New models of health and social care for people in later life: mapping of innovation in services in two regions of the United Kingdom using a mixed method approach.

BACKGROUND: Innovation for reforming health and social care is high on the policy agenda in the United Kingdom in response to the growing needs of an ageing population. However, information about new innovations of care being implemented is sparse. METHODS: We mapped innovations for people in later life in two regions, North East England and South East Scotland. Data collection included discussions with stakeholders (n = 51), semi-structured interviews (n = 14) and website searches that focused on technology, evaluation and health inequalities. We analysed qualitative data using framework and thematic analyses. Quantitative data were analysed descriptively. RESULTS: One hundred eleven innovations were identified across the two regions. Interviewees reported a wide range of technologies that had been rapidly introduced during the COVID-19 pandemic and many remained in use. Digital exclusion of certain groups of older people was an ongoing concern. Innovations fell into two groups; system-level ones that aimed to alleviate systems pressures such as preventing hospital (re)admissions, and patient-level ones which sought to enhance health and wellbeing directly. Interviewees were aware of the importance of health inequalities but lacked data to monitor the impact of innovations on these, and evaluation was challenging due to lack of time, training, and support. Quantitative findings revealed that two thirds of innovations (n = 74, 67%) primarily focused on the system level, whilst a third (n = 37, 33%) primarily focused on the patient-level. Overall, over half (n = 65, 59%) of innovations involved technologies although relatively few (n = 12, 11%) utilised advanced technologies. Very few (n = 16, 14%) focused on reducing health inequalities, and only a minority of innovations (n = 43, 39%) had undergone evaluation (most of which were conducted by the service providers themselves). CONCLUSIONS: We found a wide range of innovative care services being developed for people in later life, yet alignment with key policy priorities, such as addressing health inequalities, was limited. There was a strong focus on technology, with little consideration for the potential to widen the health inequality gap. The absence of robust evaluation was also a concern as most innovations were implemented without support to monitor effectiveness and/or without plans for sustainability and spread.

Among-species variation in six decades of changing migration timings explained through ecology, life-history and local migratory abundance.

Species exploiting seasonal environments must alter timings of key life-history events in response to large-scale climatic changes in order to maintain trophic synchrony with required resources. Yet, substantial among-species variation in long-term phenological changes has been observed. Advancing from simply describing such variation towards predicting future phenological responses requires studies that rigorously quantify and explain variation in the direction and magnitude of changing timings across diverse species in relation to key ecological and life-history variables. Accordingly, we fitted multi-quantile regressions to 59 years of multi-species data on spring and autumn bird migration timings through northern Scotland. We demonstrate substantial variation in changes in timings among 72 species, and tested whether such variation can be explained by species ecology, life-history and changes in local abundance. Consistent with predictions, species that advanced their migration timing in one or both seasons had more seasonally restricted diet types, fewer suitable breeding habitat types, shorter generation lengths and capability to produce multiple offspring broods per year. In contrast, species with less seasonally restricted diet types and that produce single annual offspring broods, showed no change. Meanwhile, contrary to prediction, long-distance and short-distance migrants advanced migration timings similarly. Changes in migration timing also varied with changes in local migratory abundance, such that species with increasing seasonal abundance apparently altered their migration timing, whilst species with decreasing abundance did not. Such patterns broadly concur with expectation given adaptive changes in migration timing. However, we demonstrate that similar patterns can be generated by numerical sampling given changing local abundances. Any apparent phenology-abundance relationships should, therefore, be carefully validated and interpreted. Overall, our results show that migrant bird species with differing ecologies and life-histories showed systematically differing phenological changes over six decades contextualised by large-scale environmental changes, potentially facilitating future predictions and altering temporal dynamics of seasonal species co-occurrences.

Accessing opioid agonist treatment in prison in England and Scotland remains problematic - the views of people with lived experience.

