Impact case study database

Hull’s research impact has demonstrated conceptual and practice-based knowledge with positive outcomes. Outlined below is how it has: changed professional thinking about ‘behaviour in dementia’, through implementation of guidelines and toolkits ( 4.1); improved approaches to meeting psychosocial needs of people and carers, thus reducing the need for psychotropic drugs ( 4.2); provided a suite of online digital support tools ( 4.3) and; benefitted people affected by dementia through changes in public perceptions of dementia care ( 4.4).

4.1. Changing the thinking around perceived care challenges

Hull research has informed the NICE guidelines since 2006. Coinciding with the NICE update in 2018, the British Psychological Society (BPS) launched a “Call for Action”, highlighting the still unresolved need for specialist practitioners to support care homes and families in implementing non-pharmacological alternatives to psychotropic medicines, based largely on Hull’s research (E1). The BPS also commissioned a team of clinical experts to prepare a toolkit for multi-professional teams to apply the new evidence, including Hull’s seminal findings, on the management of CB. The BPS endorsed this guidance with circulation to 609 UK NHS specialist dementia care clinical psychologists (October 2019) and made it freely available to download (E2). This has influenced thinking across the NHS: A Quality Improvement Manager, NHS England/NHS Improvement (NE and Yorkshire) says: ‘ Thank you colleagues at Hull University for work on the dementia behavioural guidelines programme (London 2019) and disseminating this at our oversubscribed ‘Whole system’ event Leeds (June 2019) ( E3i); * Hull’s Challenge Demcare e-learning has been adopted by many from our 550 strong practitioner-network; we are piloting the CLEAR © training and Hull’s CBS tool in care homes’ (E3ii).

4.2 Customised non-pharmacological dementia care for managing CB

Professionals tended to misunderstand and miss the huge burden of clinically significant CB in family care, which therefore remained ‘hidden’ until it was too late to prevent breakdown of home-care, so antipsychotic drugs were commonly prescribed. Hull’s research has provided knowledge-based tools to better identify support-needs for this previously missed cohort, and also for those at risk in care homes. The Challenging Behaviours Scale (CBS) care-home tool was adopted by 78 registered NHS service locations across the UK (2016-2019). Hull’s website, where the tools are freely available, had 489 visits (11.08.20 - 31.12.20) to access the CBS care-home tool and its equivalent for family care. Feedback on the tool has been extremely positive, e.g. Two service users state, ‘ Repeat CBS is used to evaluate final outcome’; ‘in care homes we will go back and evaluate what difference there has been and use the CBS score’. ( E4). NHS services in Scotland and Northern Ireland have adapted the CBS for their services ( E5). Thus, Hull’s diagnostics protocols allow for timely recognition of clinically significant care-needs, and also enhance resolution of challenges before these become so burdensome that care breaks down. The wide adoption stems from the fact that the protocols are written in the everyday language of carers, with psychometrically sound cut-off points for the recognition of clinically significant CB and focussed behaviour support plans for family and care home settings. A Trust-wide Pathway Lead for Psychological Intervention, (Cumbria, Northumberland, Tyne and Wear NHS FT) writes: ‘ A particular strength of Hull’s work has been its focussed ‘easy to use’ behaviour support care plans, tailored to the individual health and psychosocial needs of the person with dementia with additional targeting of support needs of family carers and care home staff.’ (E6).

4.3 A digital repository of support for the management of behavioural care

As CB was previously not recognised as a clinically-defined dementia ‘care-need’, specialist professionals struggled to support families and care-homes effectively. The Hull team developed a website to create a digital platform for making best practice training and resource tools widely available. An online tool-kit is available alongside a digital training programme; the latter has received over 1000 viewings for some products (as of 31.12.20). The platform includes, the interactive, real-life, video-based e-learning tool for producing personalised care plans, completed by 541 registered users (11.08.2020-31.12.20). The Head of Quality Improvement & Research from NHS Vale of York Clinical Commissioning Group writes: ‘..your e-learning is absolutely fantastic! I have shared with York network - all 525 CCG staff, care homes, domiciliary providers and wider (local authority/acute/ primary care/ mental health etc)’ (E7i). The community feedback of videos such as ( “ Mick shouts for Lilly and aggressive with carers”), are widely appreciated as they easily communicate the huge struggles that people with dementia and carers can face: feedback from a Core Psychiatry Trainee: ‘I found it really helpful to review why people become aggressive or display certain behaviours and actually rather than putting it all as due to dementia, often there is a very clear, personality and lifestyle related reason which we can make practical steps to address’.( E7ii). During the COVID 19 pandemic, the website's digital material functioned as a ready-made template for shifting training resources online. For example, the Newcastle Communicating and Interacting Training (CAIT), intervention for dementia practitioners, included much of the functionality from the Hull website into their own COVID online training animations on behavioural care-challenges (31.12 20 almost 7,000 views). ( E6 & E8)

