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Background The eye care workforce, particularly in lower resource settings, face challenges of limited integration into the health system, limited workforce capacity, mismatch of workforce to population need and poor quality of care. In recognition of these challenges, coupled with a gap in existing tools, provides a strong rationale for the development of the Eye care competency framework (ECCF). Methods A mixed methods approach was utilised to develop and validate the ECCF. Content was developed by extracting relevant components of existing frameworks used both within and outside of eye care. A diverse technical working group provided feedback and guidance on the structure, design, and content to create a preliminary draft. Competencies and activities were validated using a modified-Delphi study, and the framework was then piloted at four sites to understand how the tool can be implemented in different settings. Results The final version of the ECCF included eight outcomes, nine guiding principles, and content of each of the key elements, including the six domains, 22 competencies, 21 activities, 193 behaviours and 234 tasks, and the knowledge and skills that underpin them. 95/112 participants from the six WHO regions completed the modified-Delphi study, yielding an average of 96% agreement across the competencies and activities in the ECCF. The pilot showcased the versatility and flexibility of the ECCF, where each of the four sites had a different experience in implementing the ECCF. All sites found that the ECCF enabled them to identify gaps within their current workforce documentation. Conclusions The ECCF was developed using a collaborative approach, reflecting the opinions of participants and stakeholders from all around the world. The comprehensive competencies and activities developed in the ECCF encompass the diverse roles of eye care workers, and thus encourage multi-disciplinary care and better integration into the health system. It is recommended that eye care workforce planners and developers use the ECCF to support workforce development and focus on the quality and scope of eye care service provision.

As advocates for health, nurses are ideally situated to deliver effective health promotion in their daily interactions with people. This work evaluates the integration of healthy conversation training, making every contact count (MECC), into a health promotion module in an undergraduate nursing degree at a higher education institute (HEI). In all, 108 students completed the online questionnaire I year after receiving healthy conversation training. 67% of students reported the regular or occasional use of healthy conversation skills and identified a wide range of scenarios where they had used the skills. 65% of students used health action planning framework in their own personal self-care. Student nurses acknowledged barriers and enablers to their use of healthy conversation skills. Having knowledgeable mentors who role modelled healthy conversations skills in their consultations was the most frequently raised factor, in addition to lack of knowledge of local resources, time and confidence. All placement settings should ensure that registered nurses, especially those undertaking mentorship responsibilities have access to healthy conversation training.

Introduction: For most, wishes and preferences for end-of-life care are outlined in wills or advanced care plans (ACPs). However, these often do not encompass our digital lives, meaning that information on how bereaved loved ones can access and close down the deceased digital accounts are not passed on, including passwords. Digital assets may be owned by the deceased person, beneficiaries or the online service(s) used. Furthermore, digital information laws and policies, such as General Data Protection Regulation (GDPR), can obstruct this information being shared following death. As a result, loved ones may be unable to access precious and sentimental personal memories, photographs, videos and more.Theory: It has been estimated that approximately 96% of households in Great Britain have internet access, with 76% of adults using internet banking.[1] Online accounts can span from social media and TV streaming to online banking and digital currency.Use of these accounts after death is rarely considered by the general public. With the increasing use of electronic storage, more work needs to be done to ensure the safe and easy transfer of digital information before death. Digital legacies, defined as the digital information available about someone after their death, are one safety mechanism to ensure this process.Highlights: In August 2021, the Compassionate IOM Community Network presented the concept of digital legacies to the IOM Chamber of Commerce Digital Forum who are responsible for actively promoting the digital sector. It was agreed that procedures would be updated to accept digital legacies and to identify best practices. Following this, a representative from the IOM Law Society presented it back to the Society. Collaboration between Compassionate IOM and the Law Society is ongoing through exploration of procedures that could be taken by local solicitors, such as prompting discussions during the will- or ACP-writing process. Advice could include making plans for digital assets, approving a digital executor, or simply encouraging people to leave their online affairs in order.In addition to this, the IOM Government Department of Enterprise has recently released an open consultation on electronic transactions. The Compassionate IOM Community Network are lobbying the Government to extend this consultation to digital legacies and electronic death certificates.Conclusions: While the work around digital legacies on the IOM remains in its infancy, a new framework is being constructed through collaboration between the IOM Law Society and Compassionate IOM.Implications for applicability/transferability, sustainability and limitations: There remains work to be done to ensure that the process of digital legacies on the IOM is sustainable, uncomplicated and protects people when they are at their most vulnerable. Future work will aim to work with local banks to prompt discussions surrounding online banking post death.References1. Office for National Statistics. Internet access - households and individuals, Great Britain: 2020 [webpage on the internet]. [cited 2021 30 Nov]; updated 2020 Aug 7]. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/householdcharacteristics/homeinternetandsocialmediausage/bulletins/internetaccesshouseholdsandindividuals/2020

Introduction: The care needed at end of life can go beyond what services can offer. This is where volunteers can make a difference, however the nature of their support can vary. Dodd et al. [1] recognised two types of input: ‘being there’ and ‘doing for’. Similarly, Burbeck et al. [2] examined the volunteer role and found three themes; the distinctness, characteristics and experience of the role. Here, a volunteer can be mediating between patients and staff, sometimes acting as a surrogate family member. Such complexity requires further study and more detailed information about the impact on care recipients, and the volunteers themselves, would greatly assist the training and development of volunteers as well as decisions on how to maximise the use of volunteers to achieve the most benefit. Compassionate Isle of Man (IOM) has been developing the role of volunteers as Palliative Care Companions in the community. This evaluation aims to capture the impact and experience of volunteers and care recipients and examine the explicit and implicit needs for palliative care that they address. This paper will report on the pilot of the methods and initial findings.Aims: To use capability measures, qualitative and other data to identify the implicit and explicit needs for volunteer support, the short-term impact(s) on care recipients and volunteers and the implications for the training of volunteers. Methods: A prospective study will enrol care recipients and their carers at the outset of Compassionate IOM support. Baseline data will include stated needs as well as the ICEpop CAPability (ICECAP) measures [3] and interviews. Data collection will be repeated at 6 and 12 weeks and will include specially designed questionnaires and interviews to elicit perceptions of impact, satisfaction and details of the support experience. This information will be set within a cost-benefit framework to quantify the extent to which declared and undeclared needs are met, at what cost and with what benefits to care recipients and volunteers. The initial pilot study will test the methods and include at least 10 care recipients, their main carers and the related volunteers.Conclusion and implications: This pilot study will form the basis for a longer-term study which will provide essential information on the potential scope of volunteer support and their place in the overall service delivery of palliative care in the community.References1. Dodd S, Hill M, Ockenden N, Algorta GP, Payne S, Preston N, et al. ‘Being with’ or ‘doing for’? How the role of an end-of-life volunteer befriender can impact patient wellveing: interviews from a multiple qualitative case study (ELSA). Supportive Care in Cancer 2018;26(9):3163-3172. doi: https://doi.org/10.1007/s00520-018-4169-22. Burbeck R, Candy B, Low J, Rees R. Understanding the role of the volunteer in specialist palliative care: a systematic review and thematic synthesis of qualitative studies. BMC Palliative Care 2014;13(3):1-12. doi:https://doi.org/10.1186/1472-684X-13-33. University of Birmingham. ICECAP capability measures [webpage on the Internet]. [cited 2021 30 Nov]. Available from: https://www.birmingham.ac.uk/research/activity/mds/projects/haps/he/icecap/index.aspx

