Impact case study database

Reducing Dental Antibiotic Prescribing

Prior to the RAPiD trial, antibiotic prescribing in dentistry was increasing year-on-year, accounting for 10% of all antibiotics dispensed in the UK. It was estimated that 50% of dental antibiotic prescriptions were unnecessary, therefore negatively impacting on patient safety, effectiveness of treatment and contributing to the global threat of antimicrobial resistant (AMR) infections.

The RAPiD A&F intervention (2013-14) was delivered to two-thirds (1,999) of dentists in Scotland and resulted in a 6% reduction in Scotland’s national prescribing rates, equivalent to 20,000 antibiotic items over 12 months, demonstrating higher compliance with national guidelines avoiding overuse of antibiotics. Amongst the highest prescribers in the A&F intervention groups there was a 12% reduction. RAPiD directly changed SDCEP 2016 Drug Prescribing Guidance and prompted two further national antibiotic prescribing audits by NES, completed by over 50% of all dentists [E1]. RAPiD directly reversed dental antibiotic prescribing behaviour, stimulating and contributing to the 24% reduction in antibiotics prescribed since 2013; generating a benefit to the economy by saving Scotland’s NHS circa £850k [E2].

Evidence from RAPiD has also led directly to additional national antibiotic stewardship strategies. The Scottish Antimicrobial Prescribing Group implemented a similar approach for General Medical Practitioners to reduce antibiotic prescribing, with plans to include dentists in future national quality improvement interventions [E2]. RAPiD’s process evaluation led directly to the introduction of national in-practice training to improve the quality and safety of dental antibiotic prescribing [E1]. As a result of this all of Scotland’s dental practices are now required to undertake this training, which includes RAPiD style A&F, at least once every three years as part of NHS practice inspection requirements. According to the Postgraduate Dental Dean of NES: The work of the Scottish Dental Clinical Effectiveness Programme has been pivotal in promoting a change in behaviour with subsequent reduction in antimicrobial prescribing. [E1]

RAPiD has demonstrated that high quality research can be embedded in service delivery. Consequently, the impact of in-practice training is being evaluated in a national RCT to further inform national provision of education for the NHS (evaluation delayed by COVID-19, due to recommence in March 2021) [E1, E3]. RAPiD has been cited as an exemplar of research partnerships between practitioners and academia and has resulted in TRiaDS being named an A&F laboratory that has had impact on research culture in healthcare systems by the International Audit and Feedback Metalab [E4].

National Priority - Enabling evidence-based policy

The IQuaD and INTERVAL trials have generated much needed evidence for policy makers about the clinical- and cost-effectiveness of risk-based recall and S&P. The Chief Dental Officer for Scotland notes the “ significant contribution in terms of evidence and guidance” [E5] made by the Dundee team to the development of The Scottish Government’s 2018 Oral Health Improvement Plan, noting that:

the evidence they have generated from UK national trials in dental primary care has informed government thinking *which underpins the design of our preventive approach.*” [E5].

and commenting further on the value of the evidence in relation to informing models of preventive care that will form the basis of future oral health strategies:

The INTERVAL and IQuaD trials led by Dundee have provided my office with evidence to inform the design, development and cost effectiveness of the future preventive model of care [E5].

IQuaD has also been cited as the underpinning evidence for government policy in relation to changing the service provision and payment of S&P [E6], although dental policy development in the UK has been delayed due to the pandemic.

In a departure from normal process, the relevant Cochrane reviews were updated during the publication of IQuaD and INTERVAL [E7], minimising the delay between evidence generation, synthesis and adoption by practice. The findings were reported widely in the national and international news media and provided reassurance to the public that intervals between dental check-ups can be extended beyond six months without detriment to their oral health. This was particularly important given the impact of COVID-19 on the provision of dental care worldwide. Public Health England’s ‘Delivering Better Oral Health Toolkit’, to which all 26,000 NHS dentists in England and Wales are expected to comply, is being updated and has adopted the robust methods of SDCEP in order to improve quality. The INTERVAL and IQuaD findings in relation to risk-based recall and S&P were included through the related Cochrane reviews [E8].

COVID-19 informing safe practice and widening patient access

The Dundee-led partnership response to COVID-19 has resulted in evidence-based guidance and resources that have supported the re-opening and mobilisation of dental services internationally [E9], [E10]. The SDCEP resources were downloaded over 320,000 times in the three months from March 2020, and the rapid reviews of international dental guidelines were distributed by WHO Director for Oral Health to global stakeholders, including the worldwide network of CDOs.

