Impact case study database

The Brunel team’s research made a significant and often rapid impact on NICE guidelines on PA, and through them an impact on various other policies and implementation efforts to promote PA (Impact 1). Anokye et al’s research played a key role in the production of a novel policy, the NICE Return on Investment (ROI) Tool for PA, that facilitated creation of an improved evidence-base for local health investment decisions (Impact 2). The research stream’s increasing international reach also informs policies and debates, sometimes during collaborative research (Impact 3). The beneficiaries of Brunel’s research included policymakers and professionals who had a stronger evidence base for making decisions to invest in, promote and implement PA interventions. This should result in increased PA, and thus, eventually, improved population health, as noted above.

Diverse actions by the team encouraged impact, including through presentations and the media. While the pathways to impact were sometimes direct to relevant audiences, they were also complex and multi-layered, not always following traditional patterns. The DH, as the main policymaking user of cost-effectiveness analysis, was engaged from the outset. It supported Brunel’s programme of research explicitly because of its potential usefulness in creating a stronger evidence-base for a major policy area – the pattern is now being repeated in the team’s research in Ghana. The research was often conducted for, and sometimes with, DH bodies such as NICE. On occasions, as outlined in Table 1, the co-produced research was incorporated into policy before it was published in journal articles. These NICE policies sometimes had increasing reach as they, in turn, informed further policy documents from NICE and others, who’s networking also encouraged professionals such as physiotherapists to implement the Brunel-informed NICE guidance.

Impact 1: Contributing to NICE guidelines on Physical Activity (PA) and through them informing further policies, implementation and debates

While the original version of NICE PH44 was published in May 2013, it, and then a later refreshed version, made a significant impact throughout the relevant period since August 2013, not only directly, but also through many subsequent policies and implementation activities based on it. Following a regular guideline Surveillance check in 2016, NICE declared that the 2013 version of PH44 should be re-issued, but be refreshed with additional material (see below). The version included as Evidence (Ev)1, is therefore a later version which retains the 2013 wording showing that the Brunel team provided key parts of the evidence on which it was based: “The review of economic evaluations and the review of economic barriers and facilitators... and the economic modelling ...were carried out by Brunel University London/Health Economics Research Group (HERG). The principal authors were Anokye N, Jones T and Fox-Rushby J.” (p.58).

The Brunel reviews behind PH44 cited papers R1 and R2, and, as noted, the economic modelling was later also published as R4. Informed by this, PH44 stated the provision of brief advice to promote PA in primary care was cost effective and the guidance was relevant for the general public, commissioners and “exercise professionals, GPs, health trainers, health visitors, mental health professionals, midwives, pharmacists, practice nurses and physiotherapists” (p.6). This refreshed version of PH44 also stated: “This guideline is the basis of QS84” (p.5). That 2015 NICE Quality Standard supported action to encourage PA when people “ are in contact with the NHS” (p.5) [Ev2]. It listed the organisations that “agreed to work with NICE to ensure that those commissioning or providing services are made aware of and encouraged to use the quality standard” (p.44), including the Chartered Society of Physiotherapy and the Royal College of GPs.

NICE promoted PH44 through its website, and drew on it to inform a range of further NICE policies and actions. It drew on PH44 as a key source for its web-based interactive PA pathways which are regularly updated flowcharts of recommendations for boosting PA in diverse circumstances. For example, PH44 was one of only two sources listed for the pathway on Training for people involved in encouraging others to be physically active (NICE, updated 2019, p.11) [Ev3]. Additionally, NICE promoted use of PH44 in the Shared learning database of its PA website by featuring a 2018 plan for implementing it developed by physiotherapists at Doncaster and Bassetlaw NHS Trust [Ev4].

In 2014, NICE PH54 provided guidance on ERSs [Ev5], which as Table 1 shows was the PA intervention for which Brunel’s economic modelling started. As stated on p.45/6, PH 54 was based on three key sources of evidence. The first consisted of two reviews - one by the team including Anokye was subsequently published as R5, but was made available for NICE prior to publication. That review cited R1 and Anokye et al’s previous reviews for NICE. The second and overlapping source was “economic modelling” – this was the economic modelling (conducted by Anokye) contained in publication R5 that indicted ERSs were unlikely to achieve the cost-effectiveness usually required for an intervention to be recommended by NICE. PH54 drew on the economic evaluation to inform the main recommendations that primary care practitioners should only refer people to ERSs in limited circumstances. PH54 became a source for some NICE PA pathways.

