Impact case study database

National health policy and use in clinical practice

Inclusion in national guidelines

Several of the tools have been recommended for use in clinical practice in NICE guidance (Source 1). In 2014 QRisk2 was recommended as the sole risk tool of choice to assess cardiovascular disease risk in the NICE Cardiovascular disease guideline [CG181, 2014] (Source 1.1). New recommendations in the updated NICE guideline on hypertension in adults [NG136, 2019] (Source 1.2) include use of QRisk scores to inform antihypertensive treatment.

QDiabetes is recommended in NICE guidance (Source 1.3) on the prevention of type 2 diabetes [PH38, 2017]. The 2016 NICE guideline on multimorbidity [NG56, 2016] recommends using QAdmissions to identify adults with multimorbidity who are at risk of adverse events such as unplanned hospital admission or admission to care homes (Source 1.4). Other recommendations in guidelines include QFracture in NICE guidance [CG146, 2017] (Source 1.5) and the Scottish Intercollegiate Guideline Network (SIGN) national clinical guideline on osteoporosis management [SIGN 142; 2015] which has a key recommendation that to quantify fracture risk “ Fracture-risk assessment should be carried out, preferably using QFracture”. This assessment is then used to target pharmacological, and non-pharmacological treatments to reduce fracture risk (Source 2).

Implementation into clinical computer systems

All of the tools are publicly accessible, and most including QRisk2, QDiabetes, QFracture, QCancer, QStroke and QAdmissions have been integrated into the major UK GP clinical system (EMIS) (Source 3.1) which supplies computer systems to over 55% of GP practices in England, covering a population in excess of 30,000,000 people (Source 3.2).

The tools are also available as free open-source software (see links in section 2) to facilitate transparency, further research and use internationally. Google analytics show that since 2014, there have been over 2,000,000 hits to the QPrediction websites, with hits from most countries worldwide (Source 4).

Some tools have also been implemented in other GP clinical systems and by other suppliers including occupational health, pharmacy, secondary care and the private sector. For example, Wellpoint health kiosks which use QRisk3 are currently deployed in many occupational settings throughout the UK including the Ministry of Defence, Department of Health, DVLA, Kent County Council, Scottish Power, Scottish Water (Source 5).

Use and recommendations in clinical practice

QRisk is integral to policy guidance and practice such as currently being used in NHS Health checks, a national programme offering health checks to adults in England aged 40 to 74 (Source 6). It is designed to help prevent and detect early signs of heart disease, kidney disease, Type 2 diabetes and dementia and incorporates assessment of cardiovascular disease risk. Over 6,000,000 people in England received an NHS Health check between 2013 and 2017 (Source 6, p5).

The QRisk lifetime version of the tool is used by Public Health England on its NHS One You website (Source 7) to estimate heart age, with the aim of increasing awareness of heart health and acting as an incentive to make simple lifestyle changes. This was widely publicised by Public Health England in September 2018 . By June 2017 the website had been viewed by approximately 2,900,000 people, with approximately 1,200,000 completions of the tool (Source 8).

QCancer is designed to prompt GPs to think about diagnosis of cancer and refer high risk patients to hospital sooner, with the aim of patients being diagnosed at an earlier stage when there are more treatment options likely to improve survival. The QCancer tool is recommended by Cancer Research UK, and its use is being facilitated by Macmillan which has successfully piloted the tool and is promoting its use as a cancer decision support tool in clinical practice across the country (Source 9).

Evaluations and evidence of benefits

In the NHS Health Check prevention programme in England people with a 10-year QRisk score of 10% or more are considered to be high risk of cardiovascular disease and are offered lifestyle advice, behaviour change support and considered for statin treatment. A microsimulation study by researchers at the University of Cambridge (Source 10) estimated that in England each year the programme is preventing approximately 300 premature deaths (before age 80) and resulting in an additional 1,000 people being free of cardiovascular disease, dementia, and lung cancer at age 80 years. The study also found that the programme has a greater absolute impact on health for people living in the most deprived areas, accordingly the programme as a whole is reducing health inequalities.