The SDCEP AGP Mitigation Rapid Review conclusions i) not to recommend preprocedural mouthwash and ii) that fallow time could safely be reduced to a minimum of 10 minutes, informed the Chief Medical Officers independent committee on AGP’s and was supported by all 4 of the UK’s Chief Dental Officers. Within 4 weeks of publication (25-09-20) the UK Infection Prevention Control guidance, published by Public Health England, changed its recommendation to take account of the SDCEP AGP Review [E11]. The British Dental Association estimates that the reduction in fallow time, from 60 minutes to 10 minutes, could increase access to UK dental care from 20% to between 60-70% [E12]. According to Public Health England:

The programme of research undertaken at SDCEP and led by Professor Clarkson has had far reaching impact for both dental policy and service delivery both nationally and internationally. [E8]

By informing UK, European, Australian, American and Canadian clinical guidelines and policies, and through impact on local physiotherapy practice, Morris’s research has changed practice and service delivery for thousands of stroke survivors:

International Impact: Morris’s research examining comparative effectiveness of bilateral versus unilateral task training for arm recovery [R1, R2] informed Canadian best practice guidelines recommending that bilateral training is not superior to unilateral training for arm function and dexterity [E1]. R1 was a highlighted study within the Canadian 2020 Stroke Rehabilitation Clinician Handbook [E2] that guides physiotherapy practice in stroke rehabilitation for around 50,000 Canadian stroke survivors annually. Similarly, the research was included in the evidence review [E3] influencing 2014 Dutch Physiotherapy guidelines on bilateral training in stroke [E4]. Guideline recommendations are the benchmark against which physiotherapy practice audit is performed in those countries and as world leaders in stroke rehabilitation guideline development, guidelines from these countries are used globally to inform practice.

Review findings that assessment from a physiotherapist improves mobility and function informed the Australian Government 2015 quality indicator for acute stroke care [E5] that “ physiotherapy assessment within 48 hours of hospital admission is a good indicator of rehabilitation activity”. The quality and safety of 120 Australian rehabilitation services serving 56,000 stroke survivors annually is measured against this indicator in the National Stroke Audit [E6]. Reports show an increase from 67% in 2017 to 72% in 2019 of rehabilitation units meeting the indicator, demonstrating that review findings influenced policy that led to change in rehabilitation service delivery.

International recommendations for strategies to change behaviour and improve uptake and maintenance of post-stroke physical activity have been informed by Morris’s research. The review examining effectiveness of post-stroke physical activity promotion [R6] was included as evidence supporting the American Heart Association’s strategic policy statement [E7], specifically the recommendation for use of tailored counselling to enhance self-management and adherence to physical activity. These policies determine targeted interventions and surveillance of cardiovascular health at national, state and local levels across the USA. The recommendation for use of tailored approaches to physical activity promotion within the German National Recommendations for Physical Activity and Physical Activity Promotion in Adults with Pre-Existing Diseases [E8] was directly informed by this research [R6]. The recommendations are used to guide the work of the national working group on physical activity at the German Federal Ministry of Health and national implementation of physical activity strategies.

National and Local Impact: The Cochrane Review finding that dose intensity of 30-60 minutes physiotherapy on 5-7 days per week is required for mobility and function influenced the 2020 update to the National Stroke Improvement Programme for Scotland [E9] as indicated by the National Lead for Rehabilitation, Scottish Stroke Improvement programme who is also Stroke Managed Clinical Network Lead, NHS Grampian [E10]: “I’m responsible for the rehabilitation elements of the National Stroke Improvement Plan. That piece of work has influenced one of the guidelines…we are recommending, nationally, that each Health Board provides rehabilitation to people on a needs-led basis at least five days a week, if they require that level of intervention”. The improvement plan influences service delivery by around 1500 practitioners for 13,000 people who have stroke annually in Scotland.

Morris’s research into understanding physical activity after stroke [R4, R5, R6] also influenced how post-rehabilitation exercise services are provided for 1500 stroke survivors in NHS Grampian per year [E10]: “We know from work around ten years ago about exercise after stroke. It was heavily pushed, in terms of, we need to provide stroke specific exercise classes for people. In practice, that was quite difficult to actually put in place….So, what we’ve done, is look at what options are there for physical activity available in Grampian. And we’ve got a list of stroke specific exercise classes – yes, that’s the right thing for some people, but we’ve also got walking groups, swimming clubs that have supervised support… And by using this evidence to say that behavioural interventions help people to engage too in physical activity and exercise, then we have a range of interventions that support people to do that, because everyone is individual, and we can’t expect one treatment fits all”.

Over 60% of neonatal deaths and 50% of maternal deaths arise from poor quality care [E3]. This research was the first to evidence midwifery as an essential intervention to improve survival, health and well-being for women and newborn infants, bringing clarity to the policy debate about the contribution of midwifery to quality care. The conceptual and theoretical developments and evidence have influenced global and national decision-makers, forming the rationale for transformative structural change to such an extent that the language and concepts have seeped into common use in low-, middle, and high-income countries as confirmed by the Technical Advisor, Midwifery in the WHO [E1]: ‘ Globally it [R1] has changed the language that we use in talking about midwifery… it has become embedded into major global structures and right down to country level’.

