Impact case study database

The What Works study has shaped national policy and practice around the design, delivery and quality assurance of dementia education and training for the health and social care workforce at governmental, provider and practitioner levels.

Changing governmental perspectives of and policy on dementia training

In England, at a governmental level, the findings of the What Works study have shaped governmental and arms-length body perspectives of and policy and guidance on dementia training, moving this from a position prioritising numbers trained (in Governmental mandates to HEE 2013-16) to one also actively promoting the importance of training quality, as evidenced through subsequent policy and guidance issued. For example, the revised ‘Dementia Training Standards Framework’ published in 2018, (authors Skills for Health, HEE and Skills for Care), which sets the national standards for dementia training for all health and social care services and staff in England [IM1] , cites the components of effective training identified in the What Works study, as setting the national quality standards for training design and delivery. “ The outcomes of the research include the key components of effective dementia education training.” Prior to this revision, no national standards for dementia training quality were identified or recommended by HEE.

What Works Research programme outputs include translation of key features of effective dementia education and training into an audit tool (The Dementia Training Design and Delivery Audit Tool (DeTDAT)) for use by training commissioners and providers to inform design, delivery, review and commissioning of training, and to audit their provision against indicators of good practice identified in the study.

The ‘Dementia Care Pathway’ (2018) and benchmark guidance for dementia diagnosis and post-diagnostic support were developed by the Royal College of Psychiatrists on behalf on NHS England, as part of the Five-Year plan for Mental Health. The pathway incorporates the ‘What Works? Study’ findings, in the context of their inclusion within the Dementia Training Standards Framework “The right workforce, with the right capacity and skill mix, is essential for ensuring the delivery of NICE-recommended care… The Dementia Training Standards Framework … sets out standards needed in dementia education and training,”. Evidence underpinning the guidance [IM2] states “ Quality assurance [of dementia training] can be delivered with the help of the Dementia Training Design and Delivery Audit Tool (DeTDAT) and Auditor’s Manual”; key outputs of the What Works study.

In 2019 the Minister of State for Care with HEE and Skills for Care issued a dementia training call to action to all health and social care service providers [IM3], recommending not only that training remains a priority but stating “We would encourage those designing or commissioning training to quality assure their products against the findings of the ‘What Works’ Study (Leeds Beckett University) to help to reduce variability in training quality.”

National and wider adoption as a quality standard for dementia training design and commissioning

This recognition of the need for quality on training has led to uptake and recommendation of the components of effective dementia training identified in the research programme.

This has been adopted by providers across health and social care:

Nationally HEE [IM4] states the research provides core insight into the components required for delivery of effective dementia education and training in England. It has adopted the research programme’s DeTDAT audit tool, as the mechanism for the development and quality assurance of all its commissioned or recommended dementia training programmes. “ This audit tool has been adopted by HEE as its standard method for assessing dementia education and training materials and packages that it recommends via its dementia training website.”

Surr was commissioned to undertake audits of 40 dementia training programmes, using the DeTDAT, with those meeting audit standards then listed as recommended by HEE on the web-site.

The study also features in national clinical and practice guidance in the UK and the USA. In the UK The Society and College of Radiographers cite the study findings as evidence of training factors most likely to lead to positive outcomes, in their clinical practice guideline for the radiography workforce [ IM5].

Internationally, the research findings on features of effective dementia training underpin guidance for employers and educators of direct care workers outlined in the ‘Competency Guide for Dementia Care’ written by Georgia Alzheimer’s and Dementia Related Collaborative [IM6] as part of the Georgia, USA, State Plan for Dementia. The guidance draws directly on our systematic review findings in its recommendations around training design to maximise application of learning into practice: “ Use minimal lecture-only or reading-only strategies for content delivery”, “ Use role play, scenarios, discussion, and peer learning strategies to get content across that can help them to figure out their own answers through practicing behaviors.” and “Deliver shorter (90 minutes is recommended) and more frequent sessions. A combined total of eight hours of training on a specific dimension appears to be most effective.”