Introduction: Dementia presents a major challenge for health care systems with aging populations. Over 46 million people live with dementia worldwide and is estimated to increase to 131.5 million by 2050.[1] Diagnosis is important as it allows people with dementia (PWD) to get treatment, care and support to help them manage their condition. However, during the early stages of dementia much of the care occurs at home carried out by an informal/non-professional carer. There is a growing need for an evidence-based approach to home support for people with dementia and their carers.Methods: Sixty volunteers will be randomised into two groups with a 2:1 intervention to control allocation ratio. The app developed by Memory Lane Games, will present images with associated questions in the form of a quiz. The non-personalised app will have 12 games based on general topics, such as geographic locations or food, which cannot be altered. The personalised app will allow the PWD to upload their own images and search the app database for games of their choice. All participants will be asked to use the app at least once a week for six months. Quality of life (QoL) and communication will be assessed at baseline, week 13 and week 26. Semi-structured interviews will be administered at week 13 and week 26.Results: The app emulates key features of reminiscence and distraction therapy, both of which have been shown to improve communication between the PWD and their carer, as well as improve their QoL.[2] Therefore the hypothesis is that engagement with the personalised content may lead to an improvement in QoL for both PWD and their carer, and also facilitate communication.We aim to have the interim (week 13) results by the time of the International Conference on Integrated Care 2022.Conclusions: By increasing face-to-face engagement between the PWD and their carer via the app, there may be a positive benefit to the PWD and/or their carers.Implications for applicability/transferability, sustainability and limitations: This randomised control trial (RCT) will test the feasibility of future studies and examine the direction of effect on QoL and communication. If the results are promising, the app has scope to be distributed across the world. It may also have the potential to be tailored towards neurodivergent people, such as people diagnosed with autism.As the app is digital, it requires access to an electronic device able to run the app, as well as internet connection. Some people may not be able to afford a device and/or may not have internet access. References1. Prince M, Wimo A, Guerchet M, Ali GC, Wu YT, Prina M. World Alzheimer Report 2015: The global impact of dementia: an analysis of prevalence, incidence, cost and trends. United Kingdom: Alzheimer’s Disease International; 2015. [cited 2021 18 Nov]. Available from: https://www.alz.co.uk/research/WorldAlzheimerReport2015.pdf2. Cotelli M, Manenti R, Zanetti O. Reminiscence therapy in dementia: A review. Maturitas 2012;72(3):203-205. doi: 10.1016/j.maturitas.2012.04.008

Background Many countries implementing pro-poor reforms to expand subsidized health care, especially for the poor, recognize that high-quality healthcare, and not just access alone, is necessary to meet the Sustainable Development Goals. As the poor are more likely to use low quality health services, measures to improve access to health care need to emphasise quality as the cornerstone to achieving equity goals. Current methods to evaluate health systems financing equity fail to take into account measures of quality. This paper aims to provide a worked example of how to adapt a popular quantitative approach, Benefit Incidence Analysis (BIA), to incorporate a quality weighting into the computation of public subsidies for health care. Methods We used a dataset consisting of a sample of households surveyed in 10 provinces of Indonesia in early-2018. In parallel, a survey of public health facilities was conducted in the same geographical areas, and information about health facility infrastructure and basic equipment was collected. In each facility, an index of service readiness was computed as a measure of quality. Individuals who reported visiting a primary health care facility in the month before the interview were matched to their chosen facility. Standard BIA and an extended BIA that adjusts for service quality were conducted. Results Quality scores were relatively high across all facilities, with an average of 82%. Scores for basic equipment were highest, with an average score of 99% compared to essential medicines with an average score of 60%. Our findings from the quality-weighted BIA show that the distribution of subsidies for public primary health care facilities became less ‘pro-poor’ while private clinics became more ‘pro-rich’ after accounting for quality of care. Overall the distribution of subsidies became significantly pro-rich (CI = 0.037). Conclusions Routine collection of quality indicators that can be linked to individuals is needed to enable a comprehensive understanding of individuals’ pathways of care. From a policy perspective, accounting for quality of care in health financing assessment is crucial in a context where quality of care is a nationwide issue. In such a context, any health financing performance assessment is likely to be biased if quality is not accounted for.

Summary Background COBRA-BPS (Control of Blood Pressure and Risk Attenuation-Bangladesh, Pakistan, Sri Lanka), a multi-component hypertension management programme that is led by community health workers, has been shown to be efficacious at reducing systolic blood pressure in rural communities in Bangladesh, Pakistan, and Sri Lanka. In this study, we aimed to assess the budget required to scale up the programme and the incremental cost-effectiveness ratios. Methods In a cluster-randomised trial of COBRA-BPS, individuals aged 40 years or older with hypertension who lived in 30 rural communities in Bangladesh, Pakistan, and Sri Lanka were deemed eligible for inclusion. Costs were quantified prospectively at baseline and during 2 years of the trial. All costs, including labour, rental, materials and supplies, and contracted services were recorded, stratified by programme activity. Incremental costs of scaling up COBRA-BPS to all eligible adults in areas covered by community health workers were estimated from the health ministry (public payer) perspective. Findings Between April 1, 2016, and Feb 28, 2017, 11 510 individuals were screened and 2645 were enrolled and included in the study. Participants were examined between May 8, 2016, and March 31, 2019. The first-year per-participant costs for COBRA-BPS were US$10·65 for Bangladesh, $10·25 for Pakistan, and $6·42 for Sri Lanka. Per-capita costs were $0·63 for Bangladesh, $0·29 for Pakistan, and $1·03 for Sri Lanka. Incremental cost-effectiveness ratios were $3430 for Bangladesh, $2270 for Pakistan, and $4080 for Sri Lanka, per cardiovascular disability-adjusted life year averted, which showed COBRA-BPS to be cost-effective in all three countries relative to the WHO-CHOICE threshold of three times gross domestic product per capita in each country. Using this threshold, the cost-effectiveness acceptability curves predicted that the probability of COBRA-BPS being cost-effective is 79·3% in Bangladesh, 85·2% in Pakistan, and 99·8% in Sri Lanka. Interpretation The low cost of scale-up and the cost-effectiveness of COBRA-BPS suggest that this programme is a viable strategy for responding to the growing cardiovascular disease epidemic in rural communities in low-income and middle-income countries where community health workers are present, and that it should qualify as a priority intervention across rural settings in south Asia and in other countries with similar demographics and health systems to those examined in this study. Funding The UK Department of Health and Social Care, the UK Department for International Development, the Global Challenges Research Fund, the UK Medical Research Council, Wellcome Trust.