4.4 Empowering people with dementia, their families and the public to manage the perceived behavioural changes associated with the condition

The research findings have been widely disseminated beyond scholarly journals. For example, Moniz-Cook was invited to speak at the 2018 Latitude Festival (a rock festival with 35,000 attendances), addressing issues around preventable behavioural challenges in dementia ( E9). Hull’s research has stimulated widespread discussion and debate about the terminology. Moniz-Cook was invited to present a symposium at the Alzheimer Europe conference (The Hague, October, 2019) attended by 954 participants from 46 countries ( E10i). Worldwide debate on language followed the symposium, involving people with dementia such as the #BanBPSD campaigners, the European Working Group for people with dementia and individuals such as an individual who lives with dementia and blogs about her experiences with over 3,000 followers noticed. In January 2020 at the launch of Hull’s work on the Power of Language she wrote: “ I’ve had long held views about the language used by professionals. My pet hate is ‘Challenging behaviour’…which makes us out to be at fault instead of others simply not understanding our distress.” ( E10ii). This work gathered international ‘voices’ of people with dementia (54), carers (229) and stakeholders (378) to re-shape language and enhance positive practice.

Moniz-Cook presented Hull’s international collaborative research at the first dementia summit (February 2020) attended by > 80 leaders, live streamed to > 700 participants across the UK. The organisers commented, ‘ This session was one of the most popular during the day for our online audience and we have been asked by many to share footage of the session’ ( E11). Since the start of the REF period in 2014, when Moniz-Cook was the winner of the NHS Innovator of the year ( E12), Hull’s research has helped change thinking and actions from simply responding to behaviour, to understanding the psychosocial needs of people with dementia and carers and offering tailored support. The diligent work of everyone caring for people with dementia, is slowly shifting the public debate around dementia and how distress can be alleviated ( E13). In 2020 the National Institute for Health Research recognised the distress faced by people with dementia and the needs of care homes, and awarded £1.2 million to support the widespread adoption of our approach thus continuing the impact into the future ( E14).

The major impact of our research has been to characterise chronic cough as a disease distinct from asthma and Chronic Obstructive Pulmonary Disease (COPD) and to develop methodology to study it; subsequently, this has allowed drug development in a new therapeutic area. Hence, pharmaceutical companies have novel products in which to invest, and most importantly are able to bring relief to previously undiagnosed and untreatable patients.

2.1 & 2.2 Disease classification and Patient benefit

The simple diagnostic questionnaire, Hull Airway Reflux Questionnaire (HARQ), which the Hull team developed is now validated in 39 different countries and is available in 20 different languages. It is freely available online on ISSC.info; 8,546 UK patients accessed and completed the questionnaire in a single year (Evidence 1). In 2020, the use of these online resources was endorsed in the new International Guidelines (Evidence 2). The relief afforded to patients, who are able at last to understand their symptoms as cough hypersensitivity is difficult to understate (Evidence 3).

Patients who were previously dismissed as neurotic because no clear label could be attached, can now be told they have cough hypersensitivity, a disorder of the vagal afferent nerves. Such patients have usually undergone multiple investigation such as endoscopy, CT scan and challenge testing only to be told there is nothing wrong. Inappropriate treatment in the form of anti-asthma, antibiotic, or anti-acid therapy is prescribed, frequently on a long term basis. One patient’s account is detailed as an example of the huge impact the Hull team’s work has had: “ I have suffered from all the symptoms you describe in your article, to a chronic degree for the last 7 or more years. I have seen so many consultants and specialists they are too numerous to mention. I have undergone all the tests relating to this problem several times over and have taken all the prescribed medications for reflux to no avail and I am still no nearer any sort of a fix. I am depressed and anxious (medicated) due to the worry of the condition of my lungs, airway and throat and the possibility of long term damage or even cancer. ... Your article is the first time in those 7 years that I have seen a diagnosis that entirely matches my symptoms! I am elated ...” (Evidence 4).

