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Frailty increases vulnerability to adverse events (falls, illness) resulting in poorer health outcomes in later life. Persistent pain is common and impactful in older adults with frailty. Pain impact is potentially modifiable, and addressing it is important for supporting this population. The Pain in Older People with Frailty study aimed to generate evidence and develop service models to improve pain management for older adults with frailty and inform service provision for this underserved population. Phase 1: Map research evidence and synthesise findings from randomised controlled trials of multi-component pain management programmes and psychological therapies for community-dwelling older adults. Phase 2: In-depth qualitative interviews with community-dwelling older adults living with frailty and persistent pain, to explore pain experience and engagement with healthcare staff regarding pain. Phase 3: Service identification (four regions) including qualitative interviews with staff from pain service types (community, secondary care and specialist/tertiary) and generic community services to identify barriers and facilitators for older adults with pain and frailty to engage with pain management services. Phase 4: Co-design workshops with older adults, staff and commissioners to develop service guidance (supported by costing information) tailored to the needs of older adults with frailty and pain. Mixed-method, co-design study. Phase 2: Community-dwelling adults (≥ 75 years) with frailty and persistent pain. Phase 3: Staff from pain services and community services, and service commissioners. Phase 4: Older adults, staff and third sector representatives. Phase 1: Systematic review data; Phase 2: qualitative interview data (grounded theory); Phase 3: qualitative interview data (thematic analysis); Phase 4: workshop data. Phase 1: Across 31 randomised controlled trials, intervention mechanisms included enhancing self-efficacy, promoting positive psychological strategies, refocusing attention to manage pain and engaging in physical activity to improve well-being and reduce pain impact. Most interventions showed potential benefits for older adults. Phase 2: Interviews with 26 older adults living with pain and frailty highlighted key themes: pain experience, pain acceptance, support seeking decisions and accessing support. Phase 3: Forty-two staff shared their perspectives on supporting older adults with frailty and pain. Phase 4: Findings were shared during workshops involving 47 stakeholders (older adults, general practices, staff and third sector representatives). Stakeholders proposed service recommendations. A health economist calculated per-patient cost estimates for different service models. Limited representation from adults with severe frailty. There is no need for a dedicated pain and frailty service. Integrating pain management into existing frailty and community services should better meet the needs of frail older adults. This should include training community staff about persistent pain, referral options and establishing pathways for reporting pain and routine enquiry. Service directories, including voluntary and community organisations, could provide resources for staff and older adults. Adapting content and delivery of existing pain services will better support older adults with frailty and unmanaged pain requiring additional support. How should general practices identify older adults with frailty and pain who would most benefit from referral to pain services? How can information and awareness of pain management services be improved for this population? This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR131319. Some people as they age are frailer than others meaning they have less reserve to recover from illnesses. Pain is common in older people with frailty and can impact on daily life and wellbeing. Pain increases the risk of worsening frailty. Since pain impact can often be managed, addressing it is an important way to support older adults. The Pain in Older People with Frailty (POPPY) study aimed to understand how best to support older people with frailty and pain and to understand good service provision for this group. The study included four phases: A review of studies of psychological therapies (e.g. talking therapies) and pain management programmes for older adults. Programmes often include education, practice sessions and group sessions. Interviews with older people with frailty and pain to explore their pain experience and interactions with healthcare staff about their pain. Interviews with pain service and community service staff, and commissioners (who decide which services to fund) to understand how services could better meet the needs of older adults with frailty. Workshops with older adults and staff to discuss study findings and consider what a good service for frail older adults would look like. The study included patient and public involvement. Findings were shared via presentations and publications. Older adults with frailty and pain need opportunities to report pain and should be asked about pain during routine health consultations. There is no need for a separate pain and frailty service. Instead, pain management should be included within existing frailty and community services. Additionally, lists of local community groups could provide a useful resource. Adapting current pain services will ensure better care for those with unmanaged pain.