An independent study in the Lancet (Source 11) compared four strategies for determining eligibility for blood pressure treatment, including one based solely on blood pressure values, two strategies based on NICE hypertension guidelines (2011 and 2019) which consider a combination of QRisk2 scores, blood pressure measurements and medical conditions, and one based on using a threshold for QRisk2 scores alone. The study estimated that 322,921 cardiovascular events would be avoided in the UK over 10 years using QRisk2 scores alone to determine eligibility for blood pressure-lowering treatment compared with 233,152 events based on the 2011 NICE guideline, and 270,233 for the 2019 NICE guideline. It concluded that a risk-based strategy using QRisk2 scores was the most efficient strategy, and could prevent over a third more cardiovascular disease events than the 2011 NICE guideline and a fifth more than the 2019 NICE guideline.

A Public Health England feasibility review in 2016 of tools for identifying people at high risk of developing diabetes in NHS Health Checks found QDiabetes to be more accurate than the method used in NHS Health Checks at the time based on body mass index and blood pressure (Source 12). For example, the sensitivity was 66% using QDiabetes compared with 57% (Source 12, p6). QDiabetes is now one of the validated risk assessment tools for diabetes included in the NHS Health Check programme (Source 6).

An international guideline panel has proposed using QCancer colorectal cancer scores to identify people with increased risk (15-year risk above 3%) for colorectal cancer screening rather than a strategy of screening all people aged 50 to 79 years (Source 13). This recommendation was based on a modelling study and a linked systematic review of the benefits, harms, and burdens of colorectal screening. The modelling study predicted that in people with a QCancer risk score of 3% an estimated 5 to 6 colorectal cancer deaths would be prevented over 15 years per 1000 people screened. The panel proposed QCancer as it is “ one of the best performing models for both men and women”, and because it has been externally validated, has good calibration, is available as on online calculator and can predict risk over a 15-year time horizon (Source 13, p13).

(Superscript=section 3 references, upper case letter=evidence source)

Smoking is the largest avoidable cause of death and disability in the UK, typically reducing life expectancy by ten years. Our work has contributed to a reduction in UK smoking prevalence (from 18% in 2014 to 15% in 2018, equivalent to around 2,000,000 fewer smokers in 2018) larger than in the USA and other rich countries, which has already helped to prevent thousands of premature deaths, cases of morbidity, hundreds of stillbirths and substantial NHS costs. Quitting smoking improves life expectancy, wellbeing, protects children and the unborn child, reduces poverty and improves productivity.

PATHWAYS TO IMPACT

We work closely on evidence translation with the Tobacco Advisory Group of the RCP; the National Institute for Health and Care Excellence (NICE) (Britton chair of PH48 Guideline Development Group 2011-13; Chair of Public Health Advisory Committee (PHAC) D 2013-16; member of PH45 Guideline Group and Quality Standards Committee); the Medicines and Healthcare products Regulatory Agency (MHRA), on e-cigarette safety (Britton member of expert working group 2019-20); on policy advocacy with Action on Smoking and Health (Britton a Board member since 2000) and with the National Centre for Smoking Cessation Training (NCSCT), co-producing research-informed clinician guidance and training.⁷ Dissemination also occurs through Public Health England (PHE) via their Tobacco Control Implementation Board (Britton chair since 2014).

IMPACT ON POLICY AND LEGISLATION

As described in detail below, and as acknowledged by PHE, our research in a range of policy areas has been extremely valuable in demonstrating policy effectiveness and hence ensuring both the adoption and maintenance of new policies. As described by the Tobacco Control Programme Lead for PHE “It is no exaggeration to say that [research at the University of Nottingham] has had a central role in shaping the tobacco control policy and practice changes promoted by Public Health England” [A]. These impacts include:

The 2017 Tobacco Control Plan for England [B] : This defines policies to reduce smoking prevalence in England and cites two RCP reports as evidence on harms to children, and on the need to help smokers with mental health problems to quit^1.i,1.ii [B p10 & ref 31, p13 & ref 47]. It recommends screening for smoking in all women attending antenatal care with routine use of carbon monoxide monitors as part of a new NHS care bundle for reducing stillbirth [B p11], for which our work⁴ was underpinning evidence [H.1 p13 & ref 7]. It further recommends automatic provision of cessation support for women identified as smokers, requiring women to ‘opt-out,’ citing our work in justification⁶ [B p10 & ref 36, p30].