BACKGROUND: In 2014, Indonesia launched a single payer national health insurance scheme with the aim of covering the entire population by 2024. The objective of this paper is to assess the equity with which contributions to the health financing system were distributed in Indonesia over 2015 - 2019. METHODS: This study is a secondary analysis of nationally representative data from the National Socioeconomic Survey of Indonesia (2015 - 2019). The relative progressivity of each health financing source and overall health financing was determined using a summary score, the Kakwani index. FINDINGS: Around a third of health financing was sourced from out-of-pocket (OOP) payments each year, with direct taxes, indirect taxes and social health insurance (SHI) each taking up 15 - 20%. Direct taxes and OOP payments were progressive sources of health financing, and indirect tax payments regressive, for all of 2015 - 2019. SHI contributions were regressive except in 2017 and 2018. The overall health financing system was progressive from 2015 to 2018, but this declined year by year and became mildly regressive in 2019. INTERPRETATION: The declining progressivity of the overall health financing system between 2015 - 2019 suggests that Indonesia still has a way to go in developing a fair and equitable health financing system that ensures the poor are financially protected. FUNDING: This study is supported through the Health Systems Research Initiative in the UK, and is jointly funded by the Department of International Development, the Economic and Social Research Council, the Medical Research Council and the Wellcome Trust.

PurposePalliative care requires integration between services, organisations and the community. A series of community engagement programmes, named “Listening Events”, were conducted across the Isle of Man. The aim was to involve the community in the development of Hospice strategy by sharing their views on the future of palliative and end of life care.Design/methodology/approachThree Listening Event programmes were conducted in community settings, secondary schools and the Isle of Man’s University College. The investigators facilitated discussions on current knowledge of Hospice services, what would matter to people should they need to use these, and how Hospice could best serve the community in the future. Participants and investigators noted thoughts and comments. Data were analysed using thematic analysis.FindingsIn total, 899 people participated from across the community. Main themes surrounded effective care, person-centred care and integrated care. Most themes agreed across the three programmes, despite some nuances.Originality/valueThe results were used as an evidence base from which Hospice Isle of Man’s new strategy was derived in order to ensure that it aligned with the community’s needs. By initiating conversations and discussions in the community, the Listening Events may have also increased understanding about hospice care.

Background: Accounts of stress are common among students on nursing programmes. Prolonged high levels of stress can contribute to poor learning, the development of detrimental health behaviours, attrition and burnout. Aims: To examine the health and wellbeing implications of undertaking a BSc nursing degree in the UK for first-year students. Methods: Qualitative narrative analysis of 100 written student reflections on the influences on their health and wellbeing was undertaken. Findings: Nursing students must juggle multiple competing demands on their physical capabilities, personal resources, income and time. Students are constantly seeking to achieve balance and personal equilibrium through the use of a variety of coping strategies. Conclusion: This work calls upon the profession, the nursing regulator, nursing programmes within higher education institutions and health Trusts to review the framework and content of undergraduate BSc nurse education. Programme requirements should enhance the health and wellbeing of students while simultaneously delivering education and practice opportunities necessary to meet professional requirements.

BackgroundCompetency frameworks are being taken up by a growing number of sectors and for a broad range of applications. However, the topic of competency frameworks is characterised by conceptual ambiguity, misunderstanding and debate. Lack of consistency in the conceptualisation and use of key terminology creates a barrier to research and development, consensus, communication and collaboration, limiting the potential that competency frameworks have to deal with real workforce challenges. This paper aims to advance the field by conducting a detailed review of the literature to understand the underlying causes of conceptual differences and divergent views and proposing a re-conceptualisation of competency framework terminology for use by the health sector.MethodsA broad scoping review of literature was conducted to identify publications relating to the conceptualisation of competency frameworks and key terms, examine how they are conceptualised and determine how this evolved. In addition, a purposive sample of health-related competency frameworks was chosen to illustrate how the terms and concepts are currently being applied in the health context.ResultsOf the 4 155 records identified, 623 underwent text searches and broad quantitative analysis, and 70 were included for qualitative analysis. Quantitative analysis identified 26 key terms, which were coded under six thematic headings. Qualitative analysis using the thematic areas revealed two distinct conceptualisations of competency frameworks and their terminology emerging concurrently in the education and employment sectors, with different underpinnings and purposes. As competency frameworks have developed, these two conceptualisations intertwined, resulting in the same terms being used to convey different concepts. Examination of health-related frameworks showed that this merging of concepts is prominent, with lack of consistency in definitions and use of key terms even within a single organisation.Discussion and conclusionsBuilding on previous efforts to address the lack of conceptual clarity surrounding competency frameworks, this paper proposes a re-conceptualisation of the terminology that encompasses two distinct competency framework interpretations, using a glossary of mutually exclusive terms to differentiate concepts. The re-conceptualisation holds relevance for multiple competency framework applications within health, enabling harmonisation, clear communication, consensus-building and effective implementation of competency frameworks.

ObjectiveThe objective of this paper is to establish whether existing eye care competency frameworks (ECCF) are fit for purpose, and set out a comprehensive ECCF that better meets the needs of the eye care workforce and broader population.Methods and analysisWe carried out a two-stage process. The first was to conduct a desk review of existing frameworks and models relevant to eye care competencies. The second was to conduct a broad stakeholder consultation of global eye care experts to affirm the gaps found in the first stage, and to inform the development of a comprehensive ECCF.ResultsWe reviewed 52 competency frameworks, competency standards and models related to eye care (including 11 from the UK) and found that there were three types of gaps, such as: (1) narrow in focus on specific occupational groups; (2) limitations in the competencies expected from an eye care worker and (3) limitations in regional focus, such that they could not easily be applied in a global context.Having affirmed these gaps during the stakeholder consultation stage, we developed a more comprehensive ECCF structure, which composed of six domains: practice, professionalism, learning and development, management and leadership, community and advocacy, and evidence. This broader structure seeks to address the gaps found in the desk review.ConclusionThe review showed that there was a need to develop a comprehensive ECCF that can be easily contextualised, encapsulate the roles of the diverse eye care workforce, and be a tool for eye care workforce planning and development to meet the needs of a global population.

