Background:Little is known about the psychological impact of community crime in older victims, whether signposting to their general practitioner is helpful, or the barriers and facilitators to help-seeking. Previous pilot work suggested that a 'cognitive-behavioural therapy'-informed Victim Improvement Package showed promise for treating psychological distress in older victims, but further evaluation was needed. Methods:The study was undertaken between June 2017 and June 2023 in selected areas of a United Kingdom city using Safer Neighbourhood Teams. Safer Neighbourhood Teams consist of a group of police personnel, working across several local authority areas, who are dedicated to managing victims in the community. Within 2 months of the crime, police Safer Neighbourhood Teams screened 3192 victims, aged 65 or over who had reported a crime, for psychological distress using the Generalised Anxiety Disorder-2 and Patient Health Questionnaire-2 items. Those identified as distressed were advised (signposted) by the police to seek help from their general practitioner. The impact of signposting was evaluated using qualitative and quantitative methods. At 3 months post crime, 877 older victims were reassessed by our researchers and, if still distressed, invited to participate in a randomised controlled trial. This compared the addition of our Victim Improvement Package to treatment as usual against treatment as usual alone. The Victim Improvement Package used a manual to guide our talking therapy (cognitive-behavioural therapy), delivered individually and weekly, for up to an hour by a mental health charity. Up to 10 sessions were offered. Outcomes:The Beck Depression Inventory, version 2, and the Beck Anxiety Inventory, combined in a composite score, were used to evaluate clinical effectiveness. Measures were collected at baseline (3 months post crime), post intervention (primary end point) and follow-up; 6 and 9 months post crime, respectively. Cost-effectiveness was evaluated using the EuroQol-5 Dimensions and a modified Client Service Receipt Inventory. Results:The police screened 24% of older victims (n = 17,611) in our selected areas. A third of the police-screened victims were significantly distressed, and for those we rescreened at 3 months post crime, almost half remained distressed. Few distressed older victims (13%) approached their general practitioner (barriers included wait times and personal beliefs they should cope), and only a third of those who did so received help. One hundred and thirty-one participants were randomised (65 = Victim Improvement Package; 66 = treatment as usual) at 3 months post crime. The primary outcome was completed in 87 (66.4%). The Victim Improvement Package was acceptable to participants, although it was not possible to recruit our target sample of 226, because of a number of hurdles, which included changes in police leadership, the coronavirus disease discovered in 2019 pandemic and possible reduced confidence in the police. We report on these, the lessons learnt, and make recommendations for further research. No treatment effect was found for the Victim Improvement Package. Mean Victim Improvement Package -0.41 (standard deviation 0.89) versus mean treatment as usual -0.19 (standard deviation 1.11); adjusted difference in means -0.039, 95% confidence interval (-0.39 to 0.31) and the Victim Improvement Package was not cost-effective. Limitations:Recruitment was challenging, with insufficient numbers recruited to meet the sample size calculation. While appearing representative of the population, only 0.7% (131/17,611) of older victims reporting a crime participated in the trial. Assessing the quality of delivery of cognitive-behavioural therapy was challenging. Conclusions:Crime significantly psychologically impacts older victims, with chronicity of symptoms. Distress can be identified by incorporating screening into routine police visits. While Victim Improvement Package remains acceptable and promising, more research is needed, including the feasibility of using typical clinical services to assess clinical effectiveness. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number 13/164/32.