Changing the way dementia training is designed and delivered, impacting staff knowledge and practice

The prominence of the study’s findings in national policy and guidance on dementia training quality assurance has facilitated widespread adoption by training and health and care service providers across the spectrum of provision, changing the way training is designed, delivered and implemented training nationally, with evidence of wider interest beyond the UK. Thus, the results have reach across training provided across NHS acute and mental health services and within care homes, impacting the training received by thousands of staff. This has led to impacts for health and social care staff attending training including, increased, knowledge, skills and confidence to deliver dementia care and changes to behaviours in practice.

In NHS acute hospital settings, the ‘DEALTS 2’ dementia simulation training programme developed by Bournemouth University and commissioned by HEE [IM7], is designed around the features of good training identified in the What Works study. It is recommended for use by HEE to train acute hospital staff on person-centred dementia care. DEALTS 2, was recognised for its innovation and quality as a finalist in the National Dementia Care Awards 2018. In 2017-18 the DEALTS 2 train-the-trainer programme was delivered to 199 staff of whom 137 were employed in acute hospital settings across all England regions, who have since disseminated the training to staff across their employing organisation. The train-the-trainer programme demonstrated significant improvements in dementia knowledge in the trainers and produced high levels of reported satisfaction with the programme and confidence to onward deliver.

In Mental Health services for example, Garrod et al [IM8] drew on the What Works findings to develop a new dementia training programme, delivered to over 160 staff. The training was found to have a statistically significant positive impact on learners’ attitudes towards people with dementia, led to a significance increase in their knowledge and confidence and impacted on how they cared for people with dementia in their day-to-day practice.

In Care home services Barchester Healthcare commissioned Leeds Beckett University to co-develop a range of new dementia e-learning modules and other educational materials for staff members, underpinned by the What Works study results. This training modules are mandatory for its c.17,000 staff, providing care for over 11,000 residents, in their 200+ care homes. Impacts [IM9] are evident through high completion rates/reach. As of 31.12.20 87-95% of all staff had completed each module, and over 131,000 total training instances had been recorded, with over 22,600 staff completing at least one module (Figures are higher than total staff due to turnover rates). The training has also produced high staff satisfaction and positive impacts on confidence to care for residents with dementia (93%+ of staff completing module evaluations stated they felt more confident and were satisfied with the training) and has been note in Care Quality Commission inspections of services in reports of homes rated as ‘Outstanding’.

Examples of staff member evaluation comments include “I really enjoyed this module and feels it has genuinely prepared me to support people with dementia in conducted meaningful activities.” “I learned much knowledge which I could apply in my work.” “The e-learning has empowered me with knowledge and has re in forced my understanding of Person centred approach whilst I will be providing dignity, compassion and respect to all the residents”

Following presentation of the findings of the research by Surr at a dementia strategy development event in Alberta, Canada, the study findings have been adopted by Calgary care home group AgeCare to underpin transformation of their dementia training provision, with 375 of their staff trained on the new programme by July 2020 [IM10]

The underpinning research has resulted in changing UK government policy in relation to prisoner health as well as leading health service, public health and criminal justice agencies in developing policy, commissioning and practice guidance. The underpinning research has also impacted directly on policy and practice in the Canadian health system.