Background In June 2021, the hospice began delivering our first ever Quality Improvement (QI) Programme. We had observed an environment that was innovative in research and could be innovative in QI. We all ‘improved quality’ but did we use QI as a framework for that improvement? Aims Our shared vision was to integrate QI into the normal working day, within a culture of continuous improvement (National Advisory Group on the Safety of Patients in England, 2013). We have now launched our QI journey with our first sequential and small steps; a QI Programme and QI Champions. Methods The programme was delivered over four days to clinical and non-clinical staff; motivated and energetic people from every department in Hospice. We delivered QI technical skills (Institute for Healthcare Improvement. How to improve [The Model for Improvement]) blending theory and practice, whilst also focusing on wider topics which support QI landing successfully in the day job. This included improvement leadership (Ovretveit, 2009), human factors (National Quality Board, 2013) and team work (Montgomery, Parkin, Chisholm, et al., 2020). These specific topics were chosen by the participants, so the programme was bespoke to their learning needs and overall the programme was designed to be a fun and interactive environment. Results We commenced evaluation with a pre-course self-assessment of QI knowledge, skills and confidence. This was repeated at the end of each facilitated day and will be concluded by a post-course self-assessment. The first cohort completes in September 2021 and we will have the programme evaluation completed the same month. Conclusions We anticipate participants will have improved QI knowledge, skills and confidence which will enable them to actively use QI in their normal working day and will also transition to become QI Champions. The QI Champion is a new role being designed to support other staff, encourage momentum and be a key part of building a network of QI Champions. We would like to share our story so far and future system plans. Sharing, learning, improving.

Background In response to the COVID-19 pandemic, the hospice moved to digital approaches. Whilst tele-rehabilitation has shown benefits for various chronic health conditions (Bhatt, Patel, Anderson, et al., 2019; Zanaboni, Hoaas, Lien, et al., 2017; Hwang, Bruning, Morris, et al., 2017), there is a gap in the literature on telehealth interventions for palliative rehabilitation. Aim To evaluate digital delivery of a palliative rehabilitation programme and obtain perceptions of users and staff. Methods All members of the Fatigue and Breathlessness (FAB) follow-on group (n=19) were invited to complete a questionnaire on the experience of transitioning to Zoom sessions. Descriptive statistics were produced using the statistical software package, Stata (Version 15; StataCorp, 2017). Qualitative data were analysed using an inductive thematic analysis framework (Braun & Clarke, 2006). Three members of the rehabilitation team were interviewed about encountered benefits and challenges. Results Thirteen members completed the questionnaire (68%) and all were positive about the transformed sessions. Eight respondents (62%) felt that the Zoom sessions were ‘no different’ or ‘better’ than in-person sessions. No adverse events were reported. Themes from open-ended comments included patient-level effects such as maintained exercise and social contact when in isolation and removed travel requirements. At the service level, there was improved access but technological challenges. Most respondents (9, 69%) suggested keeping the option of Zoom for flexibility and 46% (6) wanted both staff-led and self-led elements. The rehabilitation team felt their rapid response and team working enabled efficient transition to Zoom. This included risk assessments, particularly for those living alone. With help, users quickly learned and the virtual delivery provided opportunities to try new activities. At times, staff found the ‘silent audience’ challenging. The rehabilitation team felt the approach may only work with groups with existing rapport. Conclusions The hospice rehabilitation team now provide concurrent sessions at home via Zoom and in the hospice. These access options provide choice, appear to be acceptable and offer flexibility around changing condition status and personal factors.

Background Dementia presents a major challenge for health care systems with aging populations. Over 46 million people live with dementia worldwide. This is estimated to increase to 131.5 million by 2050 (Prince, Wimo, Guerchet, et al., 2015). Much of the care for the person with dementia in the early stages takes place at home, therefore, there is a growing need for an evidence-based approach to home support for people with dementia and their carers (Chester, Clarkson, Davies, et al., 2018). Aims This study will assess the impact of a new, personalised memory games application (App), on the quality of life (QoL) of people with dementia and their carer(s). Methods This randomised controlled trial involves volunteers as participants (20 intervention group using a personalised App and 10 controls using a non-personalised App) and recruited via study promotion posters and local community organisations. Apps will present images with associated questions in the form of a quiz. The non-personalised App will use images such as flowers, fruit and geographic locations. Personalisation means the participant, carer or family members will be able to upload their own pictures which are more meaningful to the person with dementia. All study participants will be asked to use their App once a week for six months. Anticipated Results Engagement with the personalised content in the form of a game might lead to improvement in the QoL of the person with dementia and/or their carer by facilitating and improving communication. Early analysis will be presented at Hospice UK conference. Conclusions By increasing positive engagement between the person with dementia and their carer/relative via face-to-face and remote engagements, there may be a positive benefit to patients, carers or both. This study is being funded by Memory Lane Games Limited.

Background Caring for people with dementia can be an overwhelming experience for carers who often have unmet needs and experience physical, emotional and economic pressures (National Institute for Health and Care Excellence, 2019; World Health Organization, 2019). Any support model should promote open, honest, two-way dialogue to facilitate patient choice at the end-of-life and anticipatory care planning to enable the person with dementia to achieve a good death. Approximately 1400 people live locally with a dementia diagnosis. Hospice Isle of Man has recognised the need to support people with dementia to live well and die well. Carers and people with dementia often face inequalities in accessing support services. This was identified in a scoping exercise which then resulted in the development of this model of support. Aims To develop and evaluate a hub and spoke model to support people with dementia and their carers throughout the key transition points of the disease trajectory. Methods Hub - ten sessions with carers and people with dementia. Spokes - the carers will receive bespoke training and support from the Admiral Nurse Service to reduce carer burnout and distress. The person with dementia will be supported by specially trained staff and volunteers. We aim to enable the person with dementia to remain at home, avoid unnecessary hospital admissions and plan for a good death. Carers will be given tools to help them manage their anticipatory grief and loss, whilst also supporting them to reconnect to society and move forward. Results The model is due to start in autumn 2021. The evaluation forms will be completed at the start and end of the ten sessions of the programme to gauge impact as well as levels of understanding and to identify areas of further support. Conclusions The model should help to reduce inequalities of access for carers and people with dementia by providing appropriate and timely support.

Background Measuring patient outcomes is necessary to assess the impact of care and identify areas for improvement (Etkind, Daveson, Kwok, et al., 2015; Marshall, Haywood, Fitzpatrick, 2006). It is therefore vital that staff are confident and comfortable using outcome measures. Hospice adopted three of the Outcome Assessment and Complexity Collaborative (OACC) (Witt, Murtagh, de Wolf-Linder, et al.) measures in July 2019: the Phase of Illness, Australia-modified Karnofsky Performance Status (AKPS) and Integrated Palliative care Outcome Scale (IPOS). In July 2020, Hospice investigated clinicians’ perceptions of the measures. Aim To understand clinicians use and views of the OACC measures, any problems and suggestions for improvement. Methods A survey was distributed to clinicians (n=42). Descriptive statistics were calculated using the statistical packages R and RStudio (Version 4.1.0 for Windows). Qualitative data were analysed using a thematic analysis framework (Braun & Clarke, 2006). Results Twenty-nine clinicians (response rate 69%) had used one of the three measures at least once. Twenty-five (93%), 22 (85%) and 24 (92%) stated that they use IPOS, AKPS and Phase of Illness some or all of the time, respectively. Moreover, 24 (83%), 23 (79%) and 21 (72%) clinicians felt confident appropriately using IPOS, AKPS and Phase of Illness, respectively. Respondents identified the measures as a helpful resource for person-centred assessment and monitoring. They can help open up dialogue and increase rapport between patient and clinician, and provide a ‘common language’ between clinicians. However, they felt the measures added little to a clinical assessment, particularly for Allied Health Professionals (AHPs), and an apparent focus on physical health limited holistic assessment. Respondents recommended increased application of OACC measures at handover. For AHPs, other outcome measures might be considered. Some wanted feedback on outcomes and more training on use of the measures. Conclusions In a palliative care setting, benefits were witnessed mainly in patient assessment but less in the application of outcomes. Further staff training and application of outcomes may be beneficial.

