Impact case study database

Our REF2014 impact case study presented the development of the first national guidance on the prevention of suicides in public places (Guidance on action to be taken at suicide hotspots. NIMHE, 2006) and its subsequent global impact. The current impact case study is based on both new research and entirely new claimed impacts that have occurred since August 2013.

In the UK, over 6,000 people die by suicide each year. It is a leading cause of death for young people, has higher rates among those from deprived backgrounds, and devastates the families and communities of each individual who takes their own life.

4.1 Informing national public health policy and supporting local authority practice.

**4.1a Preventing suicides in public places. Owens’ national guidance [3.2] has been used to inform the management of high-risk suicide locations. In 2015, this national guidance on preventing suicides in public places, was distributed to every public health team and local planning department (n=152] in England along with a letter from the Secretary of State for Health [5.1]. The framework in Owens’ guidance subsequently led to local authorities drawing up site-specific action plans [5.2] and by 2019, 78% of local authorities had specific actions to reduce suicides in public places included in their suicide prevention plan, and 64% (97/150) reported that these actions were already being delivered [5.2], [3.4]. Consequently, public health leads in 16 English local authorities contacted Owens for advice on the management of particular high-risk locations. Furthermore, Stoke-on-Trent City Council has worked with Owens to develop specific guidance for developers and the construction industry [5.2].

Private and voluntary sector: Many suicide attempts are made on impulse, so considering suicide risk when designing buildings is critical. Owens advised Sir Robert McAlpine Ltd on the design of high-rise buildings in the City of London and ROSPA on the design of student residences at the University of Exeter. In addition, Owens advised the National Trust on measures to reduce suicide risk at cliff-top locations such as closing a section of footpath or fencing off a stretch of cliff. This research-based advice to these various organisations was subsequently used as a model for new national guidance in both Scotland and Ireland. Highways England also subsequently used it as the basis for its strategy and guidance for preventing suicides on the strategic road network [5.3].

The University of Exeter Stranger on the Bridge study was used to develop a training module, and since March 2019 it has been delivered to every traffic officer in England (n=2,000) [5.4]. In September 2018, it also directly informed three of the recommendations within NICE Guideline 105: Preventing suicide in community and custodial settings [5.5]. The recommendations were: increased use of CCTV or other surveillance to allow staff to monitor when someone may need help; increasing the number and visibility of staff, or times when staff are available, and; ensuring training is available for relevant people.

**4.1b Utility of suicide audit. Owens’ guidance contributed to a significant upturn in the development of suicide prevention plans in local authorities. The Exeter research was identified as a seminal study and heavily cited in a report by the 2015 All Party Parliamentary Group (APPG) on Suicide and Self-Harm Prevention on the future of local suicide prevention plans [5.6]. The APPG report led PHE to commission the 2016 Local suicide prevention planning: a practice resource, and Owens was invited to play a key role in its development [5.6]. This guidance was distributed to every local public health team in England (n=152) [5.7]. A 2016 survey by PHE indicated that the number of local authorities with a plan in place or in development had increased from 70% in Jan 2015 to 95% in Jan 2017 [5.7].

**4.1c Review of local suicide prevention plans.

Exeter research (study 2.1) raised the quality of local suicide prevention work in Local Authorities. The findings and recommendations from Owens’ report [3.4] “feed directly into this sector-led improvement programme” for suicide prevention (Background section of **[5.8]**). This is a £600,000 Sector-Led Improvement programme, launched in 2018 and coordinated by the Local Government Association. During 2020, the programme delivered national masterclasses/webinars on key issues, a Must-Know Guide, and provided bespoke expert support for local authorities identified as facing particular challenges [5.8] .

4.2: Helping everyone play a part in preventing suicides.

The leaflet’s message ‘It’s safe to talk about suicide’ has empowered friends and family members to overcome their fears and initiate conversations about suicide.