Impact on UK and international prison policy impact

The underpinning research has a clear pathway to Lord Farmer’s 2017 report “The importance of strengthening prisoners’ family ties to prevent reoffending and reduce intergenerational crime” [ IM1] which was commissioned by the Secretary of State for Justice in a report in 2016 to reform prison services. Lord Farmer’s report highlights family relationships as “the golden thread” in preventing reoffending and shows prisoners who receive visitors from a family member are 39% less likely to reoffend than those that do not. This report cites [R1] in the section highlighting the importance of the prison visit to inmates (p62, reference 90) and specifically names James Woodall (p.71 paragraph 185), referring to his research relating to [R1], which shows the importance of visits to improved prisoner resettlement and reduced reoffending. LBU research pertaining to the role of prison visitors’ centres and the importance of family ties showed they aid health and well-being – this evidence was an important contribution to this report in 2017. The Farmer review is continuing to have direct policy impacts for prisoners and their families, informing the policy around secure video calls to help prisoners maintain family ties during COVID-19; and in 2020 it was reaffirmed that prison Governors must consider recommendations from the Farmer Review [ IM1] in relation to visiting services in their prisons, in the Ministry of Justice document “Strengthening prisoners’ family ties policy framework” issued in January 2019 and re-issued in January 2020.

The NIHR funded study exploring the effectiveness and cost-effectiveness of peer interventions in prison settings [R3] resulted in change in policy, commissioning and practice of prison health service delivery for national health service, public health and criminal justice agencies. The work has significantly informed NICE guideline 57 (NG57) [ IM2] published in November 2016, on the physical health of people in prison: assessment, diagnosis and management of physical health problems – advocating using peer support and mentoring to help promote a healthy lifestyle while in prison. The Health Service Delivery report for our NIHR study, out of which was published the systematic review [R3], is cited in the reference list of the full NG57 guideline document and is used to demonstrate the economic benefits of peer-led and professional-led interventions over “do-nothing” approaches to prisoner health. Specific extracts of the systematic review [R3] are referred to on pages 174, 175 and 200 of the NG57 full guideline document. NG57 is the sole guideline underpinning the September 2017 NICE Quality Standard 156 (QS156) “Physical Health of People in Prisons”. The Health Service Delivery report for our NIHR study, out of which was published the systematic review [R3], has also led Public Health England to re-evaluate and review the evidence of the impact on health outcomes of NHS commissioned health services for people in secure and detained settings. Public Health England recommended peer-led services as a component to inform future health interventions and prioritisation in England [ IM3, pg26, citation 51]. **Public Health England also developed principles and gender-specific standards to guide health commissioning of services in the female prison estate and using our research [R3] and [R4], a service standard has been developed which states that peer-education approaches should be used to support health promotion activities in the women’s estate – impacting positively for over 3000 women [ IM4, R3 cited on pages 37, 38 and 107, R4 cited on pages 151, 198 and 199]. This is particularly important given that much health policy in prison has been focused on men. The research informs processes for effective peer intervention delivery for women in prison. Linked to this, the research has been used by NHS London Clinical Networks to drive their health strategy for women in the criminal justice system in London (over 30,000 women). Our systematic review research [R3] has also informed and been cited by NHS Scotland in their ‘Reducing offending, reducing inequalities’ strategy report [ IM5, R3 referred to on pages 85 and 152] which calls for more focus on peer delivery methods in improving health, reduced re-offending and resettlement for 7500 Scottish prisoners currently in 15 prison establishments.

Internationally, the research on peer interventions in prison has been utilised to develop policy for the Government of Canada. Evidence from LBU research informed the policy framework ‘Promoting Wellness and Independence of Older Persons in CSC Custody’ undertaken by the Correctional Service Canada [ IM6 cites R3 and R4 in relation to the importance of peer support].