Commentary on : Aloufi MA, Jarden RJ, Gerdtz MF, Kapp S. Reducing stress, anxiety and depression in undergraduate nursing students: systematic review. Nurs Ed Today 2021;102:104877.1 Extensive research has identified the demands of nursing on emotional and physical well-being2 and acknowledges that mental health concerns are often reported by nurses, especially student nurses, which far exceed the stress and anxiety levels reported by other students.3 Good health and well-being within the profession is essential for the safe delivery of quality healthcare,4 and the use of effective interventions …

The World Bank is publishing nine volumes of Disease Control Priorities, 3rd edition (DCP3) between 2015 and 2018. Volume 9, Improving Health and Reducing Poverty, summarises the main messages from all the volumes and contains cross-cutting analyses. This Review draws on all nine volumes to convey conclusions. The analysis in DCP3 is built around 21 essential packages that were developed in the nine volumes. Each essential package addresses the concerns of a major professional community (eg, child health or surgery) and contains a mix of intersectoral policies and health-sector interventions. 71 intersectoral prevention policies were identified in total, 29 of which are priorities for early introduction. Interventions within the health sector were grouped onto five platforms (population based, community level, health centre, first-level hospital, and referral hospital). DCP3 defines a model concept of essential universal health coverage (EUHC) with 218 interventions that provides a starting point for country-specific analysis of priorities. Assuming steady-state implementation by 2030, EUHC in lower-middle-income countries would reduce premature deaths by an estimated 4·2 million per year. Estimated total costs prove substantial: about 9·1% of (current) gross national income (GNI) in low-income countries and 5·2% of GNI in lower-middle-income countries. Financing provision of continuing intervention against chronic conditions accounts for about half of estimated incremental costs. For lower-middle-income countries, the mortality reduction from implementing the EUHC can only reach about half the mortality reduction in non-communicable diseases called for by the Sustainable Development Goals. Full achievement will require increased investment or sustained intersectoral action, and actions by finance ministries to tax smoking and polluting emissions and to reduce or eliminate (often large) subsidies on fossil fuels appear of central importance. DCP3 is intended to be a model starting point for analyses at the country level, but country-specific cost structures, epidemiological needs, and national priorities will generally lead to definitions of EUHC that differ from country to country and from the model in this Review. DCP3 is particularly relevant as achievement of EUHC relies increasingly on greater domestic finance, with global developmental assistance in health focusing more on global public goods. In addition to assessing effects on mortality, DCP3 looked at outcomes of EUHC not encompassed by the disability-adjusted life-year metric and related cost-effectiveness analyses. The other objectives included financial protection (potentially better provided upstream by keeping people out of the hospital rather than downstream by paying their hospital bills for them), stillbirths averted, palliative care, contraception, and child physical and intellectual growth. The first 1000 days after conception are highly important for child development, but the next 7000 days are likewise important and often neglected.

Our lab has developed a new series of self-immolative MR agents for the rapid detection of enzyme activity in mouse models expressing β-galactosidase (β-gal). We investigated two molecular architectures to create agents that detect β-gal activity by modulating the coordination of water to Gd(III). The first is an intermolecular approach, wherein we designed several structural isomers to maximize coordination of endogenous carbonate ions. The second involves an intramolecular mechanism for q modulation. We incorporated a pendant coordinating carboxylate ligand with a 2, 4, 6, or 8 carbon linker to saturate ligand coordination to the Gd(III) ion. This renders the agent ineffective. We show that one agent in particular (6-C pendant carboxylate) is an extremely effective MR reporter for the detection of enzyme activity in a mouse model expressing β-gal.

Stronger primary care has been associated with important contributions to health system performance, yet countries struggle to resource it adequately, given competing demands from hospitals. Although historically China has originated influential models of primary health care, it has an enduring problem with hospital dominance in health service delivery. This paper is a historical analysis of the co-evolution of hospitals and primary care providers in China from 1835 (the year when the first hospital was built in mainland China) to 1949 (the year when the People's Republic of China was founded), which aims to shed light on approaches to primary care strengthening. We develop and use a path dependence analytic framework, specifying the critical juncture, conjuncture and post-juncture development of the institutions shaping the balance between hospitals and primary care providers in China. We find that China had historically formed the hospital-centric model involving four sets of regenerating and mutually reinforcing institutions: 1) financial resources were being disproportionally distributed to hospitals; 2) high-quality medical professionals were largely concentrated in hospitals; 3) large outpatient departments were incorporated in hospitals, which functioned as a first point of care for many patients; 4) hospitals answered primarily to the demand of the more privileged social group. The early institutionalization of a hospital-centric model of Western medicine in China from 1835 became resistant to change, and efforts to strengthen primary care eventually took a divergent low-cost and de-professionalized developmental path towards 1949. As China still has a hospital-centric health system seeded in the nineteenth century, these findings can inform the framing of contemporary options for primary care strengthening. Without addressing these deep regenerating causes using a whole-system approach, China is unlikely to achieve a primary care orientation for health system development.

Financial protection is a health system goal for all countries. Assessing progress on this relies on measuring the incidence of catastrophic health expenditures (proportion of the population whose out-of-pocket (OOP) payments for health surpass a certain threshold of household resources). Standard approaches rely on selective thresholds, however this masks varying intensities of financial hardship and poses a measurement challenge as incidence is sensitive to the choice of the threshold. We address this problem by applying the dominance approach, which tests differences in catastrophic incidence curves over a continuous range of thresholds. Iran is an interesting country for empirical application of the dominance approach given its historically high reliance on OOP payments to finance its health system and its commitment to improving financial protection through several national health policies over the last two decades. Using data from annual Household Income and Expenditure Surveys from 2005 to 2017 (sample size: 26,851-39,088 households), incidence was analyzed following this novel approach. Distribution of incidence across socio-economic status was also analyzed by estimating concentration indices and across health services or products by estimating average shares of each item. Results showed that over time catastrophic health expenditures increased for thresholds lower than 25% and decreased for thresholds higher than 35%. Catastrophic health expenditures were more equally distributed across income levels at lower thresholds, becoming concentrated amongst the rich as the threshold rose. Medicines represented the largest share of catastrophic spending for the poorest; medicines, dentistry, inpatient and ancillary services for the richest. This is the first study to apply dominance methods to analyze catastrophic health expenditures in a country over time. The analysis provides a nuanced picture of who incurs catastrophic health expenditures, to what extent hardship is experienced and what were the drivers of these expenditures - thus providing a better basis for policy responses.

