Impact case study database

Impact of Outcomes research

The evidence generated by Hilari and her team has contributed to a paradigm shift in aphasia rehabilitation. Service providers and clinicians are direct beneficiaries of the research with a resulting impact on people with aphasia. Speech and language therapists are now increasingly addressing quality of life in their rehabilitation; in an international survey, the most commonly used measure to guide clinical practice was the SAQOL-39g [3.3]. The underpinning research has had an impact on National Clinical Guidelines; the Australian Aphasia Rehabilitation Best Practice Statement 5 “Providing Intervention” states that rehabilitation should address the impact of aphasia on quality of life and cite our work as the highest level of evidence [5.1] and one of our systematic reviews on diminishing social networks after stroke and links to depression has been cited in a NICE surveillance review as key evidence for the need to update the Stroke Rehabilitation Guideline, CG 162 [5.2].

Two of our tools, the SAQOL-39g and the Scenario Test-UK, are recommended in the international ROMA consensus statement, and these tools now comprise two of the four essential measures included in the Core Outcome Set (COS) for aphasia, which is endorsed by the Collaboration of Aphasia Trialists and the internationally respected COMET Initiative [5.3]. Of all measures evaluated in the aphasia COS, the SAQOL-39g had the highest selection rate (96% compared to 74-83%). A systematic review by Neumann et al. (2019) found that the SAQOL-39g is the most frequently used quality of life measure in aphasia research. The impact the SAQOL-39g has had on clinical practice is evidenced by the fact that it is validated and currently available for use in 19 different languages [5.4].

The team has developed a bespoke online platform, City Access Resources for Aphasia (CARA), to make the SAQOL-39g and other resources developed at City available to clinicians. CARA officially launched in May 2019 and now has more than 2,475 users from across the world, including Europe, Asia, United States, Canada and Australia. The SAQOL-39g, in particular, has been accessed for use 1,343 times. Testimonials from clinicians in the UK and abroad have highlighted how use of the SAQOL-39g has transformed their practice. This has included facilitating collaborative goal setting for patients with aphasia and their families, being used as the core outcome measure across the stroke rehabilitation team and providing evidence for increased therapy that improves rehabilitation of those with aphasia [5.5].

Impact of Intervention research

Our intervention research, led by Marshall, has made a significant contribution to the aphasia therapy evidence base, which in turn guides treatment selection by practising therapists. One study is included in the most recent Cochrane review of speech and language therapy for aphasia [5.6] and there are further citations in international therapy evidence tables, such as Speech Bite (Australia) and Speech Pathology Data Base for Best Interventions and Treatment Efficacy (USA).

Patient benefits have been promoted via extensive training and outreach activities. Over 450 qualified speech and language therapists have been trained in the CommuniCATE treatments, including groups (n = 40) from USA (2015) and Australia (2018). A further 50 speech and language therapy students have been trained through placement opportunities, with a profound impact on their learning and subsequent practice. Manuals for our CommuniCATE and remote treatment approaches are available on our CARA website.

Since the project inception in 2014, at least 200 people with aphasia have directly benefited from the CommuniCATE therapies, delivered by City, the NHS and Australian clinics. Significant improvements have been achieved for those receiving treatment on measures of everyday reading and writing. Participants also report transformative benefits, such as being able to write in full sentences again and post personal stories on the internet [5.7].

EVA Park has been used at City to deliver therapy to 60 people with aphasia, using interventions that target language, communication and social support. Benefits have been demonstrated on formal measures and in the reports of users [5.8]. At least 200 service providers have benefited from practitioner EVA Park training. Forty-six aphasia services, including users from the USA, Australia, Spain and Bermuda, have been given access to EVA Park. All therapists have been trained in its use and provided with EVA Park treatment resources. To date, 427 user avatars have been created in EVA Park and over 5000 hours of therapy and support have been delivered on the platform. Feedback from service providers and recipients report important and novel benefits [5.9].