The 2019 NHS Long Term Plan [C]: This plan set out commitments for future NHS services and cited the 2018 RCP report, which demonstrated the impact of implementing tobacco dependency treatment in NHS services^1.iv, with a statement that the recommended model will be adopted by the NHS [C p35 & ref 29] and thus influence future NHS tobacco dependency treatment. The Tobacco Control Programme Lead at PHE states that “The work of John Britton, who with other Nottingham colleagues led the publication of a series of systematic reviews and economic models supporting this approach in the 2018 Royal College of Physicians Hiding in Plain Sight^1.iv report led directly to the adoption of this approach in the 2018 NHS Long Term Plan” [A]. From 2018, Britton advised senior NHS England staff on the design and costs of service provision [A].

Tobacco harm reduction: The use of electronic cigarettes to reduce tobacco-related harm through partial or complete substitution for smoking is controversial and has met strong opposition in the UK, USA, Australia, and other countries. However, the UK has adopted the internationally ground-breaking policy of promoting electronic cigarettes as a tobacco harm reduction strategy, a policy substantially underpinned by our research^1.iii [A; D pp1, 4 & ref 2; E pp5, 7 & ref 4]. The Tobacco Control Programme Lead for PHE states that “The research and evidence synthesis carried out by the Nottingham group has been fundamental to the adoption and endorsement by PHE of vaping as a reduced harm substitute for smoking” [A]. The 2016 RCP report^1.iii advocated promotion of electronic cigarettes to replace smoking and was quoted verbatim in the Introduction section of the 2018 House of Commons Science and Technology Committee report on e-cigarettes [E p5 & ref 4]. The UKCTAS submission to the Committee, led by Britton, which cites our research, commissioned by PHE and the RCP, was also quoted verbatim [E pp7, 18] and cited extensively throughout the report [E], which concluded, as our reports and submissions advocated, that e-cigarette use should be promoted as a harm reduction strategy. The UK is now a world leader in encouraging vaping instead of smoking and has seen greater annual reductions in smoking prevalence than the USA (where vaping is not medically endorsed) or Australia (where vaping nicotine is prohibited).

Smoking in English prisons: Our 2015 report on indoor air quality for the National Offender Management Service (NOMS) (which was subsequently published as a peer-reviewed article⁸), demonstrated high levels of tobacco smoke exposure in prisons. This led to NOMS commissioning an independent organisation to repeat and corroborate our findings and to cite both sources as evidence to justify English prisons becoming smoke free since March 2016 [A, F.1, F.2a, F.2b].

Legislation prohibiting smoking in cars carrying children: The 2010 RCP report Passive smoking in children^1.i was cited by the Department of Health in their consultation on this legislation [G p4 & ref 2], which was enacted in 2015.

IMPACT ON NHS SMOKING CESSATION PRACTICE

NHS stillbirth care bundle: Our review of smoking in pregnancy and stillbirth risk⁴ was underpinning evidence for the 2016 introduction of ‘opt-out’ smoking cessation provision as routine within NHS antenatal care (as a core element of the ‘Saving Babies’ Lives Care Bundle’ for reducing stillbirth) [H.1 p13 & ref 7]. An independent ‘care bundle’ evaluation found that implementation across England resulted in a decrease of 20% in stillbirths per year (approximately 600 fewer) again citing our review [H.2 p34 & ref 17]. Our review was further cited as core rationale for reducing smoking in pregnancy in version two of the care bundle (2019), designed to reduce perinatal mortality [H.3 p24 & refs 25 & 27, p68].

Changes in guidelines on NRT use globally: In 2012, the World Health Organisation (WHO) asked us to share findings from our, then unpublished, Cochrane systematic review on NRT in pregnancy³ which we were conducting. This featured prominently in WHO Recommendations for the prevention and management of tobacco use and second-hand smoke exposure in pregnancy [I.1] which concluded there was insufficient evidence for recommending NRT in pregnancy and called for further research. We updated the review with new trials and showed NRT is effective (published 2015).³ The impact of this work continues; our updated review now justifies pregnant women’s NRT use in European guidelines as well as those from the United Kingdom, Australia, New Zealand and Canada [I.2-8]. In the UK, in 2015 before the updated review was finalised, influenced by efficacy data from our major NRT trial², NICE proposed an update to UK guidance on NRT in pregnancy [I.9]; this update is ongoing (due 2021).

