David Nicholas Blane

Plain English Summary Background: Long COVID is a complex condition that can affect people following COVID-19 infection, with common symptoms including fatigue, breathlessness, brain fog. Risk factors for Long COVID include female sex, socioeconomic disadvantage, and raised body mass index (BMI). There are no established treatments for Long COVID. This study aimed to assess whether home-delivered weight management could improve Long COVID symptoms in people living with excess weight. Approach: ReDIRECT was a randomised, wait-list-controlled trial in participants with Long COVID and BMI >27kg/m 2 (>25kg/m 2 for South Asians) recruited across the UK. The intervention comprised home-delivered weight management (formula total diet replacement (850 kcal/d), or an alternative if not tolerated) and behaviour change guidance for 12 weeks, followed by food reintroduction and weight loss maintenance support for one year, provided by trained dietitians. Findings: Between December 2021 and July 2022, 234 participants were randomly assigned to intervention (116 participants) or waitlist control (118 participants) groups. The average participant age was 46 years, BMI was 35 kg/m 2 , 84% were female and 90% were of white ethnicity. The intervention improved the primary outcome (the Long COVID symptom each participant selected as the one they most wanted to improve) at 6 months. Long COVID symptoms of Fatigue, Breathlessness, Anxiety/Depression (but not Pain) also improved in the intervention group compared to the control group at six months. The intervention helped people to lose more weight at six months (-10.3kg) compared to the control group (-0.7kg). Blood pressure and health-related quality of life also improved, with no excess of serious adverse events. Conclusions: Entirely remotely delivered weight management was safe and effective at reducing Long COVID symptoms that matter most to people living with Long COVID and excess weight. Further studies are needed to determine longer-term outcomes and the reasons for observed benefits. Executive Summary Study aim: To assess whether home-delivered and professionally supported weight management could improve symptoms for people living with both Long COVID (LC) and overweight. Background: LC is a complex multi-symptom condition that can develop after COVID-19 infection. LC significantly impacts quality of life and daily function, with common symptoms including fatigue, breathlessness, and pain. Excess weight has been found to increase the chances of people developing LC and some symptoms of excess weight overlap and may aggravate those of LC. One proposed explanation for LC is widespread inflammation and weight loss has been found to reduce inflammation in other conditions such as type 2 diabetes and heart disease. Effective weight management has also improved blood pressure, quality of life, pain and fatigue. The evidence to date has mostly involved in-person clinic attendance, yet remote and digital programmes may offer advantages in complex conditions where mobility and capacity to attend out-of-home appointments are limited. At the time of this study, there were no established treatments for LC, so we sought to assess whether remotely-delivered, evidence-based and professionally supported weight management could improve symptoms for people living with both LC and overweight. Methods: Randomised controlled trial with a wait-list design, whereby the control group received delayed entry into the programme after six months (ISRCTN (International Standard Randomised Controlled Trial Number) registry 12595520). The study was delivered fully remotely, including recruitment across the UK, intervention delivery, and self-reported data collection. Ethical approval was obtained from the South-East Scotland Research Ethics Committee (REC reference number: 21/SS/0077). The protocol is published on NIHR Open Research. Eligible participants, aged ≥18 years, had a self-reported body mass index (BMI) >27kg/m 2 (>25kg/m 2 for South Asians), self-reported LC symptoms for >12 weeks before first recruitment contact, and were not currently hospitalised. A positive COVID-19 test or official LC diagnosis by a GP was not required due to the unavailability of COVID-19 tests at the pandemic's start and the emergence of LC as a new condition. Our Patient and Public Involvement (PPI) team and the funder's call requirements guided eligibility criteria. Participants were recruited across the UK via social media, LC networks, newspaper adverts, and primary care records. Participants in the intervention group were provided with the Counterweight-Plus programme, an evidence-based structured dietary weight management programme (Counterweight Ltd, London, UK). Weight loss was induced using a formula low-energy diet providing ~850 kcal/day as total diet replacement (TDR) for the first 8-12 weeks, followed by a stepped food reintroduction for 4-12 weeks and monthly visits for up to one year to support long-term weight loss maintenance. Participants who did not accept or could not tolerate the TDR were offered alternative dietary options, including meal replacements (MR), low-carbohydrate, and low-fat. Swaps between dietary approaches were facilitated to maximise adherence and weight loss. A registered dietitian delivered the programme remotely to each participant with digital support via the Counterweight App (measurement logging, progress tracking, goal setting, reflective journal, recipes, activity videos and advice). Support appointments, using video, telephone, or text chat, included an orientation and planning call one week before starting the programme and then at Week 0 (start of TDR), 1, and 3. Further follow-up appointments were scheduled monthly, with timing/content tailored to individual circumstances. Programme pauses were offered to accommodate medical or life events that impacted programme participation. Trial outcomes were self-measured remotely...