The international guidelines provide guidance to clinicians, impact positively on the patient pathway, decrease the chances of costly risks associated with cough management, i.e. CT scan induced breast cancer, and provide effective advice on often unconsidered therapeutic options (Evidence 2).

2.3 Developing new drugs for chronic cough

Hull’s work, defining at least two different pathways for the pathophysiology of chronic cough, explained why several costly clinical studies blocking the irritant receptors failed in the clinic, as a result of these findings drug development by GSK has now been abandoned. The Clinical Development Director of GlaxoSmithKline stated, “This study investigated the efficacy and safety of GSK2798745 (a TRPV4 inhibitor) in patients with chronic cough. The results of this study allowed a clear decision to be made regarding termination of development of this compound in this indication. The impact of this work was that there was a cost saving to the project with spending until study completion not required. Because of the specific design of the study, the work also prevented unnecessary recruitment of patients to a study with an ineffective drug.” ( Evidence 5).

Conversely, Hull’s research has led to the substantial investment in the development of a series of effective, novel, therapeutics by various other pharmaceutical companies. Afferent Pharmaceuticals were the first to develop an effective agent blocking vagal afferent hypersensitivity; Gefapixant (AF219/MK7264) was trialled in several phase 2 studies where Prof Morice advised on the study design and conduct. As a result of further studies on Gefapixant, Afferent Pharmaceuticals was acquired by Merck, a major global pharmaceutical company. The commercial decision was attributed in part due to Hull’s research data ( Evidence 6). The deal involved an immediate payment of $500 million, with a further $750 million payable when the drug was licensed by the US Federal Drugs Agency (application in progress). Prof Morice has continued to work with Merck and indeed was responsible for providing the advice as to the primary endpoint of their pivotal, phase 3, clinical studies (Cough 1 and Cough 2; presented at the ERS Congress September 2020). The Clinical Director of Merck wrote, “Alyn (Prof Morice) has done a wonderful job of helping educate the overall Merck team on the field of chronic cough and he has provided valuable input on the chronic cough clinical program with regards to appropriate endpoint selection, rigorous patient selection, and expert opinion support during the course of the trial.” (Evidence 7).

Finally, first data from Merck’s phase III studies of Gefapixant (Cough 1 and Cough 2), studying over 2000 patients with objectively proven chronic cough, clearly showed the effectiveness of using HARQ as a diagnostic tool. The HARQ score at baseline for these patients was 40/70, whereas the upper limit of normal people is 14; demonstrating for the first-time HARQ’s global utility (Evidence 8).

In anticipation of a UK licencing application for these new drugs the Hull team have been advising the UK’s National Institute for Health and Care Excellence (NICE) as to the correct metrics to use in their assessment of antitussive drugs. Commonly used scores such as Short-form (SF) 35 which measure quality of life (QOL) are inappropriate since patients with chronic cough are rarely physically disabled even if their lives are ruined.

Three other compounds of this new class of drug, exploiting Hull’s research that defined a mechanistic pathway, are currently in phase 2 trials. Bayer, Shionogi, and Bellus Health, have all made multi-million investments in these clinical trials; and Prof Morice is supporting the companies by advising as chief or principal investigator, e.g. “The unique combination of scientific & clinical expertise of Prof. Alyn together with this ability to optimally run and steer clinical studies has informed our research and development programs and allowed us to progress our P2X3 projects to successful demonstrating efficacy in patients with refractory chronic cough(RCC)” ( Evidence 9). Preliminary trial results show treatment success in over two thirds of patients and therefore it is highly likely that the first effective drugs for chronic cough in over 40 years will soon be available ( Evidence 10).

The research impacts are multifaceted, manifesting in the development of improved national and International guidelines ( 4.1), significant improvements in patient treatment and the provision of these services ( 4.2), whilst delivering economic benefits to medical device companies providing minimally-invasive interventions for varicose veins (VV) and vascular leg ulcers (VLU) (4.3).

4.1 Supporting National & International treatment guidelines

UoH research has been used to underpin national and international treatment guidelines both promoting an increase in the number of patients offered treatment and shaping the recommendations of what that treatment should be. Four UoH studies were cited (including References 1 and 4) as significant sources of evidence for the NICE guidelines updated in 2016 on diagnosis and management of varicose veins (CG168) ( Evidence 1i, ii). Prior to this, there was inconsistency about which patients were referred for treatment and about which treatments were most appropriate. The 2001 guidance provided the basis for referral only when VV resulted in complications, and at that point open surgery was the standard intervention. The new guidelines, based on UoH work, introduced two key changes: Endothermal ablation (ETA) is now the preferred first line intervention for VV; and that the QoL and cost effectiveness benefits, mean that the recommendation is for all symptomatic patients to be referred for vascular treatment, irrespective of complications.