Design and delivery of smoking cessation support in secondary care settings: Service design and costing proposals for cessation services, summarised in the 2018 RCP report^1.iv, drawing on our 2013 trial⁵ and similar models developed in Ottawa were cited in the 2018 NHS Long Term Plan [A, C p35 & ref 29]. Our work on provision of cessation services in mental health settings and the March 2013 RCP report Smoking and mental health^1.ii were heavily cited in PHE implementation 2015 guidance for commissioners and providers of mental health services [J p7, refs 3&7]. Our Cochrane review of NRT in pregnancy³ and NRT trial² feature prominently in two evidence reviews [K.1, K.2] for the Nov 2013 NICE guidance PH48 [K] and justify the recommendation to offer NRT to pregnant women who are unable to stop smoking with the aim of reducing cravings for cigarettes during hospital stays [K recommendation 6, p13].

NHS health professional training and development of the first Standard Treatment Programme tailored to pregnant women: Our impact on NHS training is detailed in the evidence letter from the Chief Executive of the National Centre for Smoking Cessation Training (NCSCT) [L.1]. Our consensus on how to support pregnant women to stop smoking⁷, produced in the Supporting Smokefree Pregnancies (SSP) project with the NCSCT, was used to formulate the first ever NHS Standard Treatment Programme (STP) for smoking in pregnancy [L.2] and to update NHS staff training for treating patients according to this [L.3]. NCSCT used emergent project findings to underpin the STP and changed 3 NHS online training packages and a face-to-face training course by incorporating key consensus recommendations⁷. Before being permitted to support pregnant smokers, UK health professionals must successfully complete NCSCT training modules or courses and follow the STP, hence, our work substantially underpins current NHS clinical practice. The Chief Executive of the NCSCT states “The SSP project findings have substantially helped the NCSCT to improve the quality of stop smoking support for pregnant women. […] the NCSCT guidance for standard treatments and interventions delivered to pregnant women have been significantly improved based on the evidence-base developed by the SSP project. […] the SSP project findings will continue to impact on pregnant women who are helped to stop smoking by the NHS for years to come.” Training modules were revised by November 2018; before then, 33,751 NHS professionals had completed these and, by October 2020 10,208 had completed new versions [L.1]. Similarly, prior to course curriculum changes around 1,500 health professionals completed interpersonal training courses and between November 2018 and October 2020, 390 have done so [L.1].

Awards/prizes

Britton listed in Health Services Journal top 100 clinical leaders for innovation, 2015

Coleman, 5-year Senior Investigator Award from National Institute for Health Research, 2017

(E = evidence source)**

Summary: We have developed and tested a pharmacist-led IT-based i ntervention to reduce clinically important medication errors in primary care (PINCER). PINCER has been widely implemented in general practices across England with reductions in hazardous prescribing, particularly prescribing associated with increased risk of gastrointestinal bleeding. PINCER’s impact in making primary care prescribing safer for patients has been demonstrated in its rollout to 39% of general practices in England. Its expansion continues, maintaining comparable reductions in medication errors to the original research study,⁴ which we have managed to replicate at scale and pace.

a. Development of a PINCER replication model (E1): Since 2017, PRIMIS at the University of Nottingham ( https://www.nottingham.ac.uk/primis/) has been funded by the Health Foundation to work with Spring Impact ( https://www.springimpact.org/), a non-profit global leader in social replication, to implement their systematic five-stage process to design a replication model for the scale and spread of PINCER using a social franchising approach

( https://www.health.org.uk/funding-and-partnerships/programmes/exploring-social-franchising) (E1). Social franchising involves enabling another team or organisation to deliver a proven intervention to agreed standards under a franchise agreement, with the primary aim of maximising social benefit. As a result of this work, in 2018 PINCER was selected by the AHSN Network for national adoption and spread ( https://www.ahsnnetwork.com/about-academic-health-science-networks/national-programmes-priorities) whereby PRIMIS acts as “Franchisor” and the 15 AHSNs in England act as “Franchisees”.

b. Organisational and clinical impact of PINCER (E2-E7): As of 7 December 2020, the scale and scope of the national rollout of PINCER was as follows:

• 104 (77%) CCGs in England had participated (E2).

