Impact case study database

This research underpinned the creation, piloting and evaluation of a pharmacy-based oral health intervention and an educational intervention to support the development of pharmacists’ roles in the interprofessional management and integration of oral and general health. The health intervention, piloted in late 2016, was offered to adults in receipt of free prescriptions, and consisted of a short demonstration of how teeth should be cleaned, after which patients received supporting information and advice from the Oral Health Foundation, details of local dental providers, and a bag containing a toothbrush, toothpaste and an information leaflet. Five Healthy Living Pharmacies (HLPs) in deprived County Durham communities took part in the pilot. Each pharmacy was asked to deliver the intervention to at least 200 patients; in total, 1,069 patients participated.

The focus of the impact is on the North East because poor oral health is particularly acute in the region; in Sunderland 28.4% of the population have at least one incidence of decay, tooth loss or filling, and in Middlesbrough this rises to 32.1% (national average: 23.3%) [S1]. It has since been extended into other areas.

Impact on patients

Evaluation of the pilot indicated a clear improvement in patient knowledge and intended behaviour, with 72% of the 1,069 patients who took part saying that their knowledge about oral health was now “much better”. One pharmacist reported that “ a lot of people […] actually didn’t know how to do their teeth,” and another said that “ people who thought because they had no teeth anymore, they didn’t have to go back to the dentist.” In addition, 66% said they would definitely change the way they look after their teeth. The majority (64%) of patients also agreed that the pharmacy is the right place to receive advice about their teeth [S2]. Crucially, the intervention reached patients who stand to benefit most; all patients were from deprived communities where at least one incidence of decay, tooth loss or filling (d₃mft > 0) exceeds the national average. Given the relationship between poor oral health and long-term conditions such as cardiovascular disease and diabetes, the population of patients intending to change how they care for their teeth can be expected to show an associated improvement in general health.

Behind these statistics lies a more fundamental change: patients have had a positive experience with oral healthcare. The intervention, using short and spontaneous conversations about how to care for their teeth, reengaged patients in oral healthcare and improves patient trust in healthcare professionals – important for managing dental anxiety, a major barrier to using dental services. Promisingly, 73% of patients said they wanted details of local dental practices, information that was provided by the pharmacy team.

Impact on practice

Staff at the participating HLPs completed training to enable them to provide the recommended advice specified by Public Health England in the Delivering better oral health toolkit. Qualitative interviews with these staff showed that their knowledge had improved after receiving the training; for example, “ One of the things I didn’t realise until I came back was the amount of toothpastes on the market that don’t actually have any fluoride in” [S2]. Other staff have identified how the training augments their professional practice, saying that it helped them to consider how medications may be related to oral health problems, and that they would keep sugar-free medication in mind [S3].

The pilot’s success confirmed that the concept could be replicated more widely. Health Education England covering North East and North Cumbria (HEENE) now offer pharmacy team training in oral health as accredited CPD as continuing support following the pilot. Since 2018 346 pharmacy staff from North Tyneside, Newcastle, Northumberland, South of Tyne, Teesside, County Durham and Carlisle have completed it. HEENE’s Clinical Lead says “ Pharmacy curricula do not typically incorporate oral health training, and this in-service training addresses that gap” [S4]. In response, since 2018/19 the University of Sunderland has integrated this training into its MPharm programme. Through this route , approximately 300 training pharmacists have benefited from this enhanced capacity. Alongside face-to-face training, since 2019 HEENE has delivered oral health training as e-learning modules as well as face to face events to include specialists topic, for example oral cancer [S4]. The unit’s research thus contributes to the development of both the existing and future workforce.

Impact on health policy

The success of the pilot resulted in a change in health policy at Durham County Council. In 2018-19 oral health became a local target for all 109 HLPs in the county, meaning that pharmacies must actively support their patients’ oral health to maintain their HLP status [S5]. Patients do not need to attend the dentist for guidance about oral health, but can access it in a setting they already visit, at a time convenient to them, for free. Since there is one pharmacy for every 4,850 people in England, staff in these pharmacies can prompt as many as 529,000 patients to follow signposting to dental services and take action to prevent the occurrence or worsening of oral health problems, thus also protecting their general health. The British Dental Journal’s editor agrees, saying that the intervention “ highlights how interdisciplinary collaboration can be of great potential benefit to society in general and dental patients, actual and potential, in particular” [S6].