In 2015 the European Society for Vascular Surgery released its own practice guidelines for Europe. The UoH studies were again used to support the preferential use of endothermal techniques over all other treatment options ( Evidence 2). In 2018 The Royal Society of Medicine released guidelines on the management of VLUs, and using evidence from the EVRA trial (Reference 7), for the first time these guidelines incorporated a recommendation that all patients amenable for endovenous treatment should receive this, and that it should be delivered expeditiously ( Evidence 3).

4.2 Impact on clinical care and policy implementation

In the UK in 2000 open surgery for VV or VLU accounted for 97% of the surgical procedures undertaken in the UK NHS. By 2019/20 this had dropped to 23%, and ETA had risen to 50% ( Evidence 4). The revised guidelines, based on UoH work, also served to increase the total number of procedures performed. These had fallen from 55,609 in 1998 to 24,300 in 2012, but rose again to 33,439 by 2016. The global trend has mirrored these findings, but with a significantly higher rate of growth overall than seen in the UK NHS ( Evidence 5).

The NHS introduced the mandatory collection of Patient Reported Outcome Measures (PROMs) for a number of treatments in 2009, this included for the treatment of VV. This real-world data demonstrated that following the NICE-approved, minimally-invasive, venous treatment discussed above in section 4.1, over 80% (5,260 of 6,575) patients reported significant improvements in QoL in 2018. This compares very favourably against other healthcare interventions and was not only reflected in disease-specific measures, but also the generic health questionnaire, EQ5D, which demonstrated a significant gain in Quality Adjusted Life Years ( Evidence 6i, ii). These outcomes clearly demonstrate the impact of UoH research on patients, through the adoption into guidelines and thus clinical practice.

UoH policy research has highlighted the barriers in access to care that are present across the UK. This work was included in a recent publication by the All Party Parliamentary Group on Vascular and Venous Disease ( Evidence 7) and the evidence was quoted during a debate on the floor of the House of Commons on 23^rd July 2019 by Ann Clwyd MP. These events and the evidence based guidelines from the Royal Society of Medicine, co-authored by Dr Carradice, resulted in efforts by NHS England to incentivise the care of these patients through the establishment of an NHS CQUIN (Commissioning for Quality and Innovation) scheme. This will support further improvements in the care of patients with VLU nationally ( Evidence 8).

4.3 Benefits to the healthcare technologies sector

The evidence from UoH has helped unlock brand new markets for minimally-invasive technology in the management of VV and VLU, especially through working with Medtronics, the world’s leading medical technology company. The Senior Director of Global Medical Science | Endovenous states “ Minimally-invasive endovenous treatments of varicose veins for chronic venous disease have revolutionized the treatment of patients globally. The University of Hull’s research helped to outline these benefits and drive changes in national guidelines culminating in a change of practice. This technology has subsequently improved the quality of life and outcomes of a large population of patients. As a market leader in catheter based endovenous technologies for treating chronic venous disease, we are focused on innovation and research to expand minimally invasive innovation to improve the quality of life for all patients with venous disease…....Our market estimates that the global opportunity for Chronic Venous Insufficiency (CVI) is over 7 million patients per year, of which nearly 4 million are within the US and Europe.” (Evidence 9) Medical device Industries have continued to refine existing products, Medtronics offer ClosureFast™ and the VenaSeal™, and there has been a proliferation of new companies and technologies all aiming to improve the outcomes and applicability of this treatment paradigm. Thus, there has been a tremendous growth in the global market for these new technologies from a negligible base at the commencement of UoH’s research programme in 2006; the revenue from a single modality of treatment (EVLA) in 2016 was US$ 273.6 million and market analysis predicts that this will grow to an estimated US$ 550 million by 2026 ( Evidence 10).

Research at Hull into chronic breathlessness has influenced clinicians, policy makers, funding bodies and has significantly improved the care experienced by patients and their families. Access to PC and novel symptom control has increased both nationally and globally.