PURPOSE: The purpose of this paper is to examine lived experiences of opioid agonist treatment (OAT) during and immediately following release from detention in prisons in England and Scotland. DESIGN/METHODOLOGY/APPROACH: Surveys were completed by serving prisoners in both countries and by those recently released from prison (England only). The survey findings were discussed in focus groups of people with lived experience. The combined findings from the surveys and focus groups were shared with an expert group of prison OAT providers and people with lived experience with the purpose of making recommendations for more accessible and effective OAT in custodial environments and continuity of OAT on release. FINDINGS: The quality and accessibility of OAT varied considerably between establishments. It was reported to be harder to access OAT in Scottish prisons. It was often hard for people in prison to get the dosage of OAT they felt they needed and it was generally harder to access buprenorphine than methadone in English prisons. Only Scottish people in prison were aware of long-lasting forms of buprenorphine. People in English prisons had mixed experiences of the help available in prison, with no improvement recorded since a 2016 study. People in Scottish prisons were more likely to rate the help available as poor. RESEARCH LIMITATIONS/IMPLICATIONS: The number of people accessed while actually in prison (73) was reduced by the impact of the pandemic, making it more difficult to access people in prison and because some were resistant to participating on the basis that they had already been consulted for a wide variety of research projects focused on the impact of COVID. The Scottish cohort (a total of 19 individuals comprising 14 survey respondents and five focus group members) is clearly too small a number on which to base robust claims about differences in OAT provision between the English and Scottish prison systems.. PRACTICAL IMPLICATIONS: The study identifies key barriers to accessing OAT in prisons and suggests key components of more user-friendly approaches. SOCIAL IMPLICATIONS: This study provides an overview of the recent lived experiences of people accessing OAT in prison and on release and offers valuable recommendations on how to make service provision more effective and consistent. ORIGINALITY/VALUE: This study provides an overview of the recent lived experiences of people accessing OAT in prison and on release in England and Scotland and offers valuable recommendations on how to make service provision more effective and consistent.

Characteristics and outcomes of patients with COVID-19 at high risk of disease progression receiving sotrovimab, oral antivirals, or no treatment: a retrospective cohort study.

BACKGROUND: The clinical benefit of coronavirus disease 2019 (COVID-19) treatments against new circulating variants remains unclear. We sought to describe characteristics and clinical outcomes of highest risk patients with COVID-19 receiving early COVID-19 treatments in Scotland. METHODS: Retrospective cohort study of non-hospitalized patients diagnosed with COVID-19 from December 1, 2021-October 25, 2022, using Scottish administrative health data. We included adult patients who met ≥ 1 of the National Health Service highest risk criteria for early COVID-19 treatment and received outpatient treatment with sotrovimab, nirmatrelvir/ritonavir or molnupiravir, or no early COVID-19 treatment. Index date was defined as the earliest of COVID-19 diagnosis or early COVID-19 treatment. Baseline characteristics and acute clinical outcomes in the 28 days following index were reported. Values of ≤ 5 were suppressed. RESULTS: In total, 2548 patients were included (492: sotrovimab, 276: nirmatrelvir/ritonavir, 71: molnupiravir, and 1709: eligible highest risk untreated). Patients aged ≥ 75 years accounted for 6.9% (n = 34/492), 21.0% (n = 58/276), 16.9% (n = 12/71) and 13.2% (n = 225/1709) of the cohorts, respectively. Advanced renal disease was reported in 6.7% (n = 33/492) of sotrovimab-treated and 4.7% (n = 81/1709) of untreated patients, and ≤ 5 nirmatrelvir/ritonavir-treated and molnupiravir-treated patients. All-cause hospitalizations were experienced by 5.3% (n = 25/476) of sotrovimab-treated patients, 6.9% (n = 12/175) of nirmatrelvir/ritonavir-treated patients, ≤ 5 (suppressed number) molnupiravir-treated patients and 13.3% (n = 216/1622) of untreated patients. There were no deaths in the treated cohorts; mortality was 4.3% (n = 70/1622) among untreated patients. CONCLUSIONS: Sotrovimab was often used by patients who were aged < 75 years. Among patients receiving early COVID-19 treatment, proportions of 28-day all-cause hospitalization and death were low.

