Nirandeep Rehill

Background: Despite increasing efforts to provide support for children and young people’s mental health and wellbeing, rates of poor wellbeing and probable mental health disorders continue to rise. This underscores the need for approaches that target the root causes and social determinants underlying these issues. This paper offers reflections on efforts to address these determinants at the local level, drawing on learning from the co-design phase of Kailo, a research and design initiative that works with young people and communities to shift the underlying conditions sustaining poor mental health and wellbeing, including resources, policies, relationships, and mindsets. Methods: Across two pilot sites, Northern Devon and Newham, the Kailo programme used a community-based co-design methodology and a structured process for reflective, iterative learning. Participants included young people, community partner organisations, local professionals, academics, researchers, and designers. The co-design process was integrated with research synthesis and systems mapping to ensure that emerging strategies were informed by lived experience, empirical evidence, and a systemic lens. Results: Four co-design strategies were developed through this process, involving over 300 young people and community members across the two pilot sites. While the intention was to support upstream prevention and systems-level transformation, most strategies ultimately focused on individual-level interventions. Nonetheless, the process generated important learning about the barriers and enablers to developing systems change approaches targeting social determinants and preventative action. Conclusion: Systemic co-design offers potential for developing youth-centred, locally situated policy and practice interventions. However, careful attention must be paid to the composition of co-design teams and in relation to who is included, who is more broadly engaged, and who is kept informed. This is particularly crucial when exploring system-wide solutions, rather than focusing solely on the immediate experiences of participants. While the significance of addressing social determinants was acknowledged and explored during the initial phases of problem identification and understanding, effective action in this area requires sustained collaboration, not only with young people, but also with other community members who hold valuable knowledge and experience regarding the use of, and opportunities within, systemic levers necessary to support transformative change.

Objective: We aimed to determine whether UCLP-PRIMROSE (a care innovation to reduce physical health inequalities for people with severe mental illness) could be set up in the current UK National Health Service (NHS) context and identify the processes, barriers and facilitators to implementation. Design: We employed a convergent mixed methods approach, combining interviews, ethnographic site visits and the collection of meeting notes and uptake data for core model components. Interview transcripts were analysed using reflexive thematic analysis, and all qualitative data, including interview transcripts, were analysed using the Consolidated Framework for Implementation Research. Qualitative work and insights from implementation uptake frequencies were integrated using Normalisation Process Theory. Setting: We evaluated implementation in Yorkshire and three London boroughs, mainly within general practices. Participants: We conducted interviews with 39 staff members who were implementing and/or delivering UCLP-PRIMROSE. Intervention: UCLP-PRIMROSE is an integrated evidence-based care pathway developed to reduce cardiovascular disease risk and mental health relapse in people with severe mental illness. Results: Adaptation and delivery varied in completeness and consistency across 24 general practices and their wider care teams. Factors outside the implementation teams’ influence challenged the embedding of UCLP-PRIMROSE. Factors included the impact from the immaturity of NHS integrated care systems, unintended consequences of the incentivised NHS severe mental illness physical health check and limited capacity for implementing in a system facing resourcing challenges. Drivers of successful implementation included staff being aligned with the values of the UCLP-PRIMROSE model and system leaders acting as champions. Supportive foundational processes acted as facilitators: these included protected and prioritised time for reflection, learning and problem solving. Conclusions: Implementation of UCLP-PRIMROSE was moderately successful in a relatively short period of time. At the end of the research, all teams wanted to sustain delivery. However, further pathway simplification and additional resources are required to spread UCLP-PRIMROSE beyond early pockets of good practice.

Background: Co-design approaches are increasingly used in efforts to address complex challenges, such as adolescent mental health. Benefits of these approaches are multifaceted and include strategies that better reflect local perspectives and needs, as well as the potential for improved outcomes for those involved. However, the literature has highlighted challenges and unintended consequences of co-design, such as issues with inclusivity and undue burden being placed on participants. This paper examines the methods used in the ‘Deeper Discovery and Co-design phase’ of Kailo, a place-based research and design initiative aimed at tackling the social determinants of children’s and young people’s (CYP) mental health in their local communities. Methods: Over approximately nine months, a co-design approach was used across two pilot sites. This involved more than 69 workshops and several ad hoc engagements with CYP and other community members. The goal was to explore structural challenges and develop strategies to address CYP mental health and wellbeing in their local context. The co-design work also aimed to bring together community knowledge and expertise, systems mapping and academic evidence. Results: Over 300 local CYP, community members, professionals and practitioners participated or contributed to Kailo’s Deeper Discovery phase across the two pilot sites, via group sessions, individual feedback or surveys. The study identified key barriers (e.g. logistical constraints, limitations in accessibility of processes and participation, safeguarding and participant wellbeing concerns) and enablers (e.g. flexible and accessible participation, inclusive and adaptive facilitation, and participation and influence) that shaped conditions for implementation. Moreover, it explored the requirements and tensions for methodological implementation whilst maintaining a flexible and adaptive approach, centring CYP needs and voices, and integrating different methods into the co-design process. Conclusions: The Kailo programme prioritised the contributions of CYP and their communities, aiming to foster inclusive and diverse engagement through a distinctive, adaptive, youth-centred approach. This paper outlines the co-design methodology used to support the development of locally relevant strategies addressing the social determinants of mental health. However, balancing flexibility and adaptability and centring CYP needs, voices and agency, whilst maintaining a focus on broader structural issues, remains a challenge.

