Advancing the social return on investment framework to capture the social value of public health interventions: semistructured interviews and a review of scoping reviews.

OBJECTIVES: Investment in public health has far-reaching impacts, not only on physical health but also on communities, economies and the environment. There is increasing demand to account for the wider impact of public health and the social value that can be created, which can be captured through the use of the social return on investment (SROI) framework. This study aims to explore the application of SROI and identify areas of advancement for its use in public health. STUDY DESIGN AND METHODS: Publically available SROI studies of public health interventions previously identified through published systematic scoping reviews were examined through a methodological lens. This was complemented by semistructured interviews with key public health academic experts with experience in the field of SROI. The results were thematically analysed and triangulated. RESULTS: In total, 53 studies and nine interviews were included in the analysis. All interviewees agreed that SROI is a suitable framework to demonstrate the social value of public health interventions. Developmental aspects were also identified through the analysis. This included a more systematic use of SROI principles and methodological developments. Lastly, it was identified that further advancements were needed to promote awareness of SROI and how it can be used to generate investment. CONCLUSION: By identifying key areas for advancement, the results from this study can be used to further refine the SROI framework for use within the speciality to promote investment in services and interventions that demonstrate maximum value to people, communities, economies and the environment.

An app with brief behavioural support to promote physical activity after a cancer diagnosis (APPROACH): study protocol for a pilot randomised controlled trial.

BACKGROUND: There are multiple health benefits from participating in physical activity after a cancer diagnosis, but many people living with and beyond cancer (LWBC) are not meeting physical activity guidelines. App-based interventions offer a promising platform for intervention delivery. This trial aims to pilot a theory-driven, app-based intervention that promotes brisk walking among people living with and beyond cancer. The primary aim is to investigate the feasibility and acceptability of study procedures before conducting a larger randomised controlled trial (RCT). METHODS: This is an individually randomised, two-armed pilot RCT. Patients with localised or metastatic breast, prostate, or colorectal cancer, who are aged 16 years or over, will be recruited from a single hospital site in South Yorkshire in the UK. The intervention includes an app designed to encourage brisk walking (Active 10) supplemented with habit-based behavioural support in the form of two brief telephone/video calls, an information leaflet, and walking planners. The primary outcomes will be feasibility and acceptability of the study procedures. Demographic and medical characteristics will be collected at baseline, through self-report and hospital records. Secondary outcomes for the pilot (assessed at 0 and 3 months) will be accelerometer measured and self-reported physical activity, body mass index (BMI) and waist circumference, and patient-reported outcomes of quality of life, fatigue, sleep, anxiety, depression, self-efficacy, and habit strength for walking. Qualitative interviews will explore experiences of participating or reasons for declining to participate. Parameters for the intended primary outcome measure (accelerometer measured average daily minutes of brisk walking (≥ 100 steps/min)) will inform a sample size calculation for the future RCT and a preliminary economic evaluation will be conducted. DISCUSSION: This pilot study will inform the design of a larger RCT to investigate the efficacy and cost-effectiveness of this intervention in people LWBC. TRIAL REGISTRATION: ISRCTN registry, ISRCTN18063498 . Registered 16 April 2021.

Estimation and analysis of cow-level cumulative lifetime break-even on financial resiliency.

A dairy farm's ability to generate positive profit is dependent on the cow's response to management decisions made in conjunction with input cost management. Therefore, farm managers consider a multifaceted set of choices, managing their herd not as a homogeneous group of animals, but justifying the influence of individual cows on the farm's financial performance. We combined cow-level performance records from Minnesota DHIA and farm-level financials from the University of Minnesota Center for Farm Financial Management database FINBIN (https://finbin.umn.edu/) from 2012 to 2018 to evaluate farm- and cow-level profitability. The objective of this study was to evaluate individual cow performance matched with farm-level input expenses allocated to the cow level to measure a dairy farm's ability to be profitable over time, considering input and milk price fluctuations. Conventional Minnesota dairy farms were divided into 2 groups-financially resilient and non-resilient-based on their adjusted net farm income ratio over time. Yearly farm-level expenses and revenues were allocated to cows based on performance measures provided in monthly DHIA test data, and a cumulative lifetime break-even was calculated for all cows with consecutive farm data from 2012 to 2018. Herd-level and cow-level characteristics were analyzed to test for statistical difference between resilient and non-resilient farms as well as cows who achieved their break-even versus those that did not for resilient and non-resilient farms. Results showed that resilient farms had statistically different and lower expenses than non-resilient farms, with lower heifer raising expenses ($1,839.32 vs. $1,886.20), lifetime feed expenses ($4,197.07 vs. $4,975.39), and lifetime non-feed expenses ($2,761.63 vs. $4,502.67). Resilient farms had 38.3% of cows reach break-even, whereas non-resilient farms had 25.2% of cows break even. On average, cows who achieved their break-even remained in the herd for approximately 1 yr longer for both resilient farms (1,011 d for cows who break even and 627 d for those that do not) and non-resilient farms (1,033 d for cows who break even and 683 d for those that do not). Cows on resilient farms who achieved their lifetime break-even had an average lifetime profit of $1,613.48, which was $3,095.10 higher than the lifetime profit of -$1,481.62 of cows who never reach their break-even. Cows who reached their break-even on non-resilient farms had a lifetime profit of $1,270.51, which was $3,854.11 higher than the lifetime profit of -$2,583.60 for those who did not break even. Therefore, financially resilient dairy farms were utilizing a low-input, low-output model that proved to be successful and resulted in maintained profitability across volatile and fluctuating commodity prices.

