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f5c7ef05-9a58-48a5-9c06-02ebd55d89cd Medicines optimisation Principal Investigator: Dr Simon Fraser Team members: Dr Simon Fraser (Associate Professor of Public Health. School of Primary Care and Population Sciences, Faculty of Medicine, Southampton General Hospital), Professor Chris Edwards (Professor of Rheumatology, Southampton and Associate Director of the NIHR Clinical Research Facility) Dr Chris Holroyd (Consultant Rheumatologist, University Hospital Southampton NHS Foundation Trust), Dr Kinda Ibrahim (Senior Research Fellow, Faculty of Medicine, University Hospital Southampton NHS Foundation Trust), Dr Ravina Barrett (Pharmacist, University of Portsmouth), Dr Clare Howard (Chief Pharmacist, Medicines Optimisation, Wessex AHSN), Dr Mary O’Brien (NHS England, NHS Rightcare), Dr David Culliford (Senior Medical Statistician, Health Sciences, University of Southampton), Professor Paul Roderick (Professor of Public Health, Primary Care and Population Sciences, University of Southampton), Professor James Batchelor (Director Clinical Informatics Research Unit, Faculty of Medicine, University of Southampton), Dr Matthew Stammers (Senior Endoscopy Fellow, University Hospital Southampton and Clinical Informatics Research Fellow at Clinical Informatics Research Unit) Start: 1 October 2019 Ends: 30 September 2024 Project Partners: University Hospital Southampton NHS Foundation Trust, NHS England (NHS Rightcare), University of Portsmouth, University of Southampton, Academic Health Sciences Network (AHSN) Wessex. Lay summary Painful conditions associated with age (such as arthritis) are common in the UK and safe pain relief options for older people are limited. Anti-inflammatory drugs such as ibuprofen are widely used – both bought from the pharmacy and prescribed by doctors, but they have significant risks, such as bleeding from the stomach and kidney damage. Older people and those with certain long-term medical conditions are at higher risk of experiencing bad effects from these drugs. Another issue concerns people who are taking one of a group of medications call ‘disease-modifying anti-rheumatic drugs’ (DMARDs). These drugs are often used for rheumatoid arthritis and work by slowing its progression, reducing the likelihood of severe joint damage and other related health problems. They are also used for inflammatory bowel diseases, such as Crohn’s disease. Methotrexate is one of the most commonly used DMARD in arthritis and azathioprine is one of the most commonly used in inflammatory bowel disease. Anti-TNF drugs are an important group of so called ‘biological agents’ – another type of DMARD. DMARDs are powerful drugs that require regular blood tests to check for adverse effects, such as liver problems, and guidelines advise how often these tests should be done. However, for most people, these blood tests are almost never abnormal, and could potentially be safely done less frequently. In addition, some people with inflammatory arthritis have an excellent response to DMARDs. Stopping DMARDs can lead to flare ups of disease, but the amount of therapy used may be tapered successfully to reduce dose-dependent adverse events and costs. This project involved two studies The first study showed that non-steroidal anti-inflammatory drugs (NSAIDs) are still sometimes prescribed for high-risk patients, such as older adults and those with chronic kidney disease. NSAIDs can cause acute kidney injury (AKI), leading to serious complications. This study developed a risk tool for practices to identify those who should not be prescribed NSAIDs. The second explored the frequency of blood testing for patients on Disease-Modifying Anti-Rheumatic Drugs (DMARDs) like methotrexate, commonly used for rheumatoid arthritis. Guidelines recommend 3-monthly blood tests due to potential liver issues. The research found that many tests were seldom abnormal, suggesting that low-risk patients might safely have less frequent tests if further research is done on the safety of risk-stratifying people. What did we learn? In the two different parts of the project we found that: About half of people taking the ‘disease modifying’ drugs (‘ DMARDs ’) methotrexate for rheumatoid arthritis or azathioprine for inflammatory bowel disease experienced no blood test abnormality over two years despite having to have blood tests every three months. Reducing testing frequency may therefore be safe for younger people and those without other long-term conditions. Among people taking non-steroidal anti-inflammatory drugs (‘ NSAIDs ’ like ibuprofen) the risk of kidney damage was highest among older people with combinations of long-term conditions including chronic kidney disease, diabetes, heart disease and heart failure, and high blood pressure. These people should avoid taking NSAIDs and we provided a way for GPs to identify them in their databases. What difference will this new knowledge make? DMARDs: Further investigation is needed on the safety and acceptability of reduced blood testing frequency testing for some people taking DMARDs but this could potentially result in reduced unnecessary patient anxiety and burden, fewer referrals to hospital and reduce resource use for the NHS. If testing could be reduced this would mean reduced treatment burden for patients and reduced cost and admin work for the NHS NSAIDs: GP practices can be provided with a search tool that helps identify those at highest risk of kidney damage from NSAIDs. Using this information they can review and stop NSAIDs to reduce the risk. If prescribing was stopped for some people at risk, this would reduce risk of acute kidney injury which can have lasting consequences or even be fatal What was the impact? Non-steroidal anti-inflammatory drugs (NSAIDs) As part of the medicines optimisation project we explored the risks of acute kidney injury (AKI) associated with taking non-steroidal anti-inflammatory drugs like ibuprofen and naproxen. There was a news article here about it: https://www.arc-wx.nihr.ac.uk/post/southampton-led-study-shows-need-for-painkiller-caution-to-prevent-kidney-damage and a publication here: https://bjgpopen.org/content/6/1/BJGPO.2021.0208 We developed a risk score that can help GP practices identify those patients at highest risk of NSAID-associated kidney injury. We have run this risk tool in the Dorset Intelligence and Insight Service (a database covering over 70 Dorset GP practices - more than 800,000 people) and along with colleagues from the AHSN we are running a masterclass with many of the GP practices involved to present the findings and to promote best practice in NSAID prescribing. The aim is to reduce NSAID prescribing in those at high risk of adverse outcomes like AKI. Rheumatoid arthritis (RA) and inflammatory bowel disease (IBD) are prevalent inflammatory conditions, affecting 0.8% and 0.7% of the population, respectively. Disease-modifying anti-rheumatic drugs (DMARDs), such as methotrexate for RA and azathioprine for IBD, are commonly used to control disease activity. These drugs require regular safety blood-test monitoring for liver function abnormalities, kidney function, and bone marrow toxicity. Monitoring is frequent at initiation and less frequent once a maintenance dose is established. In the UK, initiation usually occurs in secondary care, with ongoing monitoring in primary care as recommended by NICE. Regular