Explore the vast range of titles available.

BackgroundSocial prescribing (SP) typically involves linking patients in primary care with a range of local, community-based, non-clinical services. While there is a growing body of literature investigating the effectiveness of SP in improving healthcare outcomes, questions remain about how such outcomes are achieved within the everyday complexity of community health systems.AimThis qualitative case study, informed by practice theory, aimed to investigate how SP practices relevant to people at high risk of type 2 diabetes (T2D) were enacted in a primary care and community setting serving a multi-ethnic, socioeconomically deprived population.MethodsWe collected different types of qualitative data, including 35 semi-structured interviews with primary care clinicians, link workers and SP organisations; 30 hours of ethnographic observations of community-based SP activities and meetings; and relevant documents. Data analysis drew on theories of social practice, including Feldman’s (2000) notion of the organisational routine, which emphasises the creative and emergent nature of routines in practice.ResultsWe identified different, overlapping ways of practising SP: from highly creative, reflective and adaptive (‘I do what it takes’), to more constrained (‘I do what I can’) or compliant (‘I do as I’m told’) approaches. Different types of practices were in tension and showed varying degrees of potential to support patients at high risk of T2D. Opportunities to adapt, try, negotiate, and ultimately reinvent SP to suit patients’ own needs allowed practitioners to engage with complexity and provide the personalised (usually more intensive) support that patients at high risk of T2D required.ConclusionsPractitioners’ capacity to be creative in accommodating patients’ needs (‘I do what it takes’), resign to delivering insufficient SP services (‘I do what I can’) or uncritically adhere to existing conventions (‘I do as I’m told’) represented different types of SP practices, enacted within dynamic and highly contested contexts.

Background Social prescribing (SP) usually involves linking patients in primary care with services provided by the voluntary and community sector. Preliminary evidence suggests that SP may offer a means of connecting patients with community-based health promotion activities, potentially contributing to the prevention of long-term conditions, such as type 2 diabetes (T2D). Methods Using mixed-methods realist evaluation, we explored the possible contribution of SP to individual-level prevention of T2D in a multi-ethnic, socio-economically deprived population in London, UK. We made comparisons with an existing prevention programme (NHS Diabetes Prevention Programme (NDPP)) where relevant and possible. Anonymised primary care electronic health record data of 447,360 people 18+ with an active GP registration between December 2016 and February 2022 were analysed using quantitative methods. Qualitative data (interviews with 11 primary care clinicians, 11 social prescribers, 13 community organisations and 8 SP users at high risk of T2D; 36 hours of ethnographic observations of SP and NDPP sessions; and relevant documents) were analysed thematically. Data were integrated using visual means and realist methods. Results People at high risk of T2D were four times more likely to be referred into SP than the eligible general population (RR 4.31 (95% CI 4.17–4.46)), with adjustment for socio-demographic variables resulting in attenuation (RR 1.33 (95% CI 1.27–1.39)). More people at risk of T2D were referred to SP than to NDPP, which could be explained by the broad referral criteria for SP and highly supportive (proactive, welcoming) environments. Holistic and sustained SP allowed acknowledgement of patients’ wider socio-economic constraints and provision of long-term personalised care. The fact that SP was embedded within the local community and primary care infrastructure facilitated the timely exchange of information and cross-referrals across providers, resulting in enhanced service responsiveness. Conclusions Our study suggests that SP may offer an opportunity for individual-level T2D prevention to shift away from standardised, targeted and short-term strategies to approaches that are increasingly personalised, inclusive and long-term. Primary care-based SP seems most ideally placed to deliver such approaches where practitioners, providers and commissioners work collectively to achieve holistic, accessible, sustained and integrated services.

In the first of a four-part series, we describe the fundamentals of public engagement in primary care research. The article's purpose is to encourage, inform and improve the researcher's awareness about public engagement in research. For a growing number of researchers, funders and patient organisations in Europe, public engagement is a moral and ethical imperative for conducting high-quality research. Starting with an explanation of the role of public engagement in research, we highlight its diversity and benefits to research, researchers and the public members involved. We summarise principles of good practice and provide valuable resources for researchers to use in their public engagement activities. Finally, we discuss some of the issues encountered when researchers collaborate with members of the public and provide practical steps to address them. Case studies of real-life situations are used to illustrate and aid understanding. We hope this article and the other papers in this series will encourage researchers to better consider the role and practice of public engagement and the potential added value to research that collaborating with the public could provide.