Impact on UK and international prison practice

At practice level, our research on peer health delivery [Health Services Delivery report and subsequently R3] in prison has been cited by Her Majesty’s Inspectorate of Prisons in relation to their practice development for peer support in prison [ IM7, pg 4]. This research has also been used by Public Health Wales to support the planning and provision of health care for the development of a new North Wales Category C training and resettlement prison with an operational capacity of 2106 places [ IM8, cited on pages 73, 177 and 192]. This drew specifically on our typology of peer intervention approaches with this providing direct recommendations for peer interventions to form part of prison health service delivery. We have also made significant contributions to changes at HMP Leeds in relation to improving health outcomes for approximately 1000 prisoners and their families through consolidation of family ties. Indeed, data suggests some 3538 visitors to Jigsaw each month (including an average of 571 children) that have benefited. This includes an average of 176 individuals being first-time visitors to HMP Leeds. Our research has been used to inform Jigsaw’s expansion to other prisons – HMP Wealstun, for instance, which accommodates 800 people in prison. An endorsement by the Director of Jigsaw at HMP Leeds [ IM9] stated: “The support that HMP Leeds provides for prisoners and their families has been consistently rated by Her Majesty’s Inspectorate of Prisons as outstanding. This outcome is directly as a consequence of the way we have delivered our policy and practices using research evidence to inform the way we do things. Specifically, Leeds Beckett research underpins much of our policy and practice in how we have developed and managed prison visits at HMP Leeds – particularly how we create a comfortable environment for families prior to the visit and how we balance the difficult tension between security and ensuring family-centred approaches”. Finally, [R4] informed practical recommendations for standardised peer interventions for The Office of the Correctional Investigator in Canada in their investigation ‘Aging and Dying in Prison’ [ IM10]. LBU research was the main contributor that resulted in Recommendation 10 from this report that stated “ We recommend that CSC introduce standardized peer assistance and peer support programs across all institutions. These programs should be modeled along the lines of the caregiver program at Pacific Regional Treatment Centre, including a comprehensive manual, recurring training and ongoing support to peer caregivers”.

The CHPR body of research has driven an evidence-led decision process that has changed policy and practice in the design and delivery of community-centred approaches to health and wellbeing. Impactful change has occurred in the UK at national governmental, local governmental, local provider and practitioner levels and internationally with the adoption of these research findings by the Spanish public healthcare system. The ultimate beneficiaries of the impact of this research are the general public, through improvement in government policy and societal practice in relation to ownership of one’s health. Changes in societal practice relating to public health is far-reaching, both from the perspective of a general improvement in health and wellbeing throughout society to the subsequent financial savings to public health services such as the NHS.

a). Changing national policy and practice in community engagement with public health

In 2015 PHE and NHSE jointly published the document “A guide to community-centred approaches for health and wellbeing” [ IM1]. This report was prepared by South and colleagues and condenses the key findings from the body of underpinning research [R1-6] into a usable guide for all stakeholders to follow and adapt. The Guide [ IM1] is endorsed [Page 4] by Duncan Selbie [then CEO, PHE] and Simon Stevens [CEO, NHSE] who state “ As part of our joint commitment to community approaches and harnessing this renewable energy [community volunteers], NHSE and PHE have set out what works. Through this guide we outline a ‘family of approaches’ for evidence-based community-centred approaches to health and wellbeing”. The guide has been cited over 100 times in public health journal articles and directly underpins community-engagement policy and practice at national and international scales as evidenced below.

The research has driven policy and practice within NHSE. The Guide [ IM1] was implicit in the NHSE’s People and Communities Board development of the “Six principles for engaging people and communities” [ IM2, IM1 referenced on p12]. The six principles [ IM2] were adopted by NHSE in its New Models for Care Programme focused on empowering patients and communities [ IM3, p8]. The New Models of Care programme Directory [ IM3] recommends using The Guide [ IM1] as a resource to help Vanguards develop new services and implement community-centred approaches [ IM3, p.32]. In 2019, NHSE published a “Menu of evidence-based interventions and approaches for reducing health inequalities” to meet the ambitions of the NHS Long Term Plan [ IM4], the section on community-centred approaches was underpinned significantly by and referenced The Guide [ IM1].