4.2a Public education leaflet: ‘It’s safe to talk about suicide’. Exeter research revealed a deep-seated fear of talking about suicide. Significant others can play a key role in suicide prevention, but little attention was given to the resources they may need to do so effectively. The evaluation of our leaflet distribution evidenced that it was a vital information resource. This resulted in Devon County Council producing a further 30,000 hard copies which were distributed across the county through frontline agencies and community groups, including housing and benefits departments, GPs, student wellbeing services, Citizens Advice and family solicitors. Since 2016, it has been made available online through the National Suicide Prevention Alliance (NSPA)’s repository of approved resources. Also in 2016, in response to widespread demand, the leaflet was made free to share and adapt under a Creative Commons Licence. Organisations have endorsed it with their own logo and are actively distributing it, including eight local authorities besides Devon, five UK universities, the Fire Officers Association, and the RNLI [5.9]. It is promoted in Universities UK’s guidance on the creation of Suicide-Safer Universities (UUK, 2018) and Business in the Community’s guidance for employers (BITC, 2017). In 2019 it was also translated for use by local health teams in Malaysia [5.9].

**4.2b Informing national campaigns: In 2015, the leaflet’s key messages and content formed the basis for a # BiggerIssues campaign by the Campaign Against Living Miserably (CALM), estimated to have reached over 23 million people via social media, and in 2016 for the #TalkThroughTheTaboo campaign by PAPYRUS (Prevention of Young Suicide) [5.10].

The UK has come bottom in most European studies of cancer survival for decades, with much of the problem ascribed to diagnostic delays. In a statement publication from the National Cancer Director in 2009, it was estimated that 5,000 lives are lost annually in the UK from cancer when compared with average European survival rates [5.1]. The contribution of diagnostic delay to this is explicitly recognised in the 2019 NHS Long Term Plan, which specifically targets an improvement in stage of cancer at diagnosis. The target is to increase the percentage of patients diagnosed at stage 1 or 2 cancer from the current 53% to 75%, which if achieved could avert more than 5,000 estimated untimely cancer deaths. Modelling studies suggest that every week’s delay in referral for cancer diagnosis worsens survival by approximately 1% (Sud et al 2020, Lancet Oncology, 21(8), 1035-44).

4.1 Impacts on national policy

Findings from the research carried out by Hamilton and his team have directly informed the revised NICE cancer guidelines, NG12: Suspected cancer, recognition and referral (2015) [5.2], with Hamilton also being the clinical lead of the Guideline Development Group. Eleven publications from Hamilton’s research team in Exeter contributed evidence for 89 of the 210 recommendations. Seven of these publications were sole evidence for 41 of the 210 recommendations. These 2015 NICE guidelines also used evidence from research carried out by Hamilton’s team [3.5] which showed strong public support for investigation of possible cancer even at low risk. The results of this research were highly influential in lowering the threshold of cancer risk that should trigger referral for suspected cancer in NG12, from 5% to 3% (p.14 of [5.2]).

Adoption of Risk Assessment Tools (RATs) by general practitioners in England

Initially, the National Cancer Action Team disseminated RATs for four cancers to all 10,000 English general practices in mouse mat and desk easel form. Following this phase, from 2015 onwards, implementation was led by a combined Department of Health/ Macmillan initiative, which generated software for seven RATs (lung, colorectal, ovarian, oesophagus, stomach, kidney and bladder).This software has now been incorporated in the three main clinical records software and is therefore available for use by over 90% of general practices in the UK, covering more than 50 million registered patients; 36% of practices have at least one GP using it [5.3]. Each time a new test result or reported symptom reports a person’s risk for cancer to be above 2%, an alert is generated. This reminds the GP to refine the risk after discussion with the patient, seeking other relevant information such as additional symptoms or abnormal blood tests. This may then lead to referral for specialist investigation. More recently, qualitative data from a survey has also shown that GPs are still broadly supportive of RATs and this is evidenced by a range of outcome measures which reflect the increased GP cancer diagnostic activity as a result of RATs. [ 5.3]