In 1989, Oregon passed SB 27, overhauling Medicaid by insuring all impoverished residents while explicitly rationing covered treatments. Rather than excluding some of the poor, the state established the Oregon Health Services Commission (OHSC), an eleven-person citizen body tasked with developing a prioritized list of 1,600 condition-treatment pairings based on cost-effectiveness and public values. This effort became central to debates over who should determine the availability of health services in public insurance programs. We analyzed a new data source - meeting minutes and internal documents from 1990-1991 - using reflexive thematic analysis in ATLAS.ti. Themes centered on commissioners' emotional experiences, technical challenges, and the role of subjective decision-making, situated within broader discussions of judgement in participatory governance and cost-effectiveness analysis. The Commission faced profound technical obstacles, namely limited data, methodological uncertainty, and growing frustration under public pressure. As technical approaches faltered, commissioners increasingly relied on collective judgment to complete the list. The common narrative that the OHSC abandoned technical rigor overlooks the reality that health policy decisions always embed subjective judgements. Its innovation was affording those judgements to citizens rather than experts or politicians. Reliance on subjectivity reflected the nature of cost-effectiveness analyses and participatory governance, not failure.

Background Twenty-first century dentistry in first world countries should be based on sound evidence-based prevention and timely access to relevant dental care, but is not the picture currently portrayed of dentistry within the UK, by and for the key players involved (e.g., patients/public, government/commissioners, National Health Service, contract providers and performer workforce).Aims To summarise the issues that face the public, dental educators, dental workforce and commissioners of dental care in the UK (England) that were formally discussed at the British Society of Prosthodontics (BSSPD) Conference 2025.Method A panel was selected to include experts and spokespeople for the Department of Health/Chief Dental Officer, dental public health, the British Dental Association, postgraduate dental education and training, and workforce research, to debate five themes of sustainability in front of an audience of foundation dentists, dental core trainees and educational supervisors, speciality trainees, as well as general dental practitioners, specialists and consultants in prosthodontics and restorative dentistry.Conclusion The discussions of this debate on sustainability confirmed the need for novel approaches/offers with better understanding, funding and delivery of effective prevention models, urgent contract reform, with suggestions for education and health systems that can support (new and existing) dental workforce challenges.

Avoidable and unfair variation in access to palliative care exists for different groups of people and communities. Primary and community care teams deliver most palliative care and care to people at the end of life at home but the quality of care provided is variable. This is an under-researched area and receives little attention in service design and policy. This study will investigate the key contexts, resources and components required for an integrated approach to palliative care to deliver improved and more equitable outcomes for patients and carers. This mixed-methods study adopts a realist methodological approach, and comprises four work packages:A multi-perspective mixed-methods study to understand patient preferences and priorities in palliative care, prioritising recruitment of patients and family members/carers from areas of socioeconomic deprivation. Data collection will comprise: (1) qualitative interviews, (2) review of patient case notes and (3) a discrete choice experiment. Realist analysis will result in the development of theory based on the identification of the key contexts and underlying mechanisms required to achieve beneficial outcomes through an integrated approach to palliative care.A realist evaluation of existing integrated models of palliative care will involve theory-refining interviews and theory-consolidating focus groups with professionals working in three different service areas.Dynamic simulation modelling of the healthcare resources needed to deliver the proposed integrated approach, ensuring quality and equity.The theoretical and economic modelling will be tested out at two expert stakeholder workshops to determine the key enablers to implementation in practice. The study design was informed by patient and public involvement (PPI) with 16 patients and members of the public from diverse and socioeconomically deprived communities for 12 months in a National Institute for Health and Care Research-funded palliative care partnership. PPI will be continuous throughout the study, prioritising inclusivity. Ethical approval was obtained from the East of Scotland Research Ethics Service Research Ethics Committee 2, on 20 August 2025 (IRAS ID: 354755) and Health Research Authority approval on 1 October 2025. The targeted dissemination strategy will include outputs and resources for key audiences including patients and families, professionals in primary care and specialist palliative care and service commissioners. The results will inform service delivery to reduce inequities and optimise the use of finite resources to maximise impact. The study is registered with the ISRCTN UK Clinical Study Registry: https://www.isrctn.com/ISRCTN61092011.