blood-test monitoring has been linked with anxiety and depression for some patients, incurs substantial costs for healthcare providers, and increases the workload for clinicians and laboratory staff. Despite guidelines, the optimal monitoring frequency has not been established, and the extent to which patients experience prolonged periods with no abnormal tests is unclear. This study aimed to assess the extent of persistently normal blood-test results among people with RA and IBD, and to describe the frequency of blood testing to indicate health-service and patient workload. Targeted monitoring of higher-risk individuals and reduced monitoring for lower-risk patients may improve efficiency and reduce patient workload. Our large, 2-year retrospective cohort study (over 700,000 people) assessed persistently normal blood tests among people with rheumatoid arthritis (RA) taking methotrexate and those with inflammatory bowel disease (IBD) taking azathioprine. Approximately half of the patients experienced no blood-test abnormalities using NICE-recommended tests. In the RA/methotrexate cohort, abnormalities were more common in older people with reduced renal function. For the IBD/azathioprine cohort, abnormalities were less common and mainly involved reduced renal function in older people with comorbidities. The absolute risk of persistently normal blood tests was lowest among older people and those with comorbidities. Since the study, a piece of work led by Nottingham cited our work ( https://www.bmj.com/content/381/bmj-2022-074678 ) and created a model to risk stratify patients taking methotrexate. This is quite likely to change clinical practice when NICE reviews its guidance on DMARDs in due course. This work was supported by representatives of the ‘Getting It Right First Time’ programme, who also linked this issue to sustainability: ‘Saving the planet with reduced routine DMARD blood monitoring frequency BMJ 2023; 382 doi: https://doi.org/10.1136/bmj.p1645’ https://www.youtube.com/watch?v=uSriKPqdbvA&t=6s

c7fa8be0-4046-4345-a82a-ce4a38e05e07 Social network facilitated engagement in people who are Homeless to address InEqualities in alcohol related Liver Disease - The SHIELD feasibility study Principle Investigator: Dr Ryan Buchanan, University of Southampton Team: Professor Salim Khakoo, University of Southampton, Dr Mark Wright, University of Southampton, Dr Yun J Kim, University Hospital Southampton NHS Foundation Trust. Starts: 1/4/22 Ends: 1/4/23 Aim: To develop and assess the feasibility of a social network-based intervention to engage people who are homeless and at risk of alcohol-related liver disease with Hepatology services Background: Mortality in people who are homeless (PWAH) is eight times higher than the general population and liver cirrhosis is the third commonest cause of death. PWAH infrequently access hospital based Hepatology services for assessment. Alcohol consumption is a socially perpetuated behaviour that is known to cluster within human social networks. What we did Recruitment continued from February to July 2022 of people who are homeless with high risk of alcohol dependence (AUDIT score) were identified in hostels and at a homeless day centre in Southampton. Those people were then asked to take part in tests and to refer thier drinking partners to the programme. They were given supermarket vouchers as an incentive. Those homeless people who took part, filled in a survey and took part in an interview. They also had a test on their liver and were referred to liver health services. What did we find out? Fifty six peoople took part, all were from homeless hostels. Almost 20% of the group had a new diagnosis of cirrhosis, and there was a link between people who had type 2 diabetes or lived house where alcohol was present. Homeless people with hazardous alcohol consumption are socially connected to others that drink dangerously. This programme of referral can identify undiagnosed disease, however, engagement via trusted staff may be just as effective. The study highlights the importance of working with community organisations supporting underserved populations to overcome inequalities in liver disease and manage multi-morbidity. What's next? Identifying liver disease in people experiencing homelessness is progress but… Sustaining underserved populations with liver health care services after a diagnosis is made is crucial – we have since been awarded a further NIHR research grant in investigate how to approach this problem: To find out more: Follow @liverchampions https://www.southampton.ac.uk/research/projects/nihr-liver-disease-research-partnerships-liver-champions

8d9b12a7-5110-4e7e-9e3b-5c358feb6e17 ADOPTED PROJECT: Multidisciplinary Ecosystem to study Lifecourse Determinants and Prevention of Early-onset Burdensome Multimorbidity (MELD-B) ADOPTED PROJECT: Multidisciplinary Ecosystem to study Lifecourse Determinants and Prevention of Early-onset Burdensome Multimorbidity (MELD-B) Start date: 1st June 2022 End date: 28th Feb 2025 Contact: s.fraser@soton.ac.uk - link to southampton site listing Lay summary: A growing number of people are living with several long-term health conditions like diabetes, heart disease, depression or dementia. We call this multiple long-term condition multimorbidity (MLTC-M). Many things throughout a person’s life influence the chances of developing health conditions. This includes their biology (e.g. age, ethnicity), things that happen to them (e.g. infections, accidents), behaviours (e.g. smoking, diet) and broader experiences (e.g. the environment people grew up in, their education, work, income). People from more disadvantaged backgrounds and/or certain ethnicities are more likely to develop MLTC-M and to develop it earlier. The impact (or ‘burden’) of MLTC-M, and the order that people develop conditions, also vary. Our research will help understand when MLCT-M becomes ‘burdensome’ and the best opportunities for intervention. Aim To use an Artificial Intelligence (AI) enhanced analysis of birth cohort data and electronic health records to identify lifecourse time points and targets for the prevention of early-onset, burdensome MLTC-M. Plan To achieve this aim, our study is composed of five work packages: Undertake a qualitative evidence synthesis and a consensus study (Delphi) to develop deeper understanding of what ‘burdensomeness’ and ‘complexity’ mean to people living with early-onset (by age 65) MLTC-M, carers and healthcare professionals Develop a safe data environments and readiness for AI analyses across large, representative routine healthcare datasets and birth cohorts. In those safe data environments, using the WP1 burdensomeness/complexity indicators and applying AI methods, identify novel early-onset, burdensome MLTC-M clusters. Also in this work package, we will match individuals in birth cohorts into routine data MLTC-M clusters and then identify determinants of burdensome clusters and model trajectories of long-term conditions (LTCs) and burden accrual. By characterising clusters of early-life (pre-birth to 18 years) risk factors for early-onset, burdensome MLTC-M and sentinel conditions (the first LTC to occur in the lifecourse), we will define population groups in early life at risk of future MLTC-M, identify critical time points and targets for prevention, and model counterfactual prevention scenarios of interventions acting on combined risk factors at key