Areas of enduring COVID-19 prevalence: drivers of prevalence and mitigating strategies.

BACKGROUND: UK local authorities that experienced sustained high levels of COVID-19 between 1st March 2020 and 28th February 2021 were described by the UK Scientific Advisory Group for Emergencies as areas of enduring prevalence. This research was carried out in order to examine the views of local authority Directors of Public Health, who played a crucial role in the local response to COVID-19, on reasons for sustained high levels of prevalence in some areas, alongside an investigation of the mitigation strategies that they implemented during the course of the pandemic. METHODS: Interviews were conducted with Directors of Public Health in 19 local authority areas across England, between July and November 2021. This included nine areas identified as areas of enduring prevalence and ten 'comparison' areas. RESULTS: The outcomes of this study suggests that the geographical differences in prevalence rates are strongly influenced by health inequalities. Structural factors including deprivation, employment, and housing, due to their disproportionate impact on specific groups, converged with demographic factors, including ethnicity and age, and vaccination rates, and were identified as the main drivers of enduring prevalence. There are key differences in these drivers both within and, to a lesser extent, between local authorities. Other than these structural barriers, no major differences in facilitators or barriers to COVID-19 mitigation were identified between areas of varying prevalence. The main features of successful mitigation strategies were a locally tailored approach and partnership working involving local authority departments working with local health, community, voluntary and business organisations. CONCLUSIONS: This study is the first to add the voices of Directors of Public Health, who played a crucial role in the local COVID-19 response. Areas of enduring prevalence existed during the pandemic which were caused by a complex mix of structural factors related to inequalities. Participants advised that more research is needed on the effectiveness of mitigation strategies and other measures to reduce the impact of structural inequalities, to better understand the factors that drive prevalence. This would include an assessment of how these factors combine to predict transmission and how this varies between different areas.

When trust, confidence, and faith collide: refining a realist theory of how and why inter-organisational collaborations in healthcare work.

BACKGROUND: Health systems are facing unprecedented socioeconomic pressures as well as the need to cope with the ongoing strain brought about by the COVID-19 pandemic. In response, the reconfiguration of health systems to encourage greater collaboration and integration has been promoted with a variety of collaborative shapes and forms being encouraged and developed. Despite this continued interest, evidence for success of these various arrangements is lacking, with the links between collaboration and improved performance often remaining uncertain. To date, many examinations of collaborations have been undertaken, but use of realist methodology may shed additional light on how and why collaboration works, and whom it benefits. METHODS: This paper seeks to test initial context-mechanism-outcome configurations (CMOCs) of interorganisational collaboration with the view to producing a refined realist theory. This phase of the realist synthesis used case study and evaluation literature; combined with supplementary systematic searches. These searches were screened for rigour and relevance, after which CMOCs were extracted from included literature and compared against existing ones for refinement, refutation, or affirmation. We also identified demi-regularities to better explain how these CMOCs were interlinked. RESULTS: Fifty-one papers were included, from which 338 CMOCs were identified, where many were analogous. This resulted in new mechanisms such as 'risk threshold' and refinement of many others, including trust, confidence, and faith, into more well-defined constructs. Refinement and addition of CMOCs enabled the creation of a 'web of causality' depicting how contextual factors form CMOC chains which generate outputs of collaborative behaviour. Core characteristics of collaborations, such as whether they were mandated or cross-sector, were explored for their proposed impact according to the theory. CONCLUSION: The formulation of this refined realist theory allows for greater understanding of how and why collaborations work and can serve to inform both future work in this area and the implementation of these arrangements. Future work should delve deeper into collaborative subtypes and the underlying drivers of collaborative performance. REVIEW REGISTRATION: This review is part of a larger realist synthesis, registered at PROSPERO with ID CRD42019149009 .

The impact of COVID-19 on practice learning in nurse education.

The COVID-19 pandemic has impacted healthcare education and delivery, including both theory and practice learning. Academic staff responded rapidly to move teaching online during the first lockdown, with many returning to practice to deliver care or upskill practice staff to work in critical care. Many pre-registration students responded by becoming paid NHS employees, contributing to care delivery while remaining on their programme of study. Practice learning partners, despite the challenges of the pandemic, continued to support students to achieve their registration status. This occurred within the context of the Emergency and Recovery Standards, published by the Nursing and Midwifery Council between March 2020 and September 2021. This paper sets out the response of students, practice learning partners and higher education institutions involved in pre-registration nursing and midwifery programmes.