The COVID-19 pandemic accelerated the adoption of remote consultations across health care, requiring rapid adjustments in service delivery. Consequently, there is an urgent need to understand the impact of remote consultations on health pathways. This viewpoint paper explores key challenges in data sources in England that hinder research on the impact of remote consultations on health outcomes. Based on our experience conducting research on this topic, we present variations in observational study findings and their validity, considering differences in population characteristics and data sources. We provide recommendations to enhance data quality for future research, including improvements in data recording platforms and strengthened structures for linking primary and secondary care electronic health records.

Objective The COVID-19 pandemic prompted a significant increase in the use of remote consultations—by telephone or video—in both primary and secondary healthcare. The reported advantages of remote consulting for both patients and clinicians include greater efficiency, flexibility and convenience. However, disadvantages, such as the uncertainty created by a loss of face-to-face contact, have also been highlighted. The aim of this study was to explore, explain and interpret patients’ and clinicians’ perceptions and experiences of remote consultations and assist decision-making about their future use. Design A qualitative study based on semistructured online interviews. Setting Primary mental healthcare or secondary care cardiology services, London, UK, February–March 2022. Participants Primary care mental health patients (n=5), primary care clinicians (general practitioners) (n=15), secondary care cardiology patients (n=9) and secondary care cardiology clinicians (n=5). Results The results demonstrate that a range of factors have influenced the experiences of both clinicians and patients and indicate shifts in the norms of professional practice and clinician–patient relationships. Conclusions Patients and clinicians demonstrated pragmatic acceptance of remote consultations and, looking forward, a preference for a balanced ‘hybrid model’ of remote and face-to-face appointments. The study also highlights a need to consolidate and build on the informal learning and adaptation to remote consulting that has already taken place.

Kailo is a prevention framework that supports local communities to co-design evidence-informed strategies to address the social determinants of adolescent mental health and wellbeing. Similar place-based initiatives exist internationally but research into the mechanisms of change and contextual drivers is limited. Understanding how and why Kailo functions is crucial for refining the framework before it is implemented in different contexts and for informing the focus of an impact evaluation. We conducted a developmental, realist-informed evaluation to investigate how and why the Kailo framework functions, for whom and under what circumstances. The first phase of the evaluation involved a rapid realist review, observations of key processes, key informant interviews, and document analysis. These methods informed the development of a series of initial programme theories. The second phase involved testing and refining these initial programme theories through further interviews and focus groups with key informants. A realist dialogic approach was used throughout, and our work was supported by two Young People’s Advisory Groups who provided input on both the approach and theory generation. We generated a series of programme theories that shed light on the underlying mechanisms through which the Kailo framework works, the ways in which context acts as a catalyst for change, and the outcomes prioritised. These programme theories fall into six themes: 1) Alignment; 2) Time; 3) Credibility; 4) Accessible Spaces; 5) Building a Shared Understanding/Mission; and 6) Creating Hope that Change is Possible. Our study has informed the further development of the Kailo framework and lays the groundwork for a subsequent contributory impact evaluation to assess how Kailo contributes to system-level change and, ultimately, improvements in adolescent mental health and wellbeing. The programme theories generated also contribute to a wider understanding of how complex place-based approaches may function.