Online videos about EVA Park, which describe the intervention and its benefits from the perspective of therapists and those with aphasia, have attracted almost 6,000 views [5.10]. EVA Park has been recognised by the 2015 Tech4Good people’s award, which was based on a popular mandate, and by its 2016 nomination as one of the world’s 100 most inspiring uses of technology to drive social change (Nominet Trust). The EVA Park and CommuniCATE team was named as one of the 100 Nation’s Lifesavers, during the UK Universities MadeatUni Campaign. Since the outbreak of the COVID-19 pandemic in the UK, digital technologies have been at the forefront for delivering primary care. The RCSLT Telehealth Guidance issued in response to the pandemic cites our research as part of the evidence base supporting the virtual delivery of speech and language therapy services [5.11].

Impact on Public Policy and Services

Our research has led to the development of the rapid CVS test and the establishment of new CV# grading scales for quantifying the severity of RG and YB colour vision loss. The CVS test and associated protocols based on the CAD test are highly reproducible. Their adoption internationally has led to reduced variability in colour vision assessment and safer working environments by eliminating those applicants with severe deficiency who passed conventional protocols. They have also resulted in greater fairness for those less severe applicants who failed conventional tests, but pass the protocols based on the CAD test and are therefore able to carry out colour-related, safety-critical tasks with the same accuracy as normal trichromats [3.2].

The three-year project ‘Analysis of European colour vision certification requirements for Air Traffic Control (ATC) officers’ led to a change in policy by the CAA (UK) with the adoption of the CV2 grade for operators [5.1]. In 2019, the European Aviation and Space Agency (EASA) decided to adopt the CAD test and the stricter CV1 grade for Air Traffic Controllers (ATC). Since then all EASA member states require ATC operators to have normal trichromatic colour vision [5.2]. Neither the Ishihara test nor the Nagel anomaloscope assess YB colour deficiency and so the CAD test has become the default standard for ATCs. The colour vision research carried out at City, University of London has therefore had an impact on all EU air travel with the CV1 grade colour vision requirements applying to all 17,000 ATC officers improving the safety for 1,106M air passengers per year (EuroStat, 2018) [5.3].

Our research has also led to a report on colour vision assessment commissioned by the UK Maritime and Coastguard Agency (MCA) [5.4]. This report has led to significant impact, both in the UK and abroad. MCA is responsible for legislation and guidance on maritime matters and provides safety certification to seafarers. The study analysed the statistical outcomes of colour vision testing protocols previously used by the MCA using the City data set, which at the time of the study included 1,363 participants. The report identified the CV2 grading scale as a safer, simpler to administer, less variable and fairer colour vision requirement for lookout officers [5.4]. In 2018, MCA changed its policy and practice by adopting the CV2 grade and establishing guidelines alongside setting up four authorised colour vision test centres in the UK equipped with the CAD test [5.5]. Following the introduction of the new protocol, the number of appeals and retests, which were common in the past, reduced significantly. The adoption of the CV2 grade for colour vision affects the safety of everyone using UK waters including approximately 120,000 vessels and 20,700,000 international passengers arriving at UK ports in 2019 according to UK Government statistics.

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The CAD test and new CV# grading scales have also been adopted by industry for occupations where colour vision is important. For example, the CV3 grade was adopted by the Joint Industry Board (JIB) in 2017 for electrical contractors [5.7]. Use of the CV3 grade triples the number of applicants with CCVD who meet the JIB requirements. Applicants with CCVD who pass at the CV3 limit are 3-times less severe in terms of their RG colour vision loss than the most severe applicants who pass the current protocol (Fig. 10b in [3.2]). This results in both fairer and safer access to the electrical professions. In addition, the CAD test and CV# grading scales also assess YB colour vision, which is essential for detection of acquired loss.