Emotional difficulties post-stroke are common, particularly among people from minoritised ethnic communities or with aphasia, an acquired communication disorder. However, there is a shortage of supportive evidence-based interventions, and of clinical psychologists to deliver them at scale. Wellbeing After Stroke-2 (WAterS-2) is a novel, online, group psychotherapy intervention based on Acceptance and Commitment Therapy. It was designed to support post-stroke psychological adjustment, delivered by a trained non-psychologist workforce to increase potential reach. To guide equitable implementation of such interventions into routine stroke care, this study explored barriers and facilitators from the perspectives of key stakeholders: healthcare commissioners, managers, and frontline clinicians. Qualitative, semi-structured, individual interviews were conducted online with purposively recruited healthcare professionals involved in commissioning, managing, or delivering stroke care in England. The qualitative interview schedule was informed by both the Consolidated Framework for Implementation Research (CFIR) and Normalisation Process Theory (NPT), while the subsequent thematic template analysis was primarily guided by CFIR to explore contextual factors and practical strategies for equitable implementation. Fourteen interviews were conducted (Feb-April 2024), with commissioning managers (n = 8), service managers (n = 4), and clinicians (n = 2). Analyses suggested three themes around the barriers and facilitators likely to influence equitable implementation: (1) Quality of Care vs. Quality of Cash Flow - highlighting a tension between tailoring for inclusion and demonstrating clinical- and cost-effectiveness; (2) Time & Leadership - highlighting a need for leadership to prioritise time investment in equity efforts; (3) Postcode Lottery - highlighting existing variation in local infrastructure, with third-sector partnerships suggested as key enablers. Equitable implementation of online psychological support requires balancing the diverse needs of stroke survivors and the constraints of a publicly funded healthcare system. Recommended actions to enable equity provide useful insights for the development, implementation and commissioning of online mental health interventions for stroke survivors. Strategies such as embedding interventions within existing workflows, securing leadership support, and forming partnerships with community organisations may help translate online support like WAterS-2 into routine care.

In this third article of a three-article series on interviews with Dr Shantanu Nundy, an advisor in the office of the Commissioner of the US FDA on AI governance and digital health policy, we explore how the oversight of generative AI (GenAI) and large language model (LLM)-enabled medical devices extends beyond the remit of any single regulator, requiring coordination among government agencies, health systems, and practicing clinicians. We also discuss practical advice for innovators seeking to engage productively with the FDA.