Improvements in cancer referral and diagnosis

Since the introduction of the Exeter-developed RATs, referrals from primary care for suspected cancer have increased along with the number of new cancer diagnoses, and a decreased proportion of cancers being diagnosed as an emergency.

a) Increased number of two-week-wait referrals:

Two-week wait referrals for suspected cancer have increased significantly from 1.5 million annually in 2013/14 to 2.3 million in 2019/20 [5.4]. There is now strong evidence which links increased two-week referrals with better cancer survival [5.5]. This evidence cited Exeter research which showed the previous NICE guidance was associated with reduced times to diagnosis.

b) Increased proportion of cancers diagnosed using the two-week-wait referral:

From 2013/14 to 2019/20 the proportion of cancers that were detected within the two-week-referral care pathway in England has increased from 47.4% to 53.7% [5.6].

c) Decreased time between first symptom presentation of cancer to primary care and diagnosis (the ‘diagnostic interval’):

This has been examined by comparing the diagnostic interval for cancer patients whose symptoms only met the criteria in the 2015 NICE guidelines (i.e. the guidelines directly informed by Hamilton’s work) against those whose symptoms met the previous referral criteria (2005 NICE guidelines). For several cancers the new symptoms were being diagnosed more rapidly than before [5.7]. On average, using the more specific, 2015 NICE referral guidelines, patients were found to be diagnosed seven days earlier following symptom presentation. A week matters in this patient group: the best current estimate is that survival worsens by 1% for each week that diagnosis is delayed. (Sud et al 2020, Lancet Oncology, 21(8), 1035-44)

d) Decreased proportion of cancers diagnosed as an emergency:

This has fallen from 20.2% to 18.8% between 2013 and 2018 [5.6]. It is probably the strongest marker of improved GP referral practices for suspected cancer and equates to 6,000 fewer emergency presentations with cancer per year.

e) Improved cancer stage at diagnosis:

Stage 1 or 2 (i.e., more curable) cancer at diagnosis has risen from 47% to 51% between 2013 and 2018 [5.8], equating to over 10,000 more potentially curable patients annually.

f) Increased cancer survival:

The cumulative benefit of all the above improvements will inevitably be associated with better cancer survival for more patients. While some of the improvements described above will have resulted from other NHS initiatives to improve cancer referral and treatment, most of these initiatives have worked in conjunction with having clearer guidance (e.g. the NG12 NICE Guidance – **[5.2]**) about which patients in primary care should be referred for specialist assessment – which is the main contribution of the Exeter research.

g) Establishment of ‘multi-disciplinary diagnostic centres’:

Our research has also shown that features of cancer which are common across several cancer sites - such as raised platelet counts, low blood albumin, and raised blood calcium - present a clinical opportunity for earlier diagnosis [3.6]. In response to this evidence the NHS has established ‘multi-disciplinary diagnostic centres’ which use these features as entry criteria. In the NHS Long Term Plan (2019) [5.9], these centres have been expanded into Rapid Diagnostic Centres across the whole of England, again using the features we have studied to underpin their entry criteria. These Rapid Diagnostic Centres, have built on service models “ which have focused on diagnosing cancers where patients often present with non-specific symptoms and may go to their GP many times before being sent for tests.” (para. 3.59)

General practice underpins the globally recognised efficiency and effectiveness of UK healthcare, with UK primary care health professionals delivering 1.1 million consultations each working day. Delivering high quality primary care and improving patients’ experiences of healthcare are central goals of current UK national health policy. Research by the University of Exeter’s Primary Care Research Group has directly informed the initial creation, ongoing development, and improved use of the General Practice Patient Survey (GPPS). The survey empowers patients by enabling them to share their experience of their GP practice, and the data is publicly available, allowing them to make informed choices about their preferred GP practice. There has been continuous use of GPPS data by Parliament, the Department of Health and Social Care, and other NHS and local commissioning organisations to improve service delivery and patient experience.