• 25,545,538 individual patient records had been searched to identify those at risk of medication error using 13 prescribing safety indicators (E3).

• 2,688 (39%) general practices had implemented PINCER and had uploaded anonymised aggregate baseline data to the PINCER CHART Online comparative analysis service (E3).

• 206,109 patients had been identified as being at risk of at least one medication error prior to PINCER implementation (baseline) giving an overall prevalence of 8.07 patients at risk of medication error per 1,000 registered patients (E3).

In terms of clinical impact (as documented in our PINCER progress report: E4), analysis of follow-up data over a 15-month period (between December 2018 and March 2020) relative to baseline from 1,060 practices showed (pp 4-5, 59-65; E4):

• A decrease of 13,387 (14%) in the number of patients at risk of at least one medication error (92,762 patients at baseline; 79,375 patients at follow-up).

• Greatest reductions for errors associated with GI bleeding, which showed a decrease of 10,559 (26%) patients (40,720 patients at baseline; 30,161 patients at follow-up).

Given that PINCER focuses on ameliorating some of the most important prescribing errors, it is likely (based on the evidence presented in section 2) that the intervention will have reduced medication-related hospital admissions and patient harm. Indeed, the Deputy Chief Pharmaceutical Officer for NHS England states: “I am in no doubt that PINCER will have prevented hospital admissions and patient harm in England” (E5).

One of the key strengths of the national rollout of PINCER has been the ability for general practices, pharmacists and named individuals at CCGs to access comparative views of numbers of at-risk patients using the PRIMIS CHART Online comparative analysis service, including time-trended analyses ( E6). Over time, as more and more practices have been participating in the national rollout of PINCER and uploading their summative data to CHART Online, the facility has been providing a national picture of medication safety thus enabling localities to prioritise areas for their own improvement as well as evaluating the impact of the PINCER implementation. For example, in Wessex AHSN, PINCER was implemented in 236 (94%) general practices. The Clinical Lead Medicines Optimisation (MO) with Wessex AHSN and Clinical Lead for National MO Programme says: “This has given us a robust baseline measure of medication safety but more importantly, when practices implemented the PINCER intervention, we had 3,441 fewer patients at risk from clinically significant medication errors compared to baseline” (E7).

c. Upskilling the primary care pharmacy workforce (E8): As part of the national rollout, PRIMIS has been providing a comprehensive training package to support pharmacists to deliver the PINCER intervention, based on the training materials developed as part of the PINCER trial.⁴ To date, a total of 2,032 health care professionals (1,505 primary care pharmacists, 153 primary care pharmacy technicians, 176 GPs, 48 practice managers and 150 CCG/other primary care staff) have been trained to deliver the PINCER intervention through a combination of eLearning tools, online resources, live webinars and face-to-face action learning set sessions (E8). To meet demand for training, we have developed a Train-the-Trainer model to enable 8 AHSN Training Partners and 5 University of Nottingham contracted Training Associates to deliver training on our behalf.

d. Integration of PINCER indicators into third party software solutions (E9): In response to findings from the evaluation of the Health Foundation Scaling Up PINCER project in the East Midlands,⁷ PRIMIS has produced system searches that are embedded within the major GP clinical systems used in England such as EMIS WEB and The Phoenix Partnership (TPP) SystmOne. PRIMIS has developed a process for other IT system providers to embed the national PINCER indicators in their computer software. As a result, the University of Nottingham has licensed the national PINCER prescribing safety indicators to 4 major third-party suppliers for the purposes of implementing the PINCER indicators via their own software (E9). For example, the PINCER prescribing indicators are now embedded in First Databank’s clinical decision support software ‘Optimise Rx’ to improve patient safety by alerting clinicians to potential medication error at the point of prescribing

( https://www.fdbhealth.co.uk/company/press-releases/2020-02-11-fdb-partner-with-primis). Optimise Rx software has been rolled out to over 4,000 general practices in England covering more than 38,000,000 patients ( https://www.fdbhealth.co.uk/solutions/optimiserx).