Using digital technology to reduce drug-related harms: a targeted service users' perspective of the Digital Lifelines Scotland programme.

BACKGROUND: Deaths due to drug overdose are an international issue, causing an estimated 128,000 global deaths in 2019. Scotland has the highest rate of drug-related deaths in Europe, with those in the most deprived areas at greater risk than those in affluent areas. There is a paucity of research on digital solutions, particularly from the perspective of those who use drugs who additionally access harm reduction and homelessness support services. The Digital Lifelines Scotland programme (DLS) provides vulnerable people who use/d drugs with digital devices to connect with services. METHODS: This paper reports on the evaluation of the DLS from the perspective of service users who accessed services for those at risk of drug-related harms. A mixed methods approach was used including an online-survey (n = 19) and semi-structured interviews (n = 21). Survey data were analysed descriptively and interview data through inductive coding, informed by the Technology, People, Organisations and Macroenvironmental factors (TPOM) framework, to investigate the use, access, and availability of devices, and people's experiences and perceptions of them. RESULTS: Most participants lived in social/council housing (63.2%, n = 12), many lived alone (68.4%, n = 13). They were mainly over 40 years old and lived in a city. Participants described a desire for data privacy, knowledge, and education, and placed a nascent social and personal value on digital devices. Participants pointed to the person-centred individuality of the service provision as one of the reasons to routinely engage with services. Service users experienced an increased sense of value and there was a palpable sense of community, connection and belonging developed through the programme, including interaction with services and devices. CONCLUSIONS: This paper presents a unique perspective which documents the experiences of service users on the DLS. Participants illustrated a desire for life improvement and a collective and individual feeling of responsibility towards themselves and digital devices. Digital inclusion has the potential to provide avenues by which service users can safely and constructively access services and society to improve outcomes. This paper provides a foundation to further cultivate the insight of service users on digital solutions in this emerging area.

REALITIES in health disparities: Researching Evidence-based Alternatives in Living, Imaginative, Traumatised, Integrated, Embodied Systems.

Introduction: Under the backdrop of pervasive health inequalities, public health professionals, researchers and non-academic partners in the United Kingdom are mobilising to understand how and in what ways community assets can address health disparities at scale in complex systems. While there is recognition that cultural, natural and community resources can improve health outcomes, these are unequally dispersed with lack of integration in communities and health and social care systems. Researching Evidence-based Alternatives in Living, Imaginative, Traumatised, Integrated, Embodied Systems (REALITIES) is a participatory action research Scottish consortium of 57 with established community asset hubs in five localities with strong relationships uniting conflicting ways of seeing the world. Our collective of lived and felt experience community members, community-embedded researchers, academics and non-academics draws upon a variety of practices, methods, datasets and philosophies to expand existing approaches to tackling health inequalities. Methods: We present conceptual and theoretical underpinnings for our co-produced systems-level model and empirical findings from testing REALITIES across three disadvantaged localities (November 2022, ongoing). After explaining the context that led to the development of the new scalable REALITIES model for integrated public systems to interface with 'assets', we detail philosophical pillars and guiding principles for our model and how we applied these mechanisms to explain how integrated partnership working can lead to improved health outcomes across multiple public systems. Results: We present a meta-analysis from co-producing and testing the model, showing how measuring change in complex public systems involves critical investigation of People, Process, Place, Price, Power and Purpose. Our critique reflects on power imbalances and inequities in Research-practice-Policy (RPP) partnerships and suggestions for how to nurture healthy ecosystems: overcoming barriers and enabling participation; reflecting on challenges of scaling up, testability and complexity of RPP partnerships; moving from siloed learning to transdisciplinary collaboration in practice; ensuring knowledge exchange has direct impact on communities and frontline practitioners; embedding relational ethics and safeguarding into daily practice. Discussion: We propose the REALITIES model to unite alternative, sometimes conflicting, ways of thinking about public systems and community assets by continuously reflecting on entanglements between different assumptions about knowledge, reality, evidence, and unnecessary binaries between creative methodologies and scientific method.