Palliative care beyond cancer

The National Centre for Palliative Care (NCPC) minimum dataset (2015) shows that access to hospice services by people with HF increased to 15% of inpatient admissions, 24% of day care, 29% of outpatients, and 27% of hospital advisory services, from previously non-existent levels ( Evidence 1). In the North East & Yorkshire area, Prof Johnson’s clinical region, providing the UK’s first combined HF-PC service, Public Health England figures (2018) showed that patients dying with circulatory disease had the highest home death rate (an indirect measure of quality end of life care); 56.6% vs national average of 44.8%; (Evidence 2).

Johnson provided clinical academic advice for the NHS/Marie Curie/British Heart Foundation funded “Caring Together” HF/PC Programme in Glasgow. Since 2010, 78 “change-agent” practitioners representing multi-disciplinary teams across Scotland have attended the resulting Scottish government funded course. ( Evidence 3). Also, Johnson was an invited committee member of the National Confidential Enquiry for the Prevention of Deaths (Heart Failure), the report highlights the importance of access to PC in HF in their recommendations. The Scottish Government are using the PC recommendations of this enquiry to inform their new heart disease strategy (Evidence 4).

In view of Hull’s leading reputation, the team were commissioned to produce a Hospice UK/British Heart Foundation position document, detailing clinical priorities in hospice service provision for people with HF. To address the identified need the St James’ Foundation then issued a grant call for hospice-led HF service development project proposals and 17 projects across the UK were funded (total value £500,000) in 2018 ( Evidence 5).

NICE (October 2016, E0070) has endorsed the Hull tool to support national guidelines on Interstitial Pulmonary Fibrosis. Even though there are only about 30 ILD units in the UK, since October 2016 the tool has been downloaded from the HYMS website over 400 times. Furthermore, Johnson has received requests from Melbourne (Australia), Pennsylvania (USA), and Montreal (Canada) for the tool for adoption in their clinical service ( Evidence 6).

Symptom management

Work by Hull researchers on opioids, oxygen and the battery-operated hand-held fan for breath-lessness are now included in 8 (opioids) and 6 (oxygen) clinical guidelines for chronic breath-lessness around the world ( Evidence 7). Hull’s measure of the MCID in chronic breathlessness is the current global research standard. Hull researchers worked with Mayne Pharma and the Therapeutic Goods Administration of Australia for the license of Kapanol™ (a preparation of morphine) to be extended to include people with chronic breathlessness. This is a world-first as the only licensed medication for chronic breathlessness; importantly the government have included it on the public subsidy list to ensure access is maximised. These actions delineate the standard of care and the template for other regulatory bodies to follow, supporting safe access to important symptom control to the millions round the world with chronic breathlessness ( Evidence 8).

Hull’s definition of the concept of chronic breathlessness as a clinical syndrome, was used in an international survey (UK, Australia and New Zealand) which demonstrated that the overwhelming majority of respiratory (89%) and palliative (98.5%) clinicians now recognise chronic breathlessness as a distinct target for treatment. Of note, 75% responding palliative physicians and 41% respiratory physicians recommend oral morphine for breathlessness ( Evidence 9). The Hull definition was also used in a French survey; just over half of patients with COPD had unmanaged chronic breathlessness, bringing a hitherto “invisible” but distressing problem to light ( Evidence 10).

Development of novel ways to access and deliver PC

Hull research is cited in clinical guidelines and policy statements recommending integration of palliative care with HF management. Johnson was a core member of the European Association of Palliative Care’s taskforce which prepared an international position statement, including Australia and North America, regarding integration of palliative care in cardiology ( Evidence 11).

The Hull team have hosted visits from more than 20 leading healthcare professionals from around the world over the past decade; one of these, subsequently became the lead cardiologist for Glasgow’s Caring Together Project and has changed practice in Scotland, “I reconfigured our service to provide an advanced heart failure clinic, working with a nurse specialist, and established a palliative care-heart failure multidisciplinary team meeting between cardiology and palliative care services, including local hospices; both these services were strongly influenced by Johnson’s work”. ( Evidence 12). Another visiting fellow, after 2016 established a palliative care section of the Italian Respiratory Society which has held its first scientific conference in 2019 with 45 delegates; he led an Italian position statement about PC in respiratory disease December 2020 ( Evidence 13).

Based on the research from the AVSU at Hull there has been an international step-change in both the assessment of outcomes and the shift to non-interventional management of IC. This has resulted in significant benefits for patients, practitioners and health care institutions alike. Specifically, there has been a significant change to using patient-focused outcomes as a measure of treatment for IC ( 4.1); widespread adoption of SEP as a non-invasive treatment alternative for IC management ( 4.2); and incorporation of SEP into multiple national and international training guidelines ( 4.3).

