Yes / Healthcare system resilience is a conceptual approach that seeks to explore how health services adapt and respond to variability in demand and resources. As has been witnessed since the beginning of the COVID-19 pandemic, healthcare services have undergone many reconfigurations. One understudied aspect of how the 'system' is able to adapt and respond is the contribution of key stakeholders-patients and families, and in the context of the pandemic, the general public as a whole. This study aimed to understand what people were doing during the first wave of the pandemic to protect the safety of their health, and the health of others from COVID-19, and the resilience of the healthcare system. Social media (Twitter) was used as a method of recruitment due to its ability for social reach. Twenty-one participants took part in 57 semistructured interviews over three time points from June to September 2020. The included an initial interview and invitation to two follow-up interviews after 3 and 6 weeks. Interviews were conducted virtually using Zoom-an encrypted secure video conferencing software. A reflexive thematic analysis approach to analysis was used. Three themes, each with its own subthemes were identified in the analysis: (1) A 'new safety normal'; (2) Existing vulnerabilities and heightened safety and (3) Are we all in this together? This study found that the public had a role in supporting the resilience of healthcare services and systems during the first wave of the pandemic by adapting their behaviour to protect themselves and others, and to avoid overwhelming the National Health Service. People who had existing vulnerabilities were more likely to experience safety gaps in their care, and be required to step in to support their safety, despite it being more difficult for them to do so. It may be that the most vulnerable were previously required to do this extra work to support the safety of their care and that the pandemic has just illuminated this issue. Future research should explore existing vulnerabilities and inequalities, and the heightened safety consequences created by the pandemic. The National Institute for Health Research (NIHR) Yorkshire and Humber Patient Safety Translational Research Centre (NIHR Yorkshire and Humber PSTRC), Patient and Public Involvement and Engagement Research Fellow and NIHR Yorkshire and Humber PSTRC Patient Involvement in Patient Safety theme lay leader are involved in the preparation of a lay version of the findings within this manuscript.

Yes / Background The first UK wave of the Covid-19 pandemic in 2020 placed unprecedented stress on community pharmacy. Various policies and initiatives were announced during this period to support community pharmacy to continue to perform in a manner that prioritised patient safety. However, little is understood about how these policies and initiatives were implemented by staff working in community pharmacy, and the system adaptions and responses that were initiated to maintain patient safety. Objective The study aimed to investigate how staff working in UK community pharmacy during the first waves of the COVID-19 pandemic in 2020 responded and adapted to system stressors to maintain patient safety. Methods We adopted a qualitative interview approach, underpinned by Resilient Healthcare theory, with interview data collected between July 2020 and January 2021. Data were synthesised and analysed using Framework Analysis. Results 23 community pharmacy staff from England and Scotland were interviewed. We identified five themes supported by between two and six sub-themes: 1. Covid-19, an impending threat to the system. 2. Patient safety stressors during the first waves of Covid-19. 3. Altering the system, responding to system stressors. 4. Monitoring and adjusting. 5. Learning for the future. Conclusion Privileging the accounts of community pharmacy staff working on the frontline during the pandemic illuminated how responses and adaptions were developed and deployed, how continual monitoring occurred, and the factors that supported or hindered system resilience. The key learning derived from this study can serve to shorten the gap between ‘work as imagined’ and ‘work as done’, and in doing so, support the future resilience performance of community pharmacy during future outbreaks of Covid-19 or similar events. / This research was funded by the National Institute for Health Research (NIHR) Yorkshire and Humber Patient Safety Translational Research Centre (NIHR Yorkshire and Humber PSTRC).