The coronavirus disease 2019 (COVID-19) pandemic resulted in a surge of research activity. Since its outset, efforts have been made to guide the rapid generation of research in medicine. There are gaps in some areas of rehabilitation research for patients with COVID-19. The development of a specific research framework might serve to help monitor the status of research (mapping), shape and strengthen research by pointing to under-investigated areas, and promote rehabilitation research in this context. This article introduces and discusses the COVID-19 Rehabilitation Research Framework (CRRF) and presents the methodology used for its development. The questions have been developed among the World Health Organization (WHO) Rehabilitation Programme, Cochrane Rehabilitation, and the experts of its Rehabilitation-COVID-19 Evidence-based Response Action International Multiprofessional Steering Committee. The framework is divided into 2 parts and includes 20 questions organized in 4 groups: epidemiology, and evidence at the micro- (individual), meso- (health services), and macro- (health systems) levels. The CRRF offers a comprehensive view of the research areas relevant to COVID-19 and rehabilitation that are necessary to inform best practice and ensure rehabilitation services and health systems can best serve the population with COVID-19. The collaboration between Cochrane Rehabilitation and the WHO Rehabilitation Programme in establishing the CRRF brought together perspectives from the health systems, health management, and clinical evidence. The authors encourage researchers to use the CRRF when planning studies on rehabilitation in the context of COVID-19.

Drawing on international experiences, in particular lessons from China, Thailand and New York State, USA, Viroj Tangcharoensathien and colleagues argue that immediate, extensive and effective responses to contain the local transmission of corona virus at the very early stages of an epidemic can prevent health systems from disruption and from being overwhelmed.

[Abstract] The modern hospital is at once the site of healing, the locus of medical learning and a cornerstone of the welfare state. Its technological and infrastructural costs have transformed health services into one of today's fastest growing sectors, absorbing substantial proportions of national income in both developed and emerging economies. The aim of this book is to examine this growth in different countries, with a main focus on the twentieth century, and also with a backward glance to earlier shaping forces. It will explore the hospital's economic history, the relationship between public and private forms of provision, and the political context in which health systems were constructed. The collection advances the historical world map of different hospital models, ranging across Spain, Brazil, Germany, East and Central Europe, Britain, the United States and China. Collectively, these comparative cases illuminate the complexities involved in each country and bring new historical evidence to current debates on health care organisation, financing and reform.

“Health system” is a term generally considered to be relatively recent. It is defined as all organizations, institutions, and resources that produce actions whose primary purpose is to improve health, whether these be targeted at individuals (such as health-care delivery) or populations (such as public health measures). Health-care and public health institutions have a long history, but the notion of an organized “health system” is a relatively recent development (dating from the mid-20th century). In low- and middle-income countries (LMICs), Western medicine was often introduced by former colonial authorities through the construction of public hospitals, health centers, and training schools, with church authorities also making a major contribution. As in high-income countries, there was a gradual process over the latter half 20th century to construct an organized and coordinated national health system. However, health systems became a key focus of international attention only in the late 1990s, when it became apparent that achieving the health-related Millennium Development Goals (e.g., reduction of child and maternal mortality; control of HIV, TB, and malaria) was threatened less by the availability of technical solutions and more by the ability of health systems to put them into practice. More recently, the Ebola epidemic in West Africa highlighted the critical importance of health systems in ensuring health security. In response to the increased awareness of the role of health systems, significant attention has been paid to defining the health system and its goals, categorizing its elements, assessing problems and testing solutions, and seeking to identify the relationship between different health system configurations and overall performance. Over time, specific issues within the general area of health systems have received special attention, including achieving universal health coverage (where the whole population of a country has access to health care and protection against its costs), the role of primary health care, the relative merits of different ways of financing a health system, the relative roles of public and private health sectors, and the appropriate mix of different types of health worker. Many disciplines can contribute to improved understanding of health systems, including economics, sociology, anthropology, history, political science, and management science. Until recently, the discipline of economics has tended to dominate the study of health systems. However, with the emergence of health policy and systems research as an important area of study, other disciplines have been making growing contributions, especially political science and the behavioral sciences concerned with the behavior of both individuals and organizations.

Objectives To identify the competencies, behaviors, activities, and tasks required by the rehabilitation workforce, and their core values and beliefs, and to validate these among rehabilitation professionals and service users. Design Mixed methods study, involving a content analysis of rehabilitation-related competency frameworks, a modified Delphi study, and a consultation-based questionnaire of service users. Setting Desk-based research. Participants Participants who completed the first (N=77; 47%) and second (N=68; 67%) iterations of the modified Delphi study. Thirty-seven individuals participated in the service user consultation. Collectively, the participants of the mixed methods study represented a significant range of rehabilitation professions from a broad range of countries, as well as both high- and low-income settings. Interventions Not applicable. Main Outcome Measures Not applicable. Results The mixed methods study resulted in the inclusion of 4 core values, 4 core beliefs, 17 competencies, 56 behaviors, 20 activities, and 62 tasks in the Rehabilitation Competency Framework. The content analysis of rehabilitation-related competency frameworks produced an alpha list of competencies, behaviors, activities and tasks (“statements”), which were categorized into 5 domains. The final iteration of the modified Delphi study revealed an average of 95% agreement with the statements, whereas the service user consultation indicated an average of 87% agreement with the statements included in the questionnaire. Conclusions Despite the diverse composition of the rehabilitation workforce, this mixed methods study demonstrated that a strong consensus on competencies and behaviors that are shared across professions, specializations, and settings, and for activities and tasks that collectively capture the scope of rehabilitation practice. The development of the Rehabilitation Competency Framework is a pivotal step toward the twin goals of building workforce capability to improve quality of care and strengthening a common rehabilitation workforce identity that will bolster its visibility and influence at a systems-level.

BackgroundRising global concern about antimicrobial resistance has drawn attention to the use of antibiotics in livestock. Understanding the current usage of antibiotics in these animals is essential for effective interventions on the optimisation of antibiotic use. However, to date few studies have been conducted in low- and middle-income countries. This study aimed to explore the use of antibiotics and estimate the total amount of antibiotics used in pig production in Thailand.MethodsThis was a mixed-methods study including a cross-sectional questionnaire-based survey of 84 pig farmers, secondary analysis of data from a survey of 31 feed mills to estimate the amount of antibiotics mixed in pig feed and interviews with five veterinarians involved in the feed mill industry to gain an understanding of medicated feed production.FindingsHalf of the farmers reported using antibiotics for disease prevention. Use was significantly associated with farmers’ experience in raising pigs, farm income, having received advice on animal health and belonging to a farm cooperative. The estimated total amount of active ingredients mixed into medicated feed for pigs for the whole country was 843 tonnes in 2017. Amoxicillin was the most commonly used antibiotic reported by both pig farms and feed mills. The use of Critically Important Antimicrobials including colistin was common, with one-third of farmers reporting their use as oral or as injectable medication, and accounting for nearly two-thirds of antibiotics contained in medicated feed.ConclusionA majority of antibiotics used in Thai pig farms belonged to the category of Critically Important Antimicrobials. Progressive restriction in the use of antibiotics in pigs is recommended through using prescriptions to control the distribution of certain antibiotics. The government should strengthen veterinary services to improve access of farmers to animal health advice and explore alternative interventions.