TREatment of ATopic eczema (TREAT) Registry Taskforce: an international Delphi exercise to identify a core set of domains and domain items for national atopic eczema photo- and systemic therapy registries.

BACKGROUND: Evidence of immunomodulatory therapies to guide clinical management of atopic eczema (AE) is scarce, despite frequent and often off-label use. Patient registries provide valuable evidence for the effects of treatments under real-world conditions that can inform treatment guidelines, give the opportunity for health economic evaluation and the evaluation of quality of care, as well as pharmacogenetic and dynamic research, which cannot be adequately addressed in clinical trials. OBJECTIVES: The TREatment of ATopic eczema (TREAT) Registry Taskforce aims to seek international consensus on a core set of domains and items ('what to measure') for AE research registries, using a Delphi approach. METHODS: Participants from six stakeholder groups were included: doctors, nurses, nonclinical researchers, patients, industry and regulatory body representatives. The eDelphi comprised three sequential online rounds, requesting participants to rate the importance of each proposed domain item. Participants could add domain items to the proposed list in round 1. A final consensus meeting was held to ratify the core set. RESULTS: Participants (n = 479) from 36 countries accessed the eDelphi platform, of whom 86%, 79% and 74% completed rounds 1, 2 and 3, respectively. At the face-to-face consensus meeting attended by 42 participants the final core set was established containing 19 domains with 69 domain items (49 baseline and 20 follow-up items). CONCLUSIONS: This core set of domains and items to be captured by national AE systemic therapy registries will standardize data collection and thereby allow direct comparability across registries and facilitate data pooling between countries. Ultimately, it will provide greater insight into the effectiveness, safety and cost-effectiveness of photo- and systemic immunomodulatory therapies.

An assessment of the effect of contact time on cadmium phytoavailability in a pasture soil.

The length of time cadmium (Cd) is in contact with the soil has been recognised as a factor affecting phytoavailability, but the extent of this process is currently poorly understood. This study used isotopic dilution techniques (E and L values) to determine the effect of contact time on Cd phytoavailability from soil collected from a long-term phosphorus (P) fertiliser trial. Cadmium phytoavailability was determined in soil that was last fertilised with soluble Cd from P fertiliser 17 years prior to sampling (residual plots) and soil that received annual applications of P fertiliser until sampling (continuous plots). It was found that both E values and L values increased with P fertiliser (viz Cd) inputs and were significantly related to each other (r 2 = 0.82 P < 0.005). There was however no significant difference (P < 0.05) in the percentage of total Cd that was phytoavailable calculated using E values (E%) between the continuous (mean 51 %) and the residual plots (mean 51 %). There was also no significant difference (P < 0.05) in the percentage of total soil Cd that was phytoavailable calculated using L values (L%) between the continuous (mean 77 %) and residual plots (mean 87 %). These results suggest that despite Cd being in contact with the soil for 17 years, there was no difference in the size of the phytoavailable Cd pool compared to recent Cd inputs. This study should be repeated for other soil types and factored into any analysis for the long-term implications of ongoing Cd accumulation in soil on future landuse.

Ethnicity and cardiovascular health inequalities in people with severe mental illnesses: protocol for the E-CHASM study.