[ Since the creation of the GPPS pre-dates the REF2021 impact period, we only claim impacts related to its conduct, development and use since August 2013.]

4.1 Continuous use of the National GP Patient Survey

Since August 2013, the GPPS has been conducted ten times, and analysed responses from over 5.6 million NHS patients [5.1]. It forms the basis for all six current core national metrics on patient experience of care (Department of Health and Social Care, Care Quality Commission, Public Health England). GPPS is unique in that it is now an England-wide annual survey that provides rich data for a wide range of audiences, including the public, through widely accessed websites e.g. NHS, and Public Health England. Data is reported at national, Clinical Commissioning Group (CCG), and practice levels, and informs a wide range of primary care organisational and management uses.

The research that underpins the survey is a highly valued element of the GPPS and its various versions. For example, the Director of NHS Commissioning (for England), testified [5.2] the following:

‘The evidence base published by Professor Campbell and his colleagues over the last 10 years has been invaluable in adding credibility to the outputs and impact of the survey. That credibility extends to the highest levels of the NHS and directly affects our team-decision making in respect of patient experience of care provided by NHS organisations, including all general practices in England.’

4.2 Influencing national policy

Confidence in the routine use of the GPPS is underpinned by Exeter’s research and their expertise has been used to inform the further design and use of national metrics based on its data [5.1; 5.2]. GPPS survey findings are used in Parliamentary discussions to inform policy making [5.3; 5.4]. For example, analyses of GPPS data influenced the introduction of ‘Improved Access’ arrangements, for delivering routine evening and weekend appointments in primary care [5.3; 5.4]. This policy was introduced as a direct result of the surveyed decline in patient satisfaction with patients increasingly reporting being unable to access GP appointments. As a result, the Nuffield Trust was commissioned by NHS England to investigate the impact of Improved Access on continuity of care, and analysed data from the GPPS to produce a report and make recommendations for commissioners and policymakers. The Nuffield report [5.5] drew significantly on Exeter’s research on the GP patient survey and resulted in the new primary care services. Data from the survey at GP practice level is also routinely used by the Department of Health and Social Care in evaluating practice performance across a range of policies including access to services (including out-of-hours GP services) and managing winter pressures [5.6].

4.3 Informing planning of local services

GPPS data are routinely used throughout the NHS in service planning and delivery, with local and regional health commissioning services being able to access data to meet their own patient need. The GPPS website notes the role of Exeter in developing the survey [5.6], and draws directly on, and summarises Exeter’s research. For example, the survey and Exeter’s research were used to identify that out-of-hours appointments are more commonly reported in those practices where patients report more difficulty in getting appointments during normal working hours, and that the convenience of opening hours was the strongest single predictor of use of out-of-hours care [5.6]; such data has been directly used by Clinical Commissioning Groups (CCGs) to inform improvements in service provision [5.7; 5.8]. Other routine users of the GPPS data include senior (NHS Board level) NHS commissioners and planners, noting the direct link to the research base for GPPS. Using data for service planning, GP practices and CCGs extensively use information derived from the survey to better understand and support their patients and local services [5.2].

CCGs routinely receive comparative data to monitor Outcomes Indicators and for use in the NHS Improvement and Assessment Framework. In 2019, Exeter conducted a survey of 39 English CCGs regarding their use of GPPS data - 35 CCGs (representing ~4 million patient population across 7 regions) responded and were able to provide detailed, specific examples of routine use of GPPS within their planning arrangements. Of these, 23 CCGs used their GPPS data for improving extended access schemes, 11 to inform services to better meet local need, 9 to assist in monitoring of practice performance, and 5 used the data to inform consideration of alternative methods of patient consultation [5.8].

4.4 Public use of patient-reported data on primary care

As a publicly available website [5.1] the results of the GPPS surveys are accessible to the public down to the level of individual practices. The NHS website and Public Health England’s widely used ‘General Practice Profiles’ use data from GPPS to report and provide comparative data on patient experiences of GP practices. This enables patients to make informed choices over their preferred general practice - for example, on the basis of patient-reported experience of out-of-hours care or appointment availability.