IntroductionSocial prescribing is an innovation being widely adopted within the UK National Health Service policy as a way of improving the management of people with long-term conditions, such as type 2 diabetes (T2D). It generally involves linking patients in primary care with non-medical community-based interventions. Despite widespread national support, evidence for the effectiveness of social prescribing is both insufficient and contested. In this study, we will investigate whether social prescribing can contribute to T2D prevention and, if so, when, how and in what circumstances it might best be introduced.Methods and analysisWe will draw on realist evaluation to investigate the complex interpersonal, organisational, social and policy contexts in which social prescribing relevant to T2D prevention is implemented. We will set up a stakeholder group to advise us throughout the study, which will be conducted over three interconnected stages. In stage 1, we will undertake a realist review to synthesise the current evidence base for social prescribing. In stage 2, we will investigate how social prescribing relevant to people at high risk of T2D ‘works’ in a multiethnic, socioeconomically diverse community and any interactions with existing T2D prevention services using qualitative, quantitative and realist methods. In stage 3 and building on previous stages, we will synthesise a ‘transferable framework’ that will guide implementation and evaluation of social prescribing relevant to T2D prevention at scale.Ethics and disseminationNational Health Service ethics approval has been granted (reference 20/LO/0713). This project will potentially inform the adaptation of social prescribing services to better meet the needs of people at high risk of T2D in socioeconomically deprived areas. Findings may also be transferable to other long-term conditions. Dissemination will be undertaken as a continuous process, supported by the stakeholder group. Tailored outputs will target the following audiences: (1) service providers and commissioners; (2) people at high risk of T2D and community stakeholders; and (3) policy and strategic decision makers.PROSPERO registration numberCRD42020196259.

Background Over recent years there have been several major terror attacks in cities across Europe. These attacks result in deaths, physical injuries, and pose long-term threats to mental health and wellbeing of large populations. Although psychologists have completed important work on mental health responses to disaster exposure including terrorist attacks, the mental health impacts of such attacks have been comparatively less examined in academic literature than the acute health response to physical injuries. This paper reflects on Southwark Council’s pioneering public mental health response to the June 2017 terror attack at London Bridge and Borough Market. It aims to explore perceptions of the mental health impact of the incident by those living and working in the borough. Methods A rapid qualitative evaluation informed by the logic underpinning Southwark Council’s response was conducted. Seven formative interviews were undertaken with individuals involved in the response planning and/or delivery, enabling the evaluation team to establish the response’s theoretical basis. Subsequently, nineteen semi-structured interviews with consenting Council employees, residents, business owners, and workers from the Borough were conducted to understand perceived mental health impacts of the attack and the success of the Council response. Thematic analysis of transcribed interviews was undertaken to evaluate the extent to which the response was implemented successfully. Results Participants reported feeling the attack had a wide-reaching negative impact on the mental health of residents, those working in the borough and visitors who witnessed the attack. Delivering the response was a challenge and response visibility within the community was limited. Participants suggested a comprehensive systematic approach to health needs assessment informed by knowledge and relationships of key Council workers and community stakeholders is imperative when responding to terrorist incidents. Improved communication and working relationships between statutory organisations and community stakeholders would ensure community groups are better supported. Prioritising mental health needs of terror attack responders to mitigate persisting negative impacts was highlighted. Conclusions This article highlights a potential public health approach and need for developing robust practical guidance in the aftermath of terror attacks. This approach has already influenced the response to the Christchurch mosque shooting in 2019.