Developing and evaluating a brief, socially primed video intervention to enable bystander cardiopulmonary resuscitation: A randomised control trial.

BACKGROUND: Over 30,000 people experience out-of-hospital cardiac arrest in the United Kingdom annually, with only 7-8% of patients surviving. One of the most effective methods of improving survival outcomes is bystander intervention in the form of calling the emergency services and initiating chest compressions. Additionally, the public must feel empowered to act and use this knowledge in an emergency. This study aimed to evaluate an ultra-brief CPR familiarisation video that uses empowering social priming language to frame CPR as a norm in Scotland. METHODS: In a randomised control trial, participants (n = 86) were assigned to view an ultra-brief CPR video intervention or a traditional long-form CPR video intervention. Following completion of a pre-intervention questionnaire examining demographic variables and prior CPR knowledge, participants completed an emergency services-led resuscitation simulation in a portable simulation suite using a CPR manikin that measures resuscitation quality. Participants then completed questionnaires examining social identity and attitudes towards performing CPR. RESULTS: During the simulated resuscitation, the ultra-brief intervention group's cumulative time spent performing chest compressions was significantly higher than that observed in the long-form intervention group. The long-form intervention group's average compressions per minute rate was significantly higher than the ultra-brief intervention group, however both scores fell within a clinically acceptable range. No other differences were observed in CPR quality. Regarding the social identity measures, participants in the ultra-brief condition had greater feelings of expected emergency support from other Scottish people when compared to long-form intervention participants. There were no significant group differences in attitudes towards performing CPR. CONCLUSIONS: Socially primed, ultra-brief CPR interventions hold promise as a method of equipping the public with basic resuscitation skills and empowering the viewer to intervene in an emergency. These interventions may be an effective avenue for equipping at-risk groups with resuscitation skills and for supplementing traditional resuscitation training.

Emergence of novel methicillin resistant Staphylococcus pseudintermedius lineages revealed by whole genome sequencing of isolates from companion animals and humans in Scotland.

Staphylococcus pseudintermedius is an opportunistic pathogen in dogs, and infection in humans is increasingly found, often linked to contact with dogs. We conducted a retrospective genotyping and antimicrobial susceptibility testing study of 406 S. pseudintermedius isolates cultured from animals (dogs, cats and an otter) and humans across Scotland, from 2007 to 2020. Seventy-five sequence types (STs) were identified, among the 130 isolates genotyped, with 59 seen only once. We observed the emergence of two methicillin resistant Staphylococcus pseudintermedius (MRSP) clones in Scotland: ST726, a novel locally-evolving clone, and ST551, first reported in 2015 in Poland, possibly linked to animal importation to Scotland from Central Europe. While ST71 was the most frequent S. pseudintermedius strain detected, other lineages that have been replacing ST71 in other countries, in addition to ST551, were detected. Multidrug resistance (MDR) was detected in 96.4% of MRSP and 8.4% of MSSP. A single MRSP isolate was resistant to mupirocin. Continuous surveillance for the emergence and dissemination of novel MDR MRSP in animals and humans and changes in antimicrobial susceptibility in S. pseudintermedius is warranted to minimise the threat to animal and human health.

Guideline summary: assessment, diagnosis, care and support for people with dementia and their carers [Scottish Intercollegiate Guidelines Network SIGN Guideline 168].

The Scottish Intercollegiate Guidelines Network (SIGN) have recently published their guideline SIGN168 on 'Assessment, Diagnosis, Care, and Support for People with Dementia and their Carers'. The guideline makes evidence-based recommendations for best practice in the assessment, care and support of adults living with dementia. Topics featured in this guideline are limited to those prioritised by stakeholders, especially people with lived and living experience, and those not well covered under pre-existing guidance. We summarise the guideline recommendations related to identification and diagnosis of dementia, investigative procedures, postdiagnostic support living with dementia, including non-pharmacological approaches for distressed behaviours, using technology to support people with dementia, grief and dementia and changing needs of people with dementia. The guideline content is summarised as officially published, with additional commentary in the final section.

