Socioeconomic inequalities in neonatal mortality are observed globally but gaps remain in the evidence from current reviews, specifically: a wider range of socioeconomic indicators at the individual, household and area level than previous reviews, and alternative time frames to define neonatal mortality. Thus, a comprehensive updated review of the literature is required, focusing on multiple measures of socioeconomic status and alternative time frames, to assess the relationship between maternal socioeconomic status and neonatal mortality in high-income countries.

Three different search approaches will be used: electronic searching of three databases, grey literature searching and reference list checking. First, the three databases Medline, Scopus and Web of Science will be searched using relevant synonyms and adapted terms from medical subject heading terms (MeSH) in Medline for maternal socioeconomic status and neonatal mortality identified from previous systematic reviews on inequalities in adverse pregnancy outcomes. Second, grey literature will be searched by entering the relevant terms into Google. Title, abstract and full text screening will be conducted by the review team against the inclusion and exclusion criteria, with at least 10% checked by a second reviewer to assess for any bias and errors. We will also conduct the kappa statistic for inter-rater reliability. Third, the reference lists of included studies will be reviewed for any additional studies that meet the criteria. Data will be extracted using a data extraction form and extracted studies will be assessed using the Liverpool Quality Assessment Tool. A narrative synthesis will be conducted and, where appropriate, meta-analysis will be performed. If the data allow, subgroup analysis by neonatal care population and specific gestational ages will be performed.

Ethical approval is not required as all studies in this systematic review will be publicly available. The findings of this review will be presented at conferences and disseminated in peer-reviewed publications.

CRD42022315407.

Adverse pregnancy and perinatal outcomes (APPOs), including pre-term birth, pre-eclampsia and gestational diabetes, can result in maternal and neonatal morbidity and mortality, parental anxiety and increased healthcare costs. A better understanding of the causes of APPOs is essential to inform lifestyle and pharmaceutical interventions for their prevention and management. Given the difficulty of undertaking randomised controlled trials in pregnant women, triangulating evidence from across methods with different sources of bias may improve causal inference for APPOs. The purpose of the Mendelian randomisation in pregnancy (MR-PREG) collaboration is to support such triangulation using genetic (eg, Mendelian randomisation (MR)) and non-genetic (eg, partner negative controls) approaches to investigate the causal effects of maternal exposures on a comprehensive set of APPOs.

The MR-PREG collaboration includes individual participant data from three birth cohorts (two from the UK and one from Norway) and UK Biobank, as well as summary data from FinnGen and publicly available genome-wide association studies (GWAS). Data have been harmonised across studies and currently include information on up to 35 APPOs in up to 707 797 women.

The main aims of MR-PREG are to strengthen the evidence base for (1) prevention, by advancing understanding of maternal lifestyle factors on APPOs, (2) the role of pre-conceptional health, by improving understanding of the effect of maternal pre-existing conditions on APPOs, and (3) treatments, by evaluating the efficacy and safety of existing medications used for pre-existing conditions, and by identifying and testing novel or repurposed therapies for APPOs. To date, our published work has mainly addressed aims 1 and 3. Examples include triangulation of evidence from MR, conventional multivariable regression and paternal negative control, showing that higher maternal body mass index increases the risk of multiple APPOs, as well as the identification of maternal circulating metabolites and proteins that may influence birth weight.

Future priorities include increasing diversity within the MR-PREG collaboration by expanding representation of participants from non-European ancestries. We are also integrating molecular data, including circulating protein levels and placental transcriptomics, to better characterise the molecular mechanisms underlying APPOs. Additionally, we are using whole-exome and whole-genome sequencing to identify novel causal genes and to inform the prioritisation of candidate therapeutic targets for APPOs.

Severe mental illness such as psychosis is among the most disabling illnesses worldwide, disproportionately affecting minoritised ethnic groups and those in socioeconomic disadvantage. In the UK, people from Black ethnic backgrounds are more likely to experience a first episode of psychosis and to be detained under the Mental Health Act than White British people. There is a clear need for mental health services to improve cultural awareness and understanding of the broader social needs of minoritised groups, as well as the need to improve mental health literacy (MHL) within Black communities to empower individuals to seek timely mental health support. This protocol describes our programme of work which aims to assess the feasibility, acceptability and cost-effectiveness of Co-STARS, which is a co-produced, culturally appropriate tiered training package.

