Impact case study database

Changed clinician practice in pain treatment nationally and internationally leading to improved children’s quality of life

Between August 2013 and December 2020 BCPR research on psychological mechanisms [3.1-3.3] has been applied to change how clinicians manage children’s pain [5.1-5.5], by shifting the focus to cognitive-emotion processes and incorporating measurement into care pathways. As noted by the Lead of the Paediatric Pain Research Group and the Consultant Lead of Paediatric Pain Service at Great Ormond Street Hospital [5.1] the Centre’s research has “ ensured that psychological constructs and mechanisms such as pain catastrophising, approach-avoidance and attention bias, are [understood by] a range of practitioners involved in paediatric pain management” and “ led to major improvements in clinical care” [5.1]. Rather than reduce painful sensations, clinicians now target fear-cognitions in treatment. This was acknowledged by the Managing Director of Paediatric Pain at Stanford University [5.2] who said that “ the recognition and codification of Fear of Pain by Bath [has led] to policy changes in formally incorporating measurement into the standard clinical pathways of care of several paediatric pain clinics” including Los Angeles Children’s Hospital [5.2]. In turn, this has “ improved the lives and health of children in many clinical practices…and continues to inform clinicians regarding the use of…[opioids] in infants and children” [5.2].

Provided new models of healthcare management of childhood pain

Since August 2013 BCPR’s treatment approach for childhood pain [3.4] has led to the development of new services and changes in care models [5.2-5.3]. The Head of Service for Paediatric and Adolescent Chronic Pain at Evelina Hospital, London [5.3] said the BCPR have “ influenced the standards of care of many services, including mine. The assessment or outcome tools have also helped commissioners and colleagues across our networks understand the demands of assessment and management”. The “networks” refer to clinical services that the Head of Service set up including the service in London established in 2014 (population of 8,000,000), which received 200-300 referrals per annum. He used the Centre’s research “ as a reference for business cases and persuading management teams and commissioners of the rationale for our model of care” [5.3].

Changed how pain treatments are appraised leading to increased effectiveness of treatments

Since August 2013, BCPR assessment tools [3.2, 3.3] have continued to be used to help improve the lives of children in pain and their families in the UK, USA, Australia and New Zealand [5.2-5.4]. Clinical healthcare practitioners used them to assess the effectiveness of their treatment programmes for children’s pain management, leading to better treatment regimes and, as a result, improvements in children’s quality of life [5.2-5.3]. One of the best examples can be found in the adoption of BCPR measures within the electronic Persistent Pain Outcomes Collaboration (ePPOC) system. ePPOC aims to improve the quality of care and outcomes for people with chronic pain in Australia and New Zealand. Over 90 adult and paediatric pain management services currently participate in ePPOC. Since 2014 BCPR scales are one of the standard measurement tools used in all hospital-based paediatric pain centres. The Director of ePPOC [5.4] describes the Centre’s work as “ critical” to ePPOC, using the BAPQ and BAP-PIQ to “ produce information on the effectiveness of pain management interventions; develop an Australasian benchmarking system to improve pain management outcomes; [and] provide comparative data to pain management services using the benchmarks developed”. In 2020 the BCPR assessment tools [3.2, 3.3] have been independently verified as having “ utility to audit pain clinic activity and potentially a use in demonstrating beneficial outcomes to commissioners” [5.6, p. 7].

Influenced policy guidance on treating children’s pain

The BCPR research on treatment efficacy [3.5-3.6] has informed clinical guidance and policy. Nationally, this includes informing recommendations in the Royal College of Anaesthetists Faculty of Pain Medicine’s Core Standards for Pain Management Services in the UK (2015) [5.7, p. 117-118] and in the Scottish Government’s National Clinical Guidelines on the Management of Chronic Pain in Children and Young People (2018) [5.8, p. 16-17, 32, 67]. Internationally, the Director of Pain Medicine at the University of Washington’s School of Medicine [5.5] used the Centre’s research to inform guidance given to US agencies (Food and Drugs Administration), expert testimony to regulators, and contributed to practice guidelines. He said “ A central issue is to provide evidence for when opioids may be useful (or not) in treating recurrent or chronic pain in younger patients. Here again, the aforementioned Cochrane reviews have proven invaluable in these deliberations and the policies and guidelines that resulted”. In 2020 the WHO published global guidance recommendations on paediatric pain treatment [5.9, p. 32], which drew on BCPR research [3.6]. BCPR also acted as the evidence support team for this document.