Building momentum for local action on problem gambling in Leeds and Yorkshire.

Problem gambling has not been a priority within either Leeds City Council or partnership plans. However, financial inclusion, licencing and public health teams have been able to develop a cross-Council approach to problem gambling. This has been aided by an upfront payment plus annual payments to the Council that have been part of the licencing agreement for a new casino. As a result, research has been commissioned on local prevalence. This showed a higher rate of problem gamblers (1.8%) than national estimates with a similar level to nationally of those 'at risk'. The research also showed that local services had difficulties identifying problem gamblers and signposting for support. This had led to a high profile communications campaign to coincide with 'Responsible Gambling Week' complemented by training for frontline workers. The interviews undertaken for the research, plus the findings themselves, have been a powerful help in securing interest and commitment beyond the Council and to the health and third sectors. The use of local stories has helped build momentum for partnership working. For example, focus groups to explore how gambling affected migrants and medical student interviews with university students. The article will describe how increasing understanding across partners has helped build confidence to provide cross city responses to national consultations and contribute to national publications and conferences. Of even greater significance, the local National Health Service has secured funding from GambleAware for a Northern Gambling Service to be based in Leeds with satellites in the North East and Greater Manchester. This will provide treatment for those with severe gambling addiction. Additional support will come from a significant increased provision of GamCare services working to identify, screen and support problem gamblers. The use of Council premises for both of these services is testament to joint working. Recognising that this is a new emerging agenda has led to the creation of a Yorkshire and Humber Problem Gambling Working Group, endorsed by the Association of Directors of Public Health. This has resulted in shared learning and determining a consistent approach to harm. Even during a short time, the degree of interest has risen substantially. A regional gambling harm reduction framework has been produced that sets out a menu of actions. This intends to help local areas determine their own priorities. There is increasing recognition that problem gambling is a public health issue. Leadership requires a systems led, and Health in All Policies, approach to ensure problem gambling is not seen as a narrow niche issue led by public health staff. There is a need to recognise that engagement takes time. However, this is a new and emerging issue. The solutions to problem gambling are not clear and this allows for more creative, pragmatic and coproduced approaches.

Using patient and public involvement to identify priorities for research in long-term conditions management.

BACKGROUND: Patient and public involvement (PPI) is increasingly important in healthcare research. Although this is accepted at the level of individual research studies, it has been less well used in scoping fundamental research priorities. It has been suggested that patients with long-term conditions (LTCs) are well placed to influence research priorities in this area due to their accumulated experience of illness over time. AIMS: To obtain PPI in research-priority setting for a group with a special interest in LTC research. DISCUSSION: PPI representatives provided views on issues they thought required further research. The facilitators were able to move from the specifics of these ideas to identify cross-cutting research priorities. CONCLUSION: It was possible to determine broad research themes despite PPI representatives initially articulating identified issues in very specific terms. Facilitating a better understanding of the research process for PPI representatives would allow their contribution to be more effective. Implications for practice PPI should be considered at the beginning of the process when broad research priorities are considered and before the study design. This is particularly so for broad, non-specialty-focused research themes such as LTCs. More work is required to ensure the views of harder-to-reach groups are included in this type of PPI.

How patient and community involvement in diabetes research influences health outcomes: A realist review.

BACKGROUND: Patient and public involvement in diabetes research is an international requirement, but little is known about the relationship between the process of involvement and health outcomes. OBJECTIVE: This realist review identifies who benefits from different types of involvement across different contexts and circumstances. Search strategies Medline, CINAHL and EMBASE were searched to identify interventions using targeted, embedded or collaborative involvement to reduce risk and promote self-management of diabetes. People at risk/with diabetes, providers and community organizations with an interest in addressing diabetes were included. There were no limitations on date, language or study type. DATA EXTRACTION AND SYNTHESIS: Data were extracted from 29 projects using elements from involvement frameworks. A conceptual analysis of involvement types was used to complete the synthesis. MAIN RESULTS: Projects used targeted (4), embedded (8) and collaborative (17) involvement. Productive interaction facilitated over a sufficient period of time enabled people to set priorities for research. Partnerships that committed to collaboration increased awareness of diabetes risk and mobilized people to co-design and co-deliver diabetes interventions. Cultural adaptation increased relevance and acceptance of the intervention because they trusted local delivery approaches. Local implementation produced high levels of recruitment and retention, which project teams associated with achieving diabetes health outcomes. DISCUSSION AND CONCLUSIONS: Achieving understanding of community context, developing trusting relationships across sectors and developing productive partnerships were prerequisites for designing research that was feasible and locally relevant. The proportion of diabetes studies incorporating these elements is surprisingly low. Barriers to resourcing partnerships need to be systematically addressed.