In 2019, the NHS App was launched as a 'digital front door' to England's National Health Service, aiming to improve access to primary care, enhance patient experience, save time in general practitioner practices and promote self-care. This project aimed to identify and understand the use and acceptability of the NHS App, to measure the extent to which it improved patient experience and influences health service access, and to understand patterns of early take-up and participation. Qualitative work explored experiences and views on the acceptability of the app through 60 hours of observation in general practices, document analysis (approximately 100 documents), and 62 interviews and four focus groups with patients, carers, members of the public and staff across five general practices, as well as commissioners and policy-makers. Our theoretical approach used the Non-adoption, Abandonment, Scale-up, Spread and Sustainability framework. Quantitative work examined the impact of the NHS App on the usage of primary and secondary care, using routinely collected data. Firstly, using monthly NHS App user data at general practice level in England, descriptive statistics and time series analysis explored monthly NHS App use from January 2019 to May 2021. Secondly, data on the sociodemographic characteristics of the general practitioner-registered population and their healthcare needs at the general practitioner level were used as covariates to explore inequalities in app usage. Finally, NHS App usage data were also compared with measures of patient experience of care and care access extracted from the General Practitioner Patient Survey database. The qualitative analysis guided by the Non-adoption, Abandonment, Scale-up, Spread and Sustainability framework illustrated the multiple layers of complexity when introducing a constantly shifting technology into a challenging environment such as English general practice, during and after a period of considerable societal turbulence caused by the COVID-19 pandemic. Quantitative work showed there was strong adoption of the NHS App even before the onset of the pandemic, although the introduction of the COVID-19 Pass feature was linked to a fourfold increase in downloads. Analyses by sociodemographic data found higher usage in less-deprived and less ethnically diverse practices, with a generally younger population. There were 25% lower registrations in the most deprived practices (p&#x2005;<&#x2005;0.001), and 44% more registrations in the largest-sized practices (p&#x2005;<&#x2005;0.001). Registration rates were 36% higher in practices, with the highest proportion of registered White patients (p&#x2005;<&#x2005;0.001), 23% higher in practices with the largest proportion of 15- to 34-year-olds (p&#x2005;<&#x2005;0.001) and 2% lower in practices with highest proportion of people with long-term care needs (p&#x2005;<&#x2005;0.001). Analyses by patient subgroup and by patient experience of care showed mixed findings. There was no opportunity to evaluate the app or the app functionality in an experimental design. The technology itself, and the context, was changing during the study, which added challenges and complexity. The quantitative analyses used aggregated data rather than individual-level linked data. The NHS App was introduced into a complex and changing landscape. It has achieved strong uptake, with the COVID-19 Pass feature increasing adoption substantially. Overall uptake and use have followed an inverse deprivation gradient, influenced in particular by age, ethnicity and healthcare needs. Different functions of the NHS App have been used to different extents, and with different patterns over time. Further evaluation as the healthcare landscape and the functions of the NHS App evolve is warranted, including longitudinal studies using person-level data and further work on inequalities in access and use. This study is registered as ISRCTN72729780. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref.: NIHR128285) and is published in full in Health and Social Care Delivery Research; Vol. 14, No. 15. See the NIHR Funding and Awards website for further award information. In 2019, the National Health Service in England introduced a new smartphone app for patients, called the &#x2018;NHS App&#x2019;. This aims to become the &#x2018;digital front door&#x2019; to the National Health Service. Over the last 5 years, an increasing number of functions have been added to the app. For example, people are able to use it to see their medical records, book appointments, order repeat prescriptions and undertake other tasks related to their health and care. In this research study, we looked at how many people use the NHS App, what functions they use, what people think about the NHS App and whether it changes how people use the National Health Service. To do this, we used interviews and discussions with people who use (or do not use) the app, and with doctors and other staff who work in the National Health Service. We also looked at the statistics showing how often the NHS App is used. We found that the NHS App has been widely adopted by many millions of users. In the early days, this high uptake was helped by events related to the COVID pandemic, and especially the introduction of the COVID Pass. Usage has continued to grow since then. The use of the app appears to be more common in areas which are less poor, and where general practices have younger patients, and where the populations they serve are less ethnically diverse. Different features of the NHS App are used by different groups of patients to a greater or less extent. Patients who are most looked after in primary care may find the app more useful than those who are being looked after by hospital specialists. Healthcare staff and the organisations they work for have had to adapt their own work in order to introduce the NHS App into their practice.

To enable progress in digital medicine and medical AI, particularly where these technologies extend beyond the usual boundaries of medical devices, new regulatory approaches are needed. In this first article of a three-part interview series with Dr Shantanu Nundy, an advisor on AI in the FDA Commissioner&#x2019;s Office, we examine the agency&#x2019;s newly announced TEMPO pilot. The pilot aims to create new pathways for digital health in chronic disease by linking oversight, evidence generation, and reimbursement.