PH54 was also cited along with PH44 as a source in policy documents from diverse other national and local bodies. These included Public Health England (PHE) in their 2017 NHS Health Check: Best Practice Guidance (p.35) [Ev6] and, with calls for implementation of both the guidelines, in the 2015 Hertfordshire Physical Activity and Sport Framework created by Hertfordshire County Council, its 10 District Councils and various bodies in a multi-agency approach (p.5,49) [Ev7].

Findings from the pedometer trial [R6] were rapidly examined by NICE to see if policy updating was required. The report, 2019 Exceptional Surveillance of physical activity: walking and cycling (NICE guideline PH41), concluded that this major trial reinforced rather than conflicted with current advice (p.3) [Ev8]; therefore, the impact here was to strengthen rather than change existing policy.

Impact 2: Helping NICE produce their Physical Activity Return on Investment (ROI) tool

Brunel’s research was central to the development of the NICE PA ROI tool. This was a new type of policy approach. The tool’s software (and accompanying Technical Report) were available and promoted on the NICE website. They could be used by commissioners of local services to estimate the cost-effectiveness of different packages of PA interventions given the known population and current PA levels in their area. The significant role of Brunel’s research was explained in the tool’s Technical Report, dated May 2014 and produced by Matrix. This repeatedly described how the tool drew on the research, in particular the Markov model (as described in publications shown on Table 1, including the eventual R4). One example stated: “The economic model used in this tool is based on the Markov model developed by Anokye et al (2012) for the NICE Public Health Intervention Guidance on Physical Activity.” (p.9) [Ev9].

The significance of Brunel’s research on the economic assessment of interventions to promote PA was also highlighted in June 2014 in NICE’s press release launching the ROI tool for PA [Ev10]. It highlighted the direct policy impact of Brunel’s research in creating NICE tools, and through that further impacts on local policymakers as the tools “ help councils predict the health benefits for communities - and the money they could save – when they invest in activity...The NICE return on investment tools have been developed in collaboration with Brunel University, LeLan Solutions and Matrix Knowledge.” The press release also quoted PHE’s Dr Varney: “The tool will be invaluable to local authorities who wish to commission cost-effective services and interventions that help to get more people more active more often” [Ev10]. NICE, other bodies and local authorities all used or promoted the tool, for example those supporting Hertfordshire’s PA framework noted above (p.19) [Ev7]. In a 2014 policy initiative, Everybody Active, Every Day, PHE stated it had: “developed a summary of the tools (including the NICE return-on-investment tool)³⁶ that make the case for investment, and of the guidance on what local authorities and commissioners can do” (p.8) [Ev11].

Impact 3: Informing policies and debates internationally to promote Physical Activity

A 2016 position statement by the Canadian Academy of Sport and Exercise Medicine cited R4 as one of only two references for a prominent opening claim highlighting “the cost-effectiveness of exercise prescription in primary care” (second para), however briefly done [Ev12]. This position statement, published in two leading journals, has been endorsed by ten sport medicine societies, including: the Australasian College of Sports and Exercise Physicians, American Medical Society for Sports Medicine, European College of Sport & Exercise Physicians, South African Sports Medicine Association, and Swedish Society of Exercise and Sports Medicine.

Brunel’s ongoing PA research has improved the quality of debate around boosting PA. The research under way in Ghana is under the auspices of the Office of the President whose letter to Anokye corroborating the emerging impact stated it is being: “conducted to inform Ghanaian health policy to reduce obesity. I believe that the team built on the Brunel expertise in reviewing the evidence, especially on physical activity to outline key areas that needed attention. ...Through the activities of research, stakeholder engagement and consensus building I believe your work is already informing the policy debate in Ghana about tackling obesity.” [Ev13]