We co-produced a culturally appropriate, place-based, tiered MHL training package (Co-STARS) to deliver within underserved Black communities and via an e-learning package implemented among staff within mental health trusts. The training will be evaluated in stages. First, a pilot cluster randomised controlled trial will assess the feasibility and acceptability (defined as participants’ perceptions of the training’s relevance, usefulness and delivery) of a lived experience-led MHL training package delivered by Black young people with experience of mental ill health, to underserved communities in Birmingham, UK. Acceptability will be quantified through participation and completion rates and explored qualitatively via focus groups and interviews. Second, a stepped-wedge cluster randomised trial will evaluate the feasibility of an e-learning training programme for mental health professionals. We will embed a process evaluation to explore change mechanisms and identify barriers and enablers for future implementation. Third, we will use realist-informed participatory systems mapping and novel epidemiological analyses to explore downstream effects (ie, improved care access for Black ethno-racial groups within the intervention areas). Last, a cost-effectiveness framework will be developed to assess whether the intervention is good value for money in future efficacy trials. In the cluster trial, eight clusters will be randomised to the intervention arm (face-to-face training in the community) and control arm (display of MHL materials) with pre- and post-assessments in 120 participants from 8 clusters, 3 weeks apart. In the stepped wedge trial, six clusters (clinical teams within NHS mental health trusts) including 120 NHS staff in total, will move from control phase to intervention phase in a stepped wedge manner, with pre-assessments and post-assessments.

This proposal was reviewed by the Research Governance of the University of Birmingham and UK Research and Innovation (UKRI) grant reviewers. Ethics approval was granted by East of Scotland Research Ethics Service. The findings will be communicated in research conferences, stakeholder meetings, via social media, through publication in peer-reviewed journals and as a policy document.

ISRCTN10517405.

The roles of pharmacy staff have expanded to include public health functions, such as delivering harm reduction services for people who use drugs (PWUD), particularly unregulated substances and non-medical drug use, in response to an ongoing drug overdose crisis. Nonetheless, their involvement across the full spectrum of harm reduction services remains underexplored. This study mapped existing research describing or evaluating the implementation of harm reduction services for PWUD provided by pharmacy staff.

Scoping review.

MEDLINE, EMBASE, CINAHL, Web of Science, Scopus and Cochrane Library (inception to July 2025).

Studies reporting on the description or evaluation of harm reduction services for PWUD provided by pharmacy staff.

Two team members screened studies for eligibility and extracted the data. The data were analysed primarily to describe harm reduction services and the role of pharmacy staff.

43 articles were included. The most frequently reported harm reduction services were sexually transmitted and blood-borne infection care (33%), needle and syringe programmes (21%), naloxone distribution (19%) and medication treatment for opioid use disorder (19%). Pharmacy staff were integrated into multidisciplinary teams (79%), with their roles varying from education to medication prescribing. Included studies reported harm reduction services for PWUD delivered by pharmacy staff as effective, feasible and safe. However, implementations were not tailored to equity-deserving populations. Services primarily addressed opioid-related harms, while strategies focusing on the use of non-opioid substances were limited.

This scoping review highlights the diverse roles pharmacy staff play in delivering harm reduction services for PWUD. Positioned at the intersection of accessibility and healthcare delivery, pharmacy staff are ideally situated to expand access to equitable care. To fully harness this potential, future research and practice should embed harm reduction as a core philosophy, extending beyond individual interventions to support the creation of person-centred, non-judgmental and low-barrier services.

To determine the prevalence and factors associated with pain-related disabilities among First Nations people living off-reserve in Canada in 2017.

Secondary analysis of the 2017 Aboriginal Peoples Survey, a cross-sectional survey of individuals living in private dwellings throughout Canada.

First Nations people living off-reserve aged 15 years and older (n=9115; weighted n=482 066).

Pain-related disabilities, defined as pain-related activity limitations lasting ≥6 months.