timepoints. Engage key stakeholders to prioritise timepoints and targets to prevent/delay specified sentinel conditions and early-onset, burdensome MLTC-M. Partnering with our PPI Advisory Board, and through further stakeholder engagement, we will co-produce public health implementation recommendations Impact We will work with our stakeholders to use the findings from our research to influence policy and practice, and to co-produce public health advice, on preventing burdensome MLTC-M. Team: Nisreen A Alwan Associate Professor in Public Health (University of Southampton), Ashley Akbari Senior Research Manager (Swansea University) Mark Ashworth Reader in Primary Care (King’s College London), Ann Berrington Professor of Demography and Social Statistics (University of Southampton), Michael Boniface Professorial Fellow of Information Systems (University of Southampton), Jessica Enright Senior Lecturer in Computing Science (University of Glasgow), Nick Francis Professor of Primary Care Research (University of Southampton), Simon DS Fraser Associate Professor of Public Health (University of Southampton), Martin Gulliford Professor of Public Health (King’s College London), Emilia Holland Specialty Registrar in Public Health/Visiting Academic (University of Southampton), Rebecca Hoyle Professor of Applied Mathematics (University of Southampton), Sara Macdonald Professor of General Practice and Primary Care (University of Glasgow), Frances MairNorie Miller Professor of General Practice (University of Glasgow), Rhiannon Owen Associate Professor, Health Data Science (Swansea University), Shantini Paranjothy Professor and Clinical Chair in Public Health (University of Aberdeen), Ruben Sanchez-Garcia Associate Professor of Pure and Applied Mathematics (University of Southampton), Sebastian Stannard PhD student in Demography and Social Statistics, Becky Wilkinson Consultant in Public Health (Southampton City Council), Zlatko ZlatevSenior Enterprise Fellow, Electronics & Computer Science (University of Southampton) Publications Cohort profile: creation of the SAIL MELD-B e-cohort (SMC) and SAIL MELD-B children and young adult e-cohort (SMYC) to investigate the lived experience of the ‘burdensomeness’ of multimorbidity | BMJ Open The impact of living with multiple long-term conditions (multimorbidity) on everyday life – a qualitative evidence synthesis | BMC Public Health | Full Text Mapping domains of early life determinants of future multimorbidity across three UK longitudinal cohort studies | Scientific Reports Risk factors for ill health: How do we specify what is ‘modifiable’? | PLOS Global Public Health A conceptual framework for characterising lifecourse determinants of multiple long-term condition multimorbidity - Sebastian Stannard, Ann Berrington, Shantini Paranjothy, Rhiannon Owen, Simon Fraser, Rebecca Hoyle, Michael Boniface, Becky Wilkinson, Ashley Akbari, Sophia Batchelor, William Jones, Mark Ashworth, Jack Welch, Frances S Mair, Nisreen A Alwan, 2023

42074b03-6b8a-4374-ab92-19ec23c313f3 ADOPTED PROJECT: Happier Feet ADOPTED PROJECT: Happier Feet Disrupting the vicious cycle of healthcare decline in Diabetic Foot Ulceration through active prevention: The future of self-managed care Chief Investigator: Dr Andrew Weightman – University of Manchester Project Team Members: Dr Katherine Bradbury – University of Southampton, Professor Helen Dawes – University of Exeter, Mr Andrew Eccles – University of Strathclyde, Dr Safak Dogan – Loughborough University, Dr Glen Cooper – University of Manchester, Professor Frank Bowling – University of Manchester, Dr Xiyu Shi, Loughborough University, Professor Ahmeet Kondoz– Loughborough University Organisations Involved: Diabetes UK Background: There is a significant unmet clinical need for an adaptable, acceptable and adoptable technology to identify and prevent diabetic foot ulcer (DFU) formation, to enable self-management and timely clinical intervention to improve outcomes and reduce the economic burden of healthcare provision. Our primary purpose is to develop and implement an adaptable, acceptable, and cost- effective smart sensing insole technology which can detect when a DFU is likely to occur and can adapt plantar tissue loading to prevent formation, thus enabling self-management. This project proposes to build and expand on current smart insole technologies for the detection of DFUs, utilising a sensor fusion approach for their identification. A smart insole with integrated pressure (normal, shear), temperature, gait (IMU) and mechanomyography (acoustic) sensors will identify early indicators of ulceration and when movement is appropriate/inappropriate. The smart insole will respond to these inputs and adjust the foot (and gait), through an array of artificial muscles, to support better (safe/ comfortable) movement. This project aims to co-develop this new smart sensing insole with people living with diabetic foot ulcers. We hope to establish: What patients think of the idea of a smart sensing insole for early detection of DFUs which includes the provision to adjust the foot to reduce pressure on areas of likely ulceration. A prototype insole and optimised this with patient feedback. Early safety testing of this device. Security protocols to enable secure storage and sharing of data from this insole (e.g., between patient and clinicians). Publications Journal of Participatory Medicine - Developing a Smart Sensing Sock to Prevent Diabetic Foot Ulcers: Qualitative Focus Group and Interview Study In-shoe plantar temperature, normal and shear stress relationships during gait and rest periods for people living with and without diabetes | Scientific Reports

d4e68544-5bd2-44f6-bac8-dd9848c01967 WADE. Women and Desistence Engagement : An evaluation of a community-based, conditional caution pilot programme for women in the criminal justice system Principle Investigator: Sara Morgan, Fiona Maxwell Start Date: 20th November 2019 End Date: 30th March 2022 Background and study aims Compared to the previous year, in 2018 there was an overall 8% increase in theft in England and Wales and a 6% increase in crimes involving sharp instruments or knives. In order to tackle this increase in crime, many believe that more needs to be done to address the reasons why people commit crime in the first place, as well as the damage it causes to peoples’ lives. This means working together in the community to offer solutions to those affected by crime, including victims and offenders. When we discussed possible solutions with local service providers, it was felt that a tailored approach is needed for women, as their needs are unique. Women in prison are very likely to be both victims and offenders whilst, in the general population, one in four women are also victims of abuse within the home and more than half the women in prison have experienced domestic abuse themselves. In response, three projects are being piloted in Hampshire and Dorset to address the needs of women affected by crime. What does the study involve? To understand how these projects are working, we carried out group interviews with those delivering the pilot intervention projects in the community. These were primarily to understand how the projects are working. We also used information gathered from the project staff about the women using the service to understand whether women go on to seek further assistance in the community, what sort of women