Sustainable oral healthcare: what is it and how do we achieve it?

In recent years, there has been an increase in interest in what environmental sustainability means for healthcare, including oral health and dentistry. To help facilitate discussions among key stakeholders in this area, the Scottish Dental Clinical Effectiveness Programme held a workshop in November 2022. The purpose of this workshop was to explore current thinking on the subject of sustainability as it relates to oral health and to help stakeholders identify how to engage with the sustainability agenda. This paper presents an overview of the presentations and discussions from the workshop and highlights potential avenues for future work and collaboration.

Understanding exercise referrals in primary care: a qualitative study of GPs and physiotherapists.

BACKGROUND: Physical inactivity is estimated to cost the UK NHS over £1 billion per year. Healthcare practitioners have a key role in supporting increases in physical activity (PA) levels, including referring to exercise referral schemes (ERS). To date, there has been little research into practitioner perspectives on referrals to ERS. AIM: To explore the views and experiences of GPs and physiotherapists in relation to factors that influence referral and adherence to ERS. METHOD: Qualitative study of primary care-based practitioners in Glasgow, UK. Semi-structured interviews were conducted with 14 practitioners (seven GPs and seven physiotherapists). Interviews were recorded and analysed thematically. RESULTS: Four themes are presented. First, healthcare practitioners bring inherent biases to a consultation that impact their approach to PA promotion. Second, clinical time pressures are a major barrier to effective PA promotion. Third, patient-led, compassionate care is the most vital component of behaviour change, with suggestions that promoting peer support and the use of personal anecdotes to normalise vulnerabilities might be helpful. Last, providing ongoing support for change was beneficial to PA promotion. This is often accessed through ERS and is improved by better collaboration between exercise providers and referring practitioners. CONCLUSION: Practitioners believed ERS referrals could be improved with more targeted training, support for multidisciplinary working, and enhanced communication between the programmes and referrers. Additionally, supporting behaviour change requires time to develop rapport and understand patients' motivations and beliefs. Lack of time is the greatest current barrier to effective PA promotion.

What interventions have addressed the inverse care law in general practice in Scotland over the last 20 years? A systematic scoping review.

BACKGROUND: Recent evidence demonstrates persistence of the inverse care law (ICL), with fewer GPs and less funding in more deprived areas. AIM: To map out interventions that aimed to address the ICL and the rationale behind them, and to review the impact and sustainability of these interventions - what has worked, for whom, and why? METHOD: The authors searched Embase, Web of Science, MEDLINE, CINAHL, Cochrane, and BASE from 2000 to 2022 for articles describing interventions or policies that aimed to address the ICL in general practice in Scotland. A systematic grey literature search of government, NHS, and third-sector websites was also performed. All articles were double screened for inclusion. Quantitative and qualitative studies were included. Other forms of primary care, such as dental or pharmacy, were not included. RESULTS: There were 77 included articles (35 from the database search and 42 from the grey literature) reporting on 20 interventions. Interventions were categorised as: 1) enhancing financial or social support; 2) targeting specific health conditions; 3) holistic interventions targeting specific populations; and 4) enhancing generalist care. Seven key interventions accounted for over 70% of all included articles. Evidence of impact and sustainability was variable. Key lessons were summarised for each intervention and grouped by category. CONCLUSION: To address the ICL, a key recommendation is for greater investment in general practice as part of the overall NHS spend, with graded additional resources for more deprived areas depending on local population need (a 'proportionate universalism' approach).

Student and educator experiences of a student-led clinic in general practice.