4.5 Quality monitoring and inspection of primary care practices

The GPPS provides Care Quality Commission (CQC) inspectors with data on how all 6,900 GP practices in England are performing and identifies any changes over time. The published research by the University of Exeter underpins and quality-assures this process. For example, survey data currently serves as one of four national data sources for the CQC GP Insight regulatory model – an initiative that strives to achieve one of their key priorities for their 2016-21 Strategy to deliver an ‘intelligence-driven approach to regulation’ [5.9]. Indicators developed from the GPPS are used in the GP Insight model in the inspection of every GP practice in England. Inspectors use them to guide questioning and include in the ‘evidence tables’ alongside inspection reports (for example around appointment availability, and patients feeling listened to or having sufficient time).

The UK Chief Inspector of General Practice, went further in support of the importance of the GPPS data, stating:

“Around 40% of the data behind the programme (GP Insight programme) is dependent on data derived directly from the GP Patient Survey ... It remains a key element in our inspection regime and I wanted to document my support of the underpinning academic research and resultant publications which have facilitated and supported our internal processes. ”. [5.10]

4.1 Informing clinical guidelines in the UK (NHS)

Heart disease:

The suite of eleven Exeter-led Cochrane reviews, published and updated since 2009, have directly informed the recommendations of the following UK clinical guidelines on the provision of rehabilitation for heart disease patients [5.1]. NICE clinical guidelines, while not mandatory, are effectively national policy on clinical best practice in the NHS in England and are typically also adopted in Wales and Scotland. The evidence base cited in NICE CG172 [ Myocardial infarction: cardiac rehabilitation and prevention of further cardiovascular disease, November 2013] recommendations state that “All patients (regardless of their age) should be given advice about and offered a CR programme with an exercise component” and “Offer cardiac rehabilitation programmes in a choice of venues (including at the person's home, in hospital and in the community)” [5.2].

Heart failure:

More recently, the NICE Heart Failure guidelines (CG108) were updated and replaced by NG106 Chronic heart failure in adults: diagnosis and management (September 2018) [5.3]. The latest update of the Cochrane review of home- vs centre-based CR [3.1] was used by the guideline committee (in January 2017, before its publication by Cochrane) to inform its guideline update [5.4]. This in turn has informed the NICE Quality Standards in relation to CR, specifically that adults with chronic heart failure are offered “the choice of undertaking the programme at home, in the community or in a hospital setting” and based on the stated rationale that “people with chronic heart failure are typically older and may be frail or have comorbidities. This can make it difficult for them to attend group‑based programmes at hospitals or clinics.” [5.5]

4.2 Informing international clinical guidelines

The collection of Exeter-led Cochrane reviews by Taylor’s team have also been directly cited in support of nine non-UK clinical or policy guidelines, covering the USA (incl. American Heart Association, American Association of Cardiovascular and Pulmonary Rehabilitation, American College of Cardiology – 3 guidelines) and Europe (European Society of Cardiology - 6) [5.1].

Exeter-led reviews formed the core publications in informing the recently published European Society of Cardiology’s 2020 ‘Position paper’ on ‘Secondary prevention through comprehensive cardiovascular rehabilitation’ [5.6]. This paper provides a comprehensive update of ‘the practical recommendations on the core components and goals of cardiac rehabilitation intervention in different cardiovascular conditions. It cites five of the Cochrane systematic reviews produced by Taylor’s team at Exeter (including **[3.1; 3.2]**), and the findings of the ExTraMATCH II Collaboration’s individual patient data meta-analysis [3.6] as evidence of the benefits for long-term improvements in prognosis and quality of life.