PURPOSE: People with severe mental illnesses (SMI) experience a 17- to 20-year reduction in life expectancy. One-third of deaths are due to cardiovascular disease. This study will establish the relationship of SMI with cardiovascular disease in ethnic minority groups (Indian, Pakistani, Bangladeshi, black Caribbean, black African and Irish), in the UK. METHODS: E-CHASM is a mixed methods study utilising data from 1.25 million electronic patient records. Secondary analysis of routine patient records will establish if differences in cause-specific mortality, cardiovascular disease prevalence and disparities in accessing healthcare for ethnic minority people living with SMI exist. A nested qualitative study will be used to assess barriers to accessing healthcare, both from the perspectives of service users and providers. RESULTS: In primary care, 993,116 individuals, aged 18+, provided data from 186/189 (98 %) practices in four inner-city boroughs (local government areas) in London. Prevalence of SMI according to primary care records, ranged from 1.3-1.7 %, across boroughs. The primary care sample included Bangladeshi [n = 94,643 (10 %)], Indian [n = 6086 (6 %)], Pakistani [n = 35,596 (4 %)], black Caribbean [n = 45,013 (5 %)], black African [n = 75,454 (8 %)] and Irish people [n = 13,745 (1 %)]. In the secondary care database, 12,432 individuals with SMI over 2007-2013 contributed information; prevalent diagnoses were schizophrenia [n = 6805 (55 %)], schizoaffective disorders [n = 1438 (12 %)] and bipolar affective disorder [n = 4112 (33 %)]. Largest ethnic minority groups in this sample were black Caribbean [1432 (12 %)] and black African (1393 (11 %)). CONCLUSIONS: There is a dearth of research examining cardiovascular disease in minority ethnic groups with severe mental illnesses. The E-CHASM study will address this knowledge gap.

BEEF SPECIES SYMPOSIUM: Can we build the cowherd by increasing longevity of females?

Increasing longevity of beef cows by decreasing the proportion culled due to reproductive failure provides an efficient process to rebuild a cow herd and can reduce number of replacements needed to sustain a constant herd size. Rate of reproductive failure varies due to cow age, where failure in cows 2 to 4 yr of age is often greater than in cows 5 to 7 yr of age. In addition, BW of cow and calf at weaning increase as cows advance from 2 to 5 yr of age. The cumulative effect of increasing retention of young cows is improved production efficiency through decreased replacement rate and changing age structure of the herd resulting in a greater proportion of cows at maximal production potential for calf BW at weaning and cow BW at time of culling. Calculations from cow age-specific culling and BW data from commercial and research herds indicated that reducing replacement rate from 18% to 14% resulted in a 23% increase in calf BW weaned and a 2% increase in cull cow BW per pregnant replacement heifer going into the herd. Although improving longevity increases production efficiency, genetic advancement in sustained reproductive function is challenging, as it is the sequential culmination of the annual repetition of numerous discrete physiological processes, each ending in a qualitative response. Successful completion of one process is prerequisite to evaluating subsequent processes. These physiological processes are subject to nutritional threshold requirements that may vary due to genetic potential for other production traits such as milk, growth, and mature size resulting in genetic-by-nutrition interactions. This is in contrast to most traits for which EPD exist, where genetic-by-environment interactions are not considered to be significant. Extensive research concerning impact of limited nutrition on reproduction has led to recommendations that heifers and cows be fed to a threshold BW or BCS to ensure reproductive success; a process that masks nutritional interactions that might otherwise result in reproductive failure. This management approach minimizes selection for animals capable of sustained reproductive function under limited nutritional environments. Rearing and managing cows under nutritionally limited environments may lead to adaptations that result in relatively high levels of reproductive success under lower input levels. Such adaptation may improve chances for longer retention in their offspring in nutrient-limited environments.

Treatment of patients with multiple myeloma who are not eligible for stem cell transplantation: position statement of the myeloma foundation of Australia Medical and Scientific Advisory Group.

Options for treatment of elderly patients with multiple myeloma have expanded substantially following the development of immunomodulatory drugs (IMiD), proteasome inhibitors and with enhancement in safety of high-dose therapy and autologous stem cell transplant (HDT + ASCT). The recognition of biological heterogeneity among elderly patients has made delivery of therapy more challenging. An individualised approach to treatment selection is recommended in an era in which highly efficacious treatment options are available for transplant-ineligible patients. Here, we summarise recommendations for patients who are considered unsuitable for HDT + ASCT, including pretreatment considerations, and induction, maintenance and supportive care therapies.

Management of systemic AL amyloidosis: recommendations of the Myeloma Foundation of Australia Medical and Scientific Advisory Group.