Objectives To explore barriers and facilitators to behaviour change in older people with mild frailty.Design Qualitative study.Setting Community-dwelling older people living with mild frailty.Participants 64 older people with mild frailty, workers delivering the service and stakeholders.Methods Semistructured interviews were conducted between July 2022 and May 2023 with participants in a randomised controlled trial (‘HomeHealth’) of a 6-month, home-based, personalised goal setting intervention, based around the Capability-Opportunity-Motivation-Behaviour model. We purposively sampled older participants receiving the service (n=49), workers delivering it (n=7) and stakeholders supporting its delivery (n=8). Interviews explored participation experiences, including engagement, perceived progress and impact. Transcripts were analysed using thematic analysis.Results Key themes included frailty symptoms and adapting/compensating for these, self-efficacy and beliefs about capacity or need for change, familiarity with goal-setting processes and health-related knowledge, accessibility of services and outdoor environments, and enabling social support. Participants were empowered to change behaviours with support, where personalised meaningful goals were set. These were maintained where they led to a tangible outcome and had increased self-efficacy; however, new health challenges and lack of intrinsic motivation could be barriers.Conclusions Regular and continued empathic person-centred support helps empower mildly frail people who are motivated to change their behaviour. Identifying those willing and able to identify their need for change may be key to maximise service use impact.Trial registration number ISRCTN54268283.

BACKGROUND:Health promotion for people with mild frailty has the potential to improve health outcomes, but such services are scarce in practice. We developed a personalised, home-based, behaviour change, health promotion intervention (HomeHealth) and assessed its clinical effectiveness and cost-effectiveness in maintaining independent functioning in activities of daily living in older adults with mild frailty. METHODS:This trial was an individual, multicentre, parallel-group, randomised controlled trial done in England. Participants were mainly recruited from general practices in three different areas of England (the London north Thames region, east and north Hertfordshire, and west Yorkshire). Participants were individuals residing in the community who were registered with a general practice, 65 years and older with mild frailty (scoring 5 on the CFS), with a life expectancy of more than 6 months, and with capacity to consent to participate. We excluded adults residing in nursing or care homes, those with moderate-to-severe frailty or with no frailty, those receiving palliative care, and those already case managed (eg, receiving a similar ongoing intervention from the voluntary sector or community service). Eligible participants were randomly assigned 1:1 to either the HomeHealth intervention or to treatment as usual. HomeHealth is a multidomain health promotion intervention delivered by the voluntary sector at home in six sessions over 6 months. The primary outcome was independent functioning (assessed using the modified Barthel Index [BI]) at 12 months. Outcome assessments were masked and were analysed by intention to treat using linear mixed models. Incremental costs and quality-adjusted life-years (QALYs) were calculated using seemingly unrelated regression and bootstrapping. The trial is registered on the ISRCTN registry (ISRCTN54268283). FINDINGS:We recruited 388 participants between Jan 8, 2021 and July 2, 2022 (mean age 81 years, SD 6·5; 249 (64%) of 388 were women and 139 (36%) were men). 195 participants were randomly assigned to HomeHealth and 193 to treatment as usual. Median follow-up was 363 days (IQR 356-370) in the HomeHealth group and 362 days (IQR 355-373) in the treatment-as-usual group. HomeHealth did not improve BI scores at 12 months (mean difference 0·250, 95% CI -0·932 to 1·432). HomeHealth was superior to treatment as usual with a negative point estimate for incremental costs (-£796; 95% CI -2016 to 424) and positive point estimate for incremental QALYs (0·009, -0·021 to 0·039). There were 55 serious adverse events in the HomeHealth group and 85 in the treatment-as-usual group; none were intervention related. INTERPRETATION:HomeHealth is a safe intervention with a high probability of cost-effectiveness, driven by a reduction in unplanned hospital admissions. HomeHealth should be considered as a health promotion intervention for older people with mild frailty. FUNDING:National Institute for Health Research Health Technology Assessment.