Overview

The research proved MBCT-t is effective and acceptable. Since dissemination in 2017, it changed clinical practice, national and international clinical guidelines, advice offered globally and professional tinnitus training. Multiple centres since report effectiveness and long-term benefits, describing how MBCT-t makes “ an incredible difference to… patients” [G] and positive patient feedback describing it as “wonderful” [D] . Public engagement raised awareness of mindfulness for tinnitus. At least 5,000 UK tinnitus patients have already benefitted from mindfulness treatments, largely because of the research . Considering the prevalence and costs of persistent tinnitus, and lack of evidence for other treatments, the research has led to a significant reduction in the economic and health burden of tinnitus upon individuals, healthcare services and society.

Adoption of mindfulness for tinnitus in UK clinical practice

The British Tinnitus Association (BTA), a world-leading tinnitus charity, supporting a million people globally each year, reports significant clinical changes due to the research. In 2020 they stated that “ because of research evidence… published by Dr Marks” at least 49 UK audiology services now integrate “mindfulness… into their treatments for tinnitus”. Clinical testimonies indicate “ 5,000 patients have benefitted from mindfulness in just the past 2–3 years, from a baseline of almost zero prior to dissemination of Dr Marks’ research”. This estimate of 5,000 is based only upon “ testimonies from five [5] services” so “ the total number of patients benefitting from mindfulness in the past few years is… likely to be far higher” [C].

The Clinical Director of a large UK audiology hospital (Royal National ENT and Dental Hospital - RNENTDH) also reported large changes to clinical practice due to the research. From a baseline of 10 patients, mindfulness interventions now reach 865 patients annually (3,000 to date). Mindfulness has become “embedded within daily clinical practice… the benefits are likely to continue to have a positive impact on… thousands of patients” [D].

Figure 1: Change in clinical practice in 5 UK audiology services: Number of patients ever receiving mindfulness before research was disseminated (pre-2017) compared to number who have received mindfulness since research was disseminated (post-2017) [C]

The research directly influenced clinical practice in multiple services [C,D,E,F,G]. Mindfulness therapies were rarely offered to tinnitus patients prior to 2017. Publication of the research supported changes in service provision, and mindfulness is now offered to hundreds of tinnitus patients annually (see Figure 1). Reports from the BTA, RNENTDH and other testimonial letters directly attribute these changes to Dr Marks’ research [C,D,E,F,G]. For example, an Advanced Audiologist at St George’s Hospital testifies that Dr Marks’ research “ significantly change(d) the way that we operate our clinical services for tinnitus” [G].

The research also underpins recommendations in the 2018 Tinnitus Decision Aid [I], a new clinical tool that now promotes mindfulness and other psychological treatments to patients and audiology clinicians. The BTA states this is an “ important development in the field’ [C].

Integrating MBCT into International Policy and Advice

The first NICE guidelines for tinnitus management were published in 2020, stating that “ MBCT should be considered” [Ai, 1.5.4] within a stepped-care approach. The research [1] clearly influenced this conclusion, being the most robust evidence for mindfulness, rated as “critical” importance and “high to moderate” quality (Aii, pp232-234, table 58) compared with the three other mindfulness trials, rated as “very low” quality (Aii, pp.234-236 tables 59,60). Health economic modelling based on [1] supports MBCT-t as the least expensive option within a stepped-care model [Aii, p.67], demonstrating the significant economic benefits of MBCT-t, as it reduces the burdens of tinnitus in the most cost-effective way. The first European tinnitus guideline (2019) [B] for pan-European healthcare professionals recommends that “ information that should be given to patients” includes mindfulness since the underpinning research [1] indicates it is “ feasible as a treatment for tinnitus” [B p.S33].

In 2018 the BTA published new advice on mindfulness for tinnitus, based on the research [1,2], in collaboration with Dr Marks [H]. This advice has reached 1,000s of people (100s per annum) via UK Tinnitus Information Days, and over 9,000 via their website (50% internationally) last year, with numbers increasing over time (Figure 2) [C].

Figure 2: BTA website views of mindfulness advice based on the underpinning research [C]

Improved teaching and training

The research changed professional audiology training. Since 2015, Dr Marks has offered annual masterclasses in MBCT-t at the UCL Ear Institute [C], at BTA training days, and has trained 13 clinicians at the RNENTDH in MBCT-t [D]. Since 2017, a Senior Lecturer in Audiology at the University of Manchester used the research to develop audiology training to include mindfulness [C].