Self-harm presentations in emergency departments: staff attitudes and triage.

Addressing the rising incidence of self-harm and the demand this places on emergency departments (EDs) are UK Government healthcare priorities. A history of self-harm is linked with suicide risk, so self-harm is a public health issue. The ED is the first point of contact for many people who self-harm so it plays a pivotal role in access to services. Research has highlighted difficulties around triage and assessment in EDs of patients who self-harm, especially frequent attenders. The evidence base on patient experience related to addressing negative staff attitudes is lacking, despite their potent nature and impact on care. Limited knowledge of self-harm aetiology and clinical inexperience have been found to be fundamental to nurses' negative attitudes when dealing with patients who self-harm. This has been linked to negative patient outcomes, including a reluctance to engage with services. This article acknowledges positive changes that have been made and highlights the importance of the triage stage, which is a potential service improvement area, where it would be possible to start and drive positive change in the care of people who self-harm. To address knowledge gaps in education and management, clinical understanding of the aetiology of self-harm should be improved with the aid of education on self-harm cycles. Nurses should also be made aware of common myths surrounding self-harm, as these are barriers to care. Recommendations for practice include partnership working and the urgent need for formal education on this topic for all health professionals working in EDs.

A qualitative case study in the social capital of co-professional collaborative co-practice for children with speech, language and communication needs.

BACKGROUND: Effective co-practice is essential to deliver services for children with speech, language and communication needs (SLCN). The necessary skills, knowledge and resources are distributed amongst professionals and agencies. Co-practice is complex and a number of barriers, such as 'border disputes' and poor awareness of respective priorities, have been identified. However social-relational aspects of co-practice have not been explored in sufficient depth to make recommendations for improvements in policy and practice. Here we apply social capital theory to data from practitioners: an analytical framework with the potential to move beyond descriptions of socio-cultural phenomena to inform change. AIMS: Co-practice in a local authority site was examined to understand: (1) the range of social capital relations extant in the site's co-practice; (2) how these relations affected the abilities of the network to collaborate; (3) whether previously identified barriers to co-practice remain; (4) the nature of any new complexities that may have emerged; and (5) how inter-professional social capital might be fostered. METHODS & PROCEDURES: A qualitative case study of SLCN provision within one local authority in England and its linked NHS partner was completed through face-to-face semi-structured interviews with professionals working with children with SLCN across the authority. Interviews, exploring barriers and facilitators to interagency working and social capital themes, were transcribed, subjected to thematic analysis using iterative methods and a thematic framework derived. OUTCOMES & RESULTS: We identified a number of characteristics important for the effective development of trust, reciprocity and negotiated co-practice at different levels of social capital networks: macro-service governance and policy; meso-school sites; and micro-intra-practitioner knowledge and skills. Barriers to co-practice differed from those found in earlier studies. Some negative aspects of complexity were evident, but only where networked professionalism and trust was absent between professions. Where practitioners embraced and services and systems enabled more fluid forms of collaboration, then trust and reciprocity developed. CONCLUSIONS & IMPLICATIONS: Highly collaborative forms of co-practice, inherently more complex at the service governance, macro-level, bring benefits. At the meso-level of the school and support team network there was greater capacity to individualize co-practice to the needs of the child. Capacity was increased at the micro-level of knowledge and skills to harness the overall resource distributed amongst members of the inter-professional team. The development of social capital, networks of trust across SLCN support teams, should be a priority at all levels-for practitioners, services, commissioners and schools.

The changing nature of the district nurse patient relationship.

In this article Richard Griffith considers three recent developments in policy and law that have changed the nature of the relationship between district nurses and their patients. The traditional, often paternalistic, professional knows best approach must now give way to a patient focused partnership.

Reducing waste in the NHS: an overview of the literature and challenges for the nursing profession.

Waste in the NHS is estimated to account for 20% of health expenditure. This article examines the literature on reducing waste, analyses some approaches to waste reduction, and identifies the role that nurses and other health professionals can play in developing a sustainable NHS. For the purposes of the article, and to inform nursing practice, the definition of, and discussion about, waste is broader than that outlined by the Department for Environment, Food and Rural Affairs (Defra) controlled waste regulations, and the Royal College of Nursing classification. It includes clinical waste, waste arising out of clinical practice, service delivery and care, infrastructure, and carbon emissions.