AIM:To investigate the experience and perceptions of the effectiveness of retention strategies of nurses and nursing associates in district nursing services. DESIGN:Mixed methods cross-sectional online survey. METHODS:Electronic invitations were circulated via district nursing professional networks to complete an online survey in England. The survey questions were developed from international evidence-based guidance. Quantitative data were analysed descriptively and using multinomial regression analysis, tested the variation in experienced strategies by job and work characteristics. Content analysis informed qualitative data analysis. RESULTS:Three hundred and forty-five completed surveys were received. Over 60% of respondents reported experiencing strategies related to a safe working environment (75%), flexible work schedules (65%), well-being (64%) and professional development opportunities (60%). The least frequently reported strategies experienced were involvement in service policymaking (26%), reducing job demands (31%); and creating cohesive nursing teams (40%). Nurses on lower pay grades were statistically less likely than those on the higher pay bands to experience strategies involving professional growth opportunities and involvement in service decision-making. Nurses working in affluent areas were statistically more likely to report experiencing more types of retention strategies than those working in socio-economically deprived areas. Participants' views on effective strategies were mixed but attention to financial aspects (particularly travel costs), manageable workloads, flexibility in work scheduling plus tailored induction/support for those new to district nursing were given the most testimony as effective. CONCLUSIONS:Retention strategies are created and enacted by those within employing organisations, district nursing services and district nursing teams, but within the context of a wider health care and labour market system. We suggest the findings could be the starting point for review by district nursing services experiencing high vacancy rates. Our findings raise questions for subsequent investigation across health systems. PATIENT REPORTING METHOD:This paper adhered to the relevant Equator guideline A Consensus-Based Checklist for Reporting of Survey Studies (CROSS), https://doi.org/10.1007/s11606-021-06737-1. PATIENT OR PUBLIC INVOLVEMENT:This study did not include patient or public involvement in its design, conduct or reporting.

Effective retention strategies are essential for the sustainability of district nursing services. To develop tailored retention strategies, the authors of this article examine what makes district nursing different compared to hospital and other care settings. Based on literature reviews and discussion groups, the authors identify five key characteristics of district nursing. This article invites expert district nurses to review these characteristics and provide feedback. By clearly identifying the distinctiveness of district nursing, the authors aim to strengthen retention strategies and explore other potential benefits for services.

Issue Injury to the perineal tissues during childbirth is a frequent occurrence with most women likely to experience perineal injury during a first birth which, in some cases, can lead to significant long-term morbidity. The techniques used to minimise perineal injury are frequently termed ‘hands on’ and ‘hands poised’ or ‘hands off’. These terms are often undefined and used inconsistently in the literature, making it difficult to identify the best available evidence to inform midwifery practice. Aim This study aimed to answer the research questions: What do midwives do to minimise perineal injury during birth and what influences their decision-making? Methods An ethnographic study was undertaken during 2016 in a maternity unit in the southeast of England. Data were collected through participant-observation, ethnographic and semi-structured interviews and analysed using thematic analysis, informed by the pedagogic theory of threshold concepts. Findings 31 midwives participated in the study. Evidence-based decision-making to minimise perineal injury during birth was identified as a complex concept. Within the context of threshold concept theory, three main themes were identified that contributed to the complexity: troublesome language, troublesome knowledge, and troublesome environments. Conclusions Midwifery decision-making in the context of minimising perineal injury during birth is more varied and conceptually complex than has been previously described. Identification of the various aspects of troublesomeness in this context suggests that this element of practice is a midwifery threshold concept. Addressing this within midwifery curricula and practice education to enable evidence-based decision-making is important.

AIM:To explore activities performed by community nurses in community health centre clinics and during home visits. DESIGN:Cross-sectional, observational using time and motion technique. Data collected during lockdown in 2020. METHODS:Community nurses' work in clinics and during home visits were observed and recorded. The purposefully designed data collection tool covered six categories (Administration, Communication, Direct care, Documentation, Indirect care and Other) and 35 activities relative to community nurses' work. RESULTS:Eight hundred and ten complete timings were obtained. Community nurses' time was most often (86.5%) spent on Direct care, Communication, Documentation and Other activities. Patient education occurred more often in the home. CONCLUSIONS:The type, frequency and time taken to complete community nursing activities provides insight into the community nurse role. Addressing inefficient practices such as documentation and travel could serve to improve workload. REPORTING METHOD:Adheres to EQUATOR guideline STROBE for cross-sectional studies. PATIENT OR PUBLIC CONTRIBUTION:No patient or public contribution.