Objectives: We systematically appraised peer reviewed evidence assessing the impact of “place-based approaches” (PBAs) – those requiring multi-sectoral action within localities to address complex health challenges – on mental health outcomes among adolescents.Methods: We searched six databases from inception to May 2023. We defined PBAs as at least two sectors (e.g., local government, health) working collaboratively within a locality. Studies reporting mental health and substance-use among young people (aged 10–24) were included. Two authors independently assessed study quality using MMAT. Heterogeneity in PBAs, study design and outcomes prevented meta-analysis; results were narratively synthesised.Results: Thirty-three publications presented data from 22 PBA evaluations; 6 evaluations assessed mental health or wellbeing, 16 appraised substance use. Higher quality evaluations found no impact on mental health outcomes (n = 4), and some evidence for delayed initiation (n = 4) and reduced point-in-time use (n = 10) of alcohol. Evidence for impact on binge-drinking and drug use was mixed.Conclusion: Based on very few published studies of mixed quality, PBAs have not improved mental health or wellbeing among adolescents. More evidence exists to suggest PBAs can improve certain alcohol use outcomes in young people.

BackgroundThe COVID-19 pandemic has raised a wide range of challenges for health systems around the world and the National Health Service in England has been no exception. A significant proportion of infected cases require intensive care unit support and have a high mortality rate. In the early stages of the pandemic, there was neither an evidence base nor a clinical consensus on the optimal management of patients in this setting.InterventionsResponding to requests for assistance to address this evidence gap, UCLPartners, an Academic Health Science Partnership, working in collaboration with other organisations including National Institute of Health Research Applied Research Collaboration North Thames, developed a clinical academic team to synthesise clinical learning in real time. This was then disseminated using existing networks and social media to local, regional, national and international clinical teams.ConclusionAn Academic Health Science Partnership was able to respond quickly through adapting and expediting traditional methods of evidence gathering, supporting organisations to work collaboratively across their networks and so meet an urgent clinical need to the benefit of clinicians and patients.

The Intensive Care Society held a webinar on 3 April 2020 at which representatives from 11 of the most COVID-19 experienced hospital trusts in England and Wales shared learning around five specific topic areas in an open forum. This paper summarises the emerging learning and practice shared by those frontline clinicians.

Background: England, and the UK more generally, has a large burden of winter- and cold-related mortality/morbidity in comparison with nearby countries in continental Europe. Improving the energy efficiency of the housing stock may help to reduce this, as well as being important for climate change and energy security objectives.Objectives: To evaluate the impact of home energy efficiency (HEE) interventions on winter- and cold-related mortality/morbidity, including assessing the impact of winter fuel payments (WFPs) and fuel costs.Design: A mixed-methods study – an epidemiological time-series analysis, an analysis of data on HEE interventions, the development and application of modelling methods including a multicriteria decision analysis and an in-depth interview study of householders.Setting: England, UK.Participants: The population of England. In-depth interviews were conducted with 12 households (2–4 participants each) and 41 individuals in three geographical regions.Interventions: HEE interventions.Main outcome measures: Mortality, morbidity and intervention-related changes to the home indoor environment.Data sources: The Homes Energy Efficiency Database, mortality and hospital admissions data and weather (temperature) data.Results: There has been a progressive decline in cold-related deaths since the mid-1970s. Since the introduction of WFPs, the gradient of association between winter cold and mortality [2.00%, 95% confidence interval (CI) 1.74% to 2.28%] per degree Celsius fall in temperature is somewhat weaker (i.e. that the population is less vulnerable to cold) than in earlier years (2.37%, 95% CI 0.22% to 2.53%). There is also evidence that years with above-average fuel costs were associated with higher vulnerability to outdoor cold. HEE measures installed in England in 2002–10 have had a relatively modest impact in improving the indoor environment. The gains in winter temperatures (around +0.09 °C on a day with maximum outdoor temperature of 5 °C) are associated with an estimated annual reduction of ≈280 cold-related deaths in England (an eventual maximum annual impact of 4000 life-years gained), but these impacts may be appreciably smaller than those of changes in indoor air quality. Modelling studies indicate the potential importance of the medium- and longer-term impacts that HEE measures have on health, which are not observable in short-term studies. They also suggest that HEE improvements of similar annualised cost to current WFPs would achieve greater improvements in health while reducing (rather than increasing) carbon dioxide emissions. In-depth interviews suggest four distinct householder framings of HEE measures (as home improvement, home maintenance, subsidised public goods and contributions to sustainability), which do not dovetail with current ‘consumerist’ national policy and may have implications for the uptake of HEE measures.Limitations: The quantification of intervention impacts in this national study is reliant on various indirect/model-based assessments.Conclusions: Larger-scale changes are required to the housing stock in England if the full potential benefits for improving health and for reaching increasingly important climate change mitigation targets are to be realised.Future work: Studies based on data linkage at individual dwelling level to examine health impacts. There is a need for empirical assessment of HEE interventions on indoor air quality.Funding: This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full inPublic Health Research; Vol. 6, No. 11. See the NIHR Journals Library website for further project information.