e. Incorporation of PINCER into national Medicines Optimisation policy and guidance (E10-E16): Since 2015, PINCER has been incorporated into the NICE ‘Medicines Optimisation Clinical Guideline’ published 04 March 2015 (pp13,15; E10). This means that general practices throughout the country are encouraged to use the intervention. In 2017, the World Health Organisation identified ‘Medication Without Harm’ as the theme for their third Global Patient Safety Challenge which aims to reduce severe avoidable medication-related harm by 50% globally in the next 5 years. In response to this challenge, the NHS Business Services Authority produced a Medication Safety Dashboard incorporating the PINCER indicators for GI bleed (p44; E11). The Dashboard links prescribing data in primary care to hospital admissions to help the NHS monitor and prevent errors.

In January 2019, NHS England published “Investment and evolution: A five-year framework for GP Contract Reform to implement the NHS Long Term Plan”. Prescribing safety was a new quality improvement (QI) domain in the contract, with practices incentivised to demonstrate continuous quality improvement in relation to prescribing safety. The Framework stated (pp22, 103, 106; E12) “the nationally-backed rollout of the pharmacist-led information technology intervention for medical errors (PINCER or equivalent) by the AHSNs” as 1 of 4 key areas for Quality Improvement. As highlighted in the 2019/20 GMC Contract Quality and Outcomes Framework (QOF) Guidance (p101; E13) practices were encouraged to engage AHSN support for PINCER implementation to improve prescribing safety and achieve the QOF points for this domain.

PINCER has also been identified as an evidence-based approach to reducing a range of medication errors as part of the mandatory quality improvement project in the new General Medical Services (GMS) Contract Wales: QI Framework 2019-20 (pp22-23; E14). In July 2019, the NHS Patient Safety Strategy (pp17, 51; E15) highlighted PINCER as one of its Medicines Safety Improvement Programmes to “support work to reduce prescribing error rates by 50%, improving safety and reducing costs” and stated that “AHSN-supported national roll-out will reach at least 40% of GP practices [in England] by 2020.” In September 2020, the Network Contract Directed Enhanced Service Structured Medication Reviews and Medicines Optimisation Guidance cited PINCER as “an evidence-based intervention that reduces the risk of harm from clinically significant medication errors” and highlighted PINCER as a tool to help clinicians to identify patients who would benefit most from receiving a Structured Medication Review (pp5,17; E16).

f. National awards (E17): In recognition of our work, the team was shortlisted from 800 teams across the NHS Midlands and East and selected as regional winner in “The Excellence in Primary Care Award” category of the 2018 NHS70 Parliamentary Awards ( E17.1). The team was also shortlisted for the HSJ Patient Safety Awards 2020 in the category of Patient Safety Team of the Year, recognising our “outstanding contribution to healthcare through the national rollout of PINCER” ( E17.2; p61; E17.3).

(Superscript=section 3 references, E=evidence source)

a. Influencing national policy on provision of home safety equipment (E1-5)

Our research on the effectiveness of home safety education and safety equipment provision had a major impact on recommendations about home safety assessment and safety equipment provision across several national policy documents (see below). Our 2015 survey shows wide use of these documents by local authorities: 75% using National Institute for Health and Care Excellence (NICE) PH29/30 and 57% using Public Health England (PHE) guidance in decision making about child injury prevention work.

The evidence underpinning NICE PH29/30 2010 was updated in 2015, citing 14 new papers⁽⁶⁾, all from our research group ( E1 pp5-10). For example, our TMV study³ strengthened evidence supporting existing recommendations on their installation: “This study [reference 3] provides new evidence of specific interventions to prevent scalds in children. This evidence supports PH29 recommendation 9 and PH30 recommendation 3 on installation of TMVs in social and rented dwellings” ( E1 pg6).

Public Health England’s (PHE) 2018 local authority guidance “Reducing unintentional injuries in and around the home among children under five years” cites 14 of our papers^2,6 and our implementation resources⁶ ( E2 pp4-7,13,14,18,19,26, 28-32), e.g. our Cochrane review demonstrating effectiveness²: “ Research [reference 2] shows that providing safety education and free or low-cost safety equipment is effective in improving home safety and can reduce inequalities in some home safety practices” ( E2 pg19).