Exeter research by Taylor and Dalal has also directly informed the European Society of Cardiology’s international guideline on ‘ sports cardiology and exercise in patients with cardiovascular disease’ published in 2020 [5.7]. The guidance and recommendations cite seven Exeter research publications by Taylor and Dalal, including four of their Cochrane systematic reviews [5.1].

4.3 Expansion of home-based cardiac rehabilitation for heart failure in the UK

The first stage of the roll-out of the Exeter-developed REACH-HF model of cardiac rehabilitation began in April 2019 with the implementation of the REACH-HF intervention in four ‘Beacon’ sites in England/N Ireland, following a national competitive process for applications. The four NHS hospitals/trusts piloting and providing the REACH-HF model of CR for their heart failure patients, are: Gloucester, UCL Hospital London, the Wirral, and Belfast. The primary purposes of the Beacon sites are: (a) to provide a foundational infrastructure and learning to stimulate other sites across the NHS to take up REACH-HF and overcome the current NHS national shortfall of the provision of rehabilitation for heart failure (as highlighted in the 2018 NICE guidance on heart failure and the 2019 NHS Long Term Plan); (b) to collect routine data ( National Audit for Cardiac Rehabilitation (NACR) – part of NHS Digital) on heart failure patients at each site, so we can assure that similar improvements in health outcomes in the ‘real world’ setting are achieved as seen in our RCTs. [5.8]

In parallel with this, we have been working with stakeholders and the National Association of Cardiac Rehabilitation on more general roll-out of REACH-HF cardiac rehabilitation across the NHS, so that it can become available to all heart failure patients [5.9]. In Spring 2020, four further sites (Health Boards) in Scotland started implementing the REACH-HF model of cardiac rehabilitation for their existing and newly diagnosed heart failure patients. The Scottish Health Boards involved include urban (Forth Valley), rural (Lanarkshire, Ayrshire and Arran) and remote populations (Inverness, Shetland, Orkney).

The eight Beacon sites in England/Northern Ireland (since April 2019) and Scotland cover a population of 2.7 million people and an estimated 43,000 people living with heart failure. However, due to the COVID pandemic, by the end of November 2020 only 158 people had received the complete REACH-HF rehabilitation intervention at the England/NI sites (National Audit of Cardiac Rehabilitation data). Nevertheless, NACR data also show that from 2019 (May-Jan) to 2020 (Feb-Aug) the proportion of patients enrolling in home-based CR had increased substantially from 22% to 74%. The Wirral Cardiovascular Prevention and Rehabilitation Programme has integrated home-based rehabilitation for patients with heart failure (REACH-HF) through new delivery methods, both prior to and during the COVID-19 pandemic, and has been added to NICE’s Shared learning database of implementation examples (linked to NG106, NG185 and QS9 NICE guidelines and standards [5.2], [5.3], **[5.5]**).

In March 2020, Dalal was awarded a further £159,000 from the British Heart Foundation to further expand the development and implementation of the REACH-HF model of rehabilitation as a digital/electronic intervention with online training for care professionals. Between May and December 2020, 102 health care professionals (cardiac nurses, physio/exercise therapists) from over 50 NHS centres have received the REACH-HF online training. Each was also given at least 10 REACH-HF intervention packs to support over 1000 vulnerable heart failure patients affected by restricted access to cardiac rehab during the pandemic. Together, these achievements have led to the REACH-HF Collaboration receiving the 2020 BMJ Award for Stroke and Cardiovascular care [5.10].

In summary, for over a decade, an extensive programme of research encompassing systematic reviews and meta-analyses, feasibility studies and randomised trials of cardiac rehabilitation interventions in heart disease, have directly informed national policy (e.g. NICE & SIGN Guidelines) and international clinical guidelines in Europe and North America. The provision of home-based cardiac rehabilitation has expanded, and the REACH-HF model of home-based cardiac rehabilitation for heart failure has been shown to be feasible, effective and cost-effective in NHS contexts, and is also being rolled out in a growing number of areas around the UK.