Background Pragmatic trials have been suggested as a way to improve the relevance of clinical trial results to practice. PRECIS-2 (Pragmatic Explanatory Continuum Indicator Summary-2) is a trial design tool which considers how pragmatic a trial is across a number of domains. It is not known whether a pragmatic approach to all PRECIS-2 domains leads to results being more relevant to primary care. The aim of this study was to investigate the views of people with influence on primary care practice towards the design of randomised trials, pragmatic approaches to trial design, and the PRECIS-2 domains. Methods We carried out semi-structured interviews with people who influence practice in primary care in the UK. A thematic analysis was undertaken using the framework approach. Results We conducted individual or small group interviews involving an elite sample of 17 individuals. We found that an exclusively pragmatic approach to randomised trials may not always make the results of trials more applicable to primary care. For example, it may be better to have less flexibility in the way interventions are delivered in randomised trials than in practice. In addition, an appropriate balance needs to be struck when thinking about levels of resourcing and the intensity of steps needed to improve adherence in a trial. Across other aspects of a trial’s design, for example the population and trial setting, a pragmatic approach was viewed as more appropriate. Conclusions To maximize the relevance of research directed at primary care, trials should be conducted with the same populations and settings that are found in primary care. Across other aspects of trials it is not always necessary to match the conditions found in practice.

Introduction: Type 2 Diabetes Mellitus (T2DM) is a growing problem in England, with approximately 3.1 million (6.7%) people living with T2DM and a further 5 million at high risk of developing T2DM as of 2017. England’s National Health Service is undergoing rapid transformation aimed at improving population health through multi-sectoral partnerships to align and integrate needs, priorities, and goals across healthcare, public health, prevention, and social care. This qualitative study sought to understand the impact of healthcare transformation on T2DM prevention and care in England.  Theory and Methods: This study is underpinned by the understanding that health systems are complex adaptive systems characterised by continuing self-organisation, non-linear interactions, interdependent and dynamic relationships, and multiple feedback loops. With this in mind, we conducted 38 semi-structured in-depth interviews with 11 persons with T2DM (PWDs), 14 healthcare professionals/providers (HCPs), and 13 health policymakers/decision-makers (PDMs). Participants were purposively and snowball sampled. We conducted thematic analysis in QSR NVIVO11 to inductively identify themes and subthemes from the data, drawing on grounded theory techniques including line-by-line analysis and the constant comparative method.  Results: Three key themes emerged. All interviewees (across PWDs, HCPs, and PDMs) emphasised the urgency of England’s growing T2DM burden and its contributors, including obesity, socio-economic deprivation, and unhealthy food environments, as a key driver of transformation. Increased awareness of T2DM at population-level was mentioned as a parallel development.  Additionally, participants highlighted how a person-centred, holistic approach is crucial to the transformation of T2DM prevention and care. Within this theme, each interviewee group highlighted contrasting, yet overlapping, subthemes. PWDs noted their preferences for empathetic, joined-up care that considers their cultural and ethnic differences and backgrounds. HCPs described shared care planning, cultivating patient-provider relationships, and multidisciplinary teams as characteristics of high-quality, holistic care provision. PDMs pointed to population-level needs driving development of policies and initiatives to tackle T2DM, especially in health and social care integration.  Participants also identified system-level barriers to transformation and integration. Participants across all groups reported funding and human resource limitations as key challenges impacting the care continuum, from primary prevention to acute hospital-based care. PWDs observed that the health system, especially primary care, was under strain as a result. HCPs explained how organisational and change management factors, namely strategic leadership and national and local priority-setting, were critical drivers of transformation. HCPs and PDMs noted the impact of factors outside the health system, particularly democratic cycles and political agendas, on sustainability and scalability of transformation efforts.  Discussion: This study offers insights into the multi-layered factors that impact healthcare transformation on T2DM prevention and care in England. From a complex adaptive systems viewpoint, these factors span systems hardware (e.g. organisational restructuring, capital investments) and software (e.g. cultural shifts, clinical practice improvements), and bottlenecks to meaningful, sustainable transformation often occur at the nexus of the two (e.g. mindset and practice change aligned to strategic priorities and resource allocation). This study also demonstrates that the health system is an open system affected by a multitude of external factors, including inequality, structural environment, and socio-political climate.