The 2018 English National Accident Prevention Strategy cites 6 of our papers^2,6 ( E3 pp15,19,26,27,59,60); e.g. our Cochrane review²: “E vidence [reference 2] has shown that the most effective interventions are those that provide education alongside home safety checks and the provision and fitting of various items of safety equipment in the home” ( E3 pg19). In addition, DK/EO were members of the National Accident Prevention Strategy Advisory Group. Our Cochrane review was also cited in NHS Health Scotland’s 2017 Unintentional injuries and home safety guidance² ( E4 pp4,11). In 2013 the Chief Medical Officer ( E5 ch3 pp13,40; ch6 pp4,11) cited our research^2,4 as evidence of effectiveness and cost-effectiveness of education and safety equipment provision, making a new policy recommendation for implementing home safety recommendations in NICE PH29/30.

b. Influencing national and international provision of home safety equipment (E6-9)

English Hospital Episode Statistics show a decrease of 18% in hospital admissions nationally for child home injuries between 2013/14 (unable to disaggregate; n=46,895) and 2019/20 (n=38,571). Home safety equipment schemes contributed substantially to this reduction, as shown by our independent evaluation of the national scheme which demonstrated a significant reduction in hospital admission rates following the scheme ( E6, pg 5). Our survey of local authorities shows these schemes are widely implemented, with 43% of local authorities in England and Wales having a scheme in 2015. Many schemes cite our research as underpinning evidence, e.g. the Scottish home safety equipment scheme. The Royal Society for the Prevention of Accidents (RoSPA) confirmed *“research carried out by Nottingham University on home safety education, home safety checks and home safety equipment provided much of the UK evidence on which the Scottish home safety equipment scheme was based.” ( E7.1)**. Between April 2013 and June 2014 (unable to disaggregate), 900 families benefitted from the scheme ( E7.2 pg23). A similar scheme in Ontario, Canada provided equipment to 3,458 families, from April 2013 to March 2015 (unable to disaggregate), resulting in a significant reduction in emergency department attendances for home injuries (p=0.01) ( E8 pp535-6). This ongoing programme was explicitly based on our Cochrane systematic reviews^2,5: “interventions providing safety equipment seem to be more effective in improving some safety practices than those not doing so.[ references 2,5] Based on these findings…. we developed a home safety program*” ( E8 pp533,540). Our TMV trial^3,4 was a research collaboration with Glasgow Housing Association (GHA), who subsequently fitted 24,000 homes with TMVs in 2011. GHA has been taken over by the Wheatley Group, who manage 93,7000 affordable homes in Scotland and have fitted TMVs in bathroom refurbishments in a further 1,929 homes between April 2015 and March 2020 ( E9).

c. Influencing international policy and provision of parenting and home visiting programmes (E10)

Our systematic reviews of parenting and home visiting interventions demonstrating significant reductions in child injuries⁵ provide evidence underpinning Israel’s injury prevention programme in 9 hospitals reaching more than 3,000 families between April 2013 and December 2014 (unable to disaggregate) ( E10.1 pp2,10, E10.2 p10), and Maternal, Infant, and Early Childhood Home Visiting Programs in the USA, e.g. 4,587 families in New Mexico in 2017 ( E10.3 pp1,24) and 1,184 families in Utah in 2016 ( E10.4 pg1; E10.5).

d. Informing national and international practitioner guides (E11,12)

Our research, Injury Prevention Briefing (IPB) and commissioners’ guide have informed home safety recommendations in international and national practitioner guides. DK made a substantial contribution to PHE’s 2017 “Preventing unintentional injuries: A guide for all staff working with children under five years” which cites 3 of our papers⁶ ( E11.1 pp3,17,19,20) as evidenced by the Child Accident Prevention Trust (CAPT) stating “Nottingham had extensive input into the evidence-based safety advice and safety messages, drawing on findings from the Keeping Children Safe Programme.[reference 6] Members of the Keeping Children Safe team also attended each of the four launch events, setting out the evidence base for the safety advice and safety messages in the guide. When we promoted the PHE guide in a recent CAPT e-bulletin, there were 428 unique views of the article by a range of professionals” ( E12).