Impact on Commerce and the Economy

In addition to the impact on policy and practice, the CAD test has been made commercially available through City Occupational Ltd (COL). COL is a spinout company of City, University of London, which was established in August 2013 to develop, manufacture and distribute a number of tests for use in research, primary healthcare and visually demanding occupations. City, University of London licensed the Intellectual Property to COL and as a result, the company has developed and sold CAD systems to vision research institutes, universities, aviation authorities, eye clinics, defence medical centres, authorised medical examiners, vision scientists and optometrists worldwide [5.8]. For example, a multi-centre gene therapy trial for achromatopsia has chosen our colour vision tests, alongside other advanced vision tests underpinned by our research, as outcome measures [5.9].

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Results from Professor Henry’s research have had an impact on key stakeholders in the Criminal Justice process, leading to fairer access to justice. Dame Joyce Plotnikoff has highlighted the importance of the underpinning research: “ I wish to commend this ground-breaking research. It provides the first empirical evidence demonstrating the benefits of intermediary involvement in the forensic interview of typically developing of children aged between 6 and 11. This has important implications for practice in this country and other jurisdictions with an interest in the intermediary special measure…. This research will therefore assist significantly in supporting intermediary applications for primary school age children” [5.1]. More generally, according to Newlove (2018), the findings have “ played a crucial role in refuting the early concerns surrounding the introduction of RIs” [5.2].

Impact has been achieved via changes in approach by three major groups: police officers/trainers; barristers; and Registered Intermediaries. The evidence shows that better quality witness testimony will result in fairer access to justice where children, both typical and autistic, are involved as witnesses. The team’s findings have also made an impact on government advice, with some of their research cited in a UK Parliamentary Office of Science and Technology (POST) research briefing on ‘Improving Witness Testimony’ [5.3].

Police officers/trainers

Working with the UK’s leading autism charity (National Autistic Society, NAS) and the Metropolitan Police Service, the team led by Henry, produced evidence-based guidelines for police officers on how to deal with witnesses and suspects with autism [5.4]. Published in April 2017 by the NAS, the guidelines were distributed to police forces widely across the UK, with 4,569 views as of September 2019 (figures obtained from the NAS). They are cited in the ‘College of Policing’s Authorised Professional Practice on mental health’ [5.4], cited in the ‘Learning the Lessons: Improving policing policy and practice’ publication [5.4], and promoted by the National Police Autism Association (who circulated them to UK police forces/services).

The team also organised and hosted three ‘Autism and Policing’ events to raise awareness among police officers and police trainers about autism and the role of Registered Intermediaries. These events were delivered to 450 police officers and police training staff (the majority of whom had over 10 years of experience) in November 2015, March 2016 and April 2019. Delegates came from six national UK police services, with most from the Metropolitan Police Service. Feedback obtained from 316 officers attending across the three events demonstrated marked increases in knowledge and awareness about autism and the role of Registered Intermediaries, plus greatly increased confidence about interviewing people with autism [5.5]. Substantial increases in confidence around requesting an RI were also recorded (2019 event). Importantly, almost all officers attending these events considered themselves ‘likely’ or ‘very likely’ to apply this new knowledge to their professional role, many of them suggesting that the training should be mandatory (e.g., “ *Brilliant training - it should be mandatory!*”; “ *This is vital for all officers and should be compulsory.*”) [5.5]. Of the eight Police Officers in total [out of 35] who had interviewed a victim, witness or suspect with autism and/or requested the use of an intermediary since the awareness event, three agreed to a telephone interview to obtain further details. These interviews, conducted ten months after the 2019 event, revealed they were all implementing their new knowledge (e.g. Officer 3: “ *From information presented at the awareness event, it became clear to me (from the behaviours exhibited by the suspect) that the individual may be on the [autism] spectrum. Information about how to interview someone with autism was very useful as well as the types of questions etc. that should be asked...*”) [5.6].