BACKGROUND: Giving students more responsibility for real patients during medical school may help prepare them for their transition to clinical practice. Student-led clinics (SLCs) may facilitate this. Within SLCs, students take the lead role in delivering patient care while being supported and supervised by qualified clinicians. A general practice SLC was established in Dundee, with four final-year medical students and one GP involved in each clinic. AIM: This study aimed to explore students' and educators' experiences and perceptions of this SLC. METHOD: This was an exploratory case study. Semi-structured interviews were conducted with 11 students and three educators, and 18 hours of observation were conducted over six clinics. Interview transcripts and fieldnotes were integrated and thematically analysed. RESULTS: Overall, students' and educators' experiences and perceptions were positive. Students thrived in their lead role in patient care, gaining a sense of empowerment and developing confidence in their abilities. Both students and educators felt comfortable with students having this level of responsibility due to the students' stage of training and the supervision provided by educators. Teaching within the SLC involved individual discussions and group debriefs. Students felt a sense of belonging as a result of their relationships with their peers and educators. Challenges arose when the clinic ran behind schedule due to unexpected complex patients or lengthy individual discussions. CONCLUSION: The findings suggest that giving students responsibility for real patients is beneficial and feasible when adequate support is provided, and that it is possible for one GP to supervise multiple students successfully.

Evaluating adherence to ECG monitoring protocols for methadone patients in primary care.

BACKGROUND: Opioid Agonist Treatment (OAT) is the gold standard for managing Opioid Use Disorder (OUD). It is highly effective at reducing all-cause mortality and drug-related harms. Prescribing OAT, particularly methadone, is becoming increasingly complex as Scotland's OUD population ages. Older patients, with increased polypharmacy and multimorbidity, are more susceptible to QTc interval prolongation associated with methadone use. Therefore, adherence to ECG monitoring guidelines for patients prescribed methadone is crucial, though insights from substance use services indicate suboptimal compliance. Medically Assisted Treatment guidelines established by the Scottish Government advocate for shared care agreements, thus transferring OAT prescribing responsibilities to primary care. Understanding ECG monitoring guideline implementation in non-specialist services is vital for developing safe OAT services in primary care. AIM: This audit assessed adherence to NICE guidelines for ECG monitoring in OUD patients prescribed methadone in a Scottish primary care practice. METHOD: The notes of patients prescribed methadone were assessed using NICE criteria to determine eligibility for ECG monitoring. Eligible patients' medical records were reviewed to identify previous ECG investigations. RESULTS: Of 21 patients prescribed methadone, 16 qualified for ECG monitoring. Only 25% of eligible patients received ECG monitoring per NICE guideline, meaning 75% did not. CONCLUSION: These findings highlight that the issue of poor compliance with ECG monitoring guidelines is not limited to specialist services, but also affects primary care. Further exploration of barriers to guideline implementation is essential. Perhaps more resources are needed to integrate OAT services into primary care, which has taken on increased responsibilities without corresponding investment.

Estimating the risks of exposure to harmful algal toxins among Scottish harbour seals.

Harmful algal bloom (HAB) toxins consumed by marine predators through fish prey can be lethal but studies on the resulting population consequences are lacking. Over the past approximately 20 years there have been large regional declines in some harbour seal populations around Scotland. Analyses of excreta (faeces and urine from live and dead seals and faecal samples from seal haulout sites) suggest widespread exposure to toxins through the ingestion of contaminated prey. A risk assessment model, incorporating concentrations of the two major HAB toxins found in seal prey around Scotland (domoic acid (DA), and saxitoxins (STX)), the seasonal persistence of the toxins in the fish and the foraging patterns of harbour seals were used to estimate the proportion of adults and juveniles likely to have ingested doses above various estimated toxicity thresholds. The results were highly dependent on toxin type, persistence, and foraging regime as well as age class, all of which affected the proportion of exposed animals exceeding toxicity thresholds. In this preliminary model STX exposure was unlikely to result in mortalities. Modelled DA exposure resulted in doses above an estimated lethal threshold of 1900 µg/kg body mass affecting up to 3.8 % of exposed juveniles and 5.3 % of exposed adults. Given the uncertainty in the model parameters and the limitations of the data these conclusions should be treated with caution, but they indicate that DA remains a potential factor involved in the regional declines of harbour seals. Similar risks may be experienced by other top predators, including small cetaceans and seabirds that feed on similar prey in Scottish waters.