Abstract Background Patient demand, internationally, on emergency departments and urgent care treatment centres has grown. Shortages of staff, particularly of emergency medicine doctors, have compounded problems. Some countries are pursuing solutions of including non-medical practitioners e.g., nurse practitioners and physician associates/assistants in their emergency department workforces. This study investigated at the macro and meso level of the health system in England: what the rationale was and the factors influencing the current and future employment, or otherwise, of non-medical practitioners in emergency departments and urgent treatment centres. Methods Mixed qualitative methods in the interpretative tradition were employed. We undertook, in 2021–2022, a documentary analysis of national, regional and subregional policy (2017–2021), followed by semi-structured interviews of a purposive sample (n = 18) of stakeholders from national, regional and subregional levels. The data were thematically analysed and then synthesised. Results There was general national policy support for increasing the presence of non-medical practitioners as part of the solution to shortages of emergency medicine doctors. However, evidence of policy support dissipated at regional and subregional levels. There were no published numbers for non-medical practitioners in emergency departments, but stakeholders suggested they were relatively small in number, unevenly distributed and faced uncertain growth. While the experience of the COVID-19 pandemic and its aftermath were said to have made senior decision makers more receptive to workforce innovation, many factors contributed to the uncertain growth. These factors included: limited evidence on the relative advantage of including non-medical practitioners; variation in the models of service being pursued to address patient demand on emergency departments and the place of non-medical practitioners within them; the lack of a national workforce plan with clear directives; and the variation in training for non-medical practitioner roles, combined with the lack of regulation of that level of practice. Conclusions We identified many features of a system ready to introduce non-medical practitioners in emergency departments and urgent treatment centres but there were uncertainties and the potential for conflict with other professional groups. One area of uncertainty was evidence of relative advantage in including non-medical practitioners in staffing. This requires urgent attention to inform decision making for short- and long-term workforce planning. Further investigation is required to consider whether these findings are generalisable to other specialties, and to similar health systems in other countries.

We aimed to conduct the first systematic narrative review and quality appraisal of existing evidence on the psychological consequences of crime in older victims in the community and psychological interventions. We searched five databases to identify all peer-reviewed literature published in English on psychological impact and/or interventions for older crime victims and quality appraised these using the Mixed-Methods Appraisal Tool, following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines (Prospero: CRD42019140137). Evidence from included studies were narratively synthesized, along with their strengths and limitations. We found 20 studies on psychological distress in older victims, four of which included interventions. From these, we identified 30 different impacts including symptoms of anxiety, depression, post-traumatic stress disorder, emotions including humiliation and self-blame, and behavioral changes. Only feasibility interventions have been published, although promising results were reported for cognitive-behavioral informed treatments for depression and anxiety. Studies were wide-ranging in aims, crimes included, and outcomes used. Recommendations for improving the evidence-base and to raise the profile of this neglected population have been provided.