Thailand's health development since the 1970s has been focused on investment in the health delivery infrastructure at the district level and below and on training the health workforce. Deliberate policies increased domestic training capacities for all cadres of health personnel and distributed them to rural and underserved areas. Since 1975, targeted insurance schemes for different population groups have improved financial access to health care until universal health coverage was implemented in 2002. Despite its low gross national income per capita in Thailand, a bold decision was made to use general taxation to finance the Universal Health Coverage Scheme without relying on contributions from members. Empirical evidence shows substantial reduction in levels of out-of-pocket payments, the incidence of catastrophic health spending, and in medical impoverishment. The scheme has also greatly reduced provincial gaps in child mortality. Certain interventions such as antiretroviral therapy and renal replacement therapy have saved the lives of adults. Well designed strategic purchasing contributed to efficiency, cost containment, and equity. Remaining challenges include preparing for an ageing society, primary prevention of non-communicable diseases, law enforcement to prevent road traffic mortality, and effective coverage of diabetes and tuberculosis control.

We report the results of a series of validity and reliability tests performed during the development of the Women’s Capabilities Index (WCI) in Malawi. The WCI is a multidimensional measure based on Sen’s capability framework for assessing women’s quality of life. Construct validity was assessed by investigating the expected relationships of the dimensions with key socioeconomic characteristics. The majority of hypothesized associations were found to be statistically significant in the expected direction. This provides evidence that the index is measuring quality of life as intended in the conceptual model. Further evidence in support of the index’s validity was given by the high degree of correlation between the WCI and another scale measuring comparable (but not identical) domains of quality of life. The results from the internal consistency and the test–retest repeatability also offered encouraging evidence on the reliability of the instrument. This is the first study to rigorously and comprehensively test for validity and reliability a capabilities index for a low-income setting. The results of the validity and reliability tests provide supportive evidence that a locally developed measure of capabilities can be used as a robust tool for the assessment of women’s quality of life.

There is a global demand for rehabilitation services but to date little attention has been paid to rehabilitation as part of the health agenda, especially in low- and middle-income countries. The objective of the scoping review was to get an overview of the needs and unmet needs for rehabilitation services described in the literature.Electronic search was performed in PubMed and REHABDATA for studies published between 2000 and 2017.Eighty-six articles met the inclusion criteria. Results revealed a profound need for rehabilitation among different user groups with non-communicable diseases and injuries across countries. However, this need considerably outstripped the provision of services, which left many people with substantial unmet needs for rehabilitation. The main reasons for the unmet needs for rehabilitation were the absence of or unequal geographical distribution of services within a country, lack of transportation, and unaffordability of the services.There are substantial unmet needs for rehabilitation and numerous barriers to accessing services. Efforts need to focus on building the capacity for rehabilitation research predominantly in low- and middle-income countries. The comprehensive data that this review provides is useful for raising awareness for the need of rehabilitation at policy level. Implications for rehabilitation There is a profound need for rehabilitation services due to the ageing population and growing prevalence of non-communicable diseases. This scoping review shows that the need for rehabilitation considerably outstrips the provision of services. There are substantial unmet needs for rehabilitation and numerous barriers to accessing services. Concerted global action to scale up quality rehabilitation services is needed, especially in low- and middle-income countries.

The advancements in and affordability of technologies offer increasing opportunities to modernise healthcare education into packages developed to meet the expectations and requirements of the digital generation. Purposefully designed and tested Virtual Reality Learning Environments (VRLE) can offer healthcare students the means to access and revisit learning materials in ways that enhance education and meet a range of needs; including those with specific learning differences and those who have traditionally been disenfranchised. Furthermore, this will make healthcare education much more readily available to those who have been previously marginalised by distance. This paper argues that Virtual Reality (VR) has the unique potential to transform healthcare education and suggests that more providers should consider collaborating with developers and investing in the technology.

Background Hospice Isle of Man’s aim is to provide access to those who could benefit regardless of diagnosis. The hospice began offering services to non-cancer patients in 2016. Little is known about how many could benefit or the extent of the hospice’s involvement by disease category. The Isle of Man is not included in Hospice UK’s PopNAT. Aims To estimate the number of persons who could have potentially benefited from palliative and end-of-life care. To understand differences in hospice involvement by disease category. Methods The Isle of Man Registry maintains weekly Excel sheets with death certificate data. We extracted variables of interest for the period between 1 January 2013 to 31 December 2018. We created a variable for palliative need based on cause of death where there was any mention of cancer, Alzheimer’s/dementia, organ failure or a neurodegenerative condition. Using hospice records, we identified persons who received hospice care for the years 2016–2018. We estimated unmet need by comparing hospice involvement and presence of a condition likely to benefit from palliative care and compared hospice involvement by palliative disease category. Results There were 5,005 deaths between 2013 and 2018, representing 1% of the population per year. Prior to 2016, the hospice cared for 30% of persons who died. By 2018, 39% had hospice care representing a 21% increase from 2016. Of all deaths between 2013 and 2018, 30% had a palliative condition and hospice care. An additional 34% had a palliative condition but no hospice care. The hospice was involved in 88% of all cancer cases but only in a quarter or less of cases with organ failure (28%), neurodegenerative conditions (26%), or Alzheimer’s/dementia (16%). Conclusions Since 2016, more persons received hospice care. However, persons with non-cancer conditions who could benefit remained under-represented compared to those with cancer. Future studies are needed to understand the factors contributing to this difference.

Background Hospice UK is promoting ECHO™ (Extension of Community Healthcare Outcomes) to democratise specialist skills and increase confidence of staff in palliative and end-of-life care. Hospice Isle of Man is reaching the end of the first year of Project ECHO™ with local nursing homes. Aim To carry out a formative evaluation of project ECHO™ at the end of its first year of operation and prepare for a summative evaluation at the end of five years. Methods The logic model identifies resources and inputs, activities, outputs, short and longer-term outcomes. Inputs, activities and outputs come from routinely collected data and short-term outcomes from a mix of ad-hoc quantitative data from surveys and qualitative data from interviews. For longer-term outcomes we have 1) set up a data collection exercise to obtain feedback from all of those experiencing bereavement, 2) identified sources of data on place of care at the end-of-life with the aim of determining whether experiences change over the period of Project ECHO™’s operation. Results We are currently conducting the formative evaluation with nursing homes using the quantitative data described in the first three categories of the logic model. We are also carrying out qualitative interviews with those who participated in the first year of Project ECHO™. We trialled a validated questionnaire (Grande et al. End-of-life skills survey) on end-of life skills and confidence which will be a required part of enrolment for those who join further ECHO™s and will map to our Island skills framework. Feedback is positive and Project ECHO™ will continue in nursing homes with further ECHO™s including residential homes and other community providers. Conclusion With the formative evaluation we are learning lessons about how best to deliver Project ECHO™ in nursing homes and extend it to other sites. We have set up measures which we hope will shed light on longer-term outcomes.