Continued professional development (CPD) provision for nurses: A qualitative exploration.

Background: For approximately 1.5 million healthcare practitioners working and registered within the United Kingdom there exists a mandatory requirement to undertake Continued Professional Development. Internationally, healthcare Continued Professional Development is fundamental for frontline staff to practice safely, effectively and maintain up to date skills combined with knowledge. A generally accepted purpose for these regulations is to help nurses and midwives maintain an updated skill set to care for patients safely and competently. This qualitative paper presents the findings from the first phase of, "Converting Willingness to Engagement" project conducting focus groups and interviews with stakeholder nurses in England, UK. This study used a phenomenological approach to draw on the lived experiences of the nurse participants who organise, manage and budget Continued Professional Development activities. Objectives: To explore ways to capture and retain nursing staff in postgraduate training and education to facilitate professional advancement, maintenance of registration and improve patient care. Design: Phase one involved a series of qualitative online (virtual) focus group discussions and interviews with stakeholder nurses who commission Continued Professional Development. Settings: A series of online (virtual) focus group discussions and interviews were then conducted between February and May 2021. Methods: A purposive sample was identified consisting of clinical service leads, advanced practitioners and matrons involved in workforce development as stakeholders. Results: Three key themes were identified; the role of the healthcare providers in staff development, staff support provision requirements, and the university's provision including Continued Professional Development. Conclusion: Partnership working allows academic partners in universities and healthcare institutions to support nurses in their endeavors to maintain their registrations, develop professionally through further education and Continued Professional Development.

Implementation of the care programme approach across health and social services for dual diagnosis clients.

BACKGROUND: Care for clients with mental health problems and concurrent intellectual disability (dual diagnosis) is currently expected to be provided through the care programme approach (CPA), an approach to provide care to people with mental health problems in secondary mental health services. When CPA was originally introduced into UK mental health services in the 1990s, its implementation was slow and problematic, being hampered in part by problems occurring at a strategic level as health and social service organizations attempted to integrate complex systems. This article reports on a study of a more recent attempt to implement CPA for dual diagnosis clients in one mental health foundation trust, aiming to gauge progress and identify factors at the strategic level that were helping or hindering progress this time round. METHODS: The study took place in a mental health National Health Service (NHS) Foundation Trust in a large English city, which was implementing a joint mental health and intellectual disability CPA policy across five of its constituent boroughs. Semi-structured interviews with key informants at Trust and borough levels focused on the Trust's overall strategy for implementing CPA and on how it was being put into practice at the front line. Documentary analysis and the administration of the Partnership Assessment Tool were also undertaken. Data were analysed using a framework approach. RESULTS: Progress in implementing CPA varied but overall was extremely limited in all the boroughs. The study identified six key contextual challenges that significantly hindered the implementation progress. These included organizational complexity; arrangements for governance and accountability; competing priorities; financial constraints; high staff turnover and complex information and IT systems. The only element of policy linked to CPA that had been widely taken up was the Greenlight Framework and Audit Toolkit (GLTK). The fact that the toolkit had targets and penalties associated with its implementation appeared to have given it priority. CONCLUSION: None of the contextual challenges identified in this study were specifically related to CPA as a policy or to the needs and circumstances of dual diagnosis clients. Nevertheless, they inhibited the types of organizational change and partnership working that implementing CPA for a client group of this kind required. Unless these more generic factors are acknowledged and addressed when introducing policies such as CPA, the chances of effective implementation will inevitably be compromised.

Towards achieving interorganisational collaboration between health-care providers: a realist evidence synthesis.