BACKGROUND:NHS frailty services commonly target more severely frail older people, despite evidence suggesting frailty can be prevented or reversed when addressed at an earlier stage. HomeHealth is a new home-based, manualised voluntary sector service supporting older people with mild frailty to maintain their independence through behaviour change. Over six appointments, a trained HomeHealth worker discusses what matters to the older person and supports them to set and achieve goals around mobility, nutrition, socialising and/or psychological wellbeing. The service showed promising effects in a feasibility trial. We aimed to test the clinical and cost-effectiveness of HomeHealth for maintaining independence in older people with mild frailty compared with treatment as usual. METHODS:In this single-blind multicentre randomised controlled trial, we recruited community-dwelling older people aged 65 years or older with mild frailty from 27 general practices, community groups and sheltered housing in London, Yorkshire, and Hertfordshire. Participants were randomly assigned (1:1) to receive either HomeHealth monthly for 6 months or treatment as usual (usual GP and outpatient care, no specific frailty services). Our primary outcome was independence in activities of daily living, measured by blinded outcome assessors using the modified Barthel Index, and analysed using linear mixed models, including 6-month and 12-month data and controlling for baseline Barthel score and site. The study was approved by the Social Care Research Ethics Committee, and all participants provided written or orally recorded informed consent. This study is registered with the ISRCTN registry, ISRCTN54268283. FINDINGS:This trial took place between Jan 18, 2021, and July 4, 2023. We recruited 388 participants (mean age 81·4 years; 64% female [n=250], 94% White British/European [n=364], 2·5% Asian [n=10], 1·5% Black [n=6], 2·0% other [n=8]). We achieved high retention for 6-month follow-up (89%, 345/388), 12-month follow-up (86%, 334/388), and medical notes data (89%, 347/388). 182 (93%) of 195 participants in the intervention group completed the intervention, attending a mean of 5·6 appointments. HomeHealth had no effect on Barthel Index scores at 12 months (mean difference 0·250, 95% CI -0·932 to 1·432). At 6 months, there was a small reduction in psychological distress (-1·237, -2·127 to -0·348) and frailty (-0·124, -0·232 to -0·017), and at 12 months, we found small positive effects on wellbeing (1·449, 0·124 to 2·775) in those receiving HomeHealth. Other outcomes in analysis to date showed no significant difference. Health economic outcomes (including quality of life, capability, health services use and care needs or burden) are pending. INTERPRETATION:This high-quality trial showed that HomeHealth did not maintain independence in older people with mild frailty, and had limited effects upon secondary outcomes. Future studies need to explore different ways to promote health in this population. FUNDING:National Institute for Health and Care Research Health Technology Assessment (NIHR HTA).

BACKGROUND:Frailty is a condition resulting from a decline in physiological reserves caused by an accumulation of several deficits, which progressively impairs the ability to recover from health adverse events. Following a promising feasibility study, the HomeHealth trial assessed a holistic tailored intervention for older adults with mild frailty to promote independence in their own homes, compared with usual care. We aimed to understand how goal setting worked among older people with mild frailty. METHODS:This study was a process evaluation alongside the HomeHealth randomised trial in older adults with mild frailty. The intervention was delivered at participants' homes, either in person or by telephone or videoconferencing. We carried out semi-structured interviews with older participants who had received the intervention (between three and six appointments), on average 233 days (range 68-465) after their last appointment, purposively sampled according to age, gender, number of sessions attended, adverse events, ethnicity, Index of Multiple Deprivation, Montreal Cognitive Assessment (MoCA) and Barthel scores, research site, and HomeHealth worker. We also conducted interviews with HomeHealth workers who delivered the intervention (n=7). Interviews explored the experience and process of goal setting, benefits and challenges, perceived progress, and behaviour change maintenance after the service had finished. Ethics approval was obtained, and all participants gave informed consent. Interviews were thematically analysed. HomeHealth workers kept formal records of goals set and assessed progress towards goals (0-2 rating scale) during six monthly-sessions, which were descriptively summarised. FINDINGS:56 interviews were completed between July 15, 2022, and May 18, 2023. Study participants (n=49) had a mean age of 80 years (range 66-94), including 32 (65%) women and 17 (35%) men. Participants self-identified as White (n=42), Asian (n=3), Black (n=2), Mixed (n=1), and other ethnic (n=1) backgrounds. Findings suggested goal setting could be both a challenge and a motivator for older participants with mild frailty. Goal setting worked well when the older person could identify a clear need and set realistic goals linked to functioning, which led to a positive sense of achievement. Challenges occurred when older people were already accessing multiple resources and health services, or where the terminology of "goals" was off-putting due to work or school connotations. Average progress towards goals was 1·15/2. Most participants set goals around improving mobility (or a combination of mobility and another goal type such as socialising), and there was evidence of participants sustaining these behaviour changes after the intervention. INTERPRETATION:Older people with mild frailty can engage well with goal setting to promote independence. The lapse between receiving the intervention and being interviewed limited recall for some participants. However, the acceptability and adherence to the intervention for older people with mild frailty, and their moderate progress towards goals, should encourage further tailored and person-centred practices to promote their independence. FUNDING:National Institute for Health Research (NIHR) Health Technology Assessment.