Overall, 22.1% (95% CI 20.9% to 23.4%) of First Nations people living off-reserve reported pain-related disabilities. Prevalence was higher among females (26.1%; 95% CI (24.3% to 28.0%)), increased with age (34.3%; 95% CI (30.3% to 38.5%) among those 45 to 54 years) and was similar across geographic areas (ranging from 21.0%; 95% CI (18.3% to 23.9%) to 22.5%; 95% CI (20.8% to 24.2%)). Pain-related disabilities increased with the number of coexisting disabilities (96.2%; 95% CI (94.3% to 97.5%) among those with >3 disabilities) and was highest among those reporting physical disabilities (ranging from 88.2%; 95% CI (85.6% to 90.4%) for those with mobility disabilities to 91.0%; 95% CI (88.6% to 92.9%) for those with disability related to flexibility). Regression models suggested that individuals with unmet basic needs, housing dissatisfaction, unmet healthcare needs, a history of mental health consultations, part-time or no employment, chronic conditions, residential school attendance or a low sense of belonging were more likely to report pain-related disabilities.

Pain-related disabilities are common among First Nations people living off-reserve, and their aetiology may be multifactorial. Continued collaboration with Indigenous partners is required to contextualise findings and to inform culturally responsive clinical and rehabilitation strategies.

The Windrush Generation describes a group of individuals who migrated, primarily from the Caribbean to the UK between 1948 and 1971, many of whom are now entering older age. Now entering later life, many face ongoing health inequalities shaped by systemic racism and cultural marginalisation. Despite a growing number of ethnic minority residents in UK care homes, little is known about the lived experiences of Black African Caribbean people in these settings, particularly at the end of life.

This qualitative study explores the experiences of Black African Caribbean care home residents and their families, focusing on how race, identity and marginalisation shape care. Guided by the Silences Framework, semistructured interviews will be conducted with up to 16 participants across diverse care home settings. Data will be analysed thematically, with attention to under-represented narratives. A Patient and Public Involvement group of African Caribbean community members has codeveloped the study and will support analysis and dissemination to ensure cultural relevance.

Ethical approval has been secured (REC: 24/WM/0151; protocol number: RG_21087; IRAS project ID: 302629), and the study will follow rigorous consent and capacity procedures, including caregiver affirmation and UBACC assessment where needed. Given the sensitive, potentially distressing focus on racism, marginalisation and end-of-life experiences, the research will be conducted by an experienced clinician-researcher using a reflexive, ethically grounded approach that safeguards both participants and researcher. Interviews will be held in private, accessible settings with appropriate advocacy, safeguarding concerns will follow care home and national protocols, and all data will be securely stored, anonymised and managed under General Data Protection Regulation and university governance, with the University of Birmingham as sponsor and data controller.

A significant proportion of adults in England and Wales report experiencing childhood trauma, which is often associated with poor health and negative social outcomes including a significant increase in the risk of poor mental health outcomes in adulthood. This proposed scoping review adopts a broad definition of childhood trauma and applies both a salutogenic framework and ecological systems theory to explore how protective factors at five ecological levels can support mental well-being. The review will also examine how protective factors vary across different population groups and contexts.

The scoping review will follow the Joanna Briggs Institute (JBI) protocol for scoping reviews. The databases that will be searched are Embase, PubMed, Web of Science, PsycINFO, CINAHL and Medline. Studies will be included if they include protective factors and involve adults aged 18 and over who have experienced childhood trauma, whether self-identified, retrospectively self-reported or measured using a validated instrument. Studies will be excluded if they focus on participants under the age of 18.

All search results will be uploaded to Covidence, duplicates removed, and titles/abstracts screened by at least two reviewers based on inclusion criteria. Full texts of potentially relevant sources will be imported into EndNote 21. Reasons for exclusions will be documented and disagreements resolved through discussion or a third reviewer. The full process will be reported using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram. Data will be extracted by at least two reviewers using a tool developed by the team based on the JBI guidance. A best-fit framework analysis will be used, using a matrix developed by the researchers including the four salutogenic domains and the five levels of the ecological framework.

Formal ethical approval is not necessary for this scoping review as it does not involve the collection of primary data. The outcomes of this study will be disseminated through peer-reviewed journal articles, conference/seminar presentations, and developed into resources for stakeholders and collaborators.

Open Science Framework (DOI 10.17605/OSF.IO/CJRUY).

Palliative care supports the physical, emotional, social and spiritual needs of people with serious life-limiting illness. Future research must align with the priorities of people approaching the end of their lives, and those close to them.

To undertake a refresh of the James Lind Alliance Palliative and End of Life Care Priority Setting Partnership, to identify and prioritise areas for future research.

The James Lind Alliance process was applied, between May 2023 and February 2025. An initial online survey collected areas for future research from participants. These were synthesised into a long list of questions and shortlisted through a second online survey. Final ranking of priorities was achieved using an adapted Nominal Group Technique within a prioritisation workshop.