engage with the project, and what changes for them as a result of using the service. This study proposal was developed in collaboration with public representatives; including offenders, victims, social care workers, domestic abuse service manager, and police officers. They have all shaped the design of the study; by informing us what types of research questions we should be asking. We continued to involve similar representatives throughout the research study; for example, to co-produce the materials used in the study, such as information sheets, and to gain feedback on the write up of the study. What will we do with the study findings? It is important that the information gained from the study reaches the widest number of people. We therefore considered who to engage, and how to reach them, from the very start of the study. The main findings will be developed into a short summary report, which will be accessible to the general public through our public representatives and collaborators. They might include charitable organisations in the community (e.g. Stop Domestic Abuse, Hampton Trust) or services that work directly with women affected by crime (e.g. NHS, probation services). Impact of the COVID-19 Pandemic The first WaDE cautions were offered from March 2019 and workshops began shortly after. Numbers were initially fewer than expected, and although some variance throughout the year would not have been unusual, there were fewer than the anticipated 10 per month for the first months of the pilot. Unfortunately, from March 2020 the COVID pandemic and stay-at-home regulations had a very significant impact on the operation of the pilot. The pilot was suspended from March as Hampshire Constabulary temporarily ceased offering conditional cautions. From March it was also not possible to deliver the WaDE programme in its intended group format, and a small number of participants who had completed the first workshop as a group completed their second part by telephone on a 1:1 basis with a HT facilitator. As an alternative, a non-mandatory, individual telephone intervention was briefly offered from March 2020 during the first period of restrictions. Overall this had an impact on the planned evaluation, resulting in a reduction in the available quantitative data for analysis (due to fewer numbers coming through the programme). Additionally, there was a planned qualitative element to the evaluation (focus groups) which were cancelled due to the restrictions. Due to the impact of COVID-19 on both the programme operation, and the staff involved in researching, the findings of the final report cover the period of September 2021 – March 2020. Reoffending Due to the suspension of the WaDE programme and the extended period between cohort A completing their workshops and the compilation of this report, reoffending data up to 12m post-intervention is now available. From the initial 27 referrals, 4 women went on to commit further offences. These were: 1 at 35 days (common assault) 1 at 157 days (shoplifting) 1 at 229 days (bladed implement) 1 at 310 days (cannabis) Two of those who reoffended had breached (not attended) any WaDE workshops, and two had completed. A chi-square comparison of the reoffending rate between those who breached and those who attended gives a χ2 value of 2.1, indicating that this difference does not meet the threshold for statistical significance. Exit Questionnaires Hampton Trust routinely ask participants in their programmes to complete an exit questionnaire, which allows for some feedback on the perceived benefits of having attended. It also provides the opportunity for some free text comments. Ten participants answered the following questions: Q1 Since being on the workshops have you identified areas of your life in which you need support? Q2 Since being on the workshop do you have a better understanding of what led you to offend? Q3 Have the workshops helped give you tools/support to make safer more positive life choices? Q4 Since being on the workshops have you accessed other services (e.g. counselling, drugs and alcohol support) or plan to do so in the near future? Q5 Do you intend to attend all or any of the follow-on 12 week programme workshops? Q6 How much have you enjoyed the WaDE workshop? Q7 In your opinion, how well presented were the workshops? Q8 To what extent have the workshops helped you with your problems? Q9 Where 10 is ‘very confident’, how confident are you of not offending in future? On the basis of these responses, the WaDE programme is evidently acceptable to, and valued, by the participants. One respondent was generally negative in her responses and indicated in the free text feedback that she felt she shouldn’t have been having to attend WaDE at all; however even she felt that the course was well presented and enjoyable. Due to the small number of responses and the limited amount of free text feedback, full thematic analysis of the responses is not likely to offer reliable identification of consistent key themes. However, for the majority of respondents the comments reflected overall high levels of satisfaction with the programme, its delivery and its usefulness in terms of helping the participants to understand and address the factors and circumstances leading to their caution. Limitations Overall The WaDE programme delivery, and consequently the size and scope of this evaluation, has been significantly impacted by the COVID-19 pandemic. Greater numbers would have added validity to our findings and allowed for meaningful associations to be explored, while qualitative research would have added a depth of understanding of the true impact of the WaDE programme on its participants. At the time of writing it is hoped that WaDE can now revert to its original model and that a steady throughput in line with original expectations on numbers will be observed. Further research is recommended, including a comparative statistical analysis with a larger cohort. Qualitative research would also be valuable to explore in-depth attitudes, towards reoffending for example, in order to provide better evidence for future decision-making. Conclusions Despite some very challenging times, the team delivering WaDE remains committed to its ongoing operation. Continuing support from the OPCC and a strong working partnership between Hampton Trust and Hampshire Constabulary has enabled the programme to ‘weather the storm’ of the pandemic and emerge ready to re-start. The flexibility and hard work of each individual throughout this time speaks to their belief in WaDE as a worthwhile and much-valued means of supporting female offenders towards a better future. Findings from the study were used to support further funding and commissioning of WaDE, while also contributing to the expansion of academic research into health and justice interventions through continued involvement of the research team This includes an evaluation of JUNO which has evolved from WaDE