Barristers

The Advocate’s Gateway (TAG), is an independent body providing free access to high-quality, practical, evidence-based guidance (‘toolkits’) on questioning vulnerable witnesses and defendants. Together with other academics and professionals, Professor Henry’s team produced two TAG toolkits describing best practice for legal and other professionals when working with and interviewing autistic people [5.7]. Since publication in 2015-16, these toolkits have been downloaded well over 3000 times. Feedback on the toolkits from senior legal professionals has been overwhelmingly positive. For example, His Honour, Judge John Phillips (Director of the Judicial College) referred to the toolkits as “ very high-quality material drafted by well-known experts”, whilst Mr Justice Haddon-Cave referred to them as “ an extraordinarily valuable resource”.

Registered Intermediaries

Professor Henry’s research and subsequent links with Intermediaries for Justice, the professional organisation for RIs, has helped consolidate the growing RI profession. Intermediaries for Justice worked with the research team delivering three Autism and Policing awareness events (see earlier section) and organising and hosting two Continuing Professional Development conferences for RIs (May 2017 and May 2018). According to the former chair of Intermediaries for Justice (IfJ) and current RI trainer Jan Jones [5.8]: “ There is no doubt that hosting the [Autism and Policing] Awareness Days had a marked affect [sic] on the understanding of the RI role in the wider CJS [Criminal Justice System]. It has joined together the RI community with other CJS professionals and highlighted the importance of research which informs practice. It would not have happened without the original study, Access to Justice for Children with Autism.”

Findings from the team’s research have informed national advice set out in the latest edition (to be published by the Ministry of Justice) of ‘Achieving Best Evidence in Criminal Proceedings: Guidance on Interviewing Victims and Witnesses, and Guidance on using Special Measures’ [5.9]. This guidance will be disseminated to and accessed by all criminal justice professionals who come into contact with vulnerable witnesses, impacting directly on RIs, barristers and police officers. Further, a revised version of the statutory ‘Code of Practice for Victims of Crime’ was published in November 2020 by the Ministry of Justice. It states that if the police need to interview a victim, they must consider the Achieving Best Evidence advice, the need for a Registered Intermediary to help the victim to communicate their evidence effectively, and any disabilities or special needs the victim has.

The research has also been commended by Dr Kevin Smith, the National Vulnerable Witness Advisor (National Crime Agency) and lead author of the new edition of Achieving Best Evidence in Criminal Proceedings, as “ of enormous benefit in encouraging operational police officers to obtain the assistance of a Registered Intermediary” [5.9]. In fact, during 2019/20 the largest increases in RI requests were by the police, which had increased by 14.6% compared to the previous year to a record high of 5,832 (Ministry of Justice Witness Intermediary Scheme Annual Report, 2019/20). Senior intermediaries also note that our research “ has in part contributed to increased requests by criminal justice professionals to have the assistance of a Registered Intermediary when eliciting evidence from vulnerable individuals” [5.10].

Further, our research findings are now integral to a new training programme for RIs, overhauled by the Ministry of Justice in 2018. Two of our research papers [3.2; 3.3] are included on the official reading list [5.8], and, to date, over 80 new RIs have been trained under this programme (since July 2018 – the scheme was suspended between June and November 2020 due to the coronavirus pandemic). The research findings from the project form part of the discussions and reflections that new RIs have with trainers on their practice, and senior intermediaries describe them as “ informing good practice and so further developing the intermediary scheme ”, noting further that they “ underpin intermediary practice with sound research findings” [5.10].

Finally, the research team is involved with Intermediaries for Justice and City Law School in developing and delivering (since October 2019) a series of continuing professional development modules at City for RIs, to further consolidate the RI profession and ensure robust standards. Following a CPD session delivered on autism-informed practice (February 2020), one RI described the team’s jointly written NAS guide for police officers as readable, well-written and explains what officers need to know. Jan Jones, the former chair of Intermediaries for Justice and current RI trainer, has concluded, “ Professor Lucy Henry’s contribution has had a definite impact on the way that vulnerable witnesses have been assisted in the justice system.” [5.8].

