system for the City of Bradford, UK. This included identifying the current research landscape and any barriers and enablers to research activity within the local authority using qualitative individual and focus group interviews, a rapid review of existing local research system models, scoping and description of the use of evidence in decision making and training opportunities and existing support for local government research. Results: We identified four key themes important to developing and sustaining a research system: leadership, resource and capacity, culture, partnerships. Some use of research in decision making was evident but research training opportunities within the local authority were limited. Health research funders are slowly adapting to the local government environment, but this remains limited and more work is needed to shift the centre of gravity towards public health, local government and the community more generally. Conclusions: We propose a model for a local authority research system that can guide the development of an exemplar whole system research framework that includes research infrastructure, data sharing, research training and skills, and co-production with local partners, to choose, use, generate, and deliver research in local government.

The richness of linked population data provides exciting opportunities to understand local health needs, identify and predict those in most need of support and evaluate health interventions. There has been extensive investment to unlock the potential of clinical data for health research in the UK. However, most of the determinants of our health are social, economic, education, environmental, housing, food systems and are influenced by local authorities. The Connected Bradford Whole System Data Linkage Accelerator was set up to link health, education, social care, environmental and other local government data to drive learning health systems, prevention and population health management. Data spanning a period of over forty years has been linked for 800,000 individuals using the pseudonymised NHS number and other data variables. This prospective data collection captures near real time activity. This paper describes the dataset and our Connected Bradford Whole System Data Accelerator Framework that covers public engagement; practitioner and policy integration; legal and ethical approvals; information governance; technicalities of data linkage; data curation and guardianship; data validity and visualisation.

We conducted a narrative systematic review to assess the health, social and financial impacts of co-located welfare services in the UK and to explore the effectiveness of and facilitators and barriers to successful implementation of these services, in order to guide future policy and practice. We searched Medline, EMBASE and other literature sources, from January 2010 to November 2020, for literature examining the impact of co-located welfare services in the UK on any outcome. The review identified 14 studies employing a range of study designs, including: one non-randomised controlled trial; one pilot randomised controlled trial; one before-and-after-study; three qualitative studies; and eight case studies. A theory of change model, developed a priori, was used as an analytical framework against which to map the evidence on how the services work, why and for whom. All studies demonstrated improved financial security for participants, generating an average of £27 of social, economic and environmental return per £1 invested. Some studies reported improved mental health for individuals accessing services. Several studies attributed subjective improvements in physical health to the service addressing key social determinants of health. Benefits to the health service were also demonstrated through reduced workload for healthcare professionals. Key components of a successful service included co-production during service development and ongoing enhanced multi-disciplinary collaboration. Overall, this review demonstrates improved financial security for participants and for the first time models the wider health and welfare benefits for participants and for health service from these services. However, given the generally poor scientific quality of the studies, care must be taken in drawing firm conclusions. There remains a need for more high quality research, using experimental methods and larger sample sizes, to further build upon this evidence base and to measure the strength of the proposed theoretical pathways in this area.

The richness of linked population data provides exciting opportunities to understand local health needs, identify and predict those in most need of support and evaluate health interventions. There has been extensive investment to unlock the potential of clinical data for health research in the UK. However, most of the determinants of our health are social, economic, education, environmental, housing, food systems and are influenced by local authorities. The Connected Bradford Whole System Data Linkage Accelerator was set up to link health, education, social care, environmental and other local government data to drive learning health systems, prevention and population health management. Data spanning a period of over forty years has been linked for 800,000 individuals using the pseudonymised NHS number and other data variables. This prospective data collection captures near real time activity. This paper describes the dataset and our Connected Bradford Whole System Data Accelerator Framework that covers public engagement; practitioner and policy integration; legal and ethical approvals; information governance; technicalities of data linkage; data curation and guardianship; data validity and visualisation.

In the CENTER-TBI core cohort, 30% of patients with TBI managed and discharged from the ED had persistent disability and a Glasgow Outcome Scale score of less than eight months following injury.3 However, initial CT findings in mTBI are not necessarily predictive of longer term disability and functional impairment following injury.4 5 Therefore, our study cohort of patients with mTBI with injuries identified on CT imaging may not be at higher risk of longer term functional impairment and need for rehabilitation than other patients with mTBI. The primary purpose of the risk assessment and selection of patients for CT imaging who have sustained head trauma in the ED is to identify potentially life-threatening injuries which may require neurosurgical intervention and admission to hospital due to the risk of deterioration.6 The aim of our work is to help clarify which injuries identified by CT imaging are in this category based on both patient characteristics and CT findings. [...]new biomarkers are welcome for both ‘indications for admission to hospital’ and ‘assessment for risk of post head injury symptoms’, which also are currently being reviewed by the National Institute for Health and Care Excellence Head Injury Guideline Update Committee.7 Although it is important that patients at risk of long-term sequelae from their injuries are identified and receive appropriate rehabilitation, it is currently difficult to identify such patients in the acute phase of their injury.8 Inpatient hospital admission has associated costs and risks, which have been exacerbated by the COVID-19 pandemic and current large increase in demand for urgent and emergency care services.