78e6cc7b-5ff9-411b-b288-1d82a03f0414 Testing the effects of food product placement on customers’ visual attention and intended product purchases: a randomised trial in a virtual supermarket setting (Phase I) Does supermarket placement affect intention to buy healthy and unhealthy foods? Principal Investigator: Janis Baird and Christina Vogel, Professor of Public Health and Epidemiology and Principal Research Fellow in Public Health Nutrition respectively, MRC Lifecourse Epidemiology Centre, University of Southampton Team: Dr Sarah Crozier, Senior Statistician, MRC Lifecourse Epidemiology Centre, University of Southampton Sarah Jenner, Senior Research Assistant at University of Southampton Dr Sarah Muir, Senior Research Fellow, University of Southampton Professor Marcus Munafo and Dr Olivia Maynard, Bristol University Ravita Taheem, Southampton City Council, Sure Start Children’s Centres Megan Brook, Public Contributor Tiana Chadwick, Public Contributo Start date: 1 October 2019 End date: 28 February 2022 Background Poor diet has been recognised as a major contributor to the burden of non- communicable diseases in the UK and costs the NHS approximately £6 Billion annually. Most adults in England consume too much salt, saturated fat and free sugar, and do not eat the recommended five daily portions of fruit and vegetables. Among low-income groups these trends are more extreme. Almost 90% of UK grocery sales occur within supermarkets4 and their subtle use of marketing techniques influences the food choices of an almost captive market. Women of childbearing age are an important target group to study because they remain primarily responsible for domestic food tasks such as shopping and cooking and their nutrition status influences the short and long-term health of their children. Our prior work in Hampshire showed that the diets of women with low educational attainment were more affected by less healthy supermarket environments than women with higher attainment. Shopping at less healthy discount and small supermarkets, with poorer availability, pricing and placement of healthy foods, was associated with poor dietary quality among women who left school aged 16 years but not among those with degree qualifications. UK government policy recognises that more effort is needed to develop interventions to improve health equitably and is introducing legislation on product placement initiatives to support families to make healthier food choices in supermarkets. Research using adequately powered clustered randomised controlled trials in supermarkets is limited, largely due to the complexity and large number of stores required. Evaluating changes in supermarket layout is notoriously challenging due to differing health and business agendas and randomisation at the store level requires commitment that is problematic in this highly competitive, commercial setting. Virtual supermarkets offer a viable alternative to investigate the likely impact of supermarket-based, healthy eating policy options using robust trial designs. Additionally, neuroscience techniques, such as eye-tracking, offer objective evidence that complements self-report behaviours, and facilitate a deeper understanding of the cognitive mechanisms underlying health-related behaviours. Such techniques have been used to examine how product placement facilitates customers’ visual attention, however there is a gap in understanding of how visual attention differs according to the healthfulness of products, particularly while placed in prominent in-store locations and whether visual attention differs according to customer’s socioeconomic position. This study aims to use experimental randomised trials and a virtual supermarket setting to determine differences in visual attention and intended purchase of healthy, unhealthy and non-food products placed in prominent in-store locations such as checkouts. It will also assess effect modification by educational attainment on these relationships to explore potential effects on inequalities. This is the first of two phases of research assessing visual responses to product placement. In this phase, heat mapping technology using Qualtrics software determined whether interest in and intended purchase of products in prominent in-store locations differed if the products were healthy, unhealthy or non-food items. We assessed effect modification by educational attainment to explore potential effects on inequalities. Women with young children (n=230), recruited through Sure Start Children’s Centres, early years setting and other community groups in Hampshire, undertook shopping trips in a virtual supermarket to assess whether their purchasing intentions differ if unhealthy foods, healthy foods or non-food items are placed in prominent positions (store entrances, checkouts and end of aisle). Preliminary findings indicated differences in women’s intention to buy certain types of products according to their educational attainment. Women with no educational qualifications beyond aged 16 years were intent on purchasing fewer healthy products when they were placed in prominent locations whereas those with higher educational attainment were intent on buying significantly more healthy products. A total of 230 women participated in phase I, exceeding our target sample size of 52. The study Women were shown a series of pictures representing six journeys through a supermarket. Pictures focused on the areas in a store where most shoppers usually pass through including the store entrance, end-of-aisles and checkouts. In the first three journeys, women needed to click all items they were interested in. In the last three journeys they needed to click all the items they would intend to buy if this was a real shop. Each set of journeys included a healthy journey, unhealthy journey and a non-food journey. What were the results? 201 women took part in a virtual supermarket survey. Overall, women in the study showed more interest in unhealthy products than healthy or non-food items. At checkouts, however, they did show more interest in non-food items. Women intended to buy more healthy and non-food items than unhealthy food items. On average they wanted to buy 12.9 healthy products per shop compared to 11.5 unhealthy products. What difference will this make? Unhealthy products can be interesting to women who shop at supermarkets but they have higher intentions to buy healthy and non-food items in noticeable places in stores. Supermarkets usually place unhealthy foods in noticeable places to make profits. Replacing these unhealthy foods with healthy or non-food items will just as likely, if not more successfully, lead to purchases. This can help families lead healthier lives. Why is this important for patients, health and care providers and policy makers ? Placing unhealthy foods in noticeable places can lead to impulse purchases of foods that can lead to obesity. Our study shows that women do not intend to buy these foods but may show interest in them. Since 2022, UK policy has banned the placement of some unhealthy foods at noticeable places in supermarkets. This research provides evidence that customers likely support this policy as they would like to buy healthy and non-food items from these locations. What we are going to be doing next? We wanted to further understand how attention to healthy, unhealthy and non-food items differ in noticeable places in supermarkets. We therefore ran eye-tracking experiments with 70 women in Hampshire. Data are being analysed. We plan to report the results of our survey and eye-tracking studies to policymakers (e.g. Department of Health and Social Care and Public Health England) via a policy brief. We also aim to share our results with families via Sure Start Children’s Centres, Facebook and Local Schools. We have plans to share our findings at public health conferences and in an academic journal.