The research conducted as part of the ESEP has provided a solid evidence base for the clinical safety and cost-effectiveness of enhanced services provided by community optometrists. The outputs from the ESEP, and previous research by the City team investigating effectiveness and refinement of glaucoma referral schemes, have informed commissioning guidance from NHS England, the College of Optometrists and the Royal College of Ophthalmologists, and NHS Improvement [5.1]. As a result, these outputs have played a major role in building the business case for Local Optical Committees (LOCs) to influence the decisions of Clinical Commissioning Groups (CCGs) to adopt MECS and GRFS pathways. The director of commissioning strategy for South East London CCG has commented “ *The CCG and the City team have directly supported more than 20 CCGs to implement their own schemes, but know that the work that we did has become almost standard practice for the whole of the NHS, and has been cited as the exemplar model by the Royal National Institute of Blind People.*” [5.2].

Minor Eye Conditions Services

The percentage of LOC regions in England that operate a MECS has increased from 55% to 71% since 2015. Over the same period an additional 4,000 optometrists have undertaken MECS accreditation. The commissioning of MECS significantly impacts referral rates from primary to secondary care, reducing the 1.7 million first attendances at ophthalmology outpatient departments by at least 10%. This is the equivalent of 170,000 HES appointments, representing net savings of GBP5,500,000.

In 2017, the Royal National Institute of Blind People, in partnership with Specsavers, the largest chain of optical practices in the UK, hosted a series of policy roundtable discussions at which a range of experts including patients, health professionals and commissioners came together to explore how improving delivery in eye care services could help increase capacity. Research from the ESEP was used as evidence for the clinical effectiveness and cost-effectiveness of MECS [5.3]. In 2016, Specsavers announced that more than 2000 of its optometrist employees have successfully become accredited to offer MECS in England [5.4], a strategic decision underpinned by our research [5.5].

Community-based Glaucoma Referral Filtering Services

Our research has also demonstrated the clinical effectiveness and cost-effectiveness of glaucoma referral filtering services (GRFS) in reducing referrals and freeing capacity in glaucoma clinics. The NICE guideline committee for glaucoma, which included ESEP team member Fenerty, recommended that ‘people planning eye care services should consider commissioning referral-filtering services (for example, repeat measures, enhanced case-finding, or referral refinement) for chronic open angle glaucoma and related conditions’ [5.6]. Commissioning guidance has also noted “ Independent monitoring of patients with a diagnosis of glaucoma (which must be established by a consultant ophthalmologist) is permitted and encouraged by NICE for those optometrists and other HCPs with training, skills and experience to the level of the CoO [College of Optometrists] Professional Diploma in Glaucoma” [5.7]. The NICE recommendation was informed by the findings of ESEP and previous research on referral refinement by members of the City team.

Clinical Management Guidelines

Underpinned by research over the past 10 years in priority areas of eye care, Lawrenson and Buckley have been engaged by the College of Optometrists through academic consultancy to lead on the development of Clinical Management Guidelines (CMGs) for the diagnosis and management of a range of eye conditions that present with varying frequency in primary and first contact care. A comprehensive process of identifying and rating the quality of evidence on the management of over 60 conditions and making specific treatment recommendations underpins each guideline (updated biennially) [5.8]. The Commission for Human Medicines (CHM) used the CMGs in their consideration of the proposal to allow optometrists to train as Independent Prescribers. They were also instrumental in the decision by the CHM to recommend that suitably qualified optometrist independent prescribers could prescribe any licensed medicine (for conditions affecting the eye, and the tissues surrounding the eye, within their recognised area of expertise and competence). The CMGs therefore have significant ongoing impact because they continue to inform the content of the Common Final Assessment for Independent Prescribing, the accreditation assessment conducted by the College of Optometrists for entry into the specialist register of therapeutic prescribers [5.9]. There are now over 500 practising optometrist independent prescribers working in specialist hospital settings and in the community. The CMG pages account for 22% of all unique page views to the College of Optometrists’ website (2,284,305 unique page views to the website and 502,387 to CMG pages in the year 2018-19).