People living with serious life-limiting illnesses, carers, friends and family members supporting them, bereaved people, health and social care professionals, volunteers working in palliative and end-of-life care and members of the public.

1032 and 626 responses were received to survey 1 and 2, respectively. 20 people with lived and professional experience attended the prioritisation workshop. An updated list of 24 priorities for palliative and end-of-life care research was produced.

The priorities reflect the range of issues shaping end-of-life experiences and serve as a call to action for researchers and funders.

The objective of this study is to co-produce a care bundle for women with multiple long-term health conditions (MLTC) that could be pilot tested and implemented in UK maternity services.

Online co-production workshops each attended by 20–30 key interest holders.

United Kingdom, October 2023-February 2024.

Women with experience of pregnancy with MLTC, healthcare professionals and other interest holders involved in commissioning, planning and delivering care for pregnant women with MLTC.

This study followed a three-step process: (1) a consolidated list of key components of care for pregnant women with MLTC was created through secondary analysis of prior collected qualitative data; (2) the list of care components was explored during four co-production workshops; and (3) findings from (1) and (2) were synthesised to develop a maternity care bundle of 4–5 key care components for pregnant women with MLTC.

A maternity care bundle of five key care components for pregnant women with MLTC.

A list of 25 care components was refined to develop a proposed care bundle of five components. These were provisions of early and reliable medication advice and decision support; creation of a ‘goals of care summary’ accessible to women and the care team; provision of continuity of midwifery care throughout pregnancy and postnatal care; provision of a named care coordinator; and a formal postnatal handover of care from the multidisciplinary care team to the General Practitioner (GP) and secondary care team involving the woman.

This study coproduced an evidence-based care bundle for pregnant women with MLTC to enhance communication and ensure individualised care and support. Further collaborative work with women and professionals is required to refine, implement and evaluate its impact on outcomes.

Inadequate production of the essential stress hormone, cortisol, results in adrenal insufficiency (AI), which is associated with significant morbidity and mortality. The current standard diagnostic test for AI is the Short Synacthen Test (SST), but this is both invasive and resource-intensive, involving cannulation and blood sampling. A novel formulation, Nasacthin, has been developed in which the same Active Pharmaceutical Ingredient can be delivered intranasally, with the resultant glucocorticoid levels either measured in serum, or in saliva samples to render the test non-invasive, thus creating a potentially more cost-effective test. The Salivary Test of Adrenal Response to Liquid Intranasal Tetracosactide (STARLIT-3) study aims to determine the diagnostic utility of the test in patients with AI.

STARLIT-3 is a randomised 2-way crossover trial which aims to collect data from 32 AI patients allocated to receive both Synacthen and Nasacthin in a random order across two study visits. Paired blood and saliva samples will be collected from participants at baseline, and then at 30 and 60 min after drug administration. Glucocorticoid levels in study samples will be quantified with the aim to determine whether the Nasacthin test is able to correctly diagnose patients with AI by estimating the positive percent agreement with the standard SST using serum cortisol at 30 and 60 min. Data on any reported harms and on the acceptability, usability and tolerability of the Nasacthin test will also be collected.

The study and subsequent amendments have been reviewed and approved by South Central—Hampshire A Research Ethics Committee. Results will be published in peer-reviewed journals and presented at national and international conferences. Plans for dissemination of results to trial participants will be developed in collaboration with patient and public involvement and engagement groups.

ISRCTN26461337.

Poor sleep is common among patients with heart failure (HF) and is associated with adverse cardiovascular outcomes. The utility of actigraphy in sleep assessment, especially among older adults, remains underexplored. This study aimed to assess sleep health among older adults with HF using actigraphy and explore associations between sleep parameters and cardiac biomarkers, functional performance and quality of life (QoL).

A cross-sectional study.

The study was conducted at an outpatient HF clinic within a tertiary cardiology service in a National Health Service hospital in the UK between March and October 2023.

A total of 150 older adults aged ≥65 years with a diagnosis of HF were enrolled.