Benefitting patients and reducing re-referral rates

By having a “ direct impact on the clinical activity of multiple audiology services across the UK” the research has benefitted patients via “ positive experiences, high satisfaction, good outcomes and low re-referral rates”, a substantial improvement upon the “low satisfaction and… high re-referral rates (associated) with more traditional treatments” [C]. In 2019, St George’s Hospital reported that 2 years of delivering MBCT-t had led to reduced tinnitus severity, high patient satisfaction (rated 4.6/5), a re-referral rate of just 1% is “ far lower than those receiving standard care” [G] and associated cost savings. Feedback from MBCT-t recipients is positive, with MBCT described as “ life-changing”, “excellent”, “magnificent”, and “the best national health treatment I have had” [D].

Public engagement

Since 2017, growing media coverage has increased awareness of and engagement in mindfulness for tinnitus by patients, clinicians [C] and services [D]. This includes reports in high-profile media outlets ( The Observer, BBC Radio Bristol (2017), *The Times (*2018), Good Houskeeping Magazine (2019), NHK Japan TV (2020) [D]. Furthermore, in 2018 the research [1] won the prestigious BTA Shapiro Prize and a finalist position in the Bath and Bristol Healthcare Awards.

Legal changes based on Dr Walker’s research are saving around 7 lives each year in Australia, preventing around 260 more serious injuries, and saving the Australian economy more than AUD34,000,000 annually due to lives saved.

Dr Walker’s research demonstrated empirically that the variance in safety during overtaking manoeuvres attributable to the rider’s appearance or actions was far lower than the variance in safety associated with non-cyclist variables such as inter-driver differences and situational factors. In other words, Walker’s work demonstrated for the first time that how a bicyclist looks or acts could only ever be a minor factor in determining their safety, and the behaviour of the overtaking driver, and their interaction with the physical environment, is far more important. As such, the research demonstrated that, above all, it is driver behaviour that needs to change to achieve greater safety. This insight directly informed policy changes, and also fed into public understanding of this road safety topic.

How the Impact occurred: The Amy Gillett Foundation

Walker’s research has proved particularly important in Australia, which has taken the lead in legislating for bicyclist safety during overtakes. Australia had identified collisions during overtaking as a critical problem: at the time this research began in 2006, central government in Australia was reporting “the most common type of crash in which cyclists were fatally injured was the cyclist being hit from behind by a motor vehicle travelling in the same lane in the same direction” [E, p.2]. In 2008, Dr Walker’s research was taken up by the Amy Gillett Foundation, a leading cycling safety organisation in Australia, driven by a core mission to reduce the death and injury of cyclists. The Amy Gillett Foundation describe Dr Walker’s findings as “pivotal” [A, B], explicitly listing it as the starting point for their A Metre Matters campaign to address overtaking collisions for bicyclists [A, B]. “Dr Walker’s finding about the variation in lateral clearance distance was the specific feature of the paper that provided insights to the campaign”, they write in their evidence letter [B]. A member of the Foundation used the methods and findings from Walker’s study as the basis for additional research in the Australian context that was published in 2011, and the combined scientific data [A,B] allowed the Foundation to argue to government that it was specifically driver behaviour during overtakes that needed regulation if bicyclist safety was to be improved. In 2009 The Foundation’s A Metre Matters campaign was launched by the CEO of the Amy Gillett Foundation, with the Australian Minister for Infrastructure and Transport, Anthony Albanese. Between 2010 and 2012 an education campaign was rolled out across Australia including billboards and advertisements. However, the campaign aimed to go beyond education, to instigate legal changes.