The CMGs are also written into the service specifications for MECS pathways by the Local Optical Committee Support Unit (LOCSU), the Northern Ireland Primary Eyecare Assessment and Referral Scheme (PEARS) and, more recently, the national service framework for COVID-19 Urgent Eyecare Services (CUES) [5.10]. CUES acted as urgent eye care community hubs during the coronavirus pandemic. The quality of the guidelines has been recognised, and they inform the management of eye conditions by optometrists and other primary healthcare professionals e.g. CMGs are referenced in BMJ Evidence and NICE Clinical Knowledge Summaries (for GPs) [5.11].

Our research has influenced a major shift from obstetric-led to midwife-led birth settings for low-risk women in the UK and internationally. The evidence base created by our research has been used in the design and development of a range of practical tools. These tools have supported change in national and global policy and the growth in numbers and quality of midwifery units in the UK and abroad. Between 2010 and 2016 the number of women who birthed in a midwifery unit in England rose from 5% to 14%, equating to an additional 58,492 midwifery unit births. A conservative estimate, based on the Birthplace in England Research Programme’s economic analysis (Schroeder et al., 2012), suggests that this represents a saving of approximately GBP10,000,000 to the NHS. The number of midwifery units in England increased from 114 in 2010 to 173 in 2019 and the number of maternity units without a midwifery unit decreased from 50% in 2010 to 20% in 2019. International change supports the increasing implementation of midwifery units worldwide.

Midwifery Unit Network (MUNet), was set up in 2015 as a community of practice to develop impact and is now a limited company. City staff were instrumental in the creation, launch and support of MUNet as a spin-off company and remain intrinsically linked through Rocca-Ihenacho (CEO and co-founder), Thaels (director), Batinelli (research advisor) and McCourt (associate). MUNet has created tools and training, underpinned by our research, aimed at expanding and improving the choice of maternity care offered to women. These include:

Midwifery Unit (MU) Standards: These evidence-based standards, informed by our research, define quality criteria for midwifery units and are aimed at improving quality of care and reducing variability of practice. The standards have been endorsed by the European Midwives Association and NICE, who state that they “ *accurately reflect recommendations in the NICE guidance on intrapartum care for healthy women and babies [CG190]. They also support statement 1 in the NICE quality standard for intrapartum care [QS105]*”. The standards are also supported by the International Confederation of Midwives and the European Board and College of Obstetrics and Gynaecology [5.1].

Midwifery Unit Standards Self-Assessment Tool: The self-assessment tool, launched in September 2019, allows midwifery units to benchmark their service against the MU Standards and develop improvement plans. The tool has been piloted in four midwifery units across Europe. Evaluation of the pilot data has demonstrated that by using the self-assessment tool, services were better able to produce structured improvement plans. These plans included high-impact actions such as environmental refurbishment, production of evidence-based clinical guidelines and pathways, information for service users and providers, professional buddy-schemes and timelines to evaluate progress and service effects [5.2].

Midwifery Unit Academy: MU Academy is the education and training arm of MUNet. It delivers e-learning modules and interactive workshops/courses for professionals and service managers worldwide. 795 professionals have attended these workshops and courses since 2017 and a further 477 e-learning modules have been completed. In 2020 alone, 500 places were purchased for Canadian professionals and 750 for UK midwives. The training has a direct impact on midwifery units through the professionals involved.