Aims Describes the development and early implementation of the Cancer Action Support Practice (CASP) pathway in South West England, aiming to improve dental care access for head and neck cancer (HNC) survivors in the primary care setting.Summary of CASP development Stakeholder engagement was central to CASP's design, involving input from general dental practitioners, local dental committees, commissioners, and secondary care teams. Funding and commissioning options were explored through the regional integrated care boards (ICBs). CASP aligns with national policy, including NHS England's guidance on oral health for cancer patients. CASP provides a structured pathway enabling HNC patients to access routine and preventive dentistry in primary care to prepare them for and maintain them after oral rehabilitation. Two commissioning models (units of dental activity uplift and sessional rate approach) were proposed, allowing regional flexibility by commissioning ICBs. Consultant-led peer review, data collection, and ongoing professional development are embedded. A pilot CASP has been commissioned in Cornwall, with further strong regional interest.Conclusion CASP demonstrates a regionally coordinated approach to improving dental access for a vulnerable and complex patient group. The model supports integration between primary and secondary care, informed by national guidance and local clinical need, and has potential applicability to other medical conditions with significant dental involvement.

Multiple long-term conditions (MLTCs), defined as the co-existence of two or more chronic health conditions, are increasingly prevalent across all age groups and disproportionately affect socioeconomically disadvantaged and ethnic minority populations. Trials targeting MLTCs face methodological challenges due to patient heterogeneity, variation in selection of conditions and limitations in design and analysis. These challenges may contribute to the lack of evidence to inform effective interventions for people with MLTCs. This study aims to systematically identify and prioritise key methodological uncertainties in the design, conduct and analysis of future trials aiming to improve health outcomes for people with MLTCs. We will conduct a four-round modified Delphi study involving key interest groups including methodologists, trialists, MLTC researchers, research funders, commissioners, regulators, people with MLTC lived experience and MLTC carers. The process will include two rounds of online questionnaires, one lived-experience meeting (in-person or virtual) and a final virtual consensus meeting. To promote inclusivity and diversity of input, participants may join at any stage. Responses from each round will be analysed and summarised to inform the next stage, with final priorities agreed through structured consensus voting. This consensus study will produce a ranked list of methodological research uncertainties to guide future research and clinical trial design, conduct and analysis in MLTCs. Findings will be disseminated through a facilitated online dissemination workshop, academic channels and targeted public engagement activities to support inclusive and relevant MLTC research.

In this second article of a three-article series on interviews with Dr Shantanu Nundy, an advisor in the office of the Commissioner of the US FDA on AI governance and digital health policy, we explore the challenge of regulating large language model (LLM)-enabled medical AI, particularly where it extends beyond the usual boundaries of medical devices and therefore challenges traditional regulatory frameworks.

This study aims to describe the legal basis and operational framework of a pan-government interagency committee that supports the introduction of vaccines during emerging infectious disease pandemics and examine the institutional implications of the Prime Minister's directive. As a policy report on regulatory enactment, we reviewed the key provisions of the "Regulations on the Establishment and Operation of the Pan-government Interagency Committee for Vaccine Introduction," enacted on January 7, 2026, after inter-ministerial consultations, public notice, and legal review. The directive states that when a crisis alert of "Alert" or higher is issued under the Framework Act on the Management of Disasters and Safety, an interagency committee is convened within the Korea Disease Control and Prevention Agency (KDCA). Chaired by the KDCA Commissioner, senior officials from relevant ministries coordinate for vaccine supply planning, regulatory information sharing, global supply monitoring, and ministry-specific action plans. The directive also provides for a working-level committee, interagency cooperation requests, and consultation with external experts. By formalizing interministerial coordination for vaccine introduction, the directive creates an institutional platform that can support sustained preparedness and policy continuity in future infectious disease emergencies.