Generation Scotland: an update on Scotland's longitudinal family health study.

PURPOSE: Generation Scotland (GS) is a large family-based cohort study established as a longitudinal resource for research into the genetic, lifestyle and environmental determinants of physical and mental health. It comprises extensive genetic, sociodemographic and clinical data from volunteers in Scotland. PARTICIPANTS: A total of 24 084 adult participants, including 5501 families, were recruited between 2006 and 2011. Within the cohort, 59% (approximately 14 209) are women, with an average age at recruitment of 49 years. Participants completed a health questionnaire and attended an in-person clinic visit, where detailed baseline data were collected on lifestyle information, cognitive function, personality traits and mental and physical health. Genotype array data are available for 20 026 (83%) participants, and blood-based DNA methylation (DNAm) data for 18 869 (78%) participants. Linkage to routine National Health Service datasets has been possible for 93% (n=22 402) of the cohort, creating a longitudinal resource that includes primary care, hospital attendance, prescription and mortality records. Multimodal brain imaging is available in 1069 individuals. FINDINGS TO DATE: GS has been widely used by researchers across the world to study the genetic and environmental basis of common complex diseases. Over 350 peer-reviewed papers have been published using GS data, contributing to research areas such as ageing, cancer, cardiovascular disease and mental health. Recontact studies have built on the GS cohort to collect additional prospective data to study chronic pain, major depressive disorder and COVID-19. FUTURE PLANS: To create a larger, richer, longitudinal resource, 'Next Generation Scotland' launched in May 2022 to expand the existing cohort by a target of 20 000 additional volunteers, now including anyone aged 12+ years. New participants complete online consent and questionnaires and provide postal saliva samples, from which genotype and salivary DNAm array data will be generated. The latest cohort information and how to access data can be found on the GS website (www.generationscotland.org).

Public preferences and willingness to pay for a net zero NHS: a protocol for a discrete choice experiment in England and Scotland.

INTRODUCTION: Climate change poses a major threat to our health, livelihoods and the planet. In 2020, the UK National Health Service (NHS) committed to reducing its Scope 1, 2 and 3 emissions to reach net zero by 2045. Although a net zero NHS would help to limit the consequences of climate change, little is known about the UK general public's values and preferences for the proposed service changes needed to reach net zero. METHODS: This study will elicit the public's preferences for actions to help achieve net zero NHS in England and Scotland using a discrete choice experiment (DCE). The DCE attributes and levels describe actions that can be taken by the NHS across key areas: buildings and estates, outdoor space, travel and transport, provision of care, goods and services and food and catering. The survey was designed using online think-aloud interviews with 17 members of the public. Two versions of the survey will be administered to a sample of up to 2200 respondents. One will include a payment vehicle as income tax increases. We will estimate the relative importance of each attribute and, for the former survey, the monetary trade-offs which individuals are willing to make between attributes. Where possible, we will match both samples to gauge preference robustness with the inclusion of the monetary payment. We will test whether respondents' preferences differ based on their socioeconomic circumstances and attitudes toward the NHS and climate change. ETHICS AND DISSEMINATION: The University of Aberdeen's School of Medicine, Medical Sciences and Nutrition Ethics Research Board has approved the study (reference: SERB/690090). All participants will provide informed consent. Results will be submitted to peer-reviewed publications and presented at relevant conferences and seminars. A lay summary of the research will be published on the Health Economics Research Unit website.

Implementation of a Web-Based Outpatient Asynchronous Consultation Service: Mixed Methods Study.

BACKGROUND: Asynchronous outpatient patient-to-provider communication is expanding in UK health care, requiring evaluation. During the pandemic, Aberdeen Royal Infirmary in Scotland expanded its outpatient asynchronous consultation service from dermatology (deployed in May 2020) to gastroenterology and pain management clinics. OBJECTIVE: We conducted a mixed methods study using staff, patient, and public perspectives and National Health Service (NHS) numerical data to obtain a rounded picture of innovation as it happened. METHODS: Focus groups (3 web-based and 1 face-to-face; n=22) assessed public readiness for this service, and 14 interviews with staff focused on service design and delivery. The service's effects were examined using NHS Grampian service use data, a patient satisfaction survey (n=66), and 6 follow-up patient interviews. Survey responses were descriptively analyzed. Demographics, acceptability, nonattendance rates, and appointment outcomes of users were compared across levels of area deprivation in which they live and medical specialties. Interviews and focus groups underwent theory-informed thematic analysis. RESULTS: Staff anticipated a simple technical system transfer from dermatology to other receptive medical specialties, but despite a favorable setting and organizational assistance, it was complicated. Key implementation difficulties included pandemic-induced technical integration delays, misalignment with existing administrative processes, and discontinuity in project management. The pain management clinic began asynchronous consultations (digital appointments) in December 2021, followed by the gastroenterology clinic in February 2022. Staff quickly learned how to explain and use this service. It was thought to function better for pain management as it fitted preexisting practices. From May to September 2022, the dermatology (adult and pediatric), gastroenterology, and pain management clinics offered 1709 appointments to a range of patients (n=1417). Digital appointments reduced travel by an estimated 44,712 miles (~71,956.81 km) compared to the face-to-face mode. The deprivation profile of people who chose to use this service closely mirrored that of NHS Grampian's population overall. There was no evidence that deprivation impacted whether digital appointment users subsequently received treatment. Only 18% (12/66) of survey respondents were unhappy or very unhappy with being offered a digital appointment. The benefits mentioned included better access, convenience, decreased travel and waiting time, information sharing, and clinical flexibility. Overall, patients, the public, and staff recognized its potential as an NHS service but highlighted informed choice and flexibility. Better communication-including the use of the term assessment instead of appointment-may increase patient acceptance. CONCLUSIONS: Asynchronous pain management and gastroenterology consultations are viable and acceptable. Implementing this service is easiest when existing administrative processes face minimal disruption, although continuous support is needed. This study can inform practical strategies for supporting staff in adopting asynchronous consultations (eg, preparing for nonlinearity and addressing task issues). Patients need clear explanations and access to technical support, along with varied consultation options, to ensure digital inclusion.

Real-world severe COVID-19 outcomes associated with use of antivirals and neutralising monoclonal antibodies in Scotland.

We sought to investigate the incidence of severe COVID-19 outcomes after treatment with antivirals and neutralising monoclonal antibodies, and estimate the comparative effectiveness of treatments in community-based individuals. We conducted a retrospective cohort study investigating clinical outcomes of hospitalisation, intensive care unit admission and death, in those treated with antivirals and monoclonal antibodies for COVID-19 in Scotland between December 2021 and September 2022. We compared the effect of various treatments on the risk of severe COVID-19 outcomes, stratified by most prevalent sub-lineage at that time, and controlling for comorbidities and other patient characteristics. We identified 14,365 individuals treated for COVID-19 during our study period, some of whom were treated for multiple infections. The incidence of severe COVID-19 outcomes (inpatient admission or death) in community-treated patients (81% of all treatment episodes) was 1.2% (n = 137/11894, 95% CI 1.0-1.4), compared to 32.8% in those treated in hospital for acute COVID-19 (re-admissions or death; n = 40/122, 95% CI 25.1-41.5). For community-treated patients, there was a lower risk of severe outcomes (inpatient admission or death) in younger patients, and in those who had received three or more COVID-19 vaccinations. During the period in which BA.2 was the most prevalent sub-lineage in the UK, sotrovimab was associated with a reduced treatment effect compared to nirmaltrelvir + ritonavir. However, since BA.5 has been the most prevalent sub-lineage in the UK, both sotrovimab and nirmaltrelvir + ritonavir were associated with similarly lower incidence of severe outcomes than molnupiravir. Around 1% of those treated for COVID-19 with antivirals or neutralising monoclonal antibodies required hospital admission. During the period in which BA.5 was the prevalent sub-lineages in the UK, molnupiravir was associated with the highest incidence of severe outcomes in community-treated patients.