03ec3658-b736-400b-ba5c-c0762b7b0f06 Understanding, addressing, and meeting the complex needs of people living with long term physical and mental health conditions: a qualitative study Lead applicant: Prof Mari Carmen Portillo and Dr Leire Ambrosio Co-applicants: Prof David Baldwin, Dr Lindsey Cherry, Dr Kate Lippiett, Dr Pritti Aggarwal, Mr William Barnaby Jones, Dr Sara McKelvie What problem will the research address and what evidence do you have this is a major concern for the public and health and care providers of Wessex? People with long term physical conditions are 2-3 times more likely to have mental health problems than the general population: at least 30% of adults with such conditions also have mental health problems (like anxiety and depression). People living with physical and mental long term conditions experience hardships relating to health, and have complex psychosocial, environmental, financial, and spiritual needs. Healthcare professionals find it difficult to provide fully integrated care for these populations, due to systematic barriers and fragmentation of services. The NHS has incorporated an initiative involving Social Prescribing Link Workers (SPLW) in response to these complex needs. SPLWs connect people to community local services to meet needs through a comprehensive person-centred approach. However, the way in which this initiative occurs in different areas and services is variable, and there is unclear guidance for primary care services about how to integrate this novel workforce into wider efforts to address and meet the complex needs of people living with long term physical and mental conditions. Where will the research take place and who will you involve? The project will be undertaken in primary care practices in Hampshire, the Isle of Wight and Oxfordshire, and with a range of local third sector organizations (e.g., Anxiety UK, Mind). Semi-structured interviews will be undertaken with people living with long term physical and mental health conditions. Subsequent focus groups will explore the range of care provider perspectives (e.g., social prescribing link workers, GPs, nurses, practice managers). We expect to interview 20-25 individuals and conduct 4-6 focus groups with 6-8 participants per group. Maximum variation sampling will focus on sociodemographic characteristics (age, sex, ethnicity, socioeconomic background), with a sharp focus on disadvantage and deprivation. Overall aim: To determine the barriers and facilitators to successful implementation of the SPLW role in primary care for individuals living with long term physical and mental conditions. Specific objectives. Identify the range of health and social needs of people living with long term physical and mental conditions. Explore provider perspectives about social prescribing link workers role implementation and effectiveness for people living with long term physical and mental conditions. Explore user perspectives about social prescribing link workers role implementation and effectiveness Explore how, SPLW implementation methods can be adapted to better meet the needs of culturally diverse populations including those living within deprived areas. Explore potential limitations of SPLW model for people living with long term physical and mental conditions. Co-produce recommendations to enable effective implementation of social prescribing link workers to address health and social needs of people living with long term physical and mental conditions. A qualitative design, utilising semi-structured interviews and focus groups will be conducted. Patients and the public will contribute to all aspects of the research process. How will the findings inform improvements in population health and patient care. Following this study, a comprehensive tailored programme will be developed to address the complex needs of people with long term physical and mental conditions including those living in deprived areas. Plans for its implementation will be explored involving key stakeholders from and integrated Care System (ICS), Primary care Networks (PCNs), Local Authorities and any other organizations/sectors that may benefit from the findings. Publications https://doi.org/10.1155/2023/7191247

9cf70c4f-6d1c-4acf-8a29-5aa00565f951 ADOPTED (PhD): PREPARE-to-ACT study: Preparing for and Responding to Emergencies – A multi-phased qualitative investigation of Patients’ And members of their RElational networks’ decisions to use urgent and emergency care during Anti-Cancer Treatment Principal Investigator: John Defty, University Hospital Southampton NHS Foundation Trust Start: September 2022 Ends: September 2026 Background Complications of anti-cancer treatment can be life threatening . Anti-cancer treatments, including chemotherapy, radiotherapy, and immunotherapy, are increasingly provided on a day-case basis , meaning that complications occur at home and necessitate a response from urgent and emergency care services . Evidence suggests people receiving anti-cancer treatment delay seeking help despite access to dedicated emergency care (acute oncology services) . Focus of research to date has been for what reasons and when , rather than how and why, people with cancer use these services. Evidence suggests patients and informal carers rely on prior instructions from cancer specialists to identify and interpret the severity of complications but find relating to this information difficult when acutely unwell . Emergency ‘contingency planning’ was identified as a priority for improving the safety of anti-cancer treatment but, there are few studies that describe how pre-treatment emergency planning influences help-seeking for complications of anti-cancer treatment . With the number of people eligible for anti-cancer treatment expected to rise by two million by 2040, the need for research is now urgent. Results from our scoping review (completed; drafted for publication) suggest preparing for and making sense of urgent and emergency care is hard work for people with cancer. It also revealed poor understanding of how this work might differ for people receiving different types of treatment. This study aims to address these gaps by answering the question: ‘How do patients and informal carers prepare and seek help for complications of different anti-cancer treatments?’

Talia Emmanuel is a PhD candidate in the Health Workforce & Systems research group at the University of Southampton. < Back What do nurses want? Improving nurses’ shift patterns - where do we start? Talia Emmanuel is a PhD candidate in the Health Workforce & Systems research group at the University of Southampton. Talia Emmanuel is a PhD candidate in the Health Workforce & Systems research group at the University of Southampton. In this blog, she summarises some key results from her recent research paper that explored nurses’ views and values around their shift patterns and working time. Talia Emmanuel -University of Southampton. As a PhD student, one must be well-prepared to answer the question…“What is your research about?”