Influencing legal changes in Australia

As detailed on the Foundation’s website [A], between 2014 and 2020 all of Australia’s 8 states and territories trialled, and then adopted, laws specifying minimum passing clearances when overtaking a bicyclist, and in each case this was directly in response to the charity’s lobbying [A]. The Amy Gillett Foundation lists that one of its missions is to continue to “promote actions to make cycling safer in Australia, including the A metre matters laws across Australia, to make sure drivers pass cyclists safely” [G]. The population of Australia potentially affected by this law can be estimated from the overall population of 25,000,000. Based on data from 2019, for cyclists aged 50 or over (the population with the lowest figures, thereby providing the most conservative estimate), at least 6% of Australians cycle on a weekly basis, 10% monthly and 17% yearly. This equates to at least 1,500,000 people who cycle weekly, 2,500,000 monthly and 4,250,000 yearly. On average 31.7% of cycling was for transport purposes, suggesting at least this proportion of cyclists are road-users. Using these extremely conservative figures, this would indicate that across the whole population, for the lifetime of legal changes that can be traced back to Dr Walker’s research, the changes protect approximately 475,000 people weekly, 792,500 monthly and 1,347,250 yearly [H, p.9, 11]. In particular, considering the number of commuters, figures from 2016 indicate that there were a combined total of 75,807 commuters in Melbourne, Sydney, Brisbane, Perth, Adelaide, Darwin and Hobart, which suggests that there are at least this many commuters across Australia protected by the new laws [I].

Saving lives, reducing injury rate and benefitting the economy through the A Metre Matters law

In each state or territory, the new overtaking laws were first introduced from 2014 onwards on a trial basis and later made permanent once official trials demonstrated they were effective at changing behaviour, and thereby improving road safety (for example see [C] for the New South Wales evaluation of their passing law trial). As the states would not introduce permanent legal changes until convinced they would work to improve safety, these government trials provide powerful evidence for the efficacy and impact of these laws that were underpinned by Dr Walker’s research. The government evaluation from New South Wales estimated, after analysing 5,979 behavioural observations, as well as police records, that minimum passing distances led to a 15% reduction in casualty crashes [C, p.7]. In the years preceding the laws, there was an average of 48 cyclist deaths per year in Australia [E, p.5]. The New South Wales data thereby allow us defensibly to estimate the laws derived from Dr Walker’s research are saving around 7 lives each year across the country. We can also estimate that these laws are preventing approximately 260 more serious injuries [D – Note that Australia’s public data only report deaths, not injuries, so this value is estimated using the UK death:serious-injury ratio for cyclists, which should be comparable]. Australia’s statistical value of life is AUD4,900,000 [F], meaning that even in the crudest monetary terms, and only counting the deaths, the safety improvements arising from this law are worth more than AUD34,000,000 to the Australian economy each year.

Maras’ research has shaped local and national changes in training, policy and practice which has improved the experiences and outcomes of autistic people in the Criminal Justice System (CJS) in the UK.

Informing best practice guidance and shaping strategy at the National Autistic Society

The National Autistic Society commented that “ Dr Maras’ research has provided a crucial evidence-base for best practice by criminal justice system professionals when working with autistic people” [A].

Maras’ findings regarding interactions between autistic people and police [1], diagnosis disclosure [2], and effective interviewing techniques for autistic individuals [4-6] are directly translated into comprehensive best practice guidance in the National Autistic Society (NAS) Guidance for Criminal Justice Professionals, revised in 2017 [Ci] and 2020 [Cii]. The Guidance describes in detail how evidence-based techniques developed by Maras (including WAFA, sketching and diagram-assisted questioning [Cii, pp. 39-43]) can be applied for autistic interviewees [C]. As a result, Maras’ interview techniques are being effectively utilised in the field, with CJS professionals finding them to be effective even when the interviewee has a learning disability and is very limited in free recall [I]. Every local UK police force has received a copy of the NAS Guidance and the online version has been downloaded over 4,000 times [A]; it is also currently being translated into different languages. The NAS Guide is referenced in the Independent Office for Police Conduct’s July 2019 Learning the Lessons magazine [D, p.5] and the College of Policing’s Authorised Professional Practice on mental health (revised in 2019) [E].

Maras’ research regarding the experiences, treatment and outcomes of autistic people in the CJS has also provided an evidence base to inform NAS strategy more broadly. Indeed, over both policy and practice, the combined impact of Maras’ work “ has been of enormous value politically” enabling the National Autistic Society to “ focus our support, lobbying and influence where it is most needed” [A].

Improving treatment of autistic individuals by Avon and Somerset Police

Avon and Somerset police stated that “ Findings from Dr Maras’ research” have been “invaluable in providing evidence for best practice for our officers and have had an impact on the Criminal Justice system in improving the treatment of autistic people and the reliability and credibility of their evidence” [G].