Human health and wellbeing depend on the environment and well-functioning ecosystems. This linkage was historically poorly recognised in both environment and health policy. Research from the Centre has changed policy mind-sets, strategies and practice. Our evidence has strengthened conservation, environmental management and investment policy at scales from local to international by clarifying the role of ‘natural capital’ in supporting human health and wellbeing.

Traditionally, environmental policies relating to human health have been dominated by hazards; our evidence means these are now balanced by the recognition of the health and wellbeing benefits of good quality natural environments. Our research impact has been amplified through active engagement and close collaborations with policy bodies who have recognised our expertise and invited participation in a range of expert advisory roles and joint projects.

4.1 Influencing international policy on natural environment and health

Our research has led to changes in international policy and strategy in both the health and environment sectors. Since 2015, we have worked with the WHO Regional Office for Europe and the Convention on Biological Diversity (CBD) on urban greenspace, biodiversity and health. Our 2014 systematic review [3.2] of links between biodiverse environments and ‘good’ health was used to inform the ratification of two key CBD decisions on biodiversity and human health, with a joint CBD/WHO report co-authored by Lovell [5.5]. These decisions invite the 195 nation state signatories, and the European Union, to act on the linkages in developing health and environmental strategies (COP12 decision XII/21; COP13 decision XIII/6). These international decisions set the context for national policymaking, including the UK Government 25 Year Plan for the Environment [5.6]. The CBD/WHO report was also used to inform the implementation of the relevant 2030 UN Sustainable Development Goals adopted in 2015 by all UN member states (especially SDG3 (health), but also SDGs 7 (water quality) and 11 (nature-based solutions to challenges related to urban well-being). The WHO’s Technical Officer said “ [The systematic review by ECEHH] was instrumental in getting the WHO to pick up that theme [benefits of nature/biodiversity for health], to make this a WHO topic.” [5.7].

Recognition of our research outputs and expertise led to Depledge and Wheeler contributing one of three chapters of the key 2016 WHO evidence review, on Urban green spaces and health, underpinning WHO urban greenspace action [5.8]. Wheeler was subsequently a member of an Expert Group advising WHO, ultimately resulting in WHO’s Urban green spaces: a brief for action for authorities promoting and supporting action for urban greenspaces. WHO’s Technical Officer on this programme said

“…this understanding of what matters is something where Exeter was different to many academic actors. There was a stronger understanding of what it takes on a local level to work on it and fund [green space] to make it functional and operational. This is where Exeter made a difference in terms of how the outputs and the research work were positioned, and how they can be useful to local practitioners.” [5.7]

4.2 Influencing national policy on natural environment and health

At the national scale, the Centre’s research resulted in a joint report and Departmental briefing that informed the Government’s position on natural environment and health. The report was produced by a collaboration between the Centre, Defra, PHE and related stakeholders, who synthesised existing evidence (including from Centre researchers) and conducted primary research. This report, along with the key WHO report [5.8], were the key sources underpinning the health aspects of the UK Government 25 Year Plan for the Environment [5.6]. Consequently, Defra has established policy commitments including the creation of national standards for Green Infrastructure, the transformation of agricultural subsidies to a focus on public goods (including health), environmental investments (e.g., planting 11m trees by 2022), and large-scale initiatives. Approximately £10 million has been committed to these health and nature programmes, reaching significant populations including over 500 schools [5.6]. The Research Adviser, at Defra explained:

“Defra wouldn’t be picking up on this agenda if there wasn’t some evidence underpinning it… I don’t think the evidence would be available to us in the same form if it wasn’t for your Centre... There’s a major value to society from understanding the health benefits - health costs and benefits are absolutely huge. So, if we can get a better handle on the health costs and benefits linked to the environment, then that’s part of a much broader agenda that Defra has realised it should be doing more on” [5.1].