Objective A major issue facing all health systems is improving population health while at the same time responding to both growing patient numbers and needs and developing and retaining the health care workforce. One policy response to workforce shortages has been the development of advanced clinical practice roles. In the context of an English national policy promoting such roles in the health service, we explored senior managers’ and senior clinicians’ perceptions of factors at the organization level that support or inhibit the introduction of advanced clinical practice roles. The investigation was framed by theories of the diffusion of innovation and the system of professions. Methods We conducted a qualitative interview study of 39 senior manager and clinicians in 19 National Health Service acute, community, mental health and ambulance organizations across a metropolitan area in 2019. Results Small numbers of advanced clinical practice roles were reported, often in single services. Four main influences were identified in the development of advanced clinical practice roles: staff shortages (particularly of doctors in training grades) combined with rising patient demand, the desire to retain individual experienced staff, external commissioners or purchasers of services looking to shape services in line with national policy, and commissioner-funded new roles in new ambulatory care services and primary care. Three factors were reported as enabling the roles: finance for substantive posts, evidence of value of the posts, and structural support within the organization. Three factors were perceived as inhibiting developing the roles: confusion and lack of knowledge amongst clinicians and managers, the availability of finance for the roles, and a nervousness (sometimes resistance) to introducing the new roles. Conclusions While the national policy was to promote advanced clinical practice roles, the evidence suggested there was and would continue to be limited implementation at the operational level. Development scenarios that introduced new monies for such roles reduced some of the inhibiting factors. However, where the introduction of roles required funding to move from one part of a service to another, and potentially from one staff group to another, the growth of these roles was and is likely to be contested. In such scenarios, research and business evidence of relative advantage will be important, as too will be supporters in powerful positions. The paucity of publicly available evidence on the effectiveness of advanced clinical practice roles across the specialties and professions in different contexts requires urgent attention.

ABSTRACT Physician associates (PAs) have been part of the UK health workforce for almost 20 years. The profession is growing rapidly with statutory regulation, protection of the title, and career progression supported by a national-level framework all in the pipeline for the near future. This article provides a brief history of the profession in the United Kingdom and prospects for its future.

Health care organisations in many countries are developing advanced clinical practitioner roles to address workforce shortages and growing demand for services. Even in countries where advanced practice roles are more established there are low numbers, clustered in a limited range of professions, mostly nursing specialities. Successful implementation of national policies encouraging increased advanced practice roles and from a broader range of professions, requires attention to all levels of the health system. There is a lack of evidence as to the motivation to take-up these roles at the micro, individual actor level. This study explored the motivations important at the micro level in influencing a range of health professionals to undertake advanced practice roles. The study used an interpretive methodology with thematic analysis and was framed by theories of motivational domains in the work environment. Semi-structured interviews were undertaken with eighteen advanced clinical practitioners working in health care organisations in England. The motivators for role take-up were found to be predominantly intrinsic reflecting participants’ desires for advancement, both personal and for their profession, and improved efficiency of patient care. Participants described experiencing limited organisational support and sometimes discouragement from other professionals. There is potential for health organisations at the meso level of health care systems to support national growth of advanced practice roles by giving attention to the motivations of diverse health professionals. We propose a new theoretical framework of motivators for advanced clinical practice role uptake at the micro level.

ABSTRACT Physician associates (PAs) are a new healthcare professional group in the UK. While PAs have been known as a stable but flexible workforce in the USA for over 50 years, little is known about their career paths in the UK's NHS. A cross sectional online survey (January 2020 – May 2020) of graduates from the longest running UK PA course investigated stability and factors influencing job retention or movement. One-hundred and sixty-two (71%) graduates provided a full response. Descriptive analysis was by early graduates (2006–2013), mid-graduates (2014–2017) and recent graduates (2018–2020). Early and mid-graduates held their first jobs for a mean of 3 years. For early graduates, the longest held job was 11 years, with a mode of 7 years. Enjoyment of the work, learning opportunities and working with supportive consultants were the most highly rated factors in PA job retention.