The tools produced by MUNet, informed by our research, continue to influence policy and provision in the UK. For example, the MU Standards have been used to ensure the new community birthing hubs provide the necessary ambience, equipment and space: “MU Net resources and training have helped to develop services across the North of England, supported leaders to develop new ways of working and new environments that women, birthing people and their families want. MU Net have been invaluable in developing service and system change” [5.3]. The MU Standards have also helped shape best practice in London; they have been written into a resource from the London Clinical Maternity Network and our research has been cited in an NHS Best Practice toolkit ‘Increasing the number of births at home and in midwifery led units ’ [5.4]. MUNet’s training resources have also been licensed by Trusts and Health Boards including Chelsea and Westminster, Wakefield, Grampian and Tayside, and bespoke training has been provided to Cheshire and Merseyside.

Our research, networking and training (through MUNet) has also had a profound impact across Europe leading to change in policy and legislation and increased numbers of midwifery units. In 2015, France implemented five pilot midwifery units. MUNet and academics at City collaborated with the French Midwifery Association to support stakeholder meetings and provide testimonial to the French Senate. The head of the French Midwifery Association, which represents 20,000 midwives and 498 maternity services, confirmed that new legislation was passed in the French Parliament on 14 December 2020, allowing the eight existing birth centres to continue their activity and planning for at least 12 more. The testimonial also notes that a multinational team including France, Belgium and Switzerland were translating the MU standards into French and that France were trialling the self-assessment toolkit. These developments have also been supported by the Vice-President of the French government’s Social Affairs Committee [5.5].

MUNet has collaborated with the Federation of Spanish Midwifery Associations, (FAME), an organisation that represents most of the midwifery associations in Spain and some 3033 midwives. The collaboration has led to policy changes that support the implementation of midwifery units and the MU standards and underpinning research have been used as evidence to support these changes. The autonomous region of Valencia has passed legislation in support of the implementation of midwifery units and Catalunya, which opened the first public service midwifery unit in 2017, is about to launch its second Alongside Midwifery Unit at Badalona in early 2021 [5.6].

There has been extensive engagement between MUNet and stakeholders across many other European countries including Italy, the Czech Republic, Bulgaria, Romania, the Netherlands, Portugal, Belgium and Malta. Training and consultation services provided by MUNet have not only improved the operation of existing midwifery units but supported the introduction of midwifery units in countries such as the Czech Republic. Testimonials from the head of the Department of Gynaecology and Obstetrics, Charles University and the chair of the Association of Birth Houses and Centers note direct impact on staff skills (less invasive approaches), processes (midwife-to-midwife coaching) and staff communication techniques [5.7].

Globally, the implementation of midwifery units has been facilitated by academics from City through online advisory meetings and use of the MU Standards as a planning tool, with support from MUNet or IMaGINE (a City-based GCRF-funded network). Senior stakeholders have been supported to explore implementation challenges and opportunities in low- and middle-income countries and to implement and evaluate pilot midwifery unit projects. A number of new midwifery units were opened in India as a pilot project supported by a collaboration involving MUNet, the WHO and the Health Ministry in India [5.8]. MUNet has collaborated with the Saudi Ministry of Health since 2018 leading to the creation of a stakeholder consultation group that works on the implementation of midwifery units. In 2020, approval was granted to initiate a midwifery unit consultation committee, which will formalise and regulate the opening of midwifery units in Saudi Arabia. Part of this project is the creation of Midwifery Unit Standards for Saudi, based on the European Midwifery Unit Standards created by MUNet and underpinned by our research [5.9]. Similarly, in Afghanistan, MUNet collaborated with the country’s Midwifery Association securing formal approval in 2020 to initiate a midwifery consultation committee, which will regulate midwifery units and create midwifery unit standards for Afghanistan, based on the European Midwifery Unit Standards [5.10]. In other countries such as Brazil the MU Standards have been translated into Portuguese, but their planned launch has been postponed to 2021 because of the coronavirus pandemic.

Research led by Meyer has had international impact on best practice in care homes. Results from our research have been translated into an international social movement for quality improvement known as My Home Life, which has now spread across England, Northern Ireland, Scotland, Wales, Australia, and Germany. Since 2013, MHL has been a driving force in setting standards and supporting quality improvement in care homes.