Background: Interorganisational collaboration is currently being promoted to improve the performance of NHS providers. However, up to now, there has, to the best of our knowledge, been no systematic attempt to assess the effect of different approaches to collaboration or to understand the mechanisms through which interorganisational collaborations can work in particular contexts. Objectives: Our objectives were to (1) explore the main strands of the literature about interorganisational collaboration and to identify the main theoretical and conceptual frameworks, (2) assess the empirical evidence with regard to how different interorganisational collaborations may (or may not) lead to improved performance and outcomes, (3) understand and learn from NHS evidence users and other stakeholders about how and where interorganisational collaborations can best be used to support turnaround processes, (4) develop a typology of interorganisational collaboration that considers different types and scales of collaboration appropriate to NHS provider contexts and (5) generate evidence-informed practical guidance for NHS providers, policy-makers and others with responsibility for implementing and assessing interorganisational collaboration arrangements. Design: A realist synthesis was carried out to develop, test and refine theories about how interorganisational collaborations work, for whom and in what circumstances. Data sources: Data sources were gathered from peer-reviewed and grey literature, realist interviews with 34 stakeholders and a focus group with patient and public representatives. Review methods: Initial theories and ideas were gathered from scoping reviews that were gleaned and refined through a realist review of the literature. A range of stakeholder interviews and a focus group sought to further refine understandings of what works, for whom and in what circumstances with regard to high-performing interorganisational collaborations. Results: A realist review and synthesis identified key mechanisms, such as trust, faith, confidence and risk tolerance, within the functioning of effective interorganisational collaborations. A stakeholder analysis refined this understanding and, in addition, developed a new programme theory of collaborative performance, with mechanisms related to cultural efficacy, organisational efficiency and technological effectiveness. A series of translatable tools, including a diagnostic survey and a collaboration maturity index, were also developed. Limitations: The breadth of interorganisational collaboration arrangements included made it difficult to make specific recommendations for individual interorganisational collaboration types. The stakeholder analysis focused exclusively on England, UK, where the COVID-19 pandemic posed challenges for fieldwork. Conclusions: Implementing successful interorganisational collaborations is a difficult, complex task that requires significant time, resource and energy to achieve the collaborative functioning that generates performance improvements. A delicate balance of building trust, instilling faith and maintaining confidence is required for high-performing interorganisational collaborations to flourish. Future work: Future research should further refine our theory by incorporating other workforce and user perspectives. Research into digital platforms for interorganisational collaborations and outcome measurement are advocated, along with place-based and cross-sectoral partnerships, as well as regulatory models for overseeing interorganisational collaborations. Study registration: The study is registered as PROSPERO CRD42019149009. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 6. See the NIHR Journals Library website for further project information.

How can the collaboration between health-care providers be improved? There are continuing concerns about poor patient care across the NHS. One of the ways in which governments have tried to solve these issues is by getting services to work together, rather than separately, to solve any problems. The aim of our review is to learn about how, why and when different approaches to working together ­ which we call interorganisational collaboration ­ can be used to improve the performance of NHS providers. We reviewed published evidence and carried out interviews with NHS staff. We also carried out interviews and a focus group with patient and public representatives. Our review finds that interorganisational collaborations can work well when a series of elements are in place, which includes the need to build trust between everyone involved. Having a belief in the collaboration is also needed to help inspire others to get involved. To try and reduce possible problems, setting priorities and having clear methods to show how improvements can be achieved are important, as well as having an agreed contract in place to ensure that any conflicts are resolved. If done well, collaboration can improve resource allocation, coordination, communication and shared learning about best practice. Our review provides valuable evidence of how different approaches to interorganisational collaboration can be used by NHS providers to work together to improve services in different situations. Our review provides different options for organisations to reflect on how well they are collaborating, which includes the involvement of key stakeholders, such as patients, the public and communities.

Co-location, an enabler for service integration? Lessons from an evaluation of integrated community care teams in East London.

In an attempt to support care integration that promotes joined up service provision and patient-centred care across care boundaries, local health and social care organisations have embarked on several initiatives and approaches. A key component of service integration is the co-location of different professional groups. In this study, we consider the extent to which co-location is an enabler for service integration by examining multi-professional community care teams. The study presents findings from a qualitative evaluation of integrated care initiatives in a borough of East London, England, undertaken between 2017 and 2018. The evaluation employed a participatory approach, the Researcher-in-Residence model. Participant observation (n = 80 hr) and both semi-structured individual (n = 16) and group interviews (six groups, n = 17 participants) were carried out. Thematic analysis of the data was undertaken. The findings show that co-location can be an effective enabler for service integration providing a basis for joint working, fostering improved communication and information sharing if conditions such as shared information systems and professional cultures (shared beliefs and values) are met. Organisations must consider the potential barriers to service integration such as differing professional identity, limited understanding of roles and responsibilities and a lack of continuity in personnel. Co-location remains an important facet in the development of multi-professional teams and local service integration arrangements, but as yet, has not been widely acknowledged as a priority in care practice. Organisations that are committed to greying care boundaries and providing joined up patient care must ensure that sufficient focus is provided at the service delivery level and not assume that decades of silo working in health and social care and strong professional cultures will be resolved by co-location.