Our research informed the Institute of Health Visiting Local Authority Child Public Health Briefing: The Health Visiting contribution to Child Accident Prevention in 2016 which cites 6 of our papers,^2,6 ( E11.2 pp1-6) and the New Zealand’s Ministry of Health “Well Child Practitioner Handbook” in 2014 which cites our Cochrane parenting review⁵ as good evidence stating “ See Kendrick et al 2013 [reference 5] for good evidence that injury prevention activity reduces unintentional injury in children and can improve home safety” ( E11.3 pp151,155). Our research also informed the Canadian Injury Prevention Resource in 2015 which cites 6 of our papers^1,5,6 ( E11.4 pp52,54,268,278,377,383,400,404,405,408) and the US Children’s Safety Network Resource Guide for Preventing Unintentional Medication Poisoning in Children in 2016 which cites 3 of our papers⁶ ( E11.5 pp5,6,9).

e. Informing international injury prevention strategies (E13)

Our research informed international strategies including Child Unintentional Deaths and Injuries in New Zealand and Prevention Strategies in 2015 which cites 4 of our papers² ( E13.1 pp47,59,71,77,90-93); the New South Wales Child Safety Good Practice Guide: Good investments in unintentional child injury prevention and safety promotion in 2016 which cites 14 of our papers^1,2,5 ( E13.2 pp23,41,42,44-46,48,52,53,55,60,61,114,116) and the European Child Safety Alliance’s Child Safety Reference Frameworks for evidence-based injury prevention strategies in 2014 which cites 5 of our papers^2,5( E13.3 pp6-8,14,15).

f. Developing resources for practitioner use (E11.1, 12, 14)

As a result of our research⁶ we produced: (i) a 75-page IPB in 2014 for practitioners, including 11 evidence-based home safety activities for use with families, which has been endorsed by NICE; (ii) a 32-page guide for commissioners of children’s services in 2016 distributed to local authorities in England and health boards in Wales and by CAPT via targeted mailing to their subscribers; and (iii) evidence-based home safety checklists, monthly safety messages and safety sessions at Children’s Centres for families in disadvantaged areas in Nottingham: Between October 2017 and June 2020, 4,451 families completed checklists, 24,400 home safety messages were distributed, 440 families attended safety sessions and 950 received home safety visits from family mentors using our evidence-based resources ( E14).

The IPB and commissioners’ guide are extensively cited by PHE’s 2017 practitioner guide ( E11.1 pp19,20) and promoted by the Institute of Health Visiting where they are the first 2 resources on their accident prevention resources page and the commissioners’ guide is described as “the first of its kind”. Their usefulness is evidenced by CAPT stating in 2017: “ This has been Nottingham University’s strength: disseminating findings with clear implications for practice through a range of formats and channels, including working in partnership to extend the reach of your work” and “Our links with public health, health visiting and early years services… show that all three of the outputs mentioned above [IPB, commissioners guide and PHE practitioners guide] are useful to practitioners and commissioners, enabling them to easily integrate evidence-based approaches into their work. We continue to promote them as key resources to support child injury prevention in the UK” ( E12).

g. Training health and social care professionals (E14-16)

We developed and delivered child home safety training focussing on use of the IPB (resulting from⁶) for 550 health and social care practitioners and family mentors in 4 sites in England (Nottingham, Bristol, Newcastle, Norwich) between 2014 and 2020 ( E14-16). The 2015 Nottingham evaluation shows 90% of practitioners increased knowledge and 87% increased confidence in home safety promotion. Three months later, practitioners had used each of the 11 home safety activities with between 100 and 250 families and at least 96% of practitioners found each activity to be useful/very useful ( E15 pp3-5). The 2016 Bristol evaluation showed using the IPB enabled discussions with parents about home safety ( E16 pg6), e.g. *“nice easily adaptable activities and guidance which get parents to think about dangers through the eyes of a child” and “encouraging parents to be aware of child development…promoting parental observation and encouraging them to be one step ahead” and increased practitioner confidence, e.g. “it has filled me with confidence in advising parents and families on how to prevent injury/accidents”. Our IPB is also extensively cited in module 2 of the Institute of Health Visiting 2015 online accident prevention training package.