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Key content The non‐technical skills (NTS) as identified in the literature. Developments in NTS training. Current assessment practices and approaches to skills assessment in obstetrics and gynaecology. Potential use of assessments of NTS in obstetrics and gynaecology. Objectives Describe the NTS required in obstetrics and gynaecology and their relationship to performance. Develop an awareness of how these skills may be formally assessed and the potential role of NTS feedback. Ethical issues What are the ethical issues relating to the involvement of trainees in education research at the same time as performing an assessment? Is another assessment feasible within the constraints of our training programme?

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Personal recovery is central to Australian mental health standards, but promoting recovery-oriented practice remains a wicked problem (ie complex, with definitions and appropriate interventions impacted upon by context and values), with limited evidence regarding effective implementation. This case study re-examines a statewide initiative to enhance recovery-oriented practice in older people’s mental health services in New South Wales from the perspective of complex adaptive systems. The initiative consisted of three key strategies: (1) statewide collaborative leadership and practice resources; (2) locally determined and led improvement projects; and (3) evaluating, disseminating and sustaining initiative outcomes. Published outcomes of the initiative, related policy and benchmarking materials and author reflections are used to propose lessons for other services and policy makers. From a systems perspective, a relatively small investment from a state policy unit to enhance a facilitating environment resulted in the emergence of local leaders and voluntary participation of services within 80% of local health districts without funding incentives. Local leaders and activities informed statewide policies and models of care to sustain practice change. Limitations included variability in project scopes and the involvement of people with lived experience, as well as the level of refinement in change management approach. Self-audit and consumer-rated experience suggest resilience of practice and culture change. The outcomes are consistent with conceptualisations of mental health services being complex adaptive systems requiring distributive leadership. Established mechanisms encouraging statewide cooperation between clinicians, service managers and policy makers may have been significant facilitators of engagement in practice change. What is known about this topic? Recovery remains an important concept for older people with mental ill health, with implementation of recovery-oriented practice a wicked problem. What does this paper add? Central policy investment in a collaborative facilitatory environment can stimulate the emergence of local leadership and investment in actions to enhance recovery orientation. As predicted by complex adaptive systems theory, the impact of the leaders developed may be broader than the sum of individual project outcomes. What are the implications for practitioners? A start where you can message can engage and enable leaders in feasible and locally relevant changes consistent with a statewide strategy. This may be a feasible approach to improving recovery orientation in mental health care services for and beyond older people, with potential implications for addressing other wicked problems in health care.

Background: In an ageing population with high levels of multi-morbidity, the preventative effects of exercise rehabilitation(ER) are significant. The NHS currently delivers ER mainly in disease-specific areas. There is a lack of published data to support the long term effectiveness of this model. In the light of emerging evidence supporting the effectiveness of physical activity for multi-morbidity, it is timely to consider different models of ER service delivery. Engagement with and adherence to ER is an important factor in its long term effectiveness. Active involvement and engagement with users is therefore essential at the service design level. The objective of this project, therefore, is to involve users in the preliminary stages of service re-design by seeking to identify and prioritise service needs from a users perspective. These priorities will be used to form the aims of a co-design project with ongoing involvement of service users, aims which can be investigated as individual research questions.Methods: Forty people with multi-morbidity participated in discussion forums. Themes from the forums were summarised and presented in a format to inform the aims of future service co-design. Results: People with multi-morbidity were interested in involvement in the re-design of NHS rehabilitation services. People felt the NHS could and should do much more to support people to exercise because the barriers and motivators for exercise are inextricably linked to the symptoms of illness. Traditional NHS models of rehabilitation were challenged and participants suggested novel and exciting ideas about potential service design. Conclusions and discussion: Participants understand the potential value of exercise and are motivated to exercise. Motivation is thwarted by perceived barriers to competence, autonomy and cultural and social relatedness. Service users have novel and exciting ideas about how the NHS could improve exercise rehabilitation services in order to improve acceptability and accessibility to all. Together with ongoing service user involvement, these ideas can form the aims of a co-design project and ultimately will be developed into research questions in an evaluation of a new complex exercise rehabilitation intervention.