Applying realist thinking to urgent questions.

Recruitment and retention are once again central to UK defence policy, and family life — mobility, separation, housing, service culture — shapes whether personnel stay. The evidence on what actually supports families is fragmented across policy domains and rarely asks what works, for whom and why. This first-author review — a collaboration with Dr Gabriela Misca and the Health Services Management Centre — is, to our knowledge, the first use of a realist approach in military research.

Using APRIL, we synthesised 64 peer-reviewed and grey literature sources across five policy domains — housing, health, education, employment and social care — into 37 programme theories, sense-checked with partners of serving personnel and with Ministry of Defence family and people policy teams.

The mechanisms that emerged are trust, fairness, identity and cognitive burden. Mobility becomes damaging when combined with fragmented systems and poor records transfer; military culture builds resilience but also stigma and self-censorship around help-seeking; poor accommodation maintenance undermines the perceived "offer"; disrupted partner employment triggers resentment or entrapment. Vulnerabilities concentrate among families with additional care needs, dispersed households living away from bases, and non-traditional family structures.

The main contribution is a military career lifecourse framework — the Four Rs: Recruitment, Retention, Readiness and Reintegration — locating where risks cluster and where support has to stay coherent across phases. A follow-up review extending these theories against international evidence, across NATO European and Five Eyes countries, is now under way.

I am a co-investigator on EPIC-PC (Equitable Palliative care In the Community through Primary Care), a £1m NIHR-funded realist study led by Dr Sarah Mitchell at the University of Leeds. Access to good palliative and end-of-life care in the community is unevenly distributed, and the study is designing an integrated neighbourhood team approach to delivering it — using realist methods to establish what would make that approach work, for whom, and in what circumstances. Earlier work in the programme used realist stakeholder workshops to examine how primary and palliative care services can be integrated to improve equality and equity at the end of life.

A recurring part of my role is bringing realist and evidence synthesis expertise to other people's questions — as methodologist, co-author or supervisor. Recent work includes an initial programme theory for how and why on-the-day surgery cancellations happen, built with a PhD student I co-supervise; a systematic review of the acceptability and use of clinical decision support tools in maternity settings; a call to centre frontline staff voices in health workforce public involvement; and work on reducing inequalities in respiratory health outcomes in the UK. I am also co-authoring a chapter on assessing relevance, richness and rigour for the Routledge volume Realist Synthesis: Principles and Practice.

Further work in progress looks at delay in cancer diagnosis in low- and middle-income countries, and at how quickly new in vitro diagnostics reach patients in the UK.