. I typically answer with “I’m trying to find ways of improving shift patterns for nurses when they’re working in hospital”. Enthusiastic nods usually follow, along with a quippy reply: “Wow, that sounds important and complicated ”. Although simply put, “important and complicated” neatly summarises the nuances of this topic. We recognise the significance of improving nurses’ working conditions in the context of persistent health workforce shortages, both nationally and internationally. However, we also realise that singular cure-all solutions are non-existent – there are too many factors at play. So, where do we start? Some of those complicating factors centre around how nurses’ working hours are organised. In hospitals, nurses often have to work in shifts that cover different periods of the 24-hour day. Previous research has identified various repercussions of working shifts (and in particular, working long shifts of 12-hours or more and night shifts): increased burnout , poor work-life balance , and risk of chronic illness and cancer on the long-term. Impacts to nurses’ performance and safety while at work have also been flagged, which pose knock-on effects on the quality of care patients ultimately receive. Despite these risks, shift work is a necessary reality for many nurses working in hospitals. Therefore, administrators and managers are tasked with organising nurses’ shifts into rotas that balance staff wellbeing with service demands and operational costs - and this is no easy feat. Further complications come from recent increased pressure on NHS employers to offer staff more say over their working patterns as a way of improving job satisfaction and their experiences of work. But this raises the question: What do nurses want? More specifically, what shift patterns do they prefer, and why? While there is some existing literature on this (an excellent summary can be found here ), our understanding of the factors that lead nurses to prefer certain shift patterns needs more work. As part of my doctoral research, I was eager to do a deep-dive into this area: I know that in order to find ways to improve nurses’ shift patterns, it is crucial to ask nurses themselves about their views and values around the organisation of their working hours. Fortunately, I had access to a rich data source around this topic: a recent survey study funded by the NIHR ARC Wessex that collected responses from nurses working across the UK and Ireland. My supervisors and I were particularly interested in nurses’ responses when asked: “ If you could choose your shift patterns, what would be the most important factor in that choice?” While we expected nurses to describe many diverse factors/preferences, we were hopeful of commonalities too. Nearly 800 nurses provided their open-ended responses to this question. We analysed all of them and developed 3 overarching themes: Theme 1, “When I want to work ”: Nurses shared many preferences for when they wanted to work, and equally, how they wanted their rest days to be arranged. Even though individual preferences differed, three general scheduling practices were also repeatedly mentioned as helpful: working less ‘harmful’ shift patterns from the start, working more consistent/predictable patterns, and having more flexibility and control over when to work. “Not working consecutive shifts so that I am exhausted by the time I get a day off.” “Know what I am doing each week, either set days or set nights, so I can predict what I am working…” “Having the freedom to give myself more days to recover between weekly shifts.” Theme 2, “Impacts to my life outside work” : Many factors emerged from nurses wanting shift patterns that enable a good work-life balance and minimise disruption to their lives outside work. Their preferences and priorities related to wanting quality recreational time with family and friends, to be able to arrange childcare easily and inexpensively, and having enough rest/recovery time to protect their own wellbeing. “Quality time with my children and family without being permanently drained, exhausted, and sad” “That the pattern could stay the same each week so it would be easier for childcare needs. Many nurseries like set days and when our rota is changing from week to week this can be difficult.” “…Not mixing days and nights in a week […] this does not observe HSE best practice guidelines and messes with the body clock and sleep patterns. It should not be allowed to happen.” Theme 3, “Improving my work environment” : Some nurses mentioned job-specific factors that influenced their choices, like wanting to work the shift patterns they believed to be best for patient care, or, working the best configuration of shifts for optimal take-home pay. But other concepts, like having sufficient staffing numbers and being able to take breaks, were also stressed. “A shift where I feel I have accomplished the care I have wanted to give for my patients” “To not have so much pressure on the shift, with the right amount of staff on and to take my break when needed”. When thinking back to the question “What shift patterns do nurses prefer, and why?”, these themes provide several helpful clues. They also highlight that while there is variation in nurses’ specific shift preferences, there are also more general scheduling practices that also support their priorities. For my research, this finding is particularly striking, as it moves away from the oft-assumption that there are “countless individual preferences that are difficult to accommodate” and toward the idea that there are more universal preferences too. Moreover, when these universal preferences are used during the scheduling process, nurses’ shift patterns can be improved overall. That sounds like a good starting point! Read our full analysis of nurses’ survey responses in the open-access research paper here Follow Talia: Twitter/X | ResearchGate Follow the UoS Health Workforce & Systems team: Twitter/X | UoS website Previous Next

22c6bc93-4002-4a39-ba1e-6b7c981fbe5f A qualitative case study to understand Young people’s food purchasing patterns in CONvenience stores in the school neighbourhood environment (Y-CON) Chief Investigators: Janis Baird and Christina Vogel, Professor of Public Health and Epidemiology and Adjunct Professor of Food Policy, MRC Lifecourse Epidemiology Centre, University of Southampton Team: Dr Sarah Muir, Senior Research Fellow, MRC Lifecourse Epidemiology Centre, University of Southampton Dr Kath Woods-Townsend, Principal Research Fellow, School of Healthcare, Enterprise and Innovation Dr Sarah Crozier, Senior Statistician, MRC Lifecourse Epidemiology Centre, University of Southampton Dr Hayward Godwin, Associate Professor of Psychology, University of Southampton Professor Marcus Munafo and Dr Olivia Maynard, Bristol University Ravita Taheem, Southampton City Council, lead on childhood obesity Partners: Bristol University, University of Southampton, Southampton City Council Start: 1 October 2024 End: 31 March 2026 Background A poor diet significantly contributes to illnesses including heart disease, diabetes and stroke. One in three children who leave primary school have obesity or overweight, raising concerns about their future health. The teenage years are crucial because this is when young people start making their own food choices, setting the stage for their lifelong eating habits. The Problem The journey to and from school often involves passing by convenience stores which rely on shoppers, such as young people, to impulse-buy products that are high in fat, salt and sugar. The presence of these stores in school neighbourhoods may be linked to the high rates of childhood obesity. Our Research Focus We used a qualitative approach to understand convenience stores near schools influence the buying patterns of young people making their own dietary decisions. Study Design Our research ran between October 2024 and March 2026. Forty-three students from two secondary schools in Hampshire took part in focus groups about how they used convenience stores near their school. Young people from the LifeLab NxtGen programme were also employed as citizen scientists: they took part in a ‘mystery shopper’ task to purchase a healthy product near the stores and reported on their experience. NxtGen researchers also worked with the team to support the analysis of findings and development of dissemination materials. Expected Outcomes Our findings will provide critical insights for shaping policies. They may help refine existing regulations on food placement and promotions, which currently exempt small businesses, potentially worsening health inequalities among young people. Engagement and Dissemination The team, including members of the NxtGen research group, have developed an infographic detailing core recommendations for independent stores in the UK to help improve young people’s access to healthier food. Plans are underway to share this infographic with our young participants, as well as policy makers and retail groups. Internationally, our research will also be presented in scientific journals and at conferences.