Continuity in general practice has clear benefits but is difficult to achieve. Mesothelioma is an incurable disease caused by asbestos exposure. People with mesothelioma potentially derive significant benefit from continuity; but more evidence is needed. To make policy relevant recommendations and develop new guidance to support people with mesothelioma, their close persons, and healthcare professionals, to achieve continuity in general practice. Stakeholder consultation workshops were undertaken to discuss the implications of realist case study data acquired earlier in the study, and form recommendations to optimise service design and delivery. Five individuals participated in a patient and public involvement capacity. Analysis consisted of three components: reflexive thematic analysis (inductive); formation of realist Context-Mechanism-Outcome configurations (retroductive) leading to programme theory refinement; and application of existing theory (deductive). Recommendations for practice, policy, and research, to facilitate continuity for people with mesothelioma in general practice, are presented. Clinician- and patient-facing outputs were developed to both contextualise and present the recommendations. Individuals providing patient and public involvement support contributed to the content and structure of outputs. This realist research deepens understanding of continuity in NHS general practice for people with mesothelioma. Findings are relevant to other patient populations, particularly those with rare conditions or palliative care needs. Recommendations and novel outputs are targeted towards clinicians, researchers, policymakers and commissioners, and may be used in educational contexts, in clinical practice, and at policy level to guide resource allocation and service development.

This study reviewed the U.S. insurance landscape for gender-affirming surgery (GAS) and examined how regional, legislative, and health care infrastructure factors influence coverage patterns to inform policy reform and advocacy. Policies from the top three insurers in each state, identified via the National Association of Insurance Commissioners, were analyzed in November 2024. Coverage was compared across census regions, and criteria concordance with the World Professional Association for Transgender Health (WPATH) Standards of Care, Version 8, was assessed. GAS fellowship availability, policy information accessibility (7-point Likert scale), and legislative favorability (Movement Advancement Project scores) were also evaluated. Coverage rates were compared across procedures using analysis of variance with post hoc Tukey tests. Poisson regression identified predictors of coverage, and ordinal logistic regression assessed predictors of policy information accessibility. All analyses were conducted in R 4.4.1. We included 144 state insurance policies, representing 77% of the U.S. market. Overall GAS coverage was 67.7%, with significantly lower rates for fertility cryopreservation (6.6%), facial feminization (37.3%), and GAS reversal (65.7%). GAS fellowship presence positively predicted coverage (p < 0.001). States with fair (p = 0.041) or medium legislative favorability (p = 0.004) had higher coverage compared with negatively rated states. Only 61.9% of policies were concordant with WPATH guidelines. Coverage information access was uniformly limited and was more limited in Southern states than in other regions (p < 0.001). Insurance coverage for GAS was inconsistent and strongly influenced by political and health care infrastructure factors rather than medical necessity. The lack of guideline concordance and systematic information barriers highlights the need for targeted reforms.

Advance care planning helps people plan for and communicate preferences about future care, including when decision-making capacity is lost. For people living with advanced multiple long-term conditions, advance care planning is challenging because decline may be unrecognised, responsibility is diffused across condition-specific services, and care is fragmented. To explore health and social care professionals' perspectives on challenges and best practices in advance care planning for people with advanced multiple long-term conditions, and to generate recommendations for improving practice. Reflexive thematic analysis of advance care planning-related interview data from a wider study examining palliative care needs and end-of-life challenges for people with multiple long-term conditions. Twenty-seven semi-structured interviews were undertaken with health and social care professionals, commissioners, and service managers in four regions of England. Three themes were generated: (1) Making multiple long-term conditions decline visible - cumulative illness burden and social adversity contributed to late recognition of deterioration; (2) System and organisational barriers - resource constraints, fragmented care, poor information sharing, and limited training created unclear ownership of advance care planning, with particular risks for people experiencing inequity; (3) Delivering advance care planning - effective advance care planning was introduced early, revisited iteratively, grounded in trusting relationships, and included families and care networks. For advanced multiple long-term conditions, advance care planning is undermined by prognostic uncertainty, care fragmentation, and inequities. Embedding prompted, iterative advance care planning into routine care, using markers such as functional decline and escalating support needs, may normalise conversations and support earlier documentation of preferences. This analysis extends needs-focused work by specifying practical mechanisms to initiate, share ownership of, and sustain advance care planning across fragmented services.

