Commissioning and co-production in health and care services in the United Kingdom and Ireland: An exploratory literature review.

INTRODUCTION: This exploratory literature review seeks to examine the literature around commissioning processes in the co-production of health and care services, focusing on two questions: How do health and care commissioning processes facilitate and/or pose barriers to co-production in service design and delivery? What are the contextual factors that influence these processes? METHOD: A systematic search of three databases (Medline, Public Health and Social Policy and Practice) and a search platform (Web of Science) was conducted for the period 2008-2023. A total of 2675 records were retrieved. After deduplication, 1925 were screened at title and abstract level. Forty-seven reports from 42 United Kingdom and Ireland studies were included in the review. A thematic synthesis of included studies was conducted in relation to the research questions. RESULTS: The review identified one overarching theme across the synthesised literature: the complexity of the commissioning landscape. Three interconnected subthemes illuminate the contextual factors that influence this landscape: commissioners as leaders of co-production; navigating relationships and the collective voice. CONCLUSION: Commissioning processes were commonly a barrier to the co-production of health and care services. Though co-production was an aspiration for many commissioners, the political and economic environment and service pressures meant that it was often not fully realised. More flexible funding models, longer-term pilot projects, an increased emphasis in social value across the health and care system and building capacity for strong leadership in commissioning is needed. PATIENT AND PUBLIC CONTRIBUTION: Patients and the public did not contribute to this review as it was a small piece of work following on from a completed project, with no budget for public involvement.

Metabolism and disposition of fluticasone furoate, an enhanced-affinity glucocorticoid, in humans.

The purpose of this study was to investigate the metabolism and disposition of fluticasone furoate, an enhanced-affinity glucocorticoid receptor agonist, in humans. In a two-part, open-label design study, five healthy male subjects received a p.o. dose of 2 mg of [(14)C]fluticasone furoate, followed 4 weeks later by an i.v. dose of 0.25 mg of [(14)C]fluticasone furoate (as a 30-min infusion). Oral absorption was rapid and estimated at approximately 30%, although the oral bioavailability was markedly lower at 1.6%, limited by extensive first-pass metabolism. Plasma clearance was 58.3 l/h, with a volume of distribution of 642 liters and a terminal elimination half-life of 15.3 h. The major circulating component identified in plasma extracts after i.v. and p.o. dosing was unchanged parent compound, with 17beta-carboxylic acid (GW694301X; M10) also being notable after p.o. administration. Mean recovery of radioactivity was approximately 92 and 102% at 216 and 168 h after i.v. and p.o. administration, respectively, with most (at least 90%) recovered in the feces. Fluticasone furoate was extensively metabolized, with only trace amounts of unchanged parent compound observed in feces following either route of administration. The predominant pathway was removal of the S-fluoromethyl carbothioate group to yield GW694301X (M10). Other pathways included oxidative defluorination to yield a hydroxyl at the C6 position. There was no evidence for metabolic loss of the furoate group from fluticasone furoate or any of its metabolites. Evidence presented suggests that enterocytes have a role in the metabolism of unabsorbed fluticasone furoate.