BACKGROUND:Delirium is common and distressing for patients receiving palliative care. Interventions targetting modifiable risk factors in other settings have been shown to prevent delirium. Research on delirium risk factors in palliative care can inform context-specific risk-reduction interventions.AIM:To investigate risk factors for the development of delirium in adult patients receiving specialist palliative care.DESIGN:Systematic review and meta-analysis (PROSPERO CRD42019157168).DATA SOURCES:CINAHL, Cochrane Database of Systematic Reviews, Embase, MEDLINE and PsycINFO (1980-2021) were searched for studies reporting the association of risk factors with delirium incidence/prevalence for patients receiving specialist palliative care. Study risk of bias and certainty of evidence for each risk factor were assessed.RESULTS:Of 28 included studies, 16 conducted only univariate analysis, 12 conducted multivariate analysis. The evidence for delirium risk factors was limited with low to very low certainty.POTENTIALLY MODIFIABLE RISK FACTORS:Opioids and lower performance status were positively associated with delirium, with some evidence also for dehydration, hypoxaemia, sleep disturbance, liver dysfunction and infection. Mixed, or very limited, evidence was found for some factors targetted in multicomponent prevention interventions: sensory impairments, mobility, catheter use, polypharmacy (single study), pain, constipation, nutrition (mixed evidence).NON-MODIFIABLE RISK FACTORS:Older age, male sex, primary brain cancer or brain metastases and lung cancer were positively associated with delirium.CONCLUSIONS:Findings may usefully inform interventions to reduce delirium risk but more high quality prospective cohort studies are required to enable greater certainty about associations of different risk factors with delirium during specialist palliative care.

Background There is international variation in hospital admission practices for patients with mild traumatic brain injury (TBI) and injuries on CT scan. Only a small proportion of patients require neurosurgical intervention, while many guidelines recommend routine admission of all patients. We aim to validate the Hull Salford Cambridge Decision Rule (HSC DR) and the Brain Injury Guidelines (BIG) criteria to select low-risk patients for discharge from the emergency department. Method A cohort from 18 countries of Glasgow Coma Scale 13-15 patients with injuries on CT imaging was identified from the multicentre Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) Study (conducted from 2014 to 2017) for secondary analysis. A composite outcome measure encompassing need for ongoing hospital admission was used, including seizure activity, death, intubation, neurosurgical intervention and neurological deterioration. We assessed the performance of our previously derived prognostic model, the HSC DR and the BIG criteria at predicting deterioration in this validation cohort. Results Among 1047 patients meeting the inclusion criteria, 267 (26%) deteriorated. Our prognostic model achieved a C-statistic of 0.81 (95% CI: 0.78 to 0.84). The HSC DR achieved a sensitivity of 100% (95% CI: 97% to 100%) and specificity of only 4.7% (95% CI: 3.3% to 6.5%) for deterioration. Using the BIG criteria for discharge from the ED achieved a higher specificity (13.3%, 95% CI: 10.9% to 16.1%) and lower sensitivity (94.6%, 95% CI: 90.5% to 97%), with 12/105 patients recommended for discharge subsequently deteriorating, compared with 0/34 with the HSC DR. Conclusion Our decision rule would have allowed 3.5% of patients to be discharged, none of whom would have deteriorated. Use of the BIG criteria may select patients for discharge who have too high a risk of subsequent deterioration to be used clinically. Further validation and implementation studies are required to support use in clinical practice.

Objective This study aimed to quantify the incidence rates of common mental and physical health conditions in mothers of children with a life-limiting condition. Methods Comparative national longitudinal cohort study using linked primary and secondary care data from the Clinical Practice Research Datalink in England. Maternal–child dyads were identified in these data. Maternal physical and mental health outcomes were identified in the primary and secondary care datasets using previously developed diagnostic coding frameworks. Incidence rates of the outcomes were modelled using Poisson regression, adjusting for deprivation, ethnicity and age and accounting for time at risk. Results A total of 35 683 mothers; 8950 had a child with a life-limiting condition, 8868 had a child with a chronic condition and 17 865 had a child with no long-term condition. The adjusted incidence rates of all of the physical and mental health conditions were significantly higher in the mothers of children with a life-limiting condition when compared with those mothers with a child with no long-term condition (eg, depression: incidence rate ratio (IRR) 1.21, 95% CI 1.13 to 1.30; cardiovascular disease: IRR 1.73, 95% CI 1.27 to 2.36; death in mothers: IRR 1.59, 95% CI 1.16 to 2.18). Conclusion This study clearly demonstrates the higher incidence rates of common and serious physical and mental health problems and death in mothers of children with a life-limiting condition. Further research is required to understand how best to support these mothers, but healthcare providers should consider how they can target this population to provide preventative and treatment services.