Systemic AL amyloidosis is a plasma cell dyscrasia with a characteristic clinical phenotype caused by multi-organ deposition of an amyloidogenic monoclonal protein. This condition poses a unique management challenge due to the complexity of the clinical presentation and the narrow therapeutic window of available therapies. Improved appreciation of the need for risk stratification, standardised use of sensitive laboratory testing for monitoring disease response, vigilant supportive care and the availability of newer agents with more favourable toxicity profiles have contributed to the improvement in treatment-related mortality and overall survival seen over the past decade. Nonetheless, with respect to the optimal management approach, there is a paucity of high-level clinical evidence due to the rarity of the disease, and enrollment in clinical trials is still the preferred approach where available. This review will summarise the Clinical Practice Guidelines on the Management of Systemic Light Chain (AL) Amyloidosis recently prepared by the Medical Scientific Advisory Group of the Myeloma Foundation of Australia. It is hoped that these guidelines will assist clinicians in better understanding and optimising the management of this difficult disease.

Measured bremsstrahlung photonuclear production of 99Mo ((99m)Tc) with 34 MeV to 1.7 GeV electrons.

(99)Mo photonuclear yield was measured using high-energy electrons from Laser Plasma Accelerators and natural molybdenum. Spectroscopically resolved electron beams allow comparisons to Monte Carlo calculations using known (100)Mo(γ,n)(99)Mo cross sections. Yields are consistent with published low-energy data, and higher energy data are well predicted from the calculations. The measured yield is (15±2)×10(-5) atoms/electron (0.92±0.11 GBq/µA) for 25 mm targets at 33.7 MeV, rising to (1391±20)×10(-5) atoms/electron (87±2 GBq/µA) for 54 mm/ 1.7 GeV, with peak power-normalized yield at 150 MeV.

Beef Species Symposium: an assessment of the 1996 Beef NRC: metabolizable protein supply and demand and effectiveness of model performance prediction of beef females within extensive grazing systems.

Interannual variation of forage quantity and quality driven by precipitation events influence beef livestock production systems within the Southern and Northern Plains and Pacific West, which combined represent 60% (approximately 17.5 million) of the total beef cows in the United States. The beef cattle requirements published by the NRC are an important tool and excellent resource for both professionals and producers to use when implementing feeding practices and nutritional programs within the various production systems. The objectives of this paper include evaluation of the 1996 Beef NRC model in terms of effectiveness in predicting extensive range beef cow performance within arid and semiarid environments using available data sets, identifying model inefficiencies that could be refined to improve the precision of predicting protein supply and demand for range beef cows, and last, providing recommendations for future areas of research. An important addition to the current Beef NRC model would be to allow users to provide region-specific forage characteristics and the ability to describe supplement composition, amount, and delivery frequency. Beef NRC models would then need to be modified to account for the N recycling that occurs throughout a supplementation interval and the impact that this would have on microbial efficiency and microbial protein supply. The Beef NRC should also consider the role of ruminal and postruminal supply and demand of specific limiting AA. Additional considerations should include the partitioning effects of nitrogenous compounds under different physiological production stages (e.g., lactation, pregnancy, and periods of BW loss). The intent of information provided is to aid revision of the Beef NRC by providing supporting material for changes and identifying gaps in existing scientific literature where future research is needed to enhance the predictive precision and application of the Beef NRC models.

An audit of interval female sterilisation by minilaparotomy at the University College Hospital, Ibadan, Nigeria.

Female sterilisation is a widely accepted and practiced family planning method. This study aimed at ascertaining the complications that followed interval minilaparotomy at the University College Hospital, Ibadan, over a 5-year period. Only women who requested sterilisation for family planning purposes were included in the study. There were 135 patients who had interval female sterilisation. Of these, 119 (88.1%) case files were available for analysis. The mean age at sterilisation was 38.2 ± 3.8 years, mean parity of 7 ± 2.0 and the mean number of living children at the time of the procedure was 6.5 ± 1.4. The mean duration of the procedure was 42.35 ± 13.07 min. The most receptive clientele for interval female sterilisation were 35 years or older and were grand multiparous. Women in the lowest Class (V) were least likely to accept female sterilisation in this study. Complications arising from the procedure were mostly minor, hence it is adjudged safe. There were no failed procedures in this study and only one of the patients had regrets about the procedure.

Review of medical discharge summaries and medical documentation in a metropolitan hospital: impact on diagnostic-related groups and Weighted Inlier Equivalent Separation.