Setting best standards and promoting relationship-centred care

MHL’s evidence-informed working methods have repeatedly been recognised as best practice by the Care Quality Commission (CQC), the independent regulator of all health and social care services in England. In 2014, MHL helped to inform the key lines of enquiry (KLOEs) in the consultation on their provider handbooks [5.1]. Additionally, MHL provided feedback on the draft provider handbooks as an independent contributor [5.2]. The final versions, published by CQC, set out the guidelines for inspecting and rating providers of health and adult social care services. These standards are now used to assess 11,300 care homes in England supporting more than 400,000 residents. Since the publication of these guidelines there have been several CQC inspection reports that identify MHL as a positive support mechanism for care home managers. In one report, CQC stated “ The programme [MHL] provides a good support mechanism for managers to reflect on [their] own performance and leadership skills” and a second report noted “ *The Deputy Manager was enrolled on My Home Life, which was an initiative run by the local authority to promote more person-centred practice in care homes. We saw examples of how this had inspired more creative practice.*” [5.3].

In tandem with the impact achieved via CQC, Meyer’s research and/or MHL have directly influenced reports from charities and thinks tanks such as: the Joseph Rowntree Foundation Care Home inquiry; The Demos Commission on Residential Care; HSJ/Serco Commission on Hospital Care for Frail Older People; and “A place to Call Home?” review by the Older People’s Commissioner for Wales [5.4]. All reports reinforce the key MHL message regarding relationship-centred care. As a result of increased awareness, MHL is being endorsed and adopted as a standard in Wales [5.4] and Northern Ireland [5.5]. Furthermore, MHL has been cited in Parliament as an example to advance the case for better standards; Paul Burstow, MP for Sutton and Cheam and Minister of State in the Department of Health at the time, commented “ Rather than care that is just about transactions, the [My Home Life] programme is about changing the nature of the relationship between those who provide care and those who receive it” [5.6].

Supporting quality improvement and practice development

MHL has had a major impact on quality improvement through its leadership support initiatives. Data from a UK telephone survey conducted by MHL in 2017 of 221 randomly selected care home managers suggested that MHL had influenced practice in 1,872 care homes, affecting the lives of approximately 56,000 residents in the UK [5.7]. Since August 2013, approximately 1,119 care home managers have participated the MHL Leadership Support programme in England, sharing best practice with staff and improving the quality of life for 33,500 residents. The MHL NW London CCG Collaborative provides further evidence of positive impact; in 2018 alone, care homes involved in MHL across NW London reported a 14% reduction in ambulance callouts, 16% in ambulance conveyances, 9% in A&E attendances and 5% in non-elective admissions. In contrast care homes not involved in MHL reported increases across the board [5.8]. Positive change was demonstrated following the leadership training provision and 93% of participants from the NW London Leadership Support programme reported increases in their ability to shift leadership style [5.8]. The Health and Social Care Workforce lead North West London CCG has stated “ *Participation in My Home Life Leadership Programme has contributed to improved leadership of the Mangers … linked to systemic changes in individual homes. The improvement of professional relationships extended beyond the care homes, into the wider health and social care community.*” [5.8].

Informed by findings from all its underpinning and ongoing research, MHL continues to support the leadership development of care home managers to take forward quality improvement in countries across the UK, Germany and Australia expanding its reach globally. For example, in a study unconnected to MHL that explored what governments could do to encourage care providers to improve quality of residential care for older people in England and Australia, the value of MHL was highlighted on more than one occasion: “ In England, managers had particular praise for the My Home Life programme … which promotes relationship-centred quality by bringing managers together for training events and support … some people thought the programme should be funded by government.” [5.9].

Significant impact has been achieved by MHL globally underpinned by the research of Meyer who was awarded a CBE in 2015 for services to nursing and older people and in 2017, celebrated as one of 150 Leading Women (1868–2018) by University of London in recognition of the impact MHL has had on both practice and research [5.10].