The shift of health care burden from acute to chronic conditions is strongly linked to lifestyle and behaviour. As a consequence, health services are attempting to develop strategies and interventions that can attend to the complex interactions of social and biological factors that shape both. In this paper we trace one of the most influential incarnations of this 'turn to the complex': the Medical Research Council (MRC) guidance on developing and evaluating complex interventions. Through an analysis of the key publications, and drawing on social scientific approaches to what might constitute complexity in this context, we suggest that such initiatives need to adjust their conceptualisation of 'the complex'. We argue that complexity needs to be understood as a dynamic, ecological system rather than a stable, albeit complicated, arrangement of individual elements. Crucially, in contrast to the experimental logic embedded in the MRC guidance, we question whether the Randomised Controlled Trial (RCT) is the most appropriate method through which to engage with complexity and establish reliable evidence of the effectiveness of complex interventions.

AimsAlcoholism within the British Sikh Punjabi (BSP) community is a severe issue caused by a complex array of psychosocial, political, and cultural factors. The current biomedical model taught at UK medical schools fails to address psychosocial aspects of disease, restricting the ability for doctors to treat patients holistically. As a result, doctors under-diagnose and under-treat patients with alcohol use disorders (AUD). There is a need to understand how medical education can address the needs of communities like the BSP to ensure better treatment and management in the future.Aims and ObjectivesTo explore the factors affecting alcohol consumption amongst the BSP community, as well as the barriers and facilitators they experience towards help-seeking. The results will help to make recommendations on how current alcohol-related teaching in medical school curriculums may be improved, and specifically, how to produce more culturally competent future doctors.MethodsTwo narrative literature reviews were conducted. 37 studies were included. The first search underwent thematic analysis with reference to a Public Health England framework, and the second underwent inductive thematic analysis. Key themes were discussed, analysed, and consequently the results from both literature searches were compared to produce appropriate recommendations.ResultsThe first review found that alcoholism is increasing in prevalence in the BSP population. The eleven themes identified corresponded to drivers, determinants, and consequences of consumption. A prominent theme identified included ‘economic and social structures influencing alcoholism within the BSP community’, which addressed the impact of gender roles, acculturation, and racial discrimination on alcohol consumption. The second review identified two themes and three subthemes. The ‘current level of alcohol-related teaching in the curriculum’ theme highlighted that approximately 14 hours is dedicated to this crucial topic. Overall, these findings indicated the need for multifaceted interventions to change the current provision of education.ConclusionCurrently, the BSP population fail to access treatment services due to fear of shame and stigma. Thus, doctors must be empathetic and sensitive to this, and be aware of how to explore psychosocial aspects of patient's lives and how this influences their AUD. Providing culturally competent services will ensure that holistic interventions are implemented, leading to earlier detection, prevention, and management of alcohol-related harms. This will ensure that individuals from the BSP community feel comfortable in help-seeking. Recommendations were targeted at medical schools and their students, with a predominant focus on the provision of culturally competent services.

BackgroundSouth Asian ancestry populations are underrepresented in genomic studies and therapeutics trials. British South Asians suffer from multi-morbidity leading to polypharmacy. Our objective was to elucidate British South Asian ancestry community perspectives on pharmacogenomic implementation and sharing pharmacogenomic clinical data for research.MethodsFour focus groups were conducted (9–12 participants in each). Two groups were mixed gender, while one group was male only and one was female only. Simultaneous interpretation was available to participants in Urdu and Bengali. Focus groups were recorded and abridged transcription and thematic analysis were undertaken.ResultsThere were 42 participants, 64% female. 26% were born in the UK or Europe. 52% were born in Bangladesh and 17% in Pakistan. 36% reported university level education.Implementation of pharmacogenomics was perceived to be beneficial to individuals but pose a risk of overburdening resource limited systems. Pharmacogenomic research was perceived to be beneficial to the community, with concerns about data privacy and misuse. Data sharing was desirable if the researchers did not have a financial stake, and benefits would be shared.Trust was the key condition for the acceptability of both clinical implementation and research. Trust was linked with medication compliance. Education, outreach, and communication facilitate trust.Conclusions (Significance and Impact of the Study)Pharmacogenomics implementation with appropriate education and communication has the potential to enhance trust and contribute to increased medication compliance. Trust drives data sharing, which would enable enhanced representation in research. Representation in scientific evidence base could cyclically enhance trust and compliance.