This chapter reviews some of the problems in the assessment of health risks associated with the disposal of waste, and questions the more traditional statistical approach used by epidemiologists and geographers alike. The two key features of the Bayesian perspective are thus the explicit incorporation of prior probabilities and the subjective assessment of these probabilities. It is argued in the rest of this chapter that the Bayesian approach is more useful for the arena of risk assessment and management, particularly as it relates to waste disposal. Bayesian philosophy combined with the decision theoretic approach to inference helps in the choice between decisions. Bayes or empirical Bayes procedures promise some improvement over current procedures for estimation of a multiplicity of related effects. The importance of a Bayesian approach to the study of waste disposal by geographers and epidemiologists alike is apparent, and warrants further empirical research in the field to verify the methodology.

Background: The coronavirus disease 2019 (COVID-19) pandemic has resulted in thousands of deaths in the UK. Those with existing comorbidities and minority ethnic groups have been found to be at increased risk of mortality. We wished to determine if there were any differences in intensive care unit (ICU) admission and 30-day hospital mortality in a city with high levels of deprivation and a large community of people of South Asian heritage. Methods: Detailed information on 582 COVID-19-positive inpatients in Bradford and Calderdale between February-August 2020 were extracted from Electronic Health Records. Logistic regression and Cox proportional hazards models were used to explore the relationship between ethnicity with admission to ICU and 30-day mortality, respectively accounting for the effect of demographic and clinical confounders. Results: The sample consisted of 408 (70%) White, 142 (24%) South Asian and 32 (6%) other minority ethnic patients. Ethnic minority patients were younger, more likely to live in deprived areas, and be overweight/obese, have type 2 diabetes, hypertension and asthma compared to white patients, but were less likely to have cancer (South Asian patients only) and COPD. Male and obese patients were more likely to be admitted to ICU, and patients of South Asian ethnicity, older age, and those with cancer were less likely. Being male, older age, deprivation, obesity, and cancer were associated with 30-day mortality. The risk of death in South Asian patients was the same as in white patients HR 1.03 (0.58, 1.82). Conclusions: Despite South Asian patients being less likely to be admitted to ICU and having a higher prevalence of diabetes and obesity, there was no difference in the risk of death compared to white patients. This contrasts with other findings and highlights the value of studies of communities which may have different ethnic, deprivation and clinical risk profiles.

Background: The roll out of coronavirus disease 2019 (COVID-19) vaccines are underway in the UK, and ensuring good uptake in vulnerable communities will be critical to reducing hospital admissions and deaths. There is emerging evidence that vaccine hesitancy is higher in ethnic minorities and deprived areas, and that this may be caused by distrust and misinformation in the community. This study aims to understand COVID-19 vaccine hesitancy in an ethnically diverse and deprived population of Bradford through the Born in Bradford (BiB) research programme. Methods: Surveys were sent to parents in BiB who had taken part in a previous Covid-19 survey (n=1727). Cross tabulations explored variation by ethnicity and deprivation. Answers to a question asking the main reason for hesitancy was analysed using thematic analysis. Results: 535 (31%) of those invited between 29 th October-9 th December 2020 participated. 48% were White British, 37% Pakistani heritage and 15% from other ethnicities; 46% were from the most deprived quintile of the Index of Multiple Deprivation. 29% of respondents do want a vaccine, 10% do not. The majority had not thought about it (29%) or were unsure (30%). Vaccine hesitancy differed by ethnicity and deprivation: 43% (95% CIs: 37-54%) of White British and 60% (35-81%) in the least deprived areas do want a vaccine, compared to 13% (9-19%) of Pakistani heritage and 20% (15-26%) in the most deprived areas. Reasons for not wanting a vaccine were commonly explained by confusion and distrust which was linked to exposure to misinformation. Conclusions: There is a risk of unequitable roll out of the vaccination programme in the UK with higher vaccine hesitancy in ethnic minorities and those living in deprived areas. There is an urgent need to tackle misinformation that is leading to uncertainty and confusion about the vaccines.

The links between financial insecurity and poor health and wellbeing are well established. Individuals experiencing financial insecurity are also more likely to face challenges in accessing the support services they need. There is evidence of unequal uptake of welfare support and benefits, particularly in some ethnic minority groups. The COVID-19 pandemic has further exacerbated financial insecurity for the most vulnerable and action is needed to improve the support provided for those affected during the recovery from the pandemic. One approach to improving uptake of benefits has been to deliver welfare services within health settings. This has the potential to increase income and possibly improve health. We conducted systematic review with a critical narrative synthesis to assess the health, social and financial impacts of welfare advice services co-located in health settings and explore the facilitators and barriers to successful implementation of these services, in order to guide future policy and practice. The review identified 14 studies published in the UK from 2010. The services provided generated on average 27GBP of social, economic and environmental return on investment per 1GBP invested. Individuals on average benefitted from an additional 2,757GBP household income per annum and cost savings for the NHS were demonstrated. The review demonstrated that improvements to health were made by addressing key social determinants of health, thereby reducing health inequalities. Co-located welfare services actively incorporated elements of proportionate universalism and targeted those, who due to predominately health needs, were most in need of this support. The nature of the welfare advice service, how it operates within a health setting, and how visible and accessible this service is to participants and professionals referring into the service, were seen as important facilitators. Co-production during service development and ongoing enhanced multi-disciplinary collaboration were also considered vital to the success of co-located services.