Background Isle of Man (IOM) is a crown dependency with 83,000 residents. To provide an evidence-base for the strategy on person-centred, palliative and end of life care, Hospice Isle of Man carried out a needs assessment. Typically this involves quantitative and qualitative data describing services and identifying gaps. Many data sources used for this purpose in the UK (e.g. Hospice UK’s PopNAT) are not available in the IOM so we compensated by extensive engagement with those working in relevant services and organisations as well as the public. Aim To carry out a needs assessment on palliative and end of life care. Methods Population demographics and weekly death data were processed to enable predictions of need for palliative and end of life care. Interviews were carried out with over 60 representatives of services and organisations involved in care for those with life limiting conditions, in elderly care, end of life or bereavement support. The questions were: ‘What works well?’, ‘What does not work well?’, ‘What are the gaps?’ and ‘What might be solutions?’ in palliative and end of life care. Adult members of the public, schoolchildren and college students were asked what would matter to them if using Hospice services to ensure a focus on person-centred care. Results We discovered that the hospice was probably reaching around half of those who could benefit but users were very positive about it. Passion for Island services, but frustration with aspects of the system, was identified among professionals and some disjointedness among third sector groups. The majority of the data are currently being analysed and will be presented at Hospice UK’s 2019 conference. Conclusion Expert views of those working in the services and charities, supplemented by person-centred perceptions of the public and available data are shedding necessary light on the Island’s needs for palliative and end of life care. (Support provided by Manx Lottery Trust)

Background Co-design of services is increasingly recognised as an important means of ensuring development of people-centred services. Young people and adolescents are not often consulted when designing adult services but Hospice Isle of Man (IoM) aimed to change that. Aims To engage with young people. To explore their attitudes towards death, dying, bereavement and Hospice. Methods Hospice IoM’s public engagement strategy started with ‘Listening Events’ in seven community settings which obtained views towards Hospice. Males and young people were under-represented so events were offered in secondary schools. A short session on end-of-life and palliative care was incorporated with activities to ascertain understanding of Hospice, uncover what was most valued and obtain recommendations for Hospice’s future. Students were asked ‘What do you know about Hospice’? ‘If you or a family member became seriously unwell and needed Hospice services, what would be most important to you?’ and ‘How could we make Hospice a better service?’ Responses were made on post-it notes and analysed using NVivo. Themes and sub-themes within responses were identified. Results 203 students (105 males, 98 female) aged 11 to 16, participated. For the first question, the themes were purpose (sub-themes helping and caring), services (sick or illness) and users. It was clear that many young people knew nothing about Hospice. For the second questions on what matters themes ‘were how you feel’, ‘support services’, ‘staff qualities’, ‘environment’, ‘loved ones’ and ‘entertainment/activities’. For the third question, community activities and age-appropriate care feature with suggestions that Hospice should feature more prominently within the local community and online. Conclusion Young people provided a wealth of information from their own perspective and appreciated being involved at this level. These findings will inform future Hospice strategies, and the engagement with youth may empower new relationships between Hospice and the Island’s next generation.

Based on projected numbers, approximately only 50% of those requiring renal replacement therapy (RRT) receive it. Many patients who require RRT live in low- and middle-income countries. The objective of this study was to examine the changing pattern over time of entry into the RRT programme in Thailand following RRT’s inclusion in the Universal Coverage Scheme. This study was an ecological study using the age-period-cohort analysis to look at dialysis registration and kidney transplant trends during RRT programme implementation. Data from 2008 to 2016 of patients diagnosed with end-stage renal disease (ESRD) were obtained from the National Health Security Office. The study found that the numbers of new patients with ESRD, aged 20–69, registered with the dialysis programme increased over time. For patients aged 20–40 years, the dialysis programme took up to 400 new patients for every 1000 new ESRD diagnoses. For kidney transplant, the rates increased slowly. The kidney transplant programme could at best treat only around 50 cases for every 1000 new ESRD diagnoses in patients aged 20–30 years. Findings of this study highlighted the importance of promoting strategies to reduce the increasing number of patients with kidney disease, to consider conservative therapy for older/frail patients, and to improve access to kidney transplantation and live-donation.

Although China’s community health system helped inspire the 1978 Alma Ata Declaration on Health for All, it currently faces the challenge of strengthening primary care in response to hospital sector dominance. As the world reaffirms its commitment towards primary health services, China’s recent history provides a salient case study of the issues at stake in optimizing the balance of care. In this study, we have used path dependence analysis to explain China’s coevolution of hospital and primary care facilities between 1949 and 2018. We have identified two cycles of path-dependent development (1949–78 and 1978–2018) involving four sets of institutions related to medical professionalization, financing, organization and governance of health facilities. Both cycles started with a critical juncture amid a radically changing societal context, when institutions favouring hospitals were initiated or renewed, leading to a process of self-reinforcement empowering the hospitals. Later in each cycle, events occurred that modified this hospital dominance. However, pro-primary care policies during these conjunctures encountered resilience from the existing institutional environment. The result was continued consolidation of hospital dominance over the long term. These recurrent constraints suggest that primary care strengthening is unlikely to be successful without a comprehensive set of policy reforms driven by a primary care coalition with strong professional, bureaucratic and community stakes, co-ordinated and sustained over a prolonged period. Our findings imply that it is important to understand the history of health systems in China, where the challenges of health systems strengthening go beyond limited resources and include different developmental paths as compared with Western countries.

As an economist, acceptance of the need for prioritization and of the value of systematic thinking about and analysis of priorities is fundamental to my thinking about resource allocation to health...

Nurses have a public health role, requiring them to promote the health of individuals and communities, and to engage at a political and policy level to improve population health. There is also a professional expectation that nurses will model healthy behaviours and take responsibility for their personal health and wellbeing. However, studies have indicated that undergraduate nurses find the academic and practice elements of their nursing programmes stressful. To manage their stress many use coping behaviours that negatively impact on their health and wellbeing and may influence their ability and willingness to effectively support health promotion in practice. It is widely recognised that environments influence health outcomes and personal health behaviours. This article addresses some of the structural causes of student nurse stress and highlights a recent educational initiative at a UK university that aims to equip student nurses with the practical skills required to engage in health promotion and thereby provide benefits for service users and student nurses alike.