Context

Bariatric surgery is a widely used intervention; over 1.8m surgeries were performed between 2008-16 worldwide, and annual numbers show a steep upward trend. Bariatric surgical research and practice typically focus on clinical outcomes such as weight loss and disease improvement, overlooking the impact of non-clinical factors on patients’ lives after surgery. As one bariatric surgeon says, “ *We as physicians and surgeons are very focussed on the medical changes to our patients after bariatric surgery **[… ] and seldom stop to analyse and reflect on the impact of the social aspects” [S1]. There is an implicit assumption that as weight is lost, patients feel better and everything in their lives falls into place [S2]. Graham’s work for the first time brought patients’ perspectives and the effects of surgery on their everyday lives firmly into multi-disciplinary bariatric care.

Impact

Graham’s research was undertaken in collaboration with clinicians and has been disseminated globally through articles in journals and professional publications, academic and practitioner conferences and patient events. Its impact extends from improved professional understanding to improved patient health and wellbeing after bariatric surgery (see diagram for overview). The eight clinicians who provide testimonials for this case study estimate that, since 2016, 555 bariatric surgeons, nurses, pharmacists, psychologists and nutritionists in the UK, Mexico and India have changed how they work as a result of Graham’s work [see breakdown in Section 5]. This includes clinicians based in Sunderland, which has one of the busiest bariatric units in the UK, and Tijuana, where 12,000 surgeries are carried out on patients from Mexico, the USA and Canada per year. They estimate that 2,550 of their patients have benefited from this research [see breakdown in Section 5]. Extrapolating from a median of 200 patients per clinician, approximately 111,000 patients around the world have benefitted. Graham is embedded in the bariatric surgical communities in the UK, India and Latin America, and these impacts result from purposeful engagement with patients and clinicians before, during and after the research.

Professional knowledge has been enhanced

Bariatric surgical clinicians have a new understanding of the social aspects of bariatric surgery and their huge importance to patients. Practitioners across the care pathway report increased awareness [S3, S1, S2, S4, S5, S6, S7]. One bariatric surgeon in England describes the research’s “phenomenal impact on our understanding of the importance of taking the non-clinical aspects of bariatric surgery into our professional practice” **[S4]. A bariatric nurse in England recognises that she didn’t realise how social factors affect patients, and that she “was unaware of how important to the patients this was.” As a result of Graham’s research, she says “I better understand what patients think about in everyday life, and that even the smallest things which most people take for granted […] are much more complex and fraught with risk than I thought” [S2]. Clinicians report improvements in their own practice from this knowledge, being able to “prepare patients for the changes that surgery brings, thereby increasing their quality of life, and giving them knowledge and confidence to deal with situations new to them”. Graham’s research also identified the need for pharmacists on multidisciplinary teams. As one patient advocate explains, Graham’s research clearly illustrates that *“the information and support provided by a pharmacist, given the changes to medication and lifelong vitamin supplementation, is crucial” [S5]**.

Practice has improved

Bariatric surgical clinicians around the world have used Graham’s research to transform their pre- and post-surgical practice [S3, S1, S2, S4, S5, S6, S7]. A surgeon in Mexico says “Graham’s work has challenged and indeed changed the way that surgeons think, and has been done in a way that has motivated surgeons like myself to apply her work in our practice and patient care” [S1]. For the first time, they have revised protocols for discussions with patients to include the social aspects of bariatric surgery in pre- and post-operative consultations. Consultations now cover topics such as how eating in the home and restaurants will be affected and whether they will tell others that they’ve had bariatric surgery, and prepare them to receive and manage negative judgments from others against this method of weight loss. He estimates that 1,000 of his patients, living in Mexico, the USA and Canada, have benefited from this change. A surgeon in India says the research has “ profoundly influenced the types of conversations I have with my patients”, confirming that they now discuss non-clinical aspects of surgery “ *not as a social conversation, but as part of the pre- and post-surgical consultations and follow up.*” [S7]. Another new inclusion in discussions is contraception [S2, S8, S4, S6]. A UK surgeon describes the change: “we now provide patients with information on contraception and suitable methods before and after surgery. We have also changed practice so that this is discussed in more detail, and patients are signposted to appropriate contraceptive services as appropriate” [S4]. This enhanced awareness has driven expansion of multidisciplinary teams. In 2015 City Hospitals Sunderland, home to one of the UK’s busiest bariatric units with between 400 and 600 surgeries per year, added a pharmacy role into the team, delivering pre-operative assessment, peri-operative monitoring, and support for community nurses and GPs. It has since created a second post to manage demand for pharmacist input [S4].

Patient care has improved

Clinicians attest that these changes improve patient care; as one surgeon said, “Graham’s research has positively influenced the UK bariatric surgical community’s approach to patients and many clinical counters are more patient-focused” [S9]. This shift towards patient-centred care has been acknowledged by other clinicians beyond the UK [S3, S7]. Graham’s risk adjustment categories are used to tailor consultations to patients’ needs. A Bariatric Surgeon in Mexico says “This helps us to understand how they may deal with the changes after surgery, and has led to more open and honest discussions with patients, which has resulted in improved care… [which has]… improved the lives of patients and helped them adjust to life after surgery” [S3]. Some clinicians have established support groups for patients in response to the research findings [S2].