Background Frailty is clinically associated with multiple adverse outcomes, including reduced quality of life and functioning, falls, hospitalisations, moves to long-term care and mortality. Health services commonly focus on the frailest, with highest levels of need. However, evidence suggests that frailty is likely to be more reversible in people who are less frail. Evidence is emerging on what interventions may help prevent or reduce frailty, such as resistance exercises and multi-component interventions, but few interventions are based on behaviour change theory. There is little evidence of cost-effectiveness. Previously, we co-designed a new behaviour change health promotion intervention (“HomeHealth”) to support people with mild frailty. HomeHealth is delivered by trained voluntary sector support workers over six months who support older people to work on self-identified goals to maintain their independence, such as strength and balance exercises, nutrition, mood and enhancing social engagement. The service was well received in our feasibility randomised controlled trial and showed promising effects upon outcomes. Aim To test the clinical and cost-effectiveness of the HomeHealth intervention on maintaining independence in older people with mild frailty in comparison to treatment as usual (TAU). Methods Single-blind individually randomised controlled trial comparing the HomeHealth intervention to TAU. We will recruit 386 participants from general practices and the community across three English regions. Participants are included if they are community-dwelling, aged 65 + , with mild frailty according to the Clinical Frailty Scale. Participants will be randomised 1:1 to receive HomeHealth or TAU for 6 months. The primary outcome is independence in activities of daily living (modified Barthel Index) at 12 months. Secondary outcomes include instrumental activities of daily living, quality of life, frailty, wellbeing, psychological distress, loneliness, cognition, capability, falls, carer burden, service use, costs and mortality. Outcomes will be analysed using linear mixed models, controlling for baseline Barthel score and site. A health economic analysis and embedded mixed-methods process evaluation will be conducted. Discussion This trial will provide definitive evidence on the effectiveness and cost-effectiveness of a home-based, individualised intervention to maintain independence in older people with mild frailty in comparison to TAU, that could be implemented at scale if effective. Trial registration ISRCTN, ISRCTN54268283 . Registered 06/04/2020.

Physician associates (PAs) have been part of the UK health workforce for almost 20 years. The profession is growing rapidly with statutory regulation, protection of the title, and career progression supported by a national-level framework all in the pipeline for the near future. This article provides a brief history of the profession in the United Kingdom and prospects for its future.

Anaesthesia Associates have been established in the UK for over 10 years, but without statutory regulation. Renewed interest surfaced based on a widening gap between patient need and workforce supply in the UK and established advanced practice non-doctor roles within healthcare systems elsewhere. However, there are no robust data on their impact on patient or hospital outcomes, or training opportunities for medical anaesthetists, and perceptions of the profession within the anaesthetic community are mixed. This paper describes an investigation into the demographics and scope of practice of Anaesthesia Associates in the UK in 2017, and the experience of working together as an anaesthetic team. Through qualitative interviews, we explored the role and relationships, the impact on medical anaesthetic training and ideas about future development. The overall experience of working with Anaesthesia Associates was positive. Successful integration requires understanding of the educational needs and competencies of all. Future development relies on strong leadership and robust patient outcome and efficiency measures. Interviewees strongly supported statutory regulation, which was agreed by the government in 2019 but not yet implemented. Anaesthesia Associates were seen as a benefit to anaesthetic departments and as such may provide part of the solution to the prevailing workforce issues in UK Anaesthesia, further critically challenged by the SARS-CoV-2 pandemic.