a7ea3c51-ca08-45ba-a500-e478bca6eb43 Motivating and sustaining engagement of young people in improving their health and that of their communities Prinicpal Investigator: Professor Mary Barker Team: Kathryn Woods-Townsend, University of Southampton, James Toop, Bite Back 2030, Matthew Ryan, University of Southampton, Joanna Sofaer, University of Southampton, Pathik Pathak, University of Southampton Start Date: 1 April 2023 End Date: 30 September 2024 Background Calls by young people for increased involvement in decisions about their health and futures are echoed by WHO and UNICEF. These reflect threats to their health from inequalities and climate change, exacerbated by COVID-19. To be “architects of their own future” and have decision-making power, young people need training and opportunities to build confidence, and structures and processes that allow them to be involved in decision making. Aims We aim to explore how best to engage and maintain engagement of young people in these activities with a view to improving their health and well-being and that of their communities Our specific objectives are to: develop and test a training course for young people in skills to support participatory action research into health and well-being; test the effectiveness of arts-based approaches in engaging young people in health improvement; understand how to create a reliable, scalable and sustainable model for effective youth activism; evaluate democratic innovations to engage young people in decision making processes to influence health policy. What did we find out? Through our project we found that young people can meaningfully participate in decision making on topics that are important to them. During the year young people were engaged in two separate ways: Firstly, BiteBack 2030’s youth advocacy programme was analysed and essential components of its success extracted. Those factors included establishing open two-way channels for communication, Working to create an environment where young people’s and staff views are equally valued, Supporting staff to develop excellent facilitation skills, Investing in young people’s skills, Campaigning on issues that young people feel are important and current and Reviewing success and challenges of each campaigns and adapt activities in response. Secondly, young people were successfully trained in research skills, advocacy and democracy during a 12-week Young Researcher Training Programme. The training programme allowed young people to investigate a health topic that was important to them and collect data from their peers and community. Their projects ranged from looking at exam stress, vaping, benefits of youth participation, to women’s health issues, failures in the PSHE curriculum and vaccine hesitancy. The results from their research went towards creating a set of health recommendations that young people felt should be prioritised for the improved health and wellbeing of young people in Southampton. A Youth Jury was held in July 2024 where the recommendations were refined based on collaboration with the Hampshire and Isle of Wight Integrated Care Partnership. The 12 amended recommendations formed the basis of a manifesto for health which included the following points to be addressed by decision makers: 1.Expand Extra-Curricular Wellness Activities. 2. Improve our methods of handling young people’s mental health by creating accessible services. 3. Respond to Vaping Proactively. 4. Deliver a comprehensive digital health platform for young people. 5.Review the PSHE Curriculum. 6. Encourage the mixed teaching of Sexual and Reproductive Education (SRE) . 7. Cultural & Religious Sensitivity . 8. Information to Parents. 9.Deliver Youth Engagement. 10. Diversify and Expand Work Experience and Financial Support for Prospective Professionals. 11. Establish Panels to Honestly Inform Young People about NHS Careers. 12. Produce Youth- Led Marketing. Evaluation of the effectiveness of the training programme, Youth Jury and Assembly at engaging young people in decision making and the resultant responses from decision makers is still ongoing. Final results will be available from spring 2025. You can see Young People talking about their recommendations here What did we do with this Knowledge? • The recommendations created by the young people within the manifesto for health were presented to the Integrated Care Partnership (ICP) and wider stakeholders in health and wellbeing at the Hampshire and IoW ICP Youth Assembly on 13th November 2024. An action plan was drawn up in collaboration with decision makers to implement the recommendations in practice. These recommendations will go towards informing the delivery of health services for young people In Hampshire and the IoW. • The criteria for a successful youth advocacy/ activism programme provide BiteBack with evidence-based conclusions that they can use to replicate and grow the success of their programmes. The links between youth health and wellbeing and participation in activism programmes was highlighted The findings from this investigation also went towards informing how we run the Young Researcher Training Programme to make sure young people are getting the most out of the experience for their health, wellbeing and future quality of life. See the BiteBack poster image BiteBack poster[83] .png Download PNG • 1.08MB BiteBack visual report (PDF What Next? The learning from this project will go towards informing how future YRTP sessions will be structured and run. For example, the advocacy and links to decision making in this project will be replicated in the next iteration. The next iteration of YRTP begins in December 2025, with a focus on developing a Southampton Youth Voices service. The learnings from BiteBack’s youth activism programme will aid other youth organisations to successfully engage young people in improving their health. This work adds to the growing body of research around the importance of youth participation and its long-term health and wellbeing benefits. Talitha McCleery, 17, took part in the programme and said: "Young people want to and deserve to be, involved in decisions that impact their health and futures. We believe that the people who sit in positions of power must prioritise consulting with young people if they want their decisions to have real change and make a positive impact." Libby Tickner, 17, who also took part, added: "We must all work together - school boards, local government, local charities and national non-governmental organisations - to ensure no opportunity is left wasted." Source: Hampshire youth assembly shares health and wellbeing ideas | Daily Echo

3a154492-5625-4fba-82b5-37d30dbaccaa Creating Learning Environments for Compassionate Care (CLECC) in mental health settings: an implementation study This project has been completed and had created the CLECC toolkit which you can see here Principal Investigator: Dr Michelle Myall Team members : Dr Michelle Myall (Senior Research and Implementation Fellow, School of Health Sciences, University of Southampton), Dr Sarah Williams (Associate Director for Research and Improvement, Solent NHS Trust) Professor Jackie Bridges (Professor of Older People's Care, School of Health Sciences, University of Southampton), Dr Jane Frankland (Senior Research Fellow, School of Health Sciences, University of Southampton), Cindy Brooks (Research Fellow, ARC Implementation team). Started: 1 October 2020 Ended : 30 September 2022 Project partners : Solent NHS Trust, Southern Health NHS Foundation Trust, NHS Improvement, Wessex AHSN, Centre for Implementation Science, University of Southampton. Co-funded by : NHS Improvement Lay summary Background There is some public concern about NHS hospital nurses’ capacity to provide compassionate care, but very little research about how to improve this situation. We have developed and piloted a programme called Creating Learning Environments for Compassionate Care (CLECC). In CLECC, all registered nurses and health care assistants from participating wards attend a study day, with a focus on team building and understanding patient experiences. A nurse educator (who is not usually part of the ward team) supports the team to try new ways of working on the ward, including regular supportive discussions on improving care. Ward managers attend learning groups to develop their leadership role. Volunteer team members receive training in observations of care and feeding back information to colleagues. In an earlier study, we piloted CLECC on four wards in two NHS hospitals, with two other wards continuing with business as usual. We found that CLECC could be put into practice on NHS hospital wards and that staff felt it improved their capacity to be compassionate. However, we found variations between the four nursing teams and two hospitals, in whether or not, staff felt able to take part in CLECC and to carry on with CLECC after the nurse educator left. We followed up the wards two years later and found that some wards had carried on using CLECC and shared the ideas with other teams. But some wards had stopped using CLECC and we found that this was influenced by amongst other factors: staffing levels, work priorities, staff turnover and managers’ support. The research findings to date suggest that each team differed in the ways they used and responded to the CLECC ideas. If we want programmes like CLECC to make a difference to patient care, we need more research to test it out in other settings. This will help us to better understand the conditions in which CLECC is most likely to make a positive difference and about how these conditions can be developed, supported and maintained. Aims of study This study will follow up to four nursing teams in mental health hospital settings who are using CLECC for the first time. We will use questionnaires, staff interviews and documentary evidence to gather data on the characteristics of organisations and teams, and the factors that influence CLECC’s progress in the first few months. We will look carefully at these data, working out the connections between the characteristics, the influencing factors and what happens when CLECC is used. We will develop a theory about how different organisational conditions affect the journey of programmes like CLECC. We will also use the study to test the best way to measure the impact of CLECC on staff well-being. How will findings be used? This research will help us understand what changes might be needed to get organisations ready for using CLECC. It will also mean we can identify in advance teams who are likely to benefit from CLECC, improving its value for money. We will use the findings to develop a guide for hospital managers to assess and improve their organisations and teams for their receptiveness to quality improvement activities like CLECC. We will share our findings with a wide range of people including patients and families, NHS managers, health and social care staff and other researchers.