Patients’ health and wellbeing has improved

Patients report improvements in physical and mental health and wellbeing as a result of these improvements. One says that clinicians’ greater appreciation for patients’ needs has given her “the right support to change, accept and understand what works to sustain a healthier and happier life” [S10], and another says that the research *“has educated me regarding bariatric surgery, which in turn has impacted my wellbeing, physical and mental health.*” Better pre-operative care means that patients “feel more confident about being open about the surgery” and empowered to be *“honest and **[*tell ] people from day one.” [S10] Improved post-operative care, and access to support groups have reduced patient isolation and increased their understanding and appreciation of themselves as individuals. One patient says that the research “made me realise I’m not alone, definitely eating better again and having more confidence as well.” [S10]

Patients’ voices are heard, and their needs and experiences recognised

Conducting qualitative research with patients means that patients’ voices about the social aspects of bariatric surgery are now being heard, with positive effects on their wellbeing. Patients say that it makes them “feel valued and listened to”; others highlight the importance of this representation, saying “It’s important to have someone to be a voice for those who have had or are considering bariatric surgery,” because “bariatric patients often feel alienated and uninvolved” [S10]. Clinicians agree that these issues are “often underestimated aspects of bariatric surgery” [S1]. By foregrounding patients’ views, Graham’s work “‘legitimised’ many issues that patients experience, and find difficult to speak about” [S11]. A patient advocate says that many people “assume that weight loss is the main outcome of surgery. Talk to any patient and you will see that quality of life issues and matters that go beyond weight are important to us. [This] research incorporates the patient voice […] so clinicians and others gain a more comprehensive understanding of bariatric surgery from the patient perspective” [S5]. The result is a change in the dynamics of doctor-patient relationships. Patients are empowered to be open about their experiences; as one surgeon says, “patients are more open in their conversations with me, which helps me to support them not only medically, but in a more holistic, patient-centred approach” [S4].

Stigmas are being confronted

Graham’s research challenges stigmas around surgery as a weight loss method, and has supported patients in overcoming discrimination. One patient says, “society sees surgery as the ‘easy’ option for obese people,” and that this research has built the foundations for changing narratives around bariatric surgery to recognise that “the operation is only a ‘tool’, the operation is predominantly for most patients the ‘easy’ bit.” Another says “the research is important as it is helping both bariatric patients and the general public understand why the surgery is so important and it's usually last resort for most patients.” This has tangible benefits; as one patient says, the research “has helped me and many others who have had surgery overcome the social discrimination we can feel” [S10].

Since 2005 Dodou has worked in partnership with the drug delivery design and development group at UCB Pharma. Spray dried solid dispersion (SDSD) products are a key part of the UCB new chemical entities pipeline for both non-clinical and clinical development. The significance of this pipeline prompted UCB to appoint an expert partner to provide new insights into manufacturing methodologies and quality control tools for the development of poorly water-soluble drugs, with the aim of developing a more accurate protocol for quality control that would be used to optimise drug stability and speed up the drug development process.

Dodou’s research demonstrated that standard screening tools used in development of spray-dried solid dispersions (SDSDs) do not fully account for the effect of the preparation method on the properties of screened ASDs [R6]. This inaccuracy meant that additional experimentation is needed, resulting in a more time-consuming and wasteful process with additional costs. Dodou’s protocol is more accurate because it incorporates the processing method throughout development of the active pharmaceutical ingredient (API), therefore removing the need for additional experimentation, creating a faster, less wasteful (and therefore cheaper) screening process. UCB implemented the new protocol in August 2018 for the screening of all SDSDs in their pipeline in both clinical and non-clinical development.

By removing the need for further post-screening experimentation, the protocol has reduced API consumption from 10g to 735mg, and screening/formulation time from 16 weeks to 9 days [R6]. Prior to this research UCB outsourced their solid dispersion screening at a cost of approximately EUR 10,000 – 15,000 per molecule; each year approximately 5 molecules are selected as potential solid dispersion candidates. This screening tool has removed the need for outsourcing this activity, thus saving between EUR 50-75,000 per year, or EUR 100-150,000 during the assessment period. The change has also enhanced the organisation’s capacity for development of new molecules: “ Adoption of this new time- and material-efficient protocol has made an impact on UCB Pharma’s capacity to speed up the lead discovery and lead optimization phases up to the clinical development of pipelines’ molecules” [S1].