Objectives The experience of providing/receiving intimate continence care between family members can be difficult and emotive. Often, for people living with dementia this seems an area of care overlooked by professionals. This study investigated the experiences of intimate continence care for people living with dementia and their family member (the family dyad), and whether they viewed this as impacting on their relationship. Method Face-to-face interviews were conducted at 6 monthly intervals over a 12-month period with 13 carers (all family members) and one person living with dementia (13 family dyads) in England. Interviews were recorded and transcribed. Analysis of the data was achieved using a descriptive phenomenological method. Findings Carers’ attitudes towards providing intimate continence care revealed a task-focused approach for some but feelings of disgust and distress for others. Four participants (including the participant living with dementia) reported that intimate continence care had strengthened their dyad relationship. However, some carers perceived the care and support received from health and social care practitioners to be insufficient, which placed extra stress on them and adversely affected their family dyad relationship. Conclusion Implications of the study suggest that integrated and effective continence care and support for people living with dementia and their carers could (1) maintain the quality of the family dyad relationship, (2) help keep the person living at home, delaying an unwanted move to a care home and (3) consequently improve overall quality of life for individuals in the family dyad. Assuring integrated and effective continence care should be a priority for service funders and quality assurance regulators.

Synthesis: Executive Summary This executive summary reports on a synthesis of three evaluations undertaken in 2019 in London National Health Services to investigate: i) The extent of adoption of advanced clinical practice (ACP) roles ii) Factors facilitating or deterring the development of the roles iii) Future plans for the development of new and existing staff in ACP roles across nursing, midwifery, allied health professions and health scientists. The evaluators were also asked to identify any published or unpublished evaluations of the involvement of ACPs in service provision. Following the publication of the ‘Multi-professional framework for advanced clinical practice in England’ (Health Education England [HEE] 2018), IPSOS Mori undertook an online national census of ACPs on behalf of HEE in summer/autumn 2019 (due to report early 2020), to provide insights into the development of ACP roles. The national survey will be shared with all NHS Trusts later in 2020. To complement the national survey two higher education institutions (HEIs) and the National Workforce Development Unit were commissioned by HEE London to conduct a qualitative evaluation of ACP roles in the NHS workforce in London. Interviews were conducted in Autumn 2019 with stakeholders employed in NHS organisations providing community, acute (secondary and tertiary services), mental health and emergency services and other organisations with roles in supporting ACP development. The details of the research are given in the individual reports in appendices. This executive summary reports the findings common across the three studies. The synthesis suggests that ACP roles are clustered around a small number of services, such as urgent and emergency care, musculoskeletal services, critical care and podiatric surgery, with very limited workforce planning about the future role of ACPs. There was found to be a low level of familiarity with the NHS advanced clinical practice multi-professional framework in trusts and with the concepts of advanced clinical practice more generally. However, all three evaluations identified enthusiasm from a wide range of professionals and senior managers around the potential of these roles to make a significant contribution across services, in terms of enhancing patient care, in line with current national policies, and staff career pathways. Some participants saw ACP posts as a means of addressing staffing shortages, particularly of trainee doctors in the acute sector. However views varied: some participants considered that ACPs were expected to work at an advanced level for their profession, bringing considerable experience to the role and as such ACPs’ practice was viewed as fundamentally different to that of trainee doctorsIdentification of funding sources for ACP posts was seen a major factor in future planning with some opportunities arising through commissioning and business planning processes, but otherwise the absence of ring-fenced finance for ACP posts was an inhibitor. Factors supporting and inhibiting the development of such roles varied to some extent between types of professions, but overall demonstrated an interplay between: the resource environment, the extent of knowledge about ACPs, the receptiveness of the service environment and pro-active change management. Participants argued that ACP roles might contribute to addressing challenges related to: increasing patient demand for health services and changing patterns of morbidity; poor retention and recruitment into health care professions and challenges of embedding technological innovations into health care service delivery in the future. Uncertainty about the evidence of the value of ACP roles in different types of services was reported to be an inhibiting factor and local evaluations were rare or undertaken in the past and not available. No participants were able to identify any local reports on patient and public views of ACP roles. Some participants expressed concern that there are currently few staff with appropriate experience and academic ability ready to progress into ACP roles in the near future and that there was a need for long term developmental pathways to allow staff to develop the required skills.