Maras’ research led to role-specific online autism training for Avon and Somerset Police, comprising modules on first response, custody and interviewing. The training was co-produced in 2018 through active collaboration between Maras and Avon and Somerset Police, and is now mandatory for all of their frontline police staff (approximately 2,000 officers) [G]. The package is currently being reviewed by the College of Policing and the National Police Chiefs Council. The content of the training is driven by Maras’ findings that have identified police training needs [1], the importance of diagnosis disclosure [2], and her research developing new interviewing techniques for autistic individuals [5, 6]. Evaluation data indicates that the 648 police officers who have completed the training demonstrated improvements in autism knowledge and awareness [G]. Consequent changes to practice as a result have been universally beneficial; for example, the Avon and Somerset Force Lead for Autism and Head of Policy for the National Police Autism Association highlighted the positive feedback they have received, for example that “ the insight it provides aids our necessary learning that approaches that are helpful for the neurodiverse are helpful for everyone”. The training has also proven beneficial for supporting officers at an organisational level within the police service, such as in recruitment or promotion interviews, and has informed policy regarding autism-friendly policing [G]. Dorset Police, Devon and Cornwall Police, Essex Police and the Metropolitan Police Service are actively seeking to adopt the training for their forces [G].

In 2019 Maras’ research [1] has also informed the design plans for adapting custody suites and related processes at Avon and Somerset Police, including 24 cells at Keynsham Police Station, and 36 cells across Avon and Somerset [G]. Plans include ensuring that cells are autism-friendly (including soft muted wall colour in cells, controllable LED lighting, TVs in cells, clearer and more detailed explanation of procedures) and autism training for custody staff [F]. Whilst COVID-19 has resulted in delays in physical changes to all cells, adaptations to custody processes are underway. Indeed, as a result of Maras’ research [1], Avon and Somerset is the first Force in the UK to change Force policy to mandate (since February 2018) that all detainees who are known or suspected to be autistic are provided with an Appropriate Adult (whose role it is to act as a safeguard and provide independent support to any suspect deemed to be vulnerable) in custody [G].

Avon and Somerset Police Force’s Lead for Autism states: “ Findings from Dr Maras’ research have been of direct relevance for the training and adjustments we have made within our force to optimise how we work with autistic people... The knowledge, training and guidance that we have produced as a result of the research has been invaluable in improving the ways that … incidents are handled” [G].

Guidance for advocates in The Advocate’s Gateway toolkits

Maras’ research regarding best practice interviewing of autistic individuals feeds into detailed guidance in Toolkits for The Advocate’s Gateway [Ji; Jii]. The toolkits are used by solicitors and barristers across the UK. Since June 2016, downloads of the ‘Planning to question someone with an autism spectrum disorder’ and the ‘Memory and sensory issues in autism’ toolkits have exceeded 6,422 and 1,988 respectively [Jiii].

Screening for autistic traits by the National Crime Agency

Bath research has also changed police approaches to cybercrime and interviewing. Specifically, as a direct consequence of the research [3], suspects for cybercrime are now routinely screened for “autistic traits” by the National Crime Agency. The Senior Officer at the National Crime Agency states: “ Research at Bath has been invaluable in updating our intelligence regarding the role of autistic traits (not autism) in cyber-dependent crime…Our Regional Organised Crime Units (ROCUs) now routinely screen for autistic traits at first contact with suspects” [H].

Shaping National Policy

Maras’ research has had a beneficial impact on the policy conversation and evolving strategy concerning the treatment of autistic individuals in the CJS. Maras was a member of the cross-government working group for the refresh of the 2014 Adult Autism Strategy and a witness on the 2019 Access to Justice inquiry session for the All-Party Parliamentary Group on Autism (APPGA), having been invited due to her research on the experiences of autistic people in the CJS and the efficacy of current police practice. Maras’ evidence-based recommendations form part of a wider portfolio of recommendations and evidence referenced in the resulting report. For example, the report states: “ In the new autism strategy, the Government should commit to making autism training mandatory for all police officers… to require all new police recruits to undergo autism-specific training, as well as creating a programme for all existing officers to receive this training” [B, p.47, 50]. The report also cites examples of the good practice that have been developed via her local collaboration with Avon and Somerset Police, including the mandatory provision of Appropriate Adults in all cases where autism is known or suspected [B, p.48].

Maras’ work locally with Avon and Somerset Police on the design of autism-friendly custody suites has also been incorporated at a national level into the Home Office’s 2019 National Custody Design Board Model [K].