Background: Few data exist on bariatric equipment and housing adaptations prescribed by occupational therapists and used by community-dwelling people with severe obesity (PwSO; body mass index (BMI) ⩾ 40 kg/m ² ). This study aimed to document the use and costs of equipment and home adaptations by community-dwelling PwSO. Methods: An observational, cross-sectional study was conducted with 25 consenting PwSO. During home visits an investigator-administered questionnaire captured use of community equipment and housing adaptations. Local and published sources directed a comprehensive micro-costing. Results: Participants were aged 40–87 years (mean 62 years), BMI 40–77 kg/m ² (mean 55 kg/m ² ): 20 were housebound. Nineteen participants (76%) used specialist equipment to accommodate larger body size. The most frequently used equipment were rise-recline chairs. Most chairs ( n = 16, 80%) were heavy duty or custom-made, with a mean cost of £2241, more than double the mean cost of standard chairs £993. Analysis indicated a relationship between increasing BMI category and escalating use and cost of bariatric equipment. Housing adaptations ranged from bathroom grab rails to full-scale house extensions including widened doorways. Wet floor showers were the most common housing adaptation (mean cost £6043). Conclusion: These results highlight areas for further research, staff training and health economic evaluation.

Background: General practitioners (GPs) working in areas of high deprivation in Scotland formed the ‘Deep End’ group in 2009 in response to the well-documented inverse care law (ICL). Aim: To understand the views and experiences of key stakeholders about responses to the ICL in general practice in Scotland over the past 20 years, and the impact of the Scottish Deep End Project. Design & setting: Qualitative study with key primary care stakeholders ( n =17) in Scotland, UK. Method: Semi-structured interviews. Results: Five main themes were identified, reflecting participants’ experiences of working in deprived areas and their views on the role of the Deep End. These themes describe how existing measures fall short of addressing the ICL, how intersecting disadvantage complicates service responses, and how sustainability, professional identity, and collective voice shape efforts to improve care in disadvantaged communities. A key recommendation was greater investment in primary care generally, but with graded additional resources for more deprived areas depending on need (a “proportionate universalism” approach). Conclusion: Despite widening health inequalities, and the long-standing evidence of the ICL in general practice in deprived areas, there is a paucity of enduring policies and interventions to tackle the ICL in Scotland. The Scottish Deep End group has created a distinctive platform for general practitioners to collectively challenge the inverse care law. Practitioner-led networks can play an essential role in addressing health inequalities, supporting professionals, and informing policy.

Background: Coming to terms with chronic pain is a complex process. In earlier research, we found that accepting chronic pain is a fluid and continuous journey, experienced within socio-cultural-political worlds, which we conceptualised as an Ecosystem. These findings showed potentially unequal opportunities to experience a positive state of acceptance, with scope for improvements. We did not know how people living with chronic pain may relate to the findings. We therefore aimed to contextualise our (earlier) findings with people who live with chronic pain and experience marginalisation, and to generate ideas for improvement based on the concept of any individual journey with acceptance taking place within an ‘Ecosystem.’ Methods: We recruited through NHS contacts. We used focus groups and diaries to collect qualitative data, which we explored using thematic analysis. The research is exploratory in nature. Results: We recruited seven participants (two men, five women), all living with severe chronic pain and multiple long-term conditions. Most described difficulty making ends meet, none were in paid employment, nor had university degree level of formal education. We found three themes from the qualitative data analysis, two focused on structural, systemic features: ‘unaccepting, disconnected and dehumanising systems: treated like ‘tick boxes,’’ and ‘connected, understanding and accepting systems: towards inclusion.’ One theme showed the individual nature of experiences; ‘individual variations in the experiences and journey of coming to terms and living with chronic pain.’ Conclusions: Our findings show new insights into phenomena associated with coming to terms (and living) with chronic pain; including how state systems, structures and societal attitudes can influence experiences. Individuals with chronic pain may accept aspects of their painful condition, however, others around them, healthcare staff and institutional structures may not accept (or account for) the nature of chronic pain, leading to distress, stigmatisation, and feeling misunderstood. We demonstrate a focus on working with individuals with chronic pain, without socioeconomic privilege, to give insights into their lives and the impact of social context including political decisions – pain is unavoidably political for those at the sharp end of these experiences.