BACKGROUND: Accurate and comprehensive clinical documentation is crucial for effective ongoing patient care, follow up and to optimise case mix-based funding. Each Diagnostic Related Group (DRG) is assigned a 'weight', leading to Weighted Inlier Equivalent Separation (WIES), a system many public and private hospitals in Australia subscribe to. AIMS: To identify the top DRG in a general medical inpatient service, the completeness of medical discharge documentation, commonly missed comorbidities and system-related issues and subsequent impact on DRG and WIES allocation. METHODS: One hundred and fifty completed discharge summaries were randomly selected from the top 10 medical DRG in our health service. From a detailed review of the clinical documentation, principal diagnoses, associated comorbidities and complications, where appropriate, the DRG and WIES were modified. RESULTS: Seventy-two (48%) of the 150 reviewed admissions resulted in a revision of DRG and WIES equivalent to an increase of AUD 142,000. Respiratory-based DRG generated the largest revision of DRG and WIES, while 'Cellulitis' DRG had the largest relative change. Twenty-seven per cent of summaries reviewed necessitated a change in coding with no subsequent change in DRG allocation or WIES. Acute renal failure, anaemia and electrolyte disturbances were the most commonly underrepresented entities in clinical discharge documentation. Seven patients had their WIES downgraded. CONCLUSION: Comprehensive documentation of principal diagnosis/diagnoses, comorbidities and their complications is imperative to optimal DRG and WIES allocation. Regular meetings between clinical and coding staff improve the quality and timeliness of medical documentation, ensure adequate communication with general practitioners and lead to appropriate funding.

Joint Alpharma-Beef Species Symposium: implications of beef heifer development systems and lifetime productivity.

Research emphasis has been placed on heifer development strategies in recent years, comparing traditional, more intensive systems to more extensive systems using less feed and relying on compensatory gain to reach a target BW. Recent research has indicated that developing heifers to a lighter target BW at breeding (i.e., 50 to 57% of mature BW compared with 60 to 65% BW) reduced development costs and did not impair reproductive performance. Research published through the late 1980s demonstrated greater negative effects of limited postweaning growth on age at puberty and pregnancy rates whereas more recent studies demonstrate less of a negative impact of delayed puberty on pregnancy rate. A limitation of most research concerning influences of nutrition on heifer development and cow reproductive performance is little or limited consideration of long-term implications. Longevity has relatively low heritability; therefore, heifer development and other management strategies have a greater potential to impact cow retention. Establishing the impact of heifer development protocols on longevity is complex, requiring consideration of nutritional factors after the start of breeding and through subsequent calvings. Lower-input heifer development, where all heifers are managed together after the postweaning period, did not impair rebreeding, but continued subsequent restriction in the form of marginal winter supplementation resulted in decreased retention in the breeding herd. Therefore, the compensatory BW gain period for restricted-growth heifers may be important to longevity and lifetime productivity. Adequate growth and development to ensure minimal calving difficulty can be of critical importance for longevity; however, providing additional supplemental feed during postweaning development to accomplish this may be less efficient than later in development. Restricting gain during postweaning development by limiting DMI or developing heifers on dormant winter forage resulted in increased economic advantages compared with developing heifers at greater rates of ADG to achieve a greater target BW. Implications of heifer development system on cow longevity must be considered when evaluating economics of a heifer enterprise; however, studies evaluating the effects of heifer development systems on cow longevity are extremely limited.

Using routine intelligence to target inspection of healthcare providers in England.

BACKGROUND: The Healthcare Commission, the national regulator for the National Health Service in England, has to assess providers (NHS trusts) on compliance with core standards in a way that targets appropriate local inspection resources. OBJECTIVES: To develop and evaluate a system for targeting inspections in 2006 of 44 standards in 567 healthcare organisations. METHODS: A wide range of available information was structured as a series of indicators (called items) that mapped to the standards. Each item was scored on a common scale (a modified Z-score), and these scores were aggregated to indicate risks of undeclared non-compliance for all trusts and standards. In addition, local qualitative intelligence was coded and scored. RESULTS: The information sets used comprised 463 875 observations structured in 1689 specific items, drawn from 83 different data streams. Follow-up inspections were undertaken on the 10% of trusts with the highest-risk scores (where the trust had declared compliance with a standard) and an additional 10% of trusts randomly selected from the remainder. The success of the targeting was measured by the number of trust declarations that were "qualified" following inspection. In the risk-based sample, the proportion of inspected standards that were qualified (26%) was significantly higher than in the random sample (13%). The success rate for targeting varied between standards and care sectors. CONCLUSION: This innovative approach to using information to target inspection activity achieved its overall aims. The method worked better for some standards and in some settings than for others, and is being improved in the light of experience gained. Such applications are increasingly important as modern regulators strive to be targeted and proportionate in their activities.