Professor Stallard’s research has improved the mental health treatment for high risk young people who self-harm. The BlueIce research programme has produced a much needed novel, digital, self-help intervention for young people with mental health problems who engage in repeated and serious self-harm. BlueIce is being widely used (intervention adoption) and has demonstrated measurable reductions in self-harm (improved mental health) and estimated cost savings to the NHS (financial savings). Impacts available from 2017 are summarised below.

(a) Intervention adoption: BlueIce has attracted much local and national publicity including news stories on the ITV, Guardian and BBC (A, B, C). It is the only self-harm prevention app for children and young people recommended in the NHS Health Education England 2018 self-harm and suicide competence framework of good clinical practice (D). It is one of only 20 mental health apps/digital services to meet the rigorous standards for national endorsement on the NHS app library (E). BlueIce won the Innovation in Digital Health Award at the 2019 National Positive Practice in Mental Health Awards (F) and was highlighted as outstanding practice by the Care Quality Commission in a recent inspection (G). BlueIce is now available to child and adolescent mental health services (CAMHS) across the UK and has been prescribed by CAMHS across Bath and North East Somerset, Buckinghamshire, Cambridgeshire, East London, Wigan, Bolton, Salford, Manchester, Trafford, Bury, Heywood, Oldham, Tameside, Stockport, Oxfordshire, Swindon, Peterborough and Wiltshire to 2,520 young people with serious, repeated self-harm. Our aim is to make BlueIce available to all CAMHS in the UK and to extend access to young adults who self-harm.

A collaboration with colleagues at the Murdoch Children's Research Institute, Melbourne, Australia (H) has resulted in BlueIce being made available via the Australian App Store (I) where it has now been downloaded on 2,760 occasions.

(b) Improved adolescent mental health: Our initial work showed that after using BlueIce for 12 weeks, 73% of young people reported that their self-harm had reduced by an average of 10 episodes per person (R1). There were significant post-use reductions on standardised measures of depression (Mood and Feelings Questionnaire: mean difference =4.91: t31=2.11; p=.04; 95% CI 0.17-9.64) and anxiety (Revised Child Anxiety and Depression Scale: mean difference=13.53: t30=3.76; p=.001; 95% CI 6.17-20.90) (R1). The independent feasibility study in Australia found that young people felt more able to manage suicidal thoughts and feelings after using BlueIce for 6 weeks (H). Young people involved in our current randomised controlled trial in the UK rate BlueIce highly (G5). Average ratings were 9.6/10 for ease of use, 7.1/10 for helpfulness, 8.0/10 would recommend BlueIce to a friend with an overall app rating of 4.1/5 stars.

For some young people BlueIce has resulted in life-changing improvements:

“If CAMHS had given me that app around 3 or 4 years ago I wouldn’t be cutting now” (J).

“I used to harm myself pretty much every day I think there were only a couple of days when I wouldn’t. Since having the app I’m like clean, I haven’t done anything” (J).

Parents also observed improvements:

“… it may not change the situation she’s struggling with, but it changes her and it’s a positive change, I don’t mean she’s bouncing round happy but more stable I guess is what I’m trying to say and it’s, it’s amazing” (J).

Finally, CAMHS professionals’ noted benefits:

“A ll ‘my girls’ (patients) are finding the app very helpful! From my point of view, the self-harming incidents are much less frequent for those using the app” (J).

(c) Financial savings. Study participants: Over the course of our study BlueIce prevented 295 episodes of self-harm in 28 young people (average of 10.5 episodes per person) (J). Because most adolescent self-harm does not result in Emergency Department treatment we modelled potential cost savings based on different assumptions (described in our Health Foundation Report p15-17 (J)). We estimated the cost of an Emergency Department attendance following self-harm at GBP362 and conservatively assumed that 1 in 100 of the episodes of self-harm that BlueIce prevented would have required hospital treatment. Modelling this to the 2,520 young people in the UK for who BlueIce has now been made available suggests a total saving to the NHS so far of at least GBP69,923. Potential future savings: The Local Government Association (2018) reported that 19,000 children attended hospital following self-harm in 2015. If BlueIce was available to all these children, taken up by half and prevented 50% of these episodes, the NHS would save GBP1,700,000 per year from reduced emergency department attendances.

Whilst the potential financial savings to the NHS are significant it is the personal benefits that are of the utmost importance. As summarised by one young person:

“It’s actually really good, it has helped a lot and I haven’t self-harmed in a while. Since using the app I’ve done it once and that is over 4 weeks which is really good” (J).