Wheelchair users represent a population with significant and often permanent mobility impairment. Despite well-established links between disability and socioeconomic deprivation, the geographic relationship between wheelchair user concentration and area-level deprivation has not previously been examined at national scale. This study aimed to identify spatial clusters of wheelchair users across Wales and characterise their association with socioeconomic deprivation across domains of the Welsh Index of Multiple Deprivation (WIMD). This cross-sectional ecological study used 43,790 NHS-registered wheelchair users across all 1,917 Lower Layer Super Output Areas (LSOAs) in Wales. Local Moran's I identified statistically significant High-High (HH) spatial clusters of wheelchair user counts. Chi-square goodness of fit tests, chi-square tests of association, and binary logistic regression quantified the association between WIMD deprivation quintile (Q1-5) and HH clustering across WIMD domain, with Benjamini-Hochberg false discovery rate correction applied throughout. One-hundred-and-ten HH clusters were identified, with 41% in the most deprived WIMD Overall quintile. Significant deprivation gradients were observed across six domains; Health and Employment showed the strongest associations, with Q1:Q5 wheelchair user ratios of 1.747 and 1.738 and up to 20-fold greater odds of HH cluster membership in the most deprived quintile. Housing and Access to Services showed divergent patterns, with clusters concentrated in areas of moderate rather than extreme deprivation. Wheelchair user spatial clustering in Wales is strongly associated with socioeconomic deprivation, but the association varies by WIMD domain. These findings provide actionable spatial evidence to support equitable NHS wheelchair service commissioning aligned with true geographic need. The geographic concentration of wheelchair users across South, Southwest, and North Wales, in communities characterised by convergent socioeconomic deprivation, indicates that commissioners may benefit from directing workforce capacity, equipment budgets, and service development towards areas of greatest need, rather than distributing resources uniformly across health board populations.Posture and mobility services that support the most health- and employment-deprived communities are likely to serve populations with greater clinical complexity. Ensuring adequate staffing, specialist assessment capacity, and timely review and follow-up in these areas may help to reduce secondary complications associated with delayed or inadequate wheelchair provision.High concentrations of wheelchair users are associated with income and education deprivation. Where deprivation compounds barriers to attending centralised services, flexible scheduling, accessible communication, and the community-based components of posture and mobility services, including home visits and community assessment, should be prioritised to ensure timely equipment review for those least able to travel.