Reproductive performance of heifers offered ad libitum or restricted access to feed for a one hundred forty-day period after weaning.

Reproductive performance was evaluated in composite heifers born over a 3-yr period that were randomly assigned to control (fed to appetite; n = 205) or restricted (fed at 80% of that consumed by controls adjusted to a common BW basis; n = 192) feeding for a 140-d period, beginning about 2 mo after weaning at 6 mo of age and ending at about 12.5 mo of age. Heifers were fed a diet of 67% corn silage, 18% alfalfa, and 9% of a protein-mineral supplement (DM basis). Restricted heifers consumed 27% less feed over the 140 d and had less ADG (0.53 +/- 0.01 vs. 0.65 +/- 0.01 kg/d; P < 0.001) than control heifers. After 140 d, all heifers were placed in common pens and subjected to an estrous synchronization protocol to facilitate AI at about 14 mo of age. Heifers were then exposed to bulls for the remainder of a 51-d breeding season. Average BW of heifers diverged within 28-d after initiation of feed restriction, and differences (P < 0.001) persisted through the prebreeding period (309 +/- 1 vs. 326 +/- 1 kg at approximately 13.5 mo of age) and subsequent grazing season (410 +/- 2 vs. 418 +/- 2 kg at about 19.5 mo of age). From the end of the 140-d restriction at about 12.5 to 19.5 mo of age, ADG was greater (P < 0.001) in restricted heifers than control heifers (0.51 +/- 0.01 vs. 0.47 +/- 0.01 kg/d). Proportion of heifers attaining puberty by 14 mo of age tended to be less (P = 0.1) in restricted (60 +/- 3%) than control-fed heifers (68 +/- 3%). Mean BW at puberty was less (P < 0.01) in restricted (309 kg) than control (327 kg) heifers. Pregnancy rate from AI tended to be less (P = 0.08) in restricted (48 +/- 4%) than control heifers (57 +/- 3%). Proportion of animals that were pubertal at breeding and pregnant from AI were positively associated (P < 0.1) with heifer age and ADG from birth to beginning of study. Final pregnancy rates were 87 and 91% for restricted and control heifers, respectively (P = 0.27). Day of breeding season that conception occurred was negatively associated with ADG from birth to weaning (P = 0.005), but was not associated with ADG within treatment (P = 0.60). Economic analysis revealed a $33 reduction in cost to produce a pregnant heifer under the restricted protocol when accounting for pregnancy rates and differences in BW and market prices between selection at weaning and marketing as open heifers at l.5 yr of age. A potential economic advantage exists for rearing replacement heifers on a restricted level of feeding during the postweaning period.

Implementation of a national, nurse-led telephone health service in Scotland: assessing the consequences for remote and rural localities.

INTRODUCTION: Internationally, nurse-led models of telephone triage have become commonplace in unscheduled healthcare delivery. Various existing models have had a positive impact on the delivery of healthcare services, often reducing the demand on accident and emergency departments and staff workload 'out of hours'. Our objective was to assess whether a model of centralised nurse telephone triage (NHS 24, introduced in Scotland in 2001) was appropriate for remote and rural areas. In this qualitative study the views and perspectives of health professionals across Scotland are explored. METHODS: Thirty-five participants were purposively selected for interviews during 2005. Two types of interview were conducted: detailed, semi-structured, face-to-face interviews with key stakeholders of NHS 24; and briefer telephone interviews with partners from NHS Boards across Scotland. A constant comparative approach was taken to analysis. Ethical approval for the study was obtained from the Scottish Multi-site Research Ethics Committee. RESULTS: The findings are comparable with other research studies of new service developments in remote and rural health care. The rigidity of the centralised triage model introduced, the need to understand variation of health service delivery, and the importance of utilising local professional knowledge were all key issues affecting performance. CONCLUSION: Remote and rural complexities need to be considered when designing new healthcare services. It is suggested that new health service designs are 'proofed' for remote and rural complexities. This study highlights that a centralised nurse-led telephone triage model was inappropriate for remote and rural Scotland, and may not be appropriate for all geographies and circumstances.