Participants were given a wrist-accelerometer to wear for 7 days. On Day 0, patients completed a 4-metre walk test (4MWT), handgrip strength test (HGST), Timed Up and Go test (TUGT), Barthel Index (BI), Kansas City Cardiomyopathy Questionnaire (KCCQ-12) and frailty assessment (Clinical Frailty Scale, CFS). Subsequently, they were fitted with an accelerometer, with the device configured to start recording the following day (Day 1). Sleep outcomes were calculated after a 7-day wear period and averaged across valid nights (minimum 3 nights of recording, noon-to-noon with ≥16 hours wear-time). Sleep parameters studied include average sleep efficiency, sleep period time window, sleep duration, sleep onset and wake up time, wake after sleep onset (WASO), sleep interruptions and Sleep Regularity Index (SRI). Inefficient sleep was defined as sleep efficiency

The primary outcome measure was sleep efficiency; all other sleep parameters were classified as secondary or exploratory outcomes.

Accelerometry data from 145 participants were analysed; 42% had inefficient sleep based on average sleep efficiency across valid nights. These patients had significantly higher plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels (p=0.044). No statistically significant difference was noted in 4MWT, HGST, TUGT, BI, KCCQ-12 and CFS between patients with sleep efficiency

Older adults with HF who had inefficient sleep had significantly higher NT-proBNP levels. Lower sleep efficiency was associated with higher functional dependence and frailty. Sleep irregularity was linked to HF symptom load, frailty, functional performance and QoL, while sleep fragmentation was associated with impaired gait speed.

To examine how patients and family members decide whether to accept a highly invasive intervention (aortic valve replacement (AVR)) when their condition (aortic stenosis (AS)) is asymptomatic and its course uncertain.

Nested, longitudinal, qualitative substudy of an ongoing randomised controlled trial (RCT) (NCT04204915) testing early intervention (EI) versus watchful waiting (WW) in patients with asymptomatic severe AS.

Six select UK sites of the RCT.

Select participants of the RCT, their next-of-kin and some who declined RCT participation.

73 interviews were conducted, with 41 participants.

Few knew much about AS before diagnosis. Uncertainty and the need for reliable information regarding symptoms and progress was a significant problem.

While some expressed unease at a major intervention for an asymptomatic condition, there were no outright objections to the idea.

Those who declined participation in the RCT did so for personal reasons, for example, their home circumstances did not permit the required period of recovery or they felt too old to risk intervention.

Reasons for accepting early intervention included the belief that the condition was serious and likely to deteriorate, and so better to have the intervention before such deterioration, as well as avoiding long waiting lists. Trusting clinicians’ judgement played a part in some decisions. Patients also wanted choice in the type of intervention received.

The longitudinal interviews (n=32) showed satisfaction in the early intervention group despite some problems in the the early recovery phase, especially for those undergoing surgical AVR.

Where evidence supports major intervention for an asymptomatic condition, patients are likely to accept the offer, although personal circumstances play an important role in decision-making. Where a condition is not well known to the public, such as AS, patients rely on clinicians and other resources to help decide. Liaison with patient groups in developing shared decision-making resources may help with complex decisions.

NCT04204915

Earlier heart failure (HF) diagnosis in the community could allow timely treatment initiation and prevent unnecessary hospitalisation, but identifying those at risk remains challenging. We aimed to summarise the performance of risk prediction models for a new diagnosis of HF.

Systematic review of multivariable incident HF risk prediction models in the community setting.

MEDLINE and Embase were searched from inception to 9 November 2023.

Observational, community-based studies reporting prediction model performance for incident HF within a 5-year time horizon.

Two reviewers independently screened and extracted data. Where possible, C-statistics (or area under the receiver operating characteristic curve) with 95% CIs were extracted. Risk of bias was assessed using the Prediction model Risk Of Bias ASsessment Tool and certainty of evidence by the Grading of Recommendations, Assessment, Development and Evaluation.

Eighteen studies described 45 prediction models, 27 used traditional statistical methods and 18 applied machine learning. Most (39/45) demonstrated acceptable discrimination (C-statistic >0.70). Overall, C-statistics ranged from 0.675 to 0.954, typically with narrow 95% CIs. External validation was performed for 31 models, but only two—the modified PCP-HF models for white men and women—were validated in three cohorts, the highest among all the models. Exploratory random-effects meta-analysis of these models showed pooled C-statistics of 0.82 (95% CI 0.82 to 0.82) for men and 0.85 (95% CI 0.82 to 0.88) for women, indicating excellent discrimination but more heterogenous performance among women. Model performance was at high risk of bias due to unreported or inappropriate handling of missing data, and the certainty of evidence was very low.