4.1 A paradigm shift to patient-focused outcomes in recent and ongoing trials

Research from Hull has underpinned a number of international guidelines that now recommend the use of both generic and disease-specific QoL outcome measures to assess efficacy of intervention in IC ( Evidence 1). Furthermore, our research supported the prioritization of the generic and disease-specific outcome measures in the guidelines update for the management of peripheral arterial disease in 2015 ( Evidence 2). Additionally, Prof Chetter was/is a member of the Trial Management Groups for 3 recently completed/ongoing National Institute of Health Research (NIHR) trials which have all incorporated patient-focused outcome measures. The NIHR HTA “ Bypass v Angioplasty in Severe Ischaemia of the Leg” (BASIL 2) (completed with 345 participants) and BASIL3 (Ongoing until May 2021 with recruitment aimed at 477 participants) trials include generic (EuroQol 5D, Short Form12) and disease-specific (VascuQol, ( Evidence 3i,.ii). The completed NIHR EME “ Does Neuromuscular Electrical Stimulation Improve the Absolute Walking Distance in Patients with Intermittent Claudication” **(**NESIC) trial (192 participants) includes generic (EQ5D, Short Form 36) and disease specific (intermittent claudication questionnaire) as outcome measures ( Evidence 3iii).

4.2 Widespread uptake of SEP as first line intervention for IC

Hull’s research is an essential component of the National Institute for Health and Care Excellence (NICE) clinical guidelines 147 (Diagnosis and management of peripheral arterial disease) which recommend that SEP should be offered as first-line intervention for all patients with IC, replacing angioplasty that should only be offered if a SEP has not produced satisfactory symptomatic improvement ( Evidence 4). Patients that have received SEP report that they are able to walk much “ further without experiencing pain” (Evidence 5i) and that their “ quality of life has improved considerably” (Evidence 5ii). International guidelines in North America, proposed jointly by the American Heart Association and American College of Cardiology ( Evidence 6) and Europe ( Evidence 1) advocate the same treatment plans again based on Hull’s published work.

During the ongoing coronavirus pandemic the Circulation Foundation, the UK's only national peripheral arterial disease charity, recognized the AVSU’s longstanding expertise in the area of SEP research, and asked the unit to produce a booklet detailing home-based SEP for patients in isolation ( Evidence 7i). Ms Rachel Bell, Chair of the Circulation Foundation stated, “... the research undertaken in Hull by Prof Chetter’s team has a huge impact upon our work and is incredibly beneficial to the mission of our charity” ( Evidence 7ii).

4.3 Impacts on healthcare practitioner training and service providers

The UK Specialty Advisory Committee for Vascular Surgical Training has, since 2018, included SEP as the first line therapy for IC into the recent additions of the UK curricula for training vascular surgeons, nurses and podiatrists, thus all new trainees in the breadth of disciplines involved in treating IC are implementing the practice defined by Hull’s work ( Evidence 8i, ii, iii). The Vascular Society of Great Britain & Ireland (VSGBI) produced a document entitled “ The provision of services for patients with vascular disease 2018”, which sets out the principles by which a vascular service should deliver optimal patient care in the UK. This publication was based on the research from the AVSU in Hull and advocates offering SEP to all patients with IC ( Evidence 9). The Past-president of the VSGBI states that the AVSU’s work on SEP has “ revolutionized the thinking of practitioners and available treatment methods” ( Evidence 10). The new training regimens are cost-effective and represent a non-invasive alterative not previously available. Research from Hull highlighted the huge variability in the provision of SEP for IC, which may only be provided by as few as 42% of UK vascular units. As a result of these findings in 2018 NICE released a Quality statement identifying the provision of SEP for IC as a high priority area for quality improvement across the UK ( Evidence 11). Furthermore, the training has been adopted across Europe as this fulfills the current best-practice guidelines ( Evidence 12) .

Similarly, in response to Public Health England’s “Getting It Right First Time (GIRFT)” programme highlighting lack of timely access to services for patients with peripheral arterial disease ( Evidence 13) the Vascular Society of Great Britain and Ireland produced a Quality Improvement Framework(QIF) in 2019 aimed at providing a best practice clinical care pathway for peripheral arterial disease. This QIF includes a target of >90% UK vascular units to provide commissioned SEP within 1 hour travel time for patients with IC ( Evidence 14)