LBU research has underpinned community-engagement strategies with health in the UK. This claim is supported by a testimonial from PHE that states, “ The research has driven PHE strategic approach to community engagement in health” [ IM5]. The adoption of The Guide [ IM1] by PHE was formally announced in an official PHE blog, which highlighted its contribution to the knowledge base and encouraged its use by local leaders and commissioners. The “family of community-centred approaches” [R6] was adopted as a taxonomy for PHE to organise evidence and resources on Healthy Communities for the newly developed PHE Knowledge platform. Subsequently, “Creating healthy communities” was stated as one of six opportunities within PHE’s new Strategy 2020-2025, for improving public health within the UK [ IM5].

b) Changing national guidelines and quality standards in community engagement with public health

Changes in National Institute for Health Care Excellence (NICE) guidance on community engagement resulted directly from the underpinning research. NICE guideline “Community engagement: improving health and wellbeing and reducing health inequalities” (NG44) ( IM6) was published in March 2016 and replaced guideline PH9. The Guide [ IM1] is referred to extensively throughout NG44 and is specifically cited on pages 8, 9 and 20. Subsequently, NG44 is the sole source document for development of NICE Quality Standard (QS) 148 “Community engagement: improving health and wellbeing” ( IM7) and NG44 contributed to development of NICE QS167 “Promoting health and preventing premature mortality in black, Asian and other minority ethnic groups”.

The Guide [ IM1] and NG44 [ IM6], which both directly emanate from the underpinning research, are the key documents utilised by national and international public health stakeholders in driving their strategies in engaging communities with public health.

c). Changing international policy and strategy in engaging communities with public health

NG44 has been utilised extensively to develop the national guidance strategies for community engagement in public health in Spain. The Library of Clinical Practice Guidelines of the National Health System (guiasalud.es) developed the 2018 document “Participacion Comunitaria: Mejorando la salud y el bienestar y reduciendo desigualdades en salud” [ IM8] [“Community Participation: Improving health and wellbeing and reducing health inequalities”]. The document is endorsed by Ministerio de Sanidad, Consumo y Bienestar Social [Ministry of Heath, Consumption and Social Welfare]. This guide states on the cover page it is adapted from NG44. This national-level document was used to create the 2019 document “Particpar para ganar salud” [ IM9] [“Participate to gain health”, p2 cites IM6 and IM8, as underpinning documents], with a localised focus for adoption of the guidance at municipal levels across the whole country. This document is endorsed by Federacion Espanola de Municipios y Provincias [Spanish Federation of Municipalities and Provinces and Red Espanola de Ciudad Saludables [Spanish Healthy City Network]. Thus, the strategy for engaging communities in public health adopted by the Spanish healthcare system, can be directly traced to the underpinning research from the CHPR at Leeds Beckett University.

d). Changing UK local government policy and strategies in community-engagement with public health, and increasing uptake of these innovative approaches by community organisations

NICE NG44 [ IM6] and The Guide [ IM1] has been utilised extensively by local councils across the UK to inform and develop their strategies to engage their local communities in public health initiatives. Currently in excess of 30 local councils across the length and breadth of Britain have completed or are developing community-health strategy documents, staff training and health audits, that utilise and cite NG44 [ IM6] or The Guide [ IM1] as a gold standard [ IM5]. Councils, and diverse examples of utilisation include; guidance on management of long-term conditions [Cornwall County Council]; health impact assessments [York, Wirral, Cumbria, Doncaster, Glasgow & Clyde Councils]; social worker training [Brent Council]; weight management programme [Rutland Council] and the “Physical Activity Strategy 2019-22” [South Tyneside Council]. NG44 [ IM6] is utilised and cited in numerous public health documentation from PH Wales. As representative evidence for local government impact we include Tower Hamlets Council, “Public Engagement Strategy 2018-2021” [ IM10], which is underpinned by The Guide [ IM1] and NG44 [ IM6, cited on p36, reference 16]. The research has also resulted in changes in practice from community organisations in how they promote community engagement with public health. PHE publishes in excess of 50 practice examples of local projects that illustrate uptake of innovative community -centred approaches and document impact through outcomes and learning [ IM5].