Our evidence is influencing public health processes at the national scale, in part through our collaboration with PHE and the Health Protection Research Unit in Environmental Change and Health. Our research findings (e.g. **[3.5]**) were used to establish the basis for the value of investing in urban green spaces for population mental health in PHE guidance to local authority planners Spatial Planning for Health [5.2]; and in PHE guidance (co-authored by Lovell) on accessible greenspace, leading to the prominence of health in the new Green Infrastructure standards for England associated with the 25 Year Plan [5.6]. Our work with Defra, PHE and the NHS, and evidence reviews of the impacts of nature-based health interventions [3.1; 3.6] have contributed to additional Government investment of £5m in social prescribing [5.6].

4.3 Influencing local policy and practice on natural environment and health

The Centre’s research directly led to the creation of a commercial tool, Greenkeeper, to evaluate the multiple economic values of urban green infrastructure. Prior to our longitudinal studies [3.5], there was no robust estimation of the magnitude of the positive impact of urban greenspace on population mental health, contributing to the under-valuing of urban nature. This work led to our collaboration with Vivid Economics and Barton Willmore on the Innovate UK-funded Greenkeeper project. This involved the development and application of our studies of mental health and physical activity values [3.3; 3.4] to incorporate health-related values in the tool. Greenkeeper has already been used for a range of purposes, including to support a 2020 call from National Trust and Heritage Lottery Fund to press the Government for £5.5bn green infrastructure funding as part of a ‘green recovery’ to address inequalities in access to nature highlighted by the Covid-19 pandemic [5.9].

At the local scale, our research has also been used to inform decision making and investment to promote the health and well-being of Dorset’s population, and reduce pressure on its health and care services. Our existing research and green space access mapping, carried out in collaboration with Public Health (PH) Dorset, underpinned the Healthy Places Strategy applied within PH Dorset’s Sustainability and Transformation Partnership and Integrated Care System. Their Head of Programmes said:

“accessibility mapping has helped to inform the identification of pilot parks…for accessibility enhancement through a blended programme of community engagement and activation, and infrastructure improvements. Research from the European Centre was instrumental in…direct investment by Public Health Dorset of £77,900…to increase engagement with natural environments/greenspaces through enhancements to physical infrastructure and social engagement” [5.4].

Cornwall Council, under significant financial pressure due to austerity, identified a need to recognise the health value as well as biodiversity benefits of the almost 2000 parks, amenity and natural open spaces managed by the Council. Collaborative work resulting from the ESRC-funded Beyond Greenspace project [3.5] led to co-produced outputs appended to the Council’s Open Space Strategy and has supported investment in and sustainable management of public open spaces for community health benefit in the future [5.3]. Health evidence input from the Centre contributed to a successful bid led by the Council (with Exeter as a Knowledge Exchange partner) to the European Structural and Investment Fund resulting in a £3.5m green space development project (with an additional £2.9m follow-on project), currently delivering >60 hectares of improved urban green space quality and accessibility in Cornish towns [5.3].

Our evidence has also directly supported improvements in care settings and built confidence in staff to support residents to make use of their outdoor spaces. Our evidence synthesis of the beneficial impacts of gardens in care homes for people with dementia [3.6], together with a co-produced systematic review with the Sensory Trust (a third sector organisation), about older people’s sensory engagement with nature, has informed practice in care homes in the South West. The Sensory Trust is a nationally leading authority on inclusive and sensory design, which works on delivery of large-scale UK government programmes. Our collaboration produced an evidence-based information and activity kit, My Nature. The Sensory Trust’s Director said:

“… we've developed something that's really valuable for [care homes] to have…we were aware that they were continuing to implement activities on the basis of [My Nature] so…that's positive… It's a result of that relationship and seeing the skills that you bring [that] opened up those opportunities for us…we definitely see a real value in having collaborations that bring research and practice together.” [5.10].

In summary, our research outputs have directly informed policy and practice at international, national and local scales, and have led to substantive collaborations embedding Exeter researchers within decision making. This was recognised in November 2019, with the designation of the Centre as a WHO Collaborating Centre on Natural Environments and Health.