Risk prediction models for a new diagnosis of HF in the community performed well, but were at high risk of bias and lacked external validation. Future model development requires appropriate data sources, robust handling of missing data, external validation and clinical testing to assess their impact on earlier HF diagnosis and outcomes.

CRD42022347120.

Vaccines are our best defence against infectious diseases, yet uptake of childhood immunisation programmes has consistently declined in the UK, with growing concerns around socioeconomic inequalities. Liverpool, in particular, demonstrated some of the lowest uptake rates in England since 2019. In response, the Health Equity Liverpool Project (HELP) implemented a hyper-localised community-led initiative between September 2023 and June 2024 to tackle vaccine hesitancy. Activities included outreach events and school-based engagement across nine sites within Liverpool. Despite promising qualitative evidence, the intervention’s impact on childhood vaccine uptake has not yet been quantified. We aim to evaluate the population level impact of the HELP intervention on the uptake of five childhood vaccines (first and second doses of the measles, mumps and rubella vaccine (MMR1, MMR2), 6-in-1 vaccine (diphtheria, tetanus, pertussis, polio, haemophilus influenzae type b and hepatitis B), pneumococcal conjugate vaccine booster dose (PCV) and rotavirus vaccine) using synthetic control methods.

We will analyse publicly available quarterly vaccine uptake data (between April 2019 and March 2025) from the Cover of Vaccination Evaluated Rapidly programme for general practices (GPs) in England. The intervention group will be defined as practices located within a 1 km radius of the intervention sites. A synthetic control group will be constructed using non-intervention GPs matched on pre-intervention vaccine uptake, and linked demographic, socioeconomic and healthcare capacity covariates. Primary outcomes are the uptake of MMR1 and MMR2 vaccines. Secondary outcomes include the uptake of 6-in-1, PCV and rotavirus vaccines. Average treatment effects will be estimated as the post-intervention difference in uptake between intervention and synthetic control groups. Sensitivity analyses will examine spillover effects, alternative spatial definitions of exposure, the biasing effect of concurrent interventions and the feasibility of analysis at small area neighbourhood level.

This study will be conducted as part of the ReCITE project, which has received ethical approval from the Liverpool School of Tropical Medicine Research Ethics Committee (Reference: 24–018) and is funded by the UK Arts and Humanities Research Council (Project Number: AH/Z505341/1). Findings will be shared with the project funder and submitted for publication in a peer-reviewed journal.

Outward medical tourism is when people seek medical treatment in a different country to the one they live in. We aimed to identify all studies that describe the impact on the UK National Health Service (NHS) of patients who require treatment due to outward medical tourism for elective surgery and report on complications, costs and benefits.

A rapid literature review. Medical and grey literature databases were searched, limited to literature published between 2012 and 2024.

Studies published in the English language, conducted in any NHS setting, describing complications, costs or benefits due to outward medical tourism for elective surgery were included. We excluded emergency and semi-urgent surgery, dental and transplant surgery, cancer treatment and fertility treatment.

Primary outcomes were costs and savings to the NHS. Secondary outcomes were type and frequency, demographics, procedures, complications, treatment, follow-up care and use of NHS resources. Results were summarised narratively. Study quality was assessed using JBI critical appraisal tools and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used for certainty of evidence for costs.

Some 35 case series and case reports and two surveys of NHS plastic surgeons were identified. Case studies described 655 patients treated in specific NHS hospitals between 2006 and 2024 for postoperative complications due to metabolic/bariatric surgery (n=385), cosmetic (n=265) and ophthalmic (n=5) surgery tourism. No cases relating to other surgical specialities were identified in the literature. Most patients were women (90%), with an average age of 38 (range 14–69) years. The most common destination for surgery was Turkey (61%). Complications were not well described for metabolic/bariatric surgery tourism; but for cosmetic surgery tourism, infection and wound dehiscence were most commonly reported. There was evidence that some patients needed complex treatment involving long hospital stays and multiple surgical interventions. Very low certainty evidence indicated that costs to the NHS from outward medical tourism for elective surgery ranged from £1058 to £19 549 per patient in 2024 prices. We found no studies that reported on the benefits of outward medical tourism.

A systematic approach is needed to collecting information on the number of people who travel abroad for elective surgery and the frequency and impact on the UK NHS of treating complications. Without these data, we cannot fully understand the risk of seeking surgery abroad.