Little is known about the provision of diagnoses to young people with mental health disorders. We investigated diagnosis provision by NHS mental health services, focusing on 17-year-olds in South London between 2009-2024, and compared with estimated disorder prevalence. To examine diagnosis provision in the population, we extracted diagnosis data from records of the NHS mental healthcare provider serving South London, using the Maudsley Biomedical Research Centre Clinical Record Interactive Search application; we then compared these data with the corresponding population size, obtained from the Office for National Statistics. To assess diagnosis provision in those with mental health disorders, we compared diagnosis data with the number of young people estimated to have met criteria for a disorder, derived from epidemiological interview data collected in the Environmental Risk (E-Risk) Longitudinal Twin Study and weighted according to characteristics of 17-year-old South Londoners. To assess diagnosis provision in those with mental health disorders within health services, we compared diagnosis data with the number estimated to have met criteria for a disorder and used any health service for their mental health, again derived from weighted E-Risk Study data. Of 17-year-olds from South London in 2009-2024, 4.0% (n=8,958/223,404) had a diagnosis in mental health records during the previous year. This diagnosis provision covered <1 in 16 of those estimated to have had a mental health disorder, and <1 in 4 of those estimated to have also used health services. Diagnosis provision was lower in girls than boys and in young people with Black/Asian/Mixed/Other ethnicity than those with White ethnicity, in those estimated to have had a mental health disorder and used health services. These findings demonstrate gaps and biases in mental health diagnosis provision for young people, including within health services, and reveal the imperative need to strengthen young people's mental healthcare. National Institute for Health Research, Medical Research Council, National Institute of Child Health and Development, Jacobs Foundation, National Society for Prevention of Cruelty to Children, Economic and Social Research Council, Prudence Trust, Wellcome Trust. Evidence before this study: Epidemiological research has found that less than half of young people with a mental health disorder report seeing a health professional for their symptoms and only a quarter to a third have seen a mental health specialist, and these findings are fairly consistent across high-income countries where this research has been conducted. For young people who see health professionals, there are likely to be barriers to the recognition and treatment of mental health disorders. We focused on the recognition of mental health disorders in young people, which is operationalised in clinical practice as provision of diagnoses. To identify studies examining mental health diagnosis provision in young people accessing health services, we searched MEDLINE with the terms "diagnos*" AND ("mental" OR "psychiatr*" OR [various terms for individual disorders]) AND ("young" OR "youth*" OR "child*" OR "adolescen*" OR "paedatric*" OR "pedatric*" OR "juvenile") AND ("clinical" OR "healthcare" OR "health care" OR "service*"). This search was supplemented by reviewing reference lists and forward citations of relevant articles. We identified several studies that found diagnosis provision varied by sociodemographic characteristics and has increased over the past two decades in young people across multiple countries for several disorders, including depression, anxiety disorders, eating disorders, autism, and attention-deficit/hyperactivity disorder (ADHD). Only a small number of studies investigated diagnosis provision within young people who met criteria for a disorder. In the Avon Longitudinal Study of Parents and Children in the UK, of 18-year-olds who met criteria for depression, only 7.0% had a diagnosis of depression documented in their primary care records. In the Child and Adolescent Twin Study in Sweden, of 9-year-olds who met criteria for ADHD, only 18.5% of boys and 12.1% of girls had a diagnosis of ADHD noted in their health records. Within an Irish child and adolescent mental health service, of 12-15-year-olds who met criteria for depressive disorder, only 28.4% received a depressive disorder diagnosis after their usual clinical assessment. These studies suggest large gaps in diagnosis provision, including within health services, and highlight possible bias by sociodemographic characteristics. A better understanding of this topic is needed to enable more effective service planning, commissioning, and policymaking.Added value of this study: This study investigated mental health diagnosis provision in 17-year-olds from South London. We examined diagnosis provision for several mental health disorders in NHS mental healthcare records. We compared these data with population and epidemiological data to calculate diagnosis provision rates in the general population, in those estimated to have met criteria for a disorder, and in those estimated to have also seen a health professional. We found that diagnosis provision substantially increased during our study period of 2009-2024, demonstrating an increase in the number of young people whose mental health needs were recognised in specialist services. However, we estimated that diagnoses were only provided to a small proportion of young people with a mental health disorder, including those within health services. Estimated diagnosis gaps were largest for those with generalised anxiety disorder and multiple disorders. We also found evidence of biases in diagnosis provision, based on gender, neighbourhood deprivation, and ethnicity.Implications of all the available evidence: Barriers to mental healthcare access for young people should be reduced by policymakers and commissioners, including through investment in adequately staffed services with skilled clinicians, enabling more young people with mental health disorders to receive cost-effective evidence-based healthcare that has long-term benefits. Greater awareness among clinicians of the under-diagnosis and bias in diagnosis of young people's mental health disorders, alongside strategies to address these problems, could improve young people's mental healthcare. Innovative scalable interventions that can reach many more young people need to be developed, evaluated, and implemented by researchers. Prevention strategies are also required, including addressing risk factors for young people's mental health disorders, and intervening early for those with symptoms before disorders develop, to reduce the future burden of mental health disorders in young people.