The reaction was swift across all regions and all fields necessary for large-scale, sustainable change: policy, guidance, education, regulation, advocacy and funding, with consequent direct impacts on quality of care.

Policy and guidance

Governments and health services in every continent have acted on the findings to strengthen midwifery, with direct impact on quality of care delivered to women and newborn infants in multiple countries [E1, E7]. The findings informed WHO and ICM guidance and standards on quality of care and strengthening midwifery [E2], becoming ‘embedded into WHO global documents’ [E1] and providing the core evidence for the transformative global WHO-UNFPA-ICM-UNICEF ‘Framework for Action for strengthening quality midwifery education for Universal Health Coverage’ [E3], used by governments and health services to strengthen midwifery education worldwide.

Citing R1 evidence as key, the Indian Government launched a programme of work in 2018 for education and regulation of professional midwives enabling all women in India (population 1.3 billion) to access midwives. This marked the first ever national strategy for midwifery and midwives in India, acknowledged by health ministers to be ‘a historic moment for Midwifery in the Country´ and ‘ a landmark policy decision’ [E4]. The WHO Technical Advisor describes the policy shift as a radical change in the model of care and notes similar impacts ‘ spilling out’ into multiple African countries, across the 11 WHO South-East Asia Region (SEARO) nations, and beyond [E1].

Education and regulation

The research evidence and QMNC Framework formed the foundation for the UK Nursing and Midwifery Council’s transformative regulatory standards for midwives [E5]. Mandatory until their revision in 2030, these standards are the basis for the education of all UK midwifery students (around 10,000 per year), with ongoing impact on the care they will continue to provide throughout their careers for around 600,000 women, babies and families annually, directly improving the care of millions of women and babies. These standards form the benchmark for the quality of all midwifery care in the UK.

Globally, the research is being used by regulators and educators to inform standards, and to improve quality both of care and of midwifery training. The research has influenced the ‘revision of the Required Competences for Registered Midwives in Sweden’ [E6] and has ‘informed establishment of an Interim Nursing and Midwifery Council to regulate the professions in South Sudan’ [E7]. In Malawi, education policy for midwifery has changed, leading to direct entry for midwifery at bachelor’s level [E12].

Across Latin American and Caribbean countries, the QMNC Framework ‘ has been a fundamental base to… the development of Competency Based Education… through the region’ benefitting 20 instructors, 177 lecturers and 4080 trained in maternal health [E8]. In Bangladesh, where the midwifery profession is new, targeted initiatives with UNFPA partners are extending the quality and reach of midwifery education for ‘ 38 educational institutions and 150 midwifery faculty and… around 400 students per year’ [E6]. This impact continues to grow; the new WHO interprofessional Midwifery Education Toolkit for maternal, newborn, sexual, reproductive and mental health integrates R1 throughout, and will be distributed to all member states in five languages: ‘ the new WHO Academy has accepted this as one of its first 10 educational courses… to be launched… in May 2021’ [E1].

Global advocacy and funding

The research has informed and prompted advocacy and action within and beyond individual countries. According to a senior health adviser at the UK Foreign, Commonwealth and Development Office, the research ‘ enabled the UK to support WHO with work on midwifery training and an action plan for countries’ [E10].

According to one Director of a WHO Collaborating Centre working across Eastern Europe, the research has ‘ influenced conceptual understanding of midwifery in countries where midwifery has been under-valued (or even non-existent) and where childbirth has become over-medicalised to the detriment of maternal and newborn experiences and outcomes’. They describe how policy makers and professionals across the region frequently reference R1 ‘ when formulating arguments to promote the development… of midwifery’, how nurses and midwives use the evidence to ‘ enhance their contribution to national maternity care strategies’ and how the thinking of senior policy makers has been ‘profoundly affected’ in respect of maternal and newborn care [E11].

The White Ribbon Alliance highlights changes at global and local level by donors as well as by countries, confirming that ‘ As a result of advocacy efforts which utilized evidence from the paper, the Government of Malawi increased the midwifery workforce with more than 50% and… established the position of Chief Midwifery Officer in Malawi’s central hospitals’ [E9]; and in Bangladesh, the research ‘has been an important tool for advocacy of midwifery care to politicians, health care leaders, managers, nurses, midwives, doctors’ [E6].

The work has directly influenced funding commitments including: USD16,000,000 from the MacArthur Foundation to “ support a revival of midwifery” in Mexico [E9] and CAD6,000,000 from the Canadian Government for Indigenous midwifery plus funding to “ support midwifery association strengthening and continuing education in Benin, DRC, Ethiopia, Haiti, Mali, South Sudan, and Tanzania” [E7]. Additionally, the Canadian and Swedish governments provided CAD50,000,000 to support midwifery in South Sudan, resulting in the ‘graduation of 45 nurses and 174 midwives; provision of antenatal care to 235,500 women and neonatal care to 58,817 babies, attendance of a skilled health professional at 59,444 births’ [E7].