Background: GP practices in Scotland are changing with the emergence of megapractices. We aimed to update analyses of GP practice sizes in Scotland, and to begin the development of a typology of GP practices. Methods: Four methods were employed: 1. Analyses of routinely published data on GP practice sizes and listed GPs to identify and quantify megapractices; 2. Qualitative interviews; 3. Creation of commercial profiles; 4. Derivation of a GP practice typology. Results: Most Scottish practices have less than 9,000 patients, but five megapractices with over 30,000 patients were identified. One had grown by over 18,000 patients in two years to almost 120,000 patients, with the next largest at almost 73,000 patients. Megapractices did not engage with interviews, but commercial profiling revealed an array of complex legal and financial arrangements for several of them. We suggest that the key parameters for describing practices should focus on: ownership, legal status and motives; the extent of service provision by doctors or Allied Health Professionals (AHPs); and practice list size. We tentatively propose four common practice types in Scotland: traditional practices, megapractices, social enterprise practices, and direct NHS provision, recognising substantial diversity amongst megapractices. Implications: Policymakers should carefully consider the risks of the current drift in approach to GP provisioning. Evaluation of the impacts of new service models on healthcare access, health outcomes and inequalities is urgently needed.

Background: Human Papillomavirus (HPV) vaccination is a key preventive strategy against cervical cancer. Despite its proven effectiveness, uptake remains low in Indonesia, particularly among women of reproductive age, due to a range of social, economic, and cultural barriers Objectives: This study explores the views and experiences of Indonesian women aged 19–45 regarding the HPV vaccine. It aims to identify barriers and facilitators affecting vaccine engagement and assess the impact of current health promotion strategies Methods: A qualitative, case-based approach was employed, involving semi-structured online interviews with ten participants five vaccinated and five unvaccinated. Par0ticipants were selected based on age, employment status, and voluntary participation. Interview transcripts were analysed thematically using an inductive approach. Results: Five key themes emerged: Cultural Influence, Information Access, Social Environment, Socioeconomic Barriers, and Suggestions for Improvement. Barriers included financial constraints, religious concerns (particularly halal certification), and limited offline promotion. Facilitators included digital media exposure, peer influence, and workplace support. Participants emphasized the need for culturally sensitive education, broader school-based programs, and inclusion of boys in vaccination efforts Conclusion: The COM-B model (Capability, Opportunity, Motivation–Behaviour) provided a useful framework for understanding the complex interplay of individual, social, and structural factors influencing HPV vaccine interest. Addressing these requires integrated, multi-level health promotion strategies. Policy recommendations include financial subsidies, inclusive education campaigns, and gender-neutral vaccination policies to improve uptake and reduce cervical cancer incidence.

The inverse care law (ICL), as described by Julian Tudor Hart in his seminal 1971 Lancet article, is the observation that ‘The availability of good medical care tends to vary inversely with the need for it in the population served.’ ¹ Tudor Hart’s main target was the threat of marketisation in health care, made clear in the second (less quoted) part of the ICL: ‘This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.’

Background Collaborative working between General practitioners (GPs) and Community Pharmacists (CPs) has led to improvements in management of long-term conditions, and has strong policy backing, yet such joint working remains patchy and under-developed. Understanding the perspectives of GPs and CPs regarding collaboration provides insights for more sustainable collaborative practices. Aim To understand the perspectives of GPs and community pharmacists concerning collaborative care practices, and to develop a framework of factors that influence this collaborative working relationship. Design & setting A systematic review of qualitative studies. Method Five databases were searched from inception to the 22^nd of April 2023 for qualitative studies exploring GP and CP views on collaborative care services. Articles were independently screened by two reviewers at title, abstract and full-text levels. Data extracted from eligible studies were analysed and synthesised thematically. Results Thirty-six studies met the inclusion criteria. Four main themes were identified: 1) How pre-existing relationships influence mutual understanding of roles, 2) the impact of location and communication on relationship building, 3) analysis of perceived costs and benefits, and 4) the motivation to develop collaborative care practices. Conclusion A complex interplay of factors influences GP and CP collaborative working, including pre-existing relationships, communication and mutual understanding, and the balance of costs and benefits to further develop these relationships. When planning future collaborative care practices, stakeholders must take the time and initiative to elucidate and understand these factors within their own unique healthcare setting to form lasting working relationships.