Article reuse guidelines: sagepub.com/journalspermissions journals.sagepub.com/home/taw 619 Special Collection Background Clinical practice guidelines are described as 'systematically developed statements to assist professional decisions about appropriate healthcare for specific clinical circumstances'. 1 They are used to provide support and advice to practitioners regarding a wide range of clinical situations, including patient monitoring, lifestyle advice, treatment choice through stepped care, and therapeutic drug monitoring. The use of clinical practice guidelines has become a common feature in modern day medicine, with many clinical decisions informed by them on a daily basis. Using clinical practice guidelines to inform treatment decisions has the advantage of improving the consistency of care in an attempt to improve overall health outcomes for

Objective Proactive deprescribing – identifying and discontinuing medicines where harms outweigh benefits – can minimise problematic polypharmacy, but has yet to be implemented into routine practice. Normalisation process theory (NPT) can provide a theory-informed understanding of the evidence base on what impedes or facilitates the normalisation of routine and safe deprescribing in primary care. This study systematically reviews the literature to identify barriers and facilitators to implementing routine safe deprescribing in primary care and their effect on normalisation potential using NPT. PubMed, MEDLINE, Embase, Web of Science, International Pharmaceutical Abstracts, CINAHL, PsycINFO and The Cochrane Library were searched (1996–2022). Studies of any design investigating the implementation of deprescribing in primary care were included. The Mixed Methods Appraisal Tool and the Quality Improvement Minimum Quality Criteria Set were used to appraise quality. Barriers and facilitators from included studies were extracted and mapped to the constructs of NPT. Key findings A total of 12,027 articles were identified, 56 articles included. In total, 178 barriers and 178 facilitators were extracted and condensed into 14 barriers and 16 facilitators. Common barriers were negative deprescribing perceptions and suboptimal deprescribing environments, while common facilitators were structured education and training on proactive deprescribing and utilising patient-centred approaches. Very few barriers and facilitators were associated with reflexive monitoring, highlighting a paucity of evidence on how deprescribing interventions are appraised. Summary Through NPT, multiple barriers and facilitators were identified that impede or facilitate the implementation and normalisation of deprescribing in primary care. However, more research is needed into the appraisal of deprescribing post-implementation.

Background: As people age, they are more likely to develop multiple long-term conditions that require complicated medicine regimens. Safely self-managing multiple medicines at home is challenging and how older people can be better supported to do so has not been fully explored. Aim: This study aimed to identify interventions to improve medicine self-management for older people living at home and the aspects of medicine self-management that they address. Design: A rapid review was undertaken of publications up to April 2022. Eight databases were searched. Inclusion criteria were as follows: interventions aimed at people 65 years of age or older and their informal carers, living at home. Interventions needed to include at least one component of medicine self-management. Study protocols, conference papers, literature reviews and articles not in the English language were not included. The results from the review were reported through narrative synthesis, underpinned by the Resilient Healthcare theory. Results: Database searches returned 14,353 results. One hundred and sixty-seven articles were individually appraised (full-text screening) and 33 were included in the review. The majority of interventions identified were educational. In most cases, they aimed to improve older people's adherence and increase their knowledge of medicines. Only very few interventions addressed potential issues with medicine supply. Only a minority of interventions specifically targeted older people with either polypharmacy, multimorbidities or frailty.

Introduction Polypharmacy, the use of ≥5 medicines, continues to increase worldwide and can become problematic potentially leading to adverse drug reactions (ADRs) and poor patient outcomes. Deprescribing - discontinuing medicines where harms outweigh benefits (1) - can help minimise problematic polypharmacy. Although deprescribing is effective in stopping medicines it has not been routinely incorporated into practice, with a lack of evidence on how deprescribing can be implemented in primary care. The support and education patients require and the training that clinicians need, must be established to effectively implement routine safe deprescribing in primary care. This scoping review was conducted to identify research gaps and determine the value of undertaking a systematic review on the barriers and facilitators of implementing deprescribing in primary care. Aim Methods The Arksey and O’Malley framework for scoping reviews was used (2). The Cochrane Library, PubMed, Embase, MEDLINE, Web of Science and International Pharmaceutical Abstracts were searched from 1996 – February 2020. Additional references were identified from reference lists of included articles. Abstracts and titles were screened and potentially relevant articles received full text screening. Inclusion criteria were quantitative, qualitative and mixed-methods literature on deprescribing in primary care. The exclusion criteria were conference papers, non-English language papers and literature on palliative care/life-limiting illness, patient self-discontinuation, withdrawal of medicine due to ADR, substance misuse, and long-term care facilities. For intervention studies; country, study design, aims, population, intervention, education used, follow-up used and findings were collected. For non-interventional studies; study design, aims, population and themes identified were collected. For the deprescribing trials, barriers and facilitators to implementing the intervention were identified. Results 4612 articles were identified and 72 articles included (32 intervention studies; 40 non-intervention). The majority of articles were from the Netherlands (15), Canada (13), USA (10), and UK (seven). Study designs included 12 RCTs, 11 quasi-experimental studies, six follow-up papers, three protocols, 19 surveys studies, eight interview studies, two observational studies, a meta-ethnography, a Q-methodology study, a process evaluation and eight narrative reviews. Five studies documented providing patient support post-deprescribing with little description of what this consisted of. The provision of patient education or clinician training was used in 14 studies. Six of seven studies incorporating patient education into their intervention were able to safely deprescribe for a significant proportion of patients. Research on the barriers and facilitators to implementing deprescribing into primary care was not routinely reported with a greater focus on the process of deprescribing, rather than implementation. Conclusion There is a paucity of research on the fundamental characteristics required for deprescribing to be routinely and safely implemented in primary care. There is a lack of description on what type of education and support patients need, and training that clinicians require, for routine safe deprescribing. Future research is needed to identify and address these factors for the benefits of deprescribing to be realised. References (1) Scott IA, Hilmer SN, Reeve E, Potter K, Le Couteur D, Rigby D, et al. Reducing Inappropriate Polypharmacy: The Process of Deprescribing. JAMA Internal Medicine. 2015;175(5):827-34. (2) Arksey H, O’Malley L. Scoping studies: towards a methodological framework. International Journal of Social Research Methodology. 2005;8(1):19-32.

Whilst the widening participation programme aims to increase the accessibility of undergraduate study for students with a lower socio-economic status, much less support is available for students wishing to progress to postgraduate study. Postgraduate study risks becoming a discipline exclusive to those from upper-middle class and upper-class backgrounds, with too few role models from lower socioeconomic backgrounds encouraging uptake. To explore class-related inequalities in academia reported by existing data through the lens of access to postgraduate study, we developed, and piloted, the CLASS (championing lower-class academic and social success) programme within our university. The programme aims to harness the lived experience of workingclass individuals to uncover the barriers to postgraduate study and to develop strategies at an institutional level. An initial understanding of the barriers and challenges current students experience have been captured in our pilot programme. Future CLASS initiatives include assessment of these barriers at a national level to harness findings through the development of strategies with universities.