Co-producing better land management? An ethnographic study of partnership working in the context of agricultural diffuse pollution.

Partnership working has become a normative principle within agri-environmental governance. With more and more benefits becoming attributed to closer multi-stakeholder collaboration, more public monies are being directed towards this cause. These benefits have been studied widely and are usually presented in terms of their contributions to environmental, economic and/or social objectives. However, in contrast to these reported outcomes of partnership working, the practical ways towards them have received little attention. What does it mean to work together on a day-to-day basis? More specifically, how do stakeholders become trusted partners, bridge interests and coordinate their actions? What collaborative working culture becomes established within partnerships and how does this in turn affect wider governance outcomes, expectations and aspirations? Answers to these questions are not only important to better understand the factors that contribute to successful ways of partnership working, but also to account for its limitations. This paper responds to this research need by drawing on the example of Farm Herefordshire. This cross-organizational partnership promotes profitable farming, healthy soils and clean water to address the problem of diffuse pollution from agricultural practices within the Wye catchment in the UK. The insights from this case study contribute to the literature in two major ways: firstly, the paper follows prompts to study such modes of collective action holistically and bottom-up to capture all their contributions and implications. It does so by employing an ethnographic research approach to investigate the social interactions and struggles that characterize joint working. This commands attention to the backstories, the actual work meetings, the discussions, the processes of consensus building, and the joint actions undertaken; secondly, the paper connects with wider social science concerns around the underlying processes and practices of governmentality that are essential for establishing social and ecological orders. Thus, the paper explores how everyday practices of partnership working contribute to the co-production of institutions, discourses, identities, and representations-which in this case become strategically deployed to nudge-rather than revolutionise-better land management practices.

Keeping patient and public partnership at the heart of medical technology development during Covid-19: examples of adaptive practice.

NIHR (National Institute for Health Research) Devices for Dignity MedTech Cooperative (D4D) and NIHR Children and Young People MedTech Cooperative (CYPMedTech) have established track records in keeping patient and public involvement (PPI) at the core of medical technology development, evaluation and implementation. The 2020 global COVID-19 pandemic presented significant challenges to maintaining this crucial focus. In this paper we describe prior successful methodologies and share examples of the adaptations made in order to continue to engage with patients and the public throughout the pandemic and beyond. We reflect on learning gained from these experiences, and new areas of scope and focus relating to broadening the reach of engagement and representation, along with associated resource requirements and impact metrics.

A phenomenological insight into what final year undergraduate student nurses perceive is the role of the Registered Nurse and who they learn this from.

Background: This paper considers the perceptions of 18 final year student nurses around their perception of the role of the nurse. Methods: A qualitative phenomenological research study was undertaken, with final year student nurses as the data source, undertaking semi-structured interviews from a United Kingdom Higher Education Institution. Data analysis was undertaken by using interpretative phenomenological analysis. Results: Findings indicate that student nurses had little insight as to the role of the nurse when commencing the programme. Being on the programme has led them to understand there are many aspects of a nurse's role including, surprisingly for them, much responsibility. It was also found that a lot of the learning that takes place comes from working with healthcare assistants, and due to this, the student nurses perceive that the role of the modern nurse is task orientated and there is little holistic care. Conclusions: The future practice of this group of registrants may be affected depending on how they move forward with their role, alongside the holistic role of the nurse being detracted from. While phenomenology does not account for generalisations but does seek to illuminate this phenomenon; however if this view were to be shared globally, then the caring aspect of nursing may well be in danger of being lost. If this assumption of the role of the nurse is shared globally, then there are inevitably implications for the nursing profession, and more importantly patient care may be affected.

Integrated Health and Social Care in England: Ten Years On.

INTRODUCTION: As part of major policy reforms begun in 2010, England introduced a wave of initiatives to encourage more integrated care between health and social care. These built on previous attempts which sought to achieve similar objectives through a focus on better partnership working. This article provides an overview and critical commentary on integrated care policy in England from 2010-2020 based on reviews by regulators, parliamentary committees and the national audit office. OVERVIEW OF POLICY: Integrated care became a priority through the work of the Future Forum, a group of leading stakeholders established due to concerns about greater competition in public health care. This led to a public statement of shared commitment to integrated care by national health and social care bodies. Early mechanisms included a pooled fund to achieve nationally set objectives, the creation of local authority led partnership boards, and high profile innovation programmes. Later in the 2010's, new health led partnerships became more dominant vehicles to achieve integrated care at regional level. IMPACT OF POLICY: Despite progress within a few local areas, and reduction in delayed discharges from hospital the overall picture from national reviews was that expected improvements were not achieved. Emergency admissions to hospital continued to grow, patients within primary care reported being less involved in their care, and health inequalities worsened. The initial response to COVID-19 was health-centric contributing to outbreaks in care homes and inadequate supplies of protective personal equipment. The ability of leaders to look beyond their organisations' interests was reported as vital for local progress. National government performance frameworks discouraged system based working and chronic underfunding of social care led to major capacity and workforce challenges. CONCLUSION: The experience of England suggests that greatest progress is made when integrated care focusses on tangible issues and when there is a clear understanding of how success will be measured. Even with considerable investment and intent progress should be expected to be slow and difficult. Layering of numerous policy initiatives provides confusion and can distract from the important work of relationship building. And ultimately, integrated care cannot by itself address major inadequacies in the underlying resources and structural inequalities.

Why do some inter-organisational collaborations in healthcare work when others do not? A realist review.

BACKGROUND: Inter-organisational collaboration is increasingly prominent within contemporary healthcare systems. A range of collaboration types such as alliances, networks, and mergers have been proposed as a means to turnaround organisations, by reducing duplication of effort, enabling resource sharing, and promoting innovations. However, in practice, due to the complexity of the process, such efforts are often rife with difficulty. Notable contributions have sought to make sense of this area; however, further understanding is needed in order to gain a better understanding of why some inter-organisational collaborations work when others do not, to be able to more effectively implement collaborations in the future. METHODS: Realist review methodology was used with the intention of formulating context-mechanism-outcome configurations (CMOCs) to explain how inter-organisational collaborations work and why, combining systematic and purposive literature search techniques. The systematic review encompassed searches for reviews, commentaries, opinion pieces, and case studies on HMIC, MEDLINE, PsycINFO, and Social Policy and Practice databases, and further searches were conducted using Google Scholar. Data were extracted from included studies according to relevance to the realist review. RESULTS: Fifty-three papers were included, informing the development of programme theories of how, why, and when inter-organisational collaborations in healthcare work. Formulation of our programme theories incorporated the concepts of partnership synergy and collaborative inertia and found that it was essential to consider mechanisms underlying partnership functioning, such as building trust and faith in the collaboration to maximise synergy and thus collaborative performance. More integrative or mandated collaboration may lean more heavily on contract to drive collaborative behaviour. CONCLUSION: As the first realist review of inter-organisational collaborations in healthcare as an intervention for improvement, this review provides actionable evidence for policymakers and implementers, enhancing understanding of mechanisms underlying the functioning and performing of inter-organisational collaborations, as well as how to configure the context to aid success. Next steps in this research will test the results against further case studies and primary data to produce a further refined theory. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019149009.

A Farrier Making Every Contact Count: A Microlevel Analysis of Farrier-Client Interaction for Partnership Working in Managing a Horse With Laminitis.

There is an evidence base in human and small animal veterinary health care contexts which understands how practitioners engage in partnership working with patients and owners to support adherence to treatment/care plans. However, as yet, it is believed there is no similar evidence base for how practitioners in equine health care contexts work with equine owners. It is argued that this is essential for understanding complex equine practitioner-owner interaction involving the prevention and management of laminitis. The aim of this study was to explore farrier-client interaction where risk management for an equine recovering from laminitis was being undertaken. A case report method involved a microlevel analysis of a farrier-client consultation. The consultation was video-recorded and analyzed using a conversation analysis approach to identify the linguistic and paralinguistic features of the interaction. These were compared with conversation analyses in other health care contexts to identify the actions being accomplished within the consultation. The analysis identified a number of joint actions, including managing epistemic stance (or knowledge rights) and deploying the animal's presence to navigate problem sequences which supported progression of the consultation through a three-stage model involving "team-", "option-", and "decision-" talk, known to be associated with partnership working in human health care contexts. The study highlights the importance of developing an empirical evidence base in equine practice for how practitioners engage with owners based on a microlevel analysis of real-world interactions. It is argued this evidence base is necessary in supporting effective practitioner training